Do you Truly Have a Penicillin Allergy?

Penicillin allergy has recently been on the news- see video below. Penicillin antibiotics are safe and effective. These important medications are often not used due to people having a diagnosis of penicillin allergy. While about 10% of the US population (~32 million people) think they have penicillin allergy, more than 90% of those individuals can take penicillins safely. The over diagnosis or incorrect labeling of penicillin allergy leads to the use of more expensive, more more potent antibiotics that can lead to increased side effects for those treated as well as increased bacterial resistance making it harder to treat serious infections. Risk for penicillin allergy can be broken down as follows:

  1. Low risk- those whose reactions have been limited to nausea, vomiting, diarrhea, or itching without rash as well as those who may only have a family history but no personal history of penicillin allergy. In addition, individuals who have a very distant history (over 10 years ago) or have had unknown reactions are also at low risk.
  2. Moderate risk- those who have had hives or other itchy rashes or other features suggestive of an allergic reaction
  3. High risk- those who have had anaphylaxis (life threatening allergic reaction), recurrent reactions to penicillins, positive testing, or multiple allergies to drugs related to penicillins

Evaluation by one of our board certified allergists can help identify people who truly have penicillin allergy. Here at Allergy Asthma Food Allergy Centers of St. Louis, we can help determine whether or not you or a loved one are truly allergic to penicillin through penicillin testing and or office based challenges to penicillin antibiotics. Contact our office to schedule an appointment.

Today Show Penicillin Allergy Story

Early Introduction of Peanut

Allergists have suspected for years that early introduction of foods likely decreases the development of food allergies. The LEAP (Learning Early About Peanut Allergy) study published in the New England Journal of Medicine in February 2015, definitively showed that early introduction and regular consumption of peanut (approximately 2 teaspoons of peanut butter 3 days per week) dramatically decreases the risk of developing peanut allergy by about 80%. Since the study was published, new guidelines were also released with the following recommendations:

  1. Children at the highest risk of developing peanut allergythose with severe eczema (atopic dermatitis) and/or egg allergy should have some form of testing to evaluate for the possible presence of peanut allergy. If testing is negative, home introduction or a supervised feeding can be done, and if the child tolerates peanut, they should regularly consume approximately 2 teaspoons of peanut butter at least three days per week. This process should start ideally between 4-6 months of age. If testing is positive, depending on the testing results and the comfort of the specialist, and office based food challenge to peanut may be done to determine if the infant is allergic before introduction at home is considered.
  2. Children in the moderate risk groupthose with mild to moderate eczema and no egg allergy should start consuming peanut (about 2 teaspoons) three days per week starting around 6 months of age. These children do not necessarily need testing before peanut is introduced, which can be done at home.
  3. Children at low risk for peanut allergy- those without signs of eczema and without egg allergy can start consuming peanut when age appropriate and according to family and cultural preferences.

While formal recommendation #3 does not stress early introduction, it is important to note that there is no real downside to early introduction, and delaying introduction even in those without eczema or egg allergy could potentially lead to an increase in developing peanut allergy compared to those who introduce early.

A question parents often have is how peanut can be introduced at home. The video below features Dr. Ruchi Gupta, one of the leading experts in food allergy, discussing home introduction of peanut. We hope you find this helpful!




If your infant or toddler is found to be allergic to peanut, do not despair. There is good recent evidence that early oral immunotherapy (OIT)/desensitization to peanut has very good outcomes (over 90% success rate when done correctly and carefully) and is safe. If you would like more information on OIT, see our Food Allergy Center of St. Louis page.

Allergy Asthma Food Allergy Centers of St. Louis- Our New Name!

As many of you know, our practice has a very large focus and significant expertise in food allergy- not just oral immunotherapy (“OIT”)/desensitization treatment for foods but also comprehensive management of food allergies.  We maintain our expertise in managing other allergic and immunologic conditions such as seasonal allergies, asthma, eczema, chronic hives, contact dermatitis, recurrent infections, and immune deficiencies. However, since treatment of food allergies has become a bigger proportion of our practice, we have decided to rebrand our practice with a new name that more closely corresponds with our mission statement.

Our mission is to use our expertise in allergy and immunology to improve the quality of life of adults and children through the diagnosis and management of asthma, food allergies, and allergic conditions.

We are thrilled to share with you our new name (Allergy Asthma Food Allergy Centers of St. Louis) and logos!

