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Reminder to record call

1

Welcome and role call

Introductions

@Bruce Goldberg

• Allergy CRG_Jan 26 2024.pptx

2

SNOMED and LOINC - representing allergy testing in SNOMED

@Farzaneh Ashrafi @Marie-Alexandra Lambot

@Bruce Goldberg

• Possible upcoming project with LOINC to improve allergy testing in SNOMED and LOINC

  • "Just to let you know, we will be discussing the priority of allergy related testing at the LOINC extension meeting in March.  We can let you know the outcome of that afterwards.  In the meantime, could you pull together what you think needs to be specifically addressed to meet your needs (i.e requirements and use cases)?
    Jim"

    James T. Case MS, DVM, PhD, FACMI
    Chief Terminologist

• SNOMED_LOINC allergy test obervables.xlsx

• Allergy testing proposal goals.docx

• SNOMED LOINC allergy testing gap analysis.docx

Jca: Is this something that would require SNOMED resources at this time? In other words, do we need to develop a project proposal to be approved by the SMT for resource allocation?  Or is it something that can be done independently and then a more formal proposal for a project can be developed once you know what is needed?  Also, it would be very nice if we could communicate to LOOINC some of the issues you note as it would be my intention that we would not create new observables directly in the International release, but we would focus on getting the LOINC parts right and then using those to generate LOINC extension concepts.  I do not see a wholesale addition of allergy observables into the international release but can see this exercise helping to improve the content in LOINC as well as SNOMED.  As for the LDTs, my impression is that if we can identify them, they should be out of scope (much as they are for the SHIELD project).

Bgo: Jim, I think there are a few considerations. Given the age of the allergy test content in SNOMED, if we intend to keep this content (now as observables rather than procedures) we should provide some needed updates in the SNOMED core to make it clinically useful. This could be undertaken independently and would be limited to adding new missing whole allergen IgE tests (e.g. Measurement of immunoglobulin E antibody to galactose-alpha-1,3 galactose (procedure)) but perhaps more importantly would be the addition of component allergen testing. Component resolved diagnostics (CRD) is an important part of in vitro allergy testing for the reasons I mentioned in my prior e-mail. Although there are hundreds of available tests, I think we could limit this to a manageable number based on importance. Further down the road we should develop a proposal to create a SNOMED extension that includes additional content from LOINC such as adding class reporting as well as adding additional tests to both the SNOMED extension and LOINC. In terms of communicating some of the issues, I did speak with Eza Hafeza, Director, Clinical Terminology Services and Operations (we used to work together in CMT) about the problem using “RAST” as a method for class results. I was told a fix will occur at some point. In terms of LDTs, I seem to remember in the past there was a field in LOINC that contained the submitters but I don’t see that at present.

3

Drug hypersensitivity update

@Bruce Goldberg

@Farzaneh Ashrafi

• @Farzaneh Ashrafi discussed the creation of 416093006 |Allergic reaction caused by drug (disorder)| subtypes based on existing concepts of type << 416098002 |Allergy to drug (finding)| (and possibility of using them as template for a batch update) with Jim and Monica.

  While they are in agreement that the creation of these concepts seems to be clinically useful, they noted the following considerations:

  This work cannot be considered part of the ongoing QI project (which is related to changes to existing concepts). Therefore, this request, considering the size of requested changes i.e. creation of >1000 concept net new concepts (based on the initial estimate), requires its own project.
  While batch update is potentially applicable, there is still a requirement for manual review of all newly created concepts and their classification as well as resolving issues such as consideration of dealing with previously inactivated concepts, etc. In addition, creation of concepts of this type and number has a direct impact on the ICD mapping project. 
  For the reasons noted above, implementation of this work will require the following:

  Completion of a project charter (please see the attached template). The document needs to be completed by the CRG and submitted to the Senior Management Team for review and assignment of priority.
  The endorsement of members will be helpful in prioritization of changes of this kind. As discussed previously, member attendance in the Allergies and hypersensitivity CRG has been scarce and has declined since completion of the implementation guide. I talked with Monica and Cathy about the possibility of a presentation to the CMAG members to evaluate and endorse the buy-in for the requested change. Cathy noted that the next CMAG meeting is currently scheduled in mid April (I will send the exact date and time shortly) and that this item can definitely be added to the agenda. Will you be interested in participation in the CMAG meeting and providing a presentation?

• Allergies and hypersensitivity CRG - Content Business Case Proposal Template.docx

4

Remodel and naming of 788802000 |Allergy to cetuximab (finding)|

@Bruce Goldberg

@Farzaneh Ashrafi

There is a CRS request questioning the naming of this concept. The modelling suggest that the concept should have a terming similar to 788781001 |Delayed allergy to red meat (finding)|.

Here is the comment by the requester: "This concept has some very odd additional modelling, such as additional causative agent of 788778006 |Galactose-alpha-1,3 galactose (substance)|, a clinical; course of sudden onset and due to a bit of tick. Probably better to make inactive and author a new allergy to cetuximab concept. The other modelling looks like it should have been 788781001 |Delayed allergy to red meat (finding)| apart from the onset."

The references I have checked support the requester comment:
"IgE to alpha-gal has been associated with two distinct forms of anaphylaxis: i) immediate onset anaphylaxis during first exposure to intravenous cetuximab, and ii) delayed onset anaphylaxis 3–6 hours after ingestion of mammalian food products (e.g., beef and pork)." https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4600073/#:~:text=IgE%20to%20alpha%2Dgal%20has,e.g.%2C%20beef%20and%20pork).
"Meats and monoclonal antibodies (cetuximab) — The cross-reactive carbohydrate determinant, alpha-gal, which is present on a range of mammalian meats, has been shown to be a potent allergen [18]. Patients who have IgE to alpha-gal can develop severe hypersensitivity reactions to the monoclonal antibody cetuximab, which also contains alpha-gal [83]. This association was made after a group of patients experienced anaphylaxis upon their initial exposure to cetuximab, indicating that they had been previously sensitized to some component of the drug."https://www.uptodate.com/contents/allergy-to-meats?search=cetuximab%20%2B%20alpha-gal%20&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H8
I am inclined to change the terming, but I am struggling how to incorporate the 385315009 |Sudden onset (qualifier