TESTS FOR ALLERGY

NEW TECHNOLOGY
In August 2009 we commissioned new allergy test systems that further extend our testing menu. Our new technology detects Specific IgE to clinically important individual allergen molecules. We continue to offer testing for allergens to whole food and inhalant allergens. The main analyser platforms and reagent systems are the Phadia ImmunoCAP 250, ImmunoCAP 1000 and ISAC ImmunoCAP. Our comprehensive menu is included in this brochure. You may request the allergens using their alphanumeric codes. Please precede these codes with Specific IgE for, or Allergy serology for, or RAST for.
allergen specific IgE values in kU/L and a semiquantitative class value. Please note that some patients with a negative or 0 class may have detectable traces of specific IgE that can have clinical significance as a marker of early sensitisation or previous significant sensitisation to insect venoms and drugs. In the most important practical advance in laboratory allergy diagnostics, the Phadia ImmunoCAP ISAC system now allows us to determine a patients specific IgE to 103 clinically important allergen molecules from 47 different allergens. Tests that define the molecule in a food to which a patient has significant specific IgE, can provide diagnostic and prognostic information for patients with serious food allergy. Our new technology allows us to do this with recombinant ImmunoCAP allergens (page 10) or as a profile with the ISAC system (page 11). We continue to offer other tests important for assessing allergy problems: Total IgE, Tryptase, Eosinophilic Cationic Protein (ECP), C1 esterase and genetic testing for Hereditary Angioedema Types I, II and III (see next page). We have always taken the view that we should offer the best available allergy testing systems and give patients the opportunity to cover the cost of more definitive higher quality testing that the government will not meet. In May 2009, the Medicare Benefits Schedule reduced rebates for Allergy testing by 1%: a reimbursement that is now less than 20% of rebates in comparable countries for laboratory allergy testing. It is almost impossible to answer a simple, sensible laboratory allergy testing request within the constraints of the level of Medicare reimbursement. Consequently, the laboratory is unable to accept Medicare reimbursement for more than very basic allergy testing requests. In this menu, we seek to give your patients clear options and choices when it comes to allergy testing. You and your patients will be pleased to know that although some new allergens and mixes are more expensive, core individual allergens and extended panels are cheaper than previously. Please send email enquiries to kbaumgart@dhm.com.au or Phone: 02 98 555 286 Karl W Baumgart Director, Immunology

Dear Colleague, Welcome to our new Allergy Test Menu, one of the largest internationally available allergy testing menus. All our specific IgE testing is now performed on the Phadia ImmunoCAP 250 and Phadia ImmunoCAP 1000 system (pages 3-10). An advantage of the Phadia ImmunoCAP system is that, for certain key foods, the 95% probability of a positive food challenge has been determined for certain levels of allergen-specific IgE (see Table below). We will continue to report

ALLERGEN SPECIFIC IgE

Specific IgE Levels Conferring Very High Risk
ALLERGEN Egg (<= 2yo) Egg (> 2yo) Milk (<=2 yo) Milk (>2 yo) Peanut Fish Tree nuts Wheat kU/L 2 7 5 15 14 20 ~15 26 PPV 95% 98% 95% 95% 100% 100% ~95% 74%

ORDERING ALLERGY TESTS

We ask that you specifically nominate which allergens you would like tested. Please do not write the allergens to be tested in the clinical notes section of the request form. A comprehensive menu of allergens that we stock and test for is available in the following pages. If allergens are not available we may use cross-reactive ones or advise you on the report. Some allergy symptoms may result from intolerance mechanisms (salicylates, amines, MSG, metabisulphite) and detection of IgE to them is not useful or possible. You can request the allergens using their alphanumeric codes. To assist staff performing data entry, we appreciate it if you precede these codes by Specific IgE for or Allergy serology for or RAST for. If you simply write RAST we will now test as follows: Child 6 years or less: dust mite, egg white, cows milk, peanut and soy (Panel A1) Adult or child over 6 years: dust mite, cat, dog, grass pollen and alternaria (Panel A2) If you write food and inhalant allergens, we will test a staple food mix (Fx5, that includes egg white, cows milk, peanut, soy, wheat and codfish), dust mite, fescue grass pollen-which cross-reacts with almost all other grasses and, alternaria-an outdoor mould with small spores that can easily be inhaled into the small airways (Panel A16). We do recommend some extended panels of individual allergens and can specifically design panels for you and your patients.

This table was derived from several large studies in which patients were challenged with the food. The positive predictive value (PPV) of a specific IgE level for a positive challenge was determined. It illustrates that specific IgE levels for individual allergens are like international currencies and are not necessarily comparable for a particular level for all the allergens. It defines levels at which a challenge, or exposure, would be highly hazardous for a patient. Importantly, many patients could have serious reactions at much lower levels.

TOTAL IgE
Normal total IgE levels (< 100 kU/L) do not exclude significant allergies. Patients with normal total IgE levels can still be allergic to bee venom, dustmite, and many other allergens. Significant specific IgE levels are extraordinarily rare in individuals with total IgE values of less than 7 kU/L. Persons with very elevated total IgE levels are more likely to have significant elevations in specific IgE. Very elevated levels of total IgE also occur in persons with severe eczema, helminthic and parasitic infestations as well as allergobronchopulmonary aspergillosis (ABPA). Monitoring total IgE levels is useful in patients on immunosuppression for their severe eczema as well as in ABPA.

OTHER COMMON INITIAL INVESTIGATION PANELS

* Please write the name and code of the panel on the request form. A8 NATIVE TREES T18 T19 T21 T73 Eucalyptus Acacia Melaleuca Australian Pine A9 FOOD SCREEN FX1 F23 F4 F1 Nut Mix Crab Wheat Egg One (1) of our panels is within our allowance under Medicare A10 NUTS F13 F17 F20 F201 Peanut Hazelnut Almond Pecan nut A11 SEAFOOD F3 F23 F24 F80 Codfish Crab Prawn Lobster

A12 CEREALS

A13 STAPLE FOODS F1 F2 F13 F14 Egg white Milk Peanut Soybean

A14 INSECTS I1 I4 I3 I70 I71 Honey bee venom Paper wasp venom Yellow Jacket Fire ant venom Mosquito

A15 LATEX & FOODS K82 F84 F87 F92 Latex Kiwi fruit Melon Banana

TRYPTASE
Elevated levels of mast cell tryptase in peripheral blood indicate systemic mast cell degranulation or an increased number of mast cells which can occur in patients with mastocytosis. Tryptase is NOT ELEVATED in persons with anaphylaxis from foods or non-parenteral agents. Elevated levels indicate an adverse reaction to a stinging insect or a reaction to an intravenous, intramuscular or subcutaneous diagnostic or therapeutic agent. Any elevated tryptase levels should be repeated after a period of time (3-10 days) to document a return to normal levels. Persistently elevated levels of tryptase are strongly suggestive of systemic mastocytosis which may not always manifest with urticaria pigmentosa. Since mastocytosis is more common in persons with stinging insect reactions, persons who have had systemic reactions to stinging insects should always have their tryptase level checked together with relevant venom specific IgE. The test is performed on serum. Normal values are < 13.5 ug/L. For these indications, the test is Medicare rebatable.