We also have a food allergy specific logo, which you will now find on our Food Allergy Center page of our website (

We thank you for your continued support, and we look forward to continuing to partner with you and your families in pursuing our mutual goal, which is “FREEDOM FROM YOUR ALLERGIES”.


Michael R. Borts, M.D.
Josie Vitale, M.D.
Manoj R. Warrier, M.D.

EpiPen and Mylan Generic Epinephrine Autoinjector Expiration Dates Extended for Some Lots.

Extended Use Dates Provided by Pfizer

Extended use dates to assist with EpiPen intermittent supply interruptions

[August 21, 2018] Due to the intermittent supply interruptions of EpiPen, FDA is alerting health care professionals and patients of updated dates through which some EpiPens and the authorized generic version, manufactured by Meridian Medical Technologies, a Pfizer company, may be used beyond the manufacturer’s labeled expiration date. To help ensure patient safety, these products should have been — and should continue to be — stored as labeled.

Based on stability data provided by Pfizer and reviewed by FDA, the following extended use dates are supported for specific batches indicated in the tables below. Patients that have the batch numbers below will be able to use them through the corresponding new use dates to help with supply. As data become available, this list can continue to expand.

FDA is not requiring or recommending that the identified batches in the following tables be relabeled with their new use dates. However, if replacement product becomes available during the extension period, then the agency expects the lots in these tables will be replaced and properly disposed of as soon as possible.

Please see the recent FDA in Brief for more information, and contact CDER Drug Shortage Staff at with questions regarding these tables.

Epinephrine Injection, USP 0.3 mg Auto-Injectors
NDC 49502-102-02 appears on the box
NDC 49502-102-01 appears on the individual device within the box

BatchManufacturer’s Original
Expiration Date
New Expiration Date
(beyond manufacturer’s
original expiry date)

EpiPen® (epinephrine injection, USP) 0.3 mg Auto-Injectors
NDC 49502-500-02 appears on the box
NDC 49502-500-01 appears on the individual device within the box

BatchManufacturer’s Original
Expiration Date
New Expiration Date
(beyond manufacturer’s
original expiry date)

Midwest Food Allergy Conference, June 9-10

View full pdf here.

Midwest FACES Conference
June 9-10 • Chicago, IL

Please mark your calendars for the first-ever Midwest Food Allergy Conference for Education and Science (Midwest FACES) on Saturday, June 9th and Sunday, June 10th, 2018. This conference is hosted by the Science and Outcomes of Allergy and Asthma Research Program (SOAAR) at Ann & Robert H. Lurie Children’s Hospital of Chicago and Northwestern Medicine.

Conference Details

Midwest FACES will bring together food allergy families, clinicians and key thought leaders throughout the Midwest region for two action-packed days of science, education, and engagement. Families who attend this conference will hear the latest research and advancements by top clinicians and researchers in the Midwest, connect with other families and build their network of support.

Additionally, at Midwest FACES, children with food allergies can find a supportive environment to connect with one another, and learn the latest research and techniques to help manage daily life with food allergies. Providing children with an opportunity to ask questions and engage with each other, clinicians, and researchers will empower them to better understand and manage their food allergy and build their network of support.

The Midwest FACES conference presents the perfect platform for exchanging ideas and creating connections among all dedicated stakeholders, in addition to learning the latest and greatest in food allergy research. Exhibitor booths will also provide an interactive, engaging space to connect food-allergic families with the industry leaders, including allergen-safe food companies and advocacy organizations- just to name a few!

Topic List

Midwest FACES will bring together food allergy families, clinicians, researchers and key thought leaders for two action-packed days that will include separate tracks for parents and children (ages 9+). Hot topics include:

  • Public Health Impact of Food Allergies
  • Diagnosis & Testing: What You Need to Know
  • Safe Food Ideas & Labeling Laws
  • School Issues: Plans, Policies, Peers & Pizza Parties
  • Microbiome & New Research
  • Immunotherapies & Emerging Treatments (physician presentations and panel with participating parents)
  • Latest in Food Allergy Prevention
  • Daily Life Tips to Reduce Stress & Anxiety
  • College Ready 101
  • Special sessions for asthma, eczema, environmental allergies and EoE
  • Plus, expert Q&A’s, vendor expo & interactive activities (live cooking, yoga demos and more!)


The Midwest FACES conference is free of charge for families and travel grants are available, as our goal is to have attendance without any cost barriers.

