to the editor: I was disappointed that the article, “The Role of Allergens in Asthma,” had such a strong recommendation regarding referral for immunotherapy. The four family physicians in our group, many family physicians throughout the Kansas City, Mo., area, and many general internists perform immunotherapy. The four of us are all Advanced Cardiac Life Support (ACLS) certified. As the director of several hospital-based ACLS courses, I have yet to have an allergist attend for the purpose of responding to a life-threatening reaction to immunotherapy injections. The rationale for this recommendation seems to have been turf protection, rather than legitimate patient care considerations.

in reply: We apologize for implying that family physicians should not or could not carry out allergen immunotherapy. Clearly, many physicians including Dr. Saxer and his colleagues in Kansas City, Mo., have taken the time to learn the technique and the necessary safety precautions. However, we understand that family physicians and general internists have limited time to spend on physician and patient education regarding immunotherapy. The new National Asthma Education and Prevention Program guidelines stress the importance of education for both allergen avoidance and immunotherapy.¹ Many articles about severe reactions, as well as practice parameters for immunotherapy, have been published in the allergy literature.^2,3 Courses on immunotherapy and the management of anaphylaxis are a well-attended feature of our meetings. We remain convinced that for the majority of busy family physicians, initiation of allergen specific immunotherapy is a legitimate reason for referral to a specialist.

editor's note: Although the recommendation to refer asthma patients to an allergy subspecialist for immunotherapy received a SORT evidence rating of “A” in the AFP article, this recommendation from the National Asthma Education and Prevention Program¹ is actually based on expert consensus, or an evidence rating of “C”. A Cochrane review has concluded that immunotherapy benefits selected patients with asthma, not that it works better when administered by an allergist or primary care clinician.² A third option would be to request that an allergist perform initial allergy testing and determine the dose, composition, and schedule for immunotherapy, with the family physician taking subsequent responsibility for the administration of injections and office monitoring. This co-management strategy leverages specialist expertise while maintaining continuity of care, and it may be a practical middle ground for family physicians caring for patients with allergen-triggered asthma.