F4 F6 F9 F14

Wheat Barley Rice Soy

A16 FOOD & INHALANTS FX5 Staple Foods G4 Grass Pollen (fescue) D1 Dust Mite M6 Alternaria

EOSINOPHILIC CATIONIC PROTEIN (ECP)

ECP is elevated in persons with active eosinophilic inflammation. It is a useful marker in the diagnosis and management of hypereosinophilic disorders. ECP is also a useful marker of allergic airways inflammation in young children. The test is performed on serum. Normal values for children are < 20 ug/L and adults < 15 ug/L. At present the test is only reimbursed by Medicare when requested in children under 12 years of age for assessment of airways inflammation (Please write asthma on clinical notes). For all other requests, the fee is $50, non-rebatable.

A3 CHILD ALLERGY ASSESSMENT PANEL (REQUEST IgE AND RAST A3)

This new panel is designed for the assessment of children at high risk of allergic disease, especially those with eczema, possible food and inhalant allergies. The cost of this panel is $108, for which a Medicare rebate of $22.95 may be available. D1 E1 E82 E5 E3 Dustmite Cat Epithelium Rabbit Epithelium Dog Horse Dander Bermuda Grass Grass Pollen (fescue) Perennial Rye Grass Parietaria judaica M6 F1 F75 F2 F3 F14 F4 F10 F13 Alternaria alternata Egg White Egg Yolk Milk Codfish Soybean Wheat Sesame Seed Peanut F202 F17 F35 F84 F91 F92 K82 M80 M70 Cashew Hazelnut Potato Kiwi Fruit Mango Banana Latex Staph. Enterotoxin A Pityrosporum orbiculare

Type I & II (C1 ESTERASE INHIBITOR) HEREDITARY ANGIOEDEMA

This should be considered in anyone with a family history of angioedema without urticaria. C1 esterase level and function, C3 and C4 should be measured at the same time to facilitate interpretation of the results. Abnormal levels occur in persons with deficiency which has autosomal dominant inheritance. Persons with this disorder usually experience symptoms from puberty onwards and may have life-threatening episodes which are not responsive to adrenaline. Many patients also experience recurrent abdominal pain due to visceral angioedema. Functional deficiency may occur on a genetic basis or in older persons it can result from an interfering autoantibody associated with lymphoma. Abnormal functional assay results should always be repeated. The C3, C4, quantitative and functional C1-esterase (C1-inhibitor) assays are performed on serum and reimbursed by Medicare. Sequencing for the detection of mutations causing Type I and II HAE is performed by the laboratory and the fee is $395 (non-rebatable).

G2 G4 G5 W21

EXTENDED ALLERGEN PANEL EXAMPLES

* Our charge for each of these panels is $80, for which a rebate of $22.95 may be available per episode. Each allergen may also be ordered separately by its code or name. Other personalised extended panels are available on request. Please call Dr Karl Baumgart to discuss your requirements. A20 INHALANTS D1 E1 E5 E3 D201 Dustmite Cat Epithelium Dog Horse Dander Blomia tropicalis Bermuda Grass Grass pollen (fescue) Perennial Rye Grass Rabbit Epithelium Common Ragweed English Plantain Lambs Quarters Parietaria judaica Eucalyptus Acacia Melaleuca Australian Pine Cladosporium herbarum Aspergillus fumigatus Alternaria alternata A21 MOULD & STORAGE MITES M1 M2 M3 M4 M5 M6 M8 M9 M10 M13 M14 M15 M70 D1 D70 D71 D72 D73 D74 D201 Penicillium notatum Cladosporium herbarum Aspergillus fumigatus Mucor racemosus Candida albicans Alternaria alternata Helminthosporium Fusarium moniliforme Stemphylium botryosum Phoma betae Epicoccum purpurascens Trichoderma viride Pityrosporum orbiculare D. pteronyssinus Acarus siro Lepidoglyphus destructor Tyrophagus putrescentiae Glycyphagus domesticus Euroglyphus maynei Blomia tropicalis A22 FOODS F1 F2 F3 F4 F5 F6 F9 F10 F13 F14 F17 F20 F27 F33 F35 F44 F45 F84 F91 F92 Egg White Milk Codfish Wheat Rye Barley Rice Sesame Seed Peanut Soybean Hazelnut Almond Beef Orange Potato Strawberry Yeast Kiwi Fruit Mango Banana A23 ANAPHYLACTIC FOODS F3 F10 F13 F17 F18 F20 F23 F24 F27 F36 F40 F41 F80 F84 F91 F92 F201 F256 F290 K82 Codfish Sesame Seed Peanut Hazelnut Brazil Nut Almond Crab Prawn Beef Coconut Tuna Salmon Lobster Kiwi Fruit Mango Banana Pecan Nut Walnut Oyster Latex

TYPE III (FACTOR XII) HEREDITARY ANGIOEDEMA

This should also be considered, mainly in women, who have angioedema without urticaria. Type III (Factor XII) Hereditary Angioedema is detected by a real-time PCR assay which detects the most common mutation in Factor XII. This is a cause of angioedema without urticaria in women. This is the only assay for this disorder which is thought to be at least as common as Type I and Type II HAE. At present there is a non-rebatable fee of $120. The laboratory can also perform sequencing of Factor XII if required. The fee is $395 (non-rebatable).

INITIAL INVESTIGATION PANELS

If you write RAST or Allergy serology, but do not specify the allergens, we will perform the tests listed under A1 (for a child 6 years or less) or A2 (Adult, or child over 6 years). Any subsequently requested additional allergens are charged according to the billing policy listed below.

A1: CHILD 6 years or less Total IgE D1 F1 F2 F13 F14 Dustmite Egg white Cows milk Peanut Soy

A2: ADULT, or CHILD over 6 years Total IgE D1 G4 E1 E5 M6 Dustmite Grass pollen (Fescue) Cat Dog Alternaria

G2 G4 G5 E82 W1 W9 W10 W21 T18 T19 T21 T73 M2 M3 M6

OTHER COMMON INITIAL INVESTIGATION PANELS

* Please write the name and code of the panel on the request form. A4 ANIMAL INHALANTS E1 E5 D1 G4 Cat Dog Dustmite Grass pollen A5 RURAL INHALANTS G17 WX1 MX1 Paspalum Weed mix Mould mix One (1) of our panels is within our allowance under Medicare A6 PETS E1 E5 E6 E82 Cat Dog Guinea pig Rabbit A7 MOULDS M2 M3 M5 M6 Cladosporium Aspergillus Candida albicans Alternaria

CORE INDIVIDUAL ALLERGENS

c Core individual allergens, $4 each Note: Requests for more than five of these will exceed our allowance under Medicare

CORE INDIVIDUAL ALLERGENS

c Core individual allergens, $4 each Note: Requests for more than five of these will exceed our allowance under Medicare

MITES (HOUSE DUST & STORAGE) c c c c c c c c c D1 D2 D70 D71 D72 D73 D74 D201 H2 Dermatophagoides pteronyssinus Dermatophagoides farinae Acarus siro Lepidoglyphus destructor Tyrophagus putrescentiae Glycyphagus domesticus Euroglyphus maynei Blomia Tropicalis House dust