Website Information

To register for the conference and access more information, including an up-to-date agenda, please visit our website at

I sincerely appreciate your time and consideration, and look forward to seeing your “FACES” on June 9th and 10th!

Oral Immunotherapy (OIT) For Food Allergies

There has been press recently on a “new” food allergy treatment by a company which plans to bring standardized doses of peanut flour to market so that individuals with peanut allergy can be desensitized. This has generated a lot of discussion and excitement in the food allergy community over the past month.

However, it is important to note that this is not really a “new” treatment. Recent studies on this type of treatment using peanut flour go back more than a decade, and this form of treatment has been offered for food allergies by practicing, board certified physicians in allergy and immunology (allergists) for at least 10 years. Our practice, Allergy, Asthma & Food Allergy Centers of St. Louis, has been offering this treatment since the summer of 2016, when our first patient (the daughter of one of our providers) was desensitized to peanut when she was 9 years-old. Since then, our practice has desensitized 35 children to peanut with smaller numbers for other food allergens. In addition, we have 58 children currently going through the OIT process as well.

So let’s back up a bit and review a few basic questions.

What is oral immunotherapy or “OIT”?
This is a process of desensitizing someone to a food to which they are allergic by giving very tiny doses of that food and slowly increasing the amount of the dose over time. It is a way to get a person who has life-threatening food allergy to be able to consume the food without having a reaction. This is not necessarily a “cure” for food allergies, and people need to consume the food on a daily basis to prevent reactions in most cases. They should also continue to have access to their epinephrine autoinjectors. However, promising studies suggest that some children (especially younger children) may not have to consume the food daily to be protected.

What is the primary goal of OIT? The primary goal of OIT is to prevent an episode of anaphylaxis with an accidental exposure. In other words, the single most important goal of OIT is to make it so a person who accidentally consumes a food allergen to which they are allergic does not have a life-threatening reaction.

Why did Allergy, Asthma & Sinus Care Center of St. Louis start offering OIT?
First, as mentioned earlier, one of our provider’s has a child who has had food allergies since infancy (as a side note, that provider still gets a little blame at home and has a certain amount of guilt for not having done more to prevent or treat food allergies sooner), so there was clearly a significant amount of self-interest in investigating food allergy treatment options in our practice. Therefore, our practice believes there is an urgent need in our community to offer options for the treatment of food allergies in all patients but especially in very young children. Let’s briefly talk about why we believe this using peanut allergy as an example.

The general consensus is that peanut allergy is only outgrown in about 20% of people who develop it. This means that the vast majority of children who are diagnosed with peanut allergy will not outgrow the allergy compared to the much greater chances of outgrowing milk and egg allergy for example. However, an excellent study from 2017 published in the Journal of Allergy and Clinical Immunology (“Early oral immunotherapy in peanut-allergic preschool children is safe and highly effective”) showed that 91% of children 9-36 months of age who were treated with OIT for peanut were able to successfully introduce peanut into their diet and did not have reactions when challenged even after stopping daily peanut treatment for 4 weeks! Let’s repeat that- basically 91% of kids who successfully went through OIT at a young age and then stopped consuming peanut daily, still did not have reactions 4 weeks later when challenged with peanut. That is incredibly exciting news, and this led us in 2017 to expand our OIT offering to infants who are diagnosed with peanut allergy. If only 20% of kids generally outgrow peanut allergy, and we can turn that number upside down and make it so that nearly every infant/toddler initially diagnosed with peanut allergy can start eating peanut without the risk for a life-threatening allergic reaction…..well, we feel strongly that the potential impact of this treatment in our local community is a game changer for food allergy, especially in our youngest patients. In fact, the authors of the study mentioned above concluded “E-OIT [early-OIT] had an acceptable safety profile and was highly successful in rapidly suppressing allergic immune responses and achieving safe dietary reintroduction.” One of our provider’s only regret is not being able to offer this sooner, especially for their own family.

While the focus of the previous paragraph was on younger children, this treatment clearly works for a majority of older children as well. While OIT is not necessarily the right option for everyone, and by no means do we intend to imply that everyone with food allergies should go through OIT (this is a very personal decision for individual families), we feel that families should have choices beyond just strict avoidance for the treatment of food allergies. We understand that a teenager who has avoided peanuts their entire life and is doing fine may have no interest in going through OIT, but we still feel that having the option for treatment available is important for our community.

Why don’t more allergy practices offer this?
While we cannot speak for everyone, there are likely several reasons for this.