WEED POLLENS c c c c c c c c W1 W4 W5 W6 W9 W10 W18 W21 Common ragweed False ragweed Wormwood Mugwort English plantain Goosefoot (Lambs quarters) Sheep sorrel Parietaria judaica

DRUGS c c c c c c c C1 C2 C5 C6 C7 C73 C74 Penicilloyl G Penicilloyl V Ampicilloyl Amoxicilloyl Cefaclor Insulin, human Gelatin, bovine

FOOD c c c F1 F2 F3 Egg white Milk Fish (cod)

c c c c c c c c c c

F40 F41 F44 F45 F47 F48 F49 F59 F75 F79 F80 F81 F82 F83 F84

Tuna Salmon Strawberry Yeast (S. cerevisiae) Garlic Onion Apple Octopus Egg yolk Gluten Lobster Cheese Cheddar-type Cheese Mould-type Chicken meat Kiwi fruit

c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c c

F218 F220 F221 F222 F224 F225 F226 F235 F237 F242 F244 F247 F253 F255 F256 F258 F259 F260 F261 F262 F263 F267 F270 F279 F280 F281 F284 F287 F290 F291 F293 F294 F299 F300 F302 F309 F315 F317 F322 F324 F329 F333 F335 F338 F340 F345 F346 F347

Paprika (sweet pepper) Cinnamon Coffee Tea Poppy seed Pumpkin Pumpkin seed Lentil Apricot Cherry Cucumber Honey Pine nut (pignoles) Plum Walnut Squid Grape Broccoli Asparagus Aubergine (eggplant) Green pepper (unripe seed) Cardamon Ginger Chili pepper Black pepper Curry Turkey meat Red Kidney Bean Oyster Cauliflower Papaya Passionfruit Sweet Chestnut Goat milk Mandarin Chickpea Green bean Coriander Red currant Hop (fruit cone) Watermelon Linseed Lupin Scallop Cochineal (Carmine red, E120) Macadamia nut Abalone Quinoa

VENOMS TREE POLLENS c c c c c c c c c T3 T7 T8 T9 T11 T15 T16 T17 T18 T19 T21 T23 T57 T73 T210 Birch Oak Elm Olive Sycamore, London plane White ash White pine Japanese cedar Eucalyptus Acacia Melaleuca Italian cypress Red Cedar Australian pine Privet pollen INSECTS c MOULDS, YEASTS & TOXINS c c c c c c c c c c c c c c c c c M1 M2 M3 M4 M5 M6 M8 M9 M10 M13 M14 M15 M70 M80 M202 M205 M227 Penicillium notatum Cladosporium herbarum Aspergillus fumigatus Mucor racemosus Candida albicans (yeast) Alternaria alternata Helminthosporium halodes Fusarium moniliforme Stemphylium botryosum Phoma betae Epicoccum purpurascens Trichoderma viride Pityrosporum orbiculare Staphylococcus enterotoxin A Cephalosporium acremonium Trichophyton rubrum Malassezia spp. OCCUPATIONALS c c c c c c K75 K76 K77 K80 K82 K84 Isocyanate TDI Isocyanate MDI Isocyanate HDI Formaldehyde/Formalin Latex, Hevea braziliensis Sunflower seed MISCELLANEOUS c c O1 O70 Cotton crude fibres Seminal fluid PARASITES c c P1 P4 Ascaris Anisakis c c c c c c c c c c c c c c c F14 F15 F17 F18 F20 F23 F24 F25 F26 F27 F31 F33 F35 F36 F37 Soya bean White bean Hazel nut Brazil nut Almond Crab Shrimp Tomato Pork Beef Carrot Orange Potato Coconut Blue mussel c c c c I6 I70 I71 I72 I202 Cockroach (Blatella germanica) Fire ant (Solenopsis invicta) Mosquito spp. (Aedes communis) Green nimitti (Cladotanytarsus) Grain weevil (Sitophilius granarius) c c c c I1 I3 I4 I5 Honey bee (Apis mellifera) Yellow jacket (Vespula spp. Common wasp) Paper wasp (Polistes spp.) Yellow hornet (Dolichovespula arenaria)

c c c c c c c c c c c c c c c F4 F5 F6 F7 F8 F9 F10 F11 F12 F13 Wheat Rye Barley Oat Maize (Corn) Rice Sesame seed Buckwheat Pea Peanut

ANIMAL & AVIAN PROTEINS c c c c c c c c c c c c c c c c c E1 E3 E4 E5 E6 E7 E71 E73 E77 E78 E79 E81 E82 E85 E201 E213 E215 Cat epithelium & dander Horse dander Cow dander Dog dander Guinea pig epithelium Pigeon droppings Mouse epithelium Rat epithelium Budgerigar droppings Budgerigar feathers Budgerigar serum proteins Sheep epithelium Rabbit epithelium Chicken feathers Canary bird feathers Parrot feathers Pigeon feathers

c c c c c c

c c c c c c c c c c c c c c c c c c c c e c c c c

F85 F86 F87 F88 F89 F90 F91 F92 F93 F94 F95 F96 F201 F202 F203 F204 F207 F208 F209 F210 F211 F212 F214 F215 F216

Celery Parsley Melons Mutton Mustard Malt Mango fruit Banana Cacao Pear Peach Avocado Pecan nut Cashew nut Pistachio Trout Clam Lemon Grapefruit Pineapple Blackberry Mushroom (champignon) Spinach Lettuce Cabbage

GRASS & GRAIN POLLENS c c c c c c c c c c G1 G2 G4 G5 G6 G8 G10 G11 G15 G17 Sweet vernal grass Bermuda grass Grass pollen (Fescue) Rye-grass Timothy grass Meadow grass Johnson grass Brome grass Cultivated wheat Paspalum

CORE ALLERGEN MIXES

c Core mixed allergens $8 Note: Requests for more than two of these will exceed our allowance under Medicare

ESOTERIC INDIVIDUAL ALLERGENS

e Esoteric individual allergens, $12 each Note: Requests for more than one of these will exceed our allowance under Medicare. Some esoteric allergen results may take up to five weeks MISCELLANEOUS Mould Mix Penicillium chrysogenum, Cladosporium herbarum, Aspergillus fumigatus, Candida albicans, Alternaria alternata, Setomelanomma rostrata e e e e e e O201 O202 O203 O207 O211 O212 Tobacco leaf Artemia salina fish feed Tetramin fish feed Daphnia fish feed Mealworm Tenebrio mollitor Streptavidin e e e e e e e T212 T213 T214 T217 T218 T222 T223 Cedar Pine Date Peppertree Virginia live oak Cypress Oil palm OCCUPATIONALS e Nut Mix Seafood Mix Peanut, Hazel nut, Brazil nut, Almond, Coconut Fish, Shrimp, Blue mussel, Tuna, Salmon Wheat, Oat, Maize, Sesame seed, Buckwheat Egg white, Milk, Fish, Wheat, Peanut, Soybean Orange, Apple, Banana, Peach Carrot, Potato, Spinach, Cucumber Tarragon, Marjoram, Thyme, Lovage Caraway, Mace, Cardamom, Clove Basil, Fennel seed, Ginger, Anise Pork, Beef, Chicken TREE POLLENS e Chemicals 1 Chemicals 2 Isocyanates (TDI, MDI, HDI), Phthalic anhydride Ethylene oxide, Phthalic anhydride, Formaldehyde, Chloramin T e e e e e e e e e e e e e e e e e e e e e e E210 E211 E214 E216 E217 E218 E219 E220 E221 E222 Fox epithelium Rabbit urine proteins Finch feathers Deer epithelium Ferret epithelium Chicken droppings Chicken serum proteins Cat serum albumin Dog serum albumin Swine serum albumin e e e e e e e e e e e e PARASITES e P2 Echinococcus e e e e T1 T2 T4 T5 T6 T10 T12 T14 T20 T22 T25 T37 T41 T44 T45 T54 T55 T56 T70 T71 T72 T201 T203 T205 T206 T207 T208 T209 T211 Box-elder Grey alder Hazel American beech Mountain juniper Walnut Willow Cottonwood Mesquite Pecan Hickory European ash Bald cypress White hickory Hackberry Cedar elm Russian olive Scotch broom Bayberry Mulberry Red mulberry Queen Palm Spruce Horse chestnut Elder Chestnut Douglas fir Linden Horn beam Sweet gum MOULDS, YEASTS & TOXINS e e e e e e e e e e e M7 M11 M12 M16 M36 M81 M201 M203 M204 M207 M209 Botrytis cinerea Rhizopus nigricans Aureobasidium pullulans Curvularia lunata Aspergillus terreus Staphylococcus enterotoxin B Tilletia tritici Trichosporon pullulans Ulocladium chartarum Aspergillus niger Penicillium frequentans DRUGS e e e e e C8 C70 C71 C202 C208 Chlorhexidine Insulin porcine Insulin bovine Suxamethonium (Succinylcholine) Tetanus toxoid INSECTS e e e e e e e e I8 I73 I76 I201 I203 I204 I206 I207 Moth Blood worm Berlin beetle Horse bot fly Mediterranean Flour Moth Horse fly Cockroach, American Cockroach, Oriental e e e I77 I75 I205 GRASS & GRAIN POLLENS e e e e e e e e e e e e e G3 G7 G9 G12 G13 G14 G16 G70 G71 G201 G202 G203 G204 Cocksfoot Common reed Redtop (Bentgrass) Cultivated rye Velvet grass Cultivated oat Meadow foxtail Wild rye grass Canary grass Barley Maize (Corn) Salt grass False oat-grass WEED & CROP POLLENS e e e e e e e e e e e e e e e e e e e e e e e W2 W3 W7 W8 W11 W12 W13 W14 W15 W16 W17 W19 W20 W22 W23 W45 W46 W82 W203 W204 W206 W207 W210 Western ragweed Giant ragweed Ox-eye daisy Dandelion Saltwort (Russian thistle) Golden rod Cocklebur Common pigweed Scale Lenscale Rough marshelder Firebush Parietaria officinalis Nettle Japanese Hop Yellow dock Alfalfa Dog fennel Careless weed Rape (Canola) Sunflower Camomille Lupin Sugar-beet VENOMS e I2 White-faced hornet (Dolichovespula maculata) European paper wasp (Polistes dominulus) European Hornet (Vespa crabro) Bumblebee e e e e e e e e e e e e e e e e e e e e e e e K70 K71 K72 K73 K74 K78 K79 K81 K83 K85 K86 K87 K201 K202 K203 K204 K205 K206 K208 K209 K211 K212 K213 K214 Green coffee bean Castor bean Ispaghula Silk waste Silk Ethylene oxide Phthalic anhydride Ficus spp. Cotton seed Chloramin T Trimellitic Anhydride (TMA) Alpha-amylase Papain Bromelin Phosphlipase Maxatase Alkalase Savinase Lysozyme Hexahydrophtalic anhydrid MTHP Anhydrid Abachi wood dust Pepsin Bougainvillea spp. e e e e e M208 M211 M226 M223 M228 Chaetomium globosum Trichophyton ment. var. interdigitale Staphylococcus enterotoxin TSST Staphylococcus enterotoxin C Aspergillus flavus

HOUSE DUST c HX2 (H2 D1 D2 I6) Dust & Mite Mix

MOULD MIXES c MX2 (M1 M2 M3 M5 M6 M8)

ANIMAL MIXES c EX1 (E1 E3 E4 E5) Animal Mix 1 Cat dander, Horse dander, Cow dander, Dog dander Cat dander, Dog dander, Guinea pig epithelium, Rat, Mouse Goose feathers, Chicken feathers, Duck feathers, Turkey feathers Budgerigar feathers, Canary bird feathers, Parakeet feathers, Parrot feathers, Finch feathers

EX2

(E1 E5 E6 E87 E88)

Animal Mix 2

FOOD MIXES c c c FX1 FX2 FX3 (F13 F17 F18 F20 F36) (F3 F24 F37 F40 F41)

EX71

(E70 E85 E86 Feather Mix E89) (E78 E201 E196 E213 E214) Bird Mix

EX72

(F4 F7 F8 F10 Cereal Mix F11) (F1 F2 F3 F4 F13 F14) (F33 F49 F92 F95) (F31 F35 F214 F244) (F272 F274 F273 F275) (F265 RF266 F267 F268) (F269 F219 F270 F271) Staple Food Mix Fruit Mix Vegetable Mix Spice Mix 1 Spice Mix 2 Spice Mix 3

c GRASS MIXES c GX2 (G2 G5 G6 G8 G10 G17) Grass Mix Bermuda grass, Rye grass, Timothy grass, Meadow grass, Johnson grass, Bahia grass c c c c Tree Mix Olive, Willow, White Pine, Eucalyptus, Acacia, Melaleuca c c

FX5 FX15 FX19 FX70 FX71 FX72 FX73

TREE MIXES c TX7 (T9 T12 T16 T18 T19 T21)

(F26 F27 F83) Meat Mix

WEED MIXES c WX1 (W1 W6 W9 W10 W11) Weed Mix Common ragweed, Mugwort, English Plantain, Goosefoot Lambs Quarters, Saltwort Common ragweed, Mugwort, Ox-eye Daisy, Dandelion, Golden rod

OCCUPATIONAL MIXES c c PAX5 PAX6 (K75 K76 K77 K79) (K78 K79 K80 K85)

WX5

(W1 W6 W7 W8 W12)

Weed & Flower Mix

ESOTERIC INDIVIDUAL ALLERGENS

e Esoteric individual allergens, $12 each Note: Requests for more than one of these will exceed our allowance under Medicare. Some esoteric allergen results may take up to five weeks MITES (HOUSE DUST & STORAGE) e D3 Dermatophagoides microceras Mouse epithelium, serum & urine proteins Turkey feathers Parakeet feathers Parakeet droppings Parakeet serum Canary bird serum Canary bird droppings Reindeer epithelium Mink epithelium BSA (bovine serum albumin) Horse serum proteins Rabbit serum proteins Chinchilla epithelium Gerbil epithelium

e e e e e e e e e e e e e e

E88 E89 E196 E197 E198 E199 E200 E202 E203 E204 E205 E206 E208 E209

ANIMAL & AVIAN PROTEINS e e e e e e e e e e E70 E72 E74 E75 E76 E80 E83 E84 E86 E87 Goose feathers Mouse urine proteins Rat urine proteins Rat serum proteins Mouse serum proteins Goat epithelium Swine epithelium Hamster epithelium Duck feathers Rat epithelium, serum & urine proteins