First, we are the community experts when it comes to food allergy (in addition to being leaders in treatment of asthma, environmental allergies, hives, and immunodeficiency). In addition to offering OIT, we offer comprehensive management of food allergies. We do numerous food challenges (well over 200/year), often to rule out food allergy or to determine if someone is still (or ever was) truly allergic to that food, so that people do not need to avoid foods unnecessarily. We have been using advanced component testing for food allergies for about 10 years (initially for egg and milk and more recently for peanuts and tree nuts). This has helped us determine over the years who may be good candidates for food challenges. The wait list for food challenges at both Cardinal Glennon Children’s Medical Center and Saint Louis Children’s Hospitals is often more than 6-12 months. We had been able to get people in for food challenges within 1-2 weeks, but as more patients have found us, this wait time has started to creep up, and as we write this, the wait time can be up to a couple of months.

Second, the practice of OIT is not standardized. Most people in academic medicine feel that since we do not know the exact, best protocol and doses that should be given for OIT, it should not be offered outside of research studies. The problem with that response is that a generation of children do not necessarily have time to wait until everyone agrees on the (single) absolute best approach. Children’s immune systems are constantly developing, but the older they get, the more likely their immune systems will become “locked into” their food allergy. We know from studies not only in food allergy but also from studies with allergy shots that the earlier people get treated, the better the long-term outcomes.

Third, the broader academic allergy community feels that the risks outweigh the benefits. We have heard at allergy meetings from some key thought leaders, statements (to paraphrase) such as “people with food allergies can simply avoid the food, and they don’t have reactions. Why treat them with OIT that has the associated risk of life-threatening allergic reactions?” “Avoidance is still the best option.” “Until we have all the necessary studies, people outside of research settings should not do OIT.” Respectfully and vehemently, we disagree. Again, we recognize that OIT is not right for everyone, but it is a valid treatment option. Most (not all) people doing this research do not have children with food allergies. Some of them seem not to recognize that terror that some of us may feel when our children may be in an environment where eating something as innocuous as a small cookie can lead to an emergency department visit or even death. They don’t understand the fear that may prevent us from eating out or going to baseball games to cheer on the Cardinals. They may not know that it is not always “fun” to be one of the only or the only child sitting at an “allergy free” table at school. There are many more examples too numerous to list here of the day to day experiences families dealing with food allergies have to go through. With all of that being said, there are significant risks in OIT, including anaphylaxis and the possible development of an inflammatory condition of the esophagus called eosinophilic esophagitis (EoE; about 3-5% in published studies), and the risks may outweigh the benefits for some people.

Finally, OIT is very labor intensive, not just for families, but for allergy practices. This is not an endeavor to be entered into lightly, which is why our practice considered this for over 3-4 years, taking the time to develop the infrastructure and excellent staffing (our front desk staff, medical assistants, nurses, office management, administrative/billing, and providers are all awesome!) required to at least start offering OIT on a smaller scale. We have grown since 2016, and we hope to continue to do so in the years to come so we can serve more of the community in a safe and efficient manner. We are proud to report that some local allergy practices in the greater St. Louis area have started referring some of their own patients to us specifically for OIT, but those practices will continue to manage the other allergy/asthma health conditions of their patients.

We welcome new patients and appreciate how much we ourselves have learned from our established patients. We are not looking to dictate one treatment for everyone. We know every individual/family is different and what works for one person may not be the best option for another. We honestly feel that medicine should be a partnership between patients and providers. Our mission is to use our expertise to improve the quality of life for adults and children through the diagnosis and management of asthma, food allergies, and other allergic conditions. We look forward to working with you and your family to improve everyone’s health outcomes. As we often say to our patients during OIT treatment, remember, this is a marathon, not a sprint.

Is There Any Reason Not To Get A Flu Vaccine?


It’s that time of the year to get a flu vaccine again. Routine vaccination against influenza A and B viruses is recommended for everyone 6 months of age and older unless there is a specific reason not to. (More on that later.)

In spite of the recommendations, fewer than 50% of Americans got a flu vaccine last year. In order to minimize the risk of an epidemic of influenza, officials would like for at least 70% of Americans to get vaccinated. There are many choices of vaccine. Unfortunately, for those who hate needles, the nasal spray vaccine is no longer available. It was found to be less effective than inactivated vaccines (flu shots) in preventing influenza illness in children. Due to that, the ACIP (Advisory Committee on Immunization Practices–a part of the Centers for Disease Control) advises against using the live intranasal flu vaccine for anyone this year.