ESOTERIC INDIVIDUAL FOOD ALLERGENS

e Esoteric individual food allergens, $12 each Note: Requests for more than one of these will exceed our allowance under Medicare. Some esoteric allergen results may take up to five weeks FOOD e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e F42 F50 F51 F54 F55 F56 F57 F58 F60 F61 F124 F147 F182 F205 F206 F213 F217 F219 F227 F231 F234 F236 F245 F246 F254 F264 F265 F266 F268 F269 F271 Haddock Chub (mackerel) Bamboo shoot Sweet potato Common millet Foxtail millet Japanese millet Pacific squid Jack mackerel (Scad) Sardine (Japanese) Pilchard Spelt wheat Gulf flounder Lima bean Herring Mackerel Rabbit meat Brussel sprouts Fennel seed Sugar-beet seed Milk boiled Vanilla Cows whey Egg Guar, guar gum (E412) Plaice Eel Caraway Mace Clove Basil Anise e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e e F272 F273 F274 F275 F276 F277 F278 F283 F285 F286 F288 F289 F292 F295 F296 F297 F298 F301 F303 F304 F305 F306 F307 F308 F310 F311 F312 F313 F314 F316 F318 F319 Tarragon Thyme Marjoram Lovage Fennel fresh Dill Bay leaf Oregano Elk-Moose meat Mares Milk Blueberry Date Guava Carambola Carob (E410) Gum arabic (E414) Tragacanth (E413) Persimmon Halibut Langust (spiny lobster) Fenugreek Lime Hake Sardine(Pilchard) Blue vetch Megrim Swordfish Anchovy Snail Rape (Canola) seed Jack fruit Beetroot e e e e e e e e e e e e e e e e e e e e e e e e F320 F321 F325 F326 F328 F330 F331 F332 F334 F336 F337 F339 F342 F343 F344 F348 F369 F381 F384 F410 F412 F413 F414 F415 Crayfish Horse meat Sheep milk Sheep whey Fig Rose hip Saffron Mint Bovine lactoferrin Jujube Sole Allspice Olive (black fresh) Raspberry Sage Lychee Catfish Red Snapper Whitefish Grouper Orange roughy Pollock Tilapia Walleye pike

ESOTERIC ALLERGEN MIXES

e Esoteric mixed allergens $12 each Note: Requests for more than one of these will exceed our allowance under Medicare. Some esoteric allergen results may take up to five weeks e RX3 (G2 G5 G17 W1 W9 W10) Inhalant 3 Bermuda grass, Rye grass, Bahia grass, Common Ragweed, English Plantain, Goosefoot Lambs Quarters Sweet Vernals grass, Bermuda grass, Rye grass, Common Ragweed, Mugwort, English Plantain, Dermatophagoides pteronyssinus, Cat dander, Aspergillus fumigatus, Cockroach Birch, Timothy grass, Mugwort, Cladosporium, Alternaria alternata Dermatophagoides pteronyssinus, Cat dander, Horse dander, Dog dander, Rabbit epithelium MOULD MIXES e MX1 (M1 M2 M3 M6) Mould Mix 1 Penicillium chrysogenum, Cladosporium herbarum, Aspergillus fumigatus, Alternaria alternata A. fumigatus, A. niger, A. terreus, A. flavus

RX4

(G2 G5 G1 W1 W6 W9)

Inhalant 4

MX4

(M3 M207 M36 M228)

Mould Mix 4

FOOD MIXES e e e e e e e FX7 FX8 FX9 FX10 FX11 FX12 FX13 FX14 FX16 FX17 FX18 FX20 FX21 (F25 F45 F47 F48 F85) (F17 F18 F33 F49 F93) (F20 F84 F87 F92 F259) (F26 F27 F75 F83 F284) (F8 F12 F15 F31 F260) (F5 F9 F35 F225 RF212) (F12 F15 F31 F35) Food Mix 7 Food Mix 8 Food Mix 9 Food Mix 10 Food Mix 11 Food Mix 12 Food Mix 13 Tomato, Yeast, Garlic, Onion, Celery Hazel nut, Brazil nut, Orange, Apple, Cacao Almond, Kiwi, Melons, Banana, Grape Pork, Beef, Egg yolk, Chicken, Turkey Maize, Pea, White bean, Carrot, Broccoli Rye, Rice, Potato, Mushroom, Pumpkin Pea, White bean, Carrot, Potato Tomato, Spinach, Cabbage, Paprika Strawberrry, Pear, Lemon, Pineapple Apple, Banana, Pear, Peach Pea, Peanut, Soybean Wheat, Rye, Barley, Rice Kiwi fruit, Melon, Banana, Peach, Pineapple Pecan nut, Cashew nut, Pistachio, Walnut Pork, Beef, Chicken meat, Turkey meat Hazel nut, Shrimp, Kiwi fruit, Banana Sesame seed, Yeast, Garlic, Celery Egg white, Cows milk, Peanut, Mustard Fish (cod), Wheat, Soybean, Hazel nut Sesame seed, Shrimp, Beef, Kiwi Orange, Lemon, Grapefruit, Mandarin Kiwi, Mango, Banana, Avocado, Papaya Apple, Pear, Peach, Cherry, Plum Lentil, Pea, White bean, Carob Cod, Herring, Mackerel, Plaice

RX5

(D1 E1 M3 I6) Inhalant 5

RX6

(T3 G6 W6 M2 M6) (D1 E1 E3 E5 E82)

Inhalant 6

RX7

Inhalant 7

TREE MIXES e e TX1 TX2 (T1 T3 T7 T8 T10) (T1 T7 T8 T14 T22) (T6 T7 T8 T14 T20) (T7 T8 T11 T12 T14) (T2 T4 T8 T12 T14) (T1 T3 T5 T7 T10) (T1 T3 T4 T7 T11) (T2 T3 T4 T7 T12) (T2 T3 T4 T15) Tree Mix 1 Tree Mix 2 Box elder, Birch, Oak, Elm, Walnut Box elder, Oak, Elm, Cottonwood, Pecan Hickory Mountain Juniper, Oak, Elm, Cottonwood, Mesquite Oak, Elm, Sycamore, Willow, Cotttonwood Grey Alder, Hazel, Elm, Willow, Cottonwood Box elder, Birch, American Beech, Oak, Walnut Box elder, Birch, Hazel, Oak, Sycamore Grey Alder, Birch, Hazel, Oak, Willow Grey Alder, Birch,White Ash

e e e e e e

(F25 F214 F216 Food Mix 14 F218) (F44 F94 F208 F210) (F49 F92 F94 F95) (F12 F13 F14) (F4 F5 F6 F9) (F84 F87 F92 F95 F210) (F201 F202 F203 F256) (F26 F27 F83 F284) (F17 F24 F84 F92) (F10 F45 F47 F85) Food Mix 16 Food Mix 17 Food Mix 18 Food Mix 20 Food Mix 21

TX3

Tree Mix 3

e e e

TX4 TX5 TX6

Tree Mix 4 Tree Mix 5 Tree Mix 6

e e e e e e

FX22 FX23 FX24 FX25 FX26 FX27 FX28 FX29 FX30 FX31 FX32 FX74

Food Mix 22 Food Mix 23 Food Mix 24 Food Mix 25

e e e

TX8 TX9 TX10

Tree Mix 8 Tree Mix 9 Tree Mix 10

ESOTERIC ALLERGEN MIXES

e Esoteric mixed allergens $12 each Note: Requests for more than one of these will exceed our allowance under Medicare. Some esoteric allergen results may take up to five weeks ANIMAL MIXES e EX70 (E6 E82 E84 E87 E88) Animal Mix 3 Guinea pig epithelium, Rabbit epithelium, Hamster epithelium, Rat, Mouse Goose feathers, Chicken feathers, Duck feathers, Parrot feathers e GX4 (G1 G5 G7 G12 G13) Grass Mix 4 Sweet Vernal grass, Rye grass, Common reed, Cultivated rye,Velvet grass Bermuda grass, Rye grass, Johnson grass, Brome grass, Velvet grass, Bahia grass e WX2

(F1 F2 F13 F89) Food Mix 26 (F3 F4 F14 F17) Food Mix 27 (F10 F24 F27 F84) Food Mix 28

WEED MIXES (W2 W6 W9 W10 W15) Weed Mix 2 Western ragweed, Mugwort, English Plantain, Goosefoot Lambs Quarters, Scale Lenscale Mugwort, English Plantain, Goosefoot Lambs Quarters, Golden rod, Nettle English Plantain, Goosefoot Lambs Quarters, Saltwort Russian Thistle, Sheep sorrel Ox-eye Daisy, Dandelion, English Plantain, Goosefoot Lambs Quarters, Golden rod Common ragweed, Western ragweed, Giant ragweed

e e e e e e

(F33 F208 F209 Food Mix 29 F302) (F84 F91 F92 F293) (F49 F94 F95 F242 F255) (F235 F12 F15 RF296) (F3 F205 F206 F254) Food Mix 30 Food Mix 31 Food Mix 32 Food Mix 74

WX3

(W6 W9 W10 W12 W20)

Weed Mix 3

GX6

EX73

(E70 E85 E86 Animal Mix 4 E213)

(G2 G5 G10 G11 G13 G17)

Grass Mix 6

WX6

(W9 W10 W11 W18)

Weed Mix 6

GRASS MIXES e GX1 (G3 G4 G5 G6 G8) Grass Mix 1 Cocksfoot, Meadow Fescue, Rye grass, Timothy grass, Meadow grass Sweet Vernal grass, Rye grass, Timothy grass, Cultivated Rye, Velvet grass

COMBINATION INHALANT MIXES e RX1 (G6 W6 W9 W21 T3) (D2 E1 E3 E5 M6) Inhalant 1 Timothy grass, Mugwort, English Plantain, Parietaria, Birch Dermatophagoides farinae, Cat dander, Horse dander, Dog dander, Alternaria alternata

WX7

(W7 W8 W9 W10 W12)

Weed Mix 7

OCCUPATIONAL MIXES e PAX1 (E3 E4 E70 E85) (M3 M6 G12 G15) (F4 F14 K87 I202) Horse & Cow dander, Goose & Chicken feathers Aspergillus, Alternaria, Wheat & Rye pollen Wheat & Soy flour, alpha-amylase, Sitophilus granarius

RX2

Inhalant 2

WX209

(W1 W2 W3)

Weed Mix 209

GX3

(G1 G5 G6 G12 G13)

Grass Mix 3

e e

PAX3 PAX4

RECOMBINANT AND NATIVE INDIVIDUAL ALLERGEN MOLECULES

n Individual Native (n) $40 each r Recombinant (r) allergen molecules $40 each

Allergen Component

ImmunoCAP ISAC Allergen Components

Allergen Source COMMON NAME LATIN NAME Protein Group

Allergen Component

ImmunoCAP ISAC Allergen Components

Allergen Source COMMON NAME LATIN NAME Protein Group

PLANTS

NON-PLANTS Bermuda grass Cynodon dactylon Timothy Timothy Timothy Timothy Timothy Timothy Birch Alder Phleum pratense Phleum pratense Phleum pratense Phleum pratense Phleum pratense Phleum pratense Betula verrucosa Alnus glutinosa Corylus avellana PR-10 protein PR-10 protein PR-10 protein Grass group 5 Grass group 1 Grass group 1 Grass group 2 nBos d 6 nBos d 8 nBos d nGal d 1 nGal d 2 nGal d 3 nGal d 5 rCyp c 1 rGad c 1 rDer f 1 rDer f 2 nDer p 1 nDer p 2 rEur m 2 rCan f 1 rCan f 2 Lipid transfer protein (nsLTP) Lipid transfer protein (nsLTP) nCan f 3 nEqu c 3 rFel d 1 nFel d 2 nMus m 1 rAlt a 1 PR-10 protein PR-10 protein PR-10 protein PR-10 protein PR-10 protein Lipid transfer protein (nsLTP) rAlt a 6 rAsp f 1 rAsp f 2 rAsp f 3 rAsp f 4 rAsp f 6 rCla h 8 Storage protein, vicilin Storage protein, Conglutin Storage protein, 11S globulin PR-10 protein Storage protein, 2S albumin PR-10 protein Lipid transfer protein (nsLTP) Storage protein, 11S globulin PR-10 protein Storage protein, b-conglycinin Storage protein, glycinin Storage protein, 2S albumin CROSS REACTIVE MARKERS, NON-PLANTS rAni s 3 nBla g 7 rDer p 10 Crude gliadin Omega-5 gliadin rPen a 1 nPen i 1 nPen m 1 Anisakis Cockroach House dust mite Shrimp Shrimp Shrimp Anisakis simplex Blattella germanica Dermatophagoides pteronyssinus Penaeus aztecus Penaeus indicus Penaeus monodon Tropomyosin Tropomyosin Tropomyosin Tropomyosin Tropomyosin Tropomyosin nApi m 1 nApi m 4 rBla g 1 rBla g 2 rBla g 4 rBla g 5 rAni s 1 BSA Cows milk lactoferrin Egg Egg Egg CSA (Livetin) Carp Cod House mite House mite House mite House mite Dog Dog Dog Horse Cat Cat Mouse Alternaria Alternaria Aspergillus Aspergillus Aspergillus Aspergillus Aspergillus Cladosporium Honey bee venom Honey bee venom Cockroach Cockroach Cockroach Cockroach Anisakis dust dust dust dust Bos domesticus Bos domesticus Bos domesticus Gallus domesticus Gallus domesticus Gallus domesticus Gallus domesticus Cyprinus carpio Gadus callarias Dermatophagoides farinae Dermatophagoides farinae Dermatophagoides pteronyssinus Dermatophagoides pteronyssinus Euroglyphus maynei Canis familiaris Canis familiaris Canis familiaris Equus caballus Felis domesticus Felis domesticus Mus musculus Alternaria alternata Alternaria alternata Aspergillus fumigatus Aspergillus fumigatus Aspergillus fumigatus Aspergillus fumigatus Aspergillus fumigatus Cladosporium herbarum Apis mellifera Apis mellifera Blattella germanica Blattella germanica Blattella germanica Blattella germanica Anisakis simplex Phospholipase A2 Melittin Lipocalin Lipocalin Serum albumin Serum albumin Uteroglobin Serum albumin Lipocalin Serum albumin Caseins Laktoferrin Ovomucoid Ovalbumin Conalbumin Serum albumin Parvalbumin Parvalbumin