As health care providers, we hear a lot of reasons (excuses) for not getting the flu vaccine. Here are a few…

I’m tough. I have never had the flu.

We hope that all of our patients have an immune system to be proud of. But the fact is that 5 to 20 percent of the US population gets influenza each year. The influenza virus doesn’t care if you have had it before or not. As our friends in advertisement would say, “Past performance is no guarantee of future returns.” So if you don’t get a flu vaccine, you are gambling that you will be lucky. There is a very good chance that one of these years your luck will run out. And if you lose, you can expect at best to feel crummy and miss a week of school or work. At its worst, you can die from influenza (even if you are healthy before you get it). The rate of death for influenza is 1.4 people for every 100,000 persons. In the greater St. Louis area of about 3 million people, that is 42 people. Ask someone who works in a hospital. People die of influenza each year. It is best to protect yourself and your friends and family that you are exposed to.

Can’t I get the flu from the vaccine?

Nope. Other than the nasal vaccine (which is no longer available), NONE of the influenza vaccines contain any live virus, and cannot cause influenza. They are either inactivated virus vaccines or a recombinant vaccine that is produced without the use of influenza virus or chicken eggs.

But people say that the flu vaccine made them sick.

An influenza vaccine can cause soreness at the injection site, and rarely it can cause aches or fever. But it cannot cause an infection. Influenza vaccine is commonly given in the late fall and early winter when people get a lot of viral infections that are not influenza. When millions of people get a vaccine, it is likely that some of them will get a cold shortly after which is not caused by the flu vaccine.

How do I know the flu vaccine will really work?

You really don’t; however it does significantly increase your odds of staying healthy. The decision of what strains of virus go in the vaccine is made months before the influenza season. Some years the educated guess of what should be in the vaccine is better than others. If the match between the vaccine and the viruses in the community is good then you reduce your risk of getting sick by 40 to 60%   Even when it is a poor match, vaccination has been shown to reduce the risk of hospitalization and death from influenza.

How do I know which influenza vaccine I should get?

Your healthcare provider can advise which vaccine is best for you.
In our practice (because we see a lot of people with allergies) we use only preservative free vaccines. If you are 65 or older, a high dose vaccine is recommended. It has four times the amount of antigen (inactivated virus) as the standard dose vaccines. It has been shown to be more effective than the standard dose vaccine for those 65 and older.

What about the vaccine during pregnancy?

Vaccination of pregnant women not only protects them against influenza-associated illness, but also protects their infants for up to the first 6 months of life.

What about egg allergy and the vaccine? Doesn’t it contain egg?

Studies have shown that even people with severe allergy to egg and tolerate the influenza vaccine, but they should be vaccinated in a healthcare setting, like our office.

So who should NOT get the vaccine?

Influenza vaccination has been associated with Guillain-Barre syndrome (a disorder in which the body’s immune system attacks the peripheral nerves resulting in weakness and tingling), but the risk is very low and the influenza infection itself has also caused this syndrome. If someone has had Guillain-Barre syndrome, then they should not get the influenza vaccine.

We hope for your sake (and ours too) that you and your family get the influenza vaccine this season.

In addition, this article by Dr. Aaron Carroll explains why getting vaccinated is important for the whole community.

Loving Your Pets



Yes, pets can cause allergies but they are adorable and make their way into your hearts and families. We get it! It is true that the gold-standard treatment for pet allergy (or allergy in general) is avoidance or to remove the trigger – i.e. remove the pet from the home. In some settings, this is the best option for the patient and/or family. However, most families are attached to their pets and would rather get rid of their allergist than get rid of their pet. Often it is not (or even a consideration for that matter).

If the pet remains in the home, the most effective intervention is to remove the pet from the bedroom. Washing the pet frequently, twice a week, may be helpful but understandably, this can be burdensome and not always practical. The use of HEPA filters may provide some benefit. The most effective option for treating pet allergy, aside from avoidance, is allergen immunotherapy or allergy shots. All dogs and cats have the potential to cause allergy.  Contrary to popular belief, there is actually no such thing as a “hypoallergenic dog” or hypoallergenic dog breeds. The particles responsible for allergy in cats are much smaller than those in dog and remain airborne for significant lengths of time. Pet allergy has the potential to cause severe allergy and asthma symptoms and should be taken seriously. We are here to help as best we can!