ANIMALS r r r r n n n E94 E220 E101 E102 E221 E204 E222 rFel d1 (recombinant cat) nFel d 2 Cat serum albumin Felis domesticus rCan f1 (recombinant dog) rCan f2 (recombinant dog) nCan f 3 Dog serum albumin Canis familiaris nBos d 6 BSA, Cow Bos spp. nSus s Pig serum albumin, Swine Sus scrofa

n r r r r r r r r rPhl p 1 (recombinant timothy) rPhl p 2 (recombinant timothy) rPhl p 4 (native timothy) rPhl p 6 (recombinant timothy) rPhl p 7 (recombinant timothy) rPhl p 11 (recombinant timothy) rPhl p 12 (recombinant timothy) rPhl p1; rPhl p5b (recombinant timothy) rPhl p7;rPhl p12 (recombinant timothy) rPhl p 5b (recombinant timothy) nCyn d 1 Bermuda grass, Cynodon dactylon r r r r r r r r r r

F334 F351 F353 F354 F355 F417 F418 F419 F420 F421 F416 F422 F423 F424 F352 F427 F425 F426 F428

nBos d Lactoferrin, Milk Bos spp. rPen a 1 Tropomyosin, Shrimp Penaeus aztecus rGly m 4 PR-10, Soy Glycine rBer e 1 Brazil nut, Bertholletia excelsa rCyp c 1 Carp Cyprinus carpio rApi g 1.01 PR-10, Celery Apium graveolens rApi g 1.02 (recombinant Celery) rPru p 1 PR-10, Peach Prunus persica rPru p 3 LTP, Peach Prunus persica rPru p 4 Profilin, Peach Prunus persica rTri a 19 Omega-5 Gliadin, Wheat Triticum spp rAra h 1 Peanut Arachis hypogaea rAra h 2 Peanut Arachis hypogaea rAra h 3 Peanut Arachis hypogaea rAra h 8 PR-10, Peanut Arachis hypogaea rAra h 9 LTP, Peanut Arachis hypogaea rCor a 8 LTP, Hazel nut Corylus avellana rGad c 1 Cod Gadus morhua rCor a 1 PR-10, Hazel nut Corylus avellana

MOULDS r r r r r r M218 M219 M220 M221 M222 M229 rAsp f1 (recombinant aspergillus) rAsp f2 (recombinant aspergillus) rAsp f 3 (recombinant aspergillus) rAsp f4 (recombinant aspergillus) rAsp f6 (recombinant aspergillus) rAlt a 1 (component alternaria)

nCyn d 1 rPhl p 1 rPhl p 2 nPhl p 4 rPhl p 5 rPhl p 6 rPhl p 11 rBet v 1 rAln g 1

LATEX r r r r r r r r K215 K217 K218 K219 K220 K221 K222 K224 rHev b 1, Latex Hevea brasiliensis rHev b 3, Latex Hevea brasiliensis rHev b 5, Latex Hevea brasiliensis rHev b 6.01, Latex Hevea brasiliensis rHev b 6.02, Latex Hevea brasiliensis rHev b 8, Profilin, Latex Hevea brasiliensis rHev b 9, Latex Hevea brasiliensis rHev b 11, Latex Hevea brasiliensis

rCor a 1.0101 Hazel pollen nCry j 1 nCup a 1 nOle e 1 rPla a 1 nPla a 2 nAmb a 1 nArt v 1 nArt v 3 rPar j 2 nSal k 1 nAct d 1 nAct d 2 nAct d 5

Japanese ceder Cryptomeria japonica Cypress Olive Plane tree Plane tree Ragweed Mugwort Mugwort Wall pellitory Saltwort Kiwi Kiwi Kiwi Kiwi Celery Carrot Apple Peach Peach Cashew nut Peanut Peanut Peanut Peanut Brazil nut Cupressus arizonica Olea europaea Platanus acerifolia Platanus acerifolia Ambrosia artemisiifolia Artemisia vulgaris Artemisia vulgaris Parietaria Judaica Salsola kali Actinidia deliciosa Actinidia deliciosa Actinidia deliciosa Actinidia deliciosa Apium graveolens Daucus carota Malus domestica Prunus persica Prunus persica Anacardium occidentale Arachis hypogaea Arachis hypogaea Arachis hypogaea Arachis hypogaea Bertholletia excelsa Corylus avellana Corylus avellana Corylus avellana Glycine max Glycine max Glycine max Sesamum indicum Triticum aestivum Triticum aestivum Triticum aestivum Triticum aestivum Hevea brasiliensis Hevea brasiliensis Hevea brasiliensis Hevea brasiliensis

GRASSES r r r r r r r r r r n G205 G206 G208 G209 G210 G211 G212 G213 G214 G215 G216

Storage mite

VENOM n K203 nApi m 1, Phospholipase A2, Bee Apis mellifera

nAct d 8 rApi g 1 rDau c 1 rMal d 1 rPru p 1 nPru p 3 rAna o 2 nAra h 1 nAra h 2 nAra h 3 rAra h 8 rBer e 1

OCCUPATIONAL ALLERGENS n n K205 K87 K201 K208 K204 K206 K213 Alkalase, Bacillus spp. nAsp o 1, a-amylase Aspergillus oryzae nCar p 1, Papain, Papaya Carica papaya nGal d 4, Lysozyme, Egg Gallus spp. Maxatase, Bacillus licheniformis Savinase, Bacillus spp. nSus s Pepsin, Swine Sus scrofa

FOODS c c c F76 F77 F78 nBos d 4 a-lactalbumin, Milk Bos spp. nBos d 5 b-lactoglobulin, Milk Bos spp. nBos d 8 Casein, Milk Bos spp. TREES r r r r r n nGal d 2 Ovalbumin, Egg Gallus spp. nGal d 1 Ovomucoid, Egg Gallus spp. nGal d 3 Conalbumin, Egg Gallus spp. T215 T216 T220 T221 T225 T224

rBet v 1 PR-10, Birch Betula verrucosa rBet v 2 Profilin, Birch Betula verrucosa rBet v 4, Birch Betula verrucosa rBet v 2, rBet v 4 Birch Betula verrucosa rBet v 6 Birch Betula verrucosa nOle e 1 Olive Olea europaea

n n n n n

c Core individual allergens, $4 each Note: These allergens are priced as core individual allergens ($4 ea) FOODS n n n F232 F233 F323

rCor a 1.0401 Hazelnut rCor a 8 Hazelnut Hazelnut Soybean Soybean Soybean Sesame seed Wheat

OTHERS (to exclude CCD reactivity) n n Ro214 K202 MUXF3 CCD, Bromelin nAna c 2 Bromelin, Pineapple Ananas comosus

nCor a 9 rGly m 4 nGly m 5 nGly m 6 nSes i 1 nTri a 18

WEEDS r n n W211 W230 W231 rPar j 2 (recombinant parietaria) nAmb a 1, Ragweed Ambrosia elatior nArt v 1, Mugwort Artemisia vulgaris

nTri a gliadin Wheat rTri a 19.0101 Wheat nTri a aA_TI rHev b 1 rHev b 3 rHev b 5 rHev b 6 Wheat Latex Latex Latex Latex

ImmunoCAP ISAC ($350 per profile)

The ISAC (Immuno Solid-phase Allergen Chip) is a microarray system developed by VBC Genomics and Phadia. ISAC can now allow laboratories to reliably and simultaneously determine specific IgE levels to a wide range of clinically important individual allergen molecules more economically than using many individual recombinant CAP allergens. Clinical studies have shown that, for example, even modest levels of serum specific IgE level to ara h 2, one of the nine major peanut allergens, are strongly predictive of more severe reactions and poor tolerance of oral challenges. Similarly, modest levels of serum specific IgE to ovomucoid, an egg allergen which is heat resistant, are strongly predictive of poor tolerance to even cooked egg in a baked cake; the first challenge usually used by allergy clinics when one is confident that a child might be starting to lose their egg allergy. The ISAC profiles are performed in batches, and the results are reported semi-quantitatively and organised into both the individual allergen molecule source, as well as the protein group from which it comes. These protein groups have particular patterns of clinical significance. For example, specific IgE to Lipid Transfer Proteins are often associated with systemic and more severe reactions in addition to oral allergy symptoms and these molecules are usually not altered with food preparation and cooking (enzyme digestion and heat). Similarly, seed storage proteins are also heat resistant and often associated with significant symptoms with cooked foods. In contrast, PR-10 proteins are heat labile and are associated with oral allergy symptoms with the raw, rather than cooked foods. Similarly, heat sensitive profilin proteins are more associated with nuisance rather than severe symptoms. Tropomyosin proteins account for dustmite-crustacean cross-reactivity. Animal albumins and fish parvalbumins are important causes of other food reactions. A table of the allergens included in the ISAC profile is shown opposite.

ISACology
CONTENTS

FEBRUARY 2010

CROSS REACTIVE MARKERS, PLANTS rBet v 4 rPhl p 7 rBet v 2 rHev b 8 rMer a 1 nOle e 2 rPhl p 12 nAna c 2 Birch Timothy Birch Latex Betula verrucosa Phleum pratense Betula verrucosa Hevea brasiliensis Calcium binding protein, Polcalcin Calcium binding protein, Polcalcin Profilin Profilin Profilin Profilin Profilin CCD marker

Individual Recombinant/ Purified Allergen Molecules and Allergen Microarray testing ImmunoCAP ISAC ComponentResolved Diagnostics
Classes of Proteins Involved in Allergy

1-2

Individual Recombinant/ Purified Allergen Molecules and Allergen Microarray testing

Previously on skin test systems or laboratory test systems, we could only measure specific IgE to an allergen source, usually a mixture of many different molecules. In the most important practical advance in laboratory allergy diagnostics, it is now possible to determine the amount of circulating specific IgE to individual allergen molecules. This can be performed for a unique molecule of interest using separate ImmunoCAPs or, for multiple molecules, on a microarray platform called the ISAC ImmunoCAP. Work began on isolating individual allergen molecules of interest in the late 1970s, and on developing microarray platforms in 2003. Early basic, and later clinical, research has resulted in mature technologies available to clinicians through specialised laboratories. Since IgE reactivity to some individual molecules can result in potentially serious clinical events, these test systems can provide new diagnostic and prognostic information to clinicians looking after allergic patients. The ability to identify which molecules are involved in allergic sensitisation is referred to as component-resolved diagnosis. The Phadia ISAC ImmunoCAP system presently profiles specific IgE to 103 individual allergen molecules from 47 different allergens, while separate ImmunoCAP reagents are available to test one molecule at a time when the question is more selected. Unfortunately, the Medicare Benefits Schedule has long neglected reimbursement levels for in vitro specific IgE testing and the current rebate ($22.95) for an episode of laboratory allergy testing is considerably less than the reagent cost of these test systems. Our laboratory charges $40 per recombinant or native individual allergen molecules, with the exception of three purified milk molecules, and $350 for the ISAC profile of 103 individual allergens on a microarray. Since ISAC is a much more cost-efficient approach to such testing, I have called this newsletter ISACology and will provide progressive updates with clinical vignettes.

2-3 4-5

Practical Clinical Applications of ISAC and Recombinant/ Native Individual Allergen Molecule Tests Indications for ISAC Profiles Indications for selected individual/ recombinant individual allergen molecule tests Suspicion of Peanut allergy Suspicion of Egg allergy

6-8

8 9

Annual mercury Mercurialis annua Olive Timothy Bromelain Olea europaea Phleum pratense Ananas comosus

10 11

10

11

BILLING POLICY FOR ALLERGY TESTING

Our policy is to respect your request for the allergens and decode them according to our best practice. If you have requested more allergens than our allowance under Medicare, we will bill your patient according to the pricing in this menu. If you have nominated the patient to be bulk-billed or if the patient has signed a Medicare assignment form, this billing policy will still apply for all tests above our allowance under Medicare. You will see in our Allergy menu that we now list a price for each allergen reagent and that this is organised into different allergen classes. Core individual allergens are $4, core mixed allergens are $8, esoteric individual allergens are $12 and esoteric mixed allergens are also $12. Our highly specialised recombinant (r) or native (n) individual allergen molecules are $40, and the ISAC profile, which tests 103 different individual allergen molecules from 47 different allergens, is $350. If the price of the allergens requested is more than the Medicare rebate of $22.95, the laboratory will not accept bulk-billing for the request and the patient will be billed according to the price on the menu and may claim a rebate, subject to coning. Practically, this means we will not accept a bulk-billed request for more than five core individual allergens, or two core mixed allergens, or more than one esoteric individual or mixed allergens. However, one core mixed allergen plus three core individual allergens would be covered by the Medicare rebate. Similarly, two core mixed allergens plus one core individual allergen would be covered under our allowance under Medicare. One esoteric mixed or individual allergen plus two core individual allergens or one core mixed allergen would be covered under our allowance under Medicare. A simple table summarises this for you and your patients.

Please note that eligible patients may be able to claim a rebate on four occasions per year for testing performed on separately collected blood, with each episode at least 14 days apart.

WHAT CAN YOU ORDER THAT IS MEDICARE REBATABLE?

Our Fee For Different Allergen Types
Core individual Core mix Esoteric Individual Esoteric Mix Recombinant/ Native ISAC Profile $4 $8 $12 $12 $40 $350

Medicare Rebatable

Private Bill

Combinations beyond the black line will be privately billed but patients may be eligible for a Medicare rebate of $22.95.

For further information regarding allergy testing please contact Dr Karl Baumgart, Director of Immunology on (02) 98 555 286 or email kbaumgart@dhm.com.au For copies of our Allergy or ISACology brochure please order through stores or view on our website www.dhm.com.au or www.bsp.com.au clinicians/publications
DHMP/B&S-AV2-2010-Brochure

DOUGLASS HANLY MOIR PATHOLOGY ABN 80 003 332 858 A subsidiary of SONIC HEALTHCARE
BARRATT & SMITH PATHOLOGY ABN 80 003 332 858 A trading name of DOUGLASS HANLY MOIR PATHOLOGY A subsidiary of SONIC HEALTHCARE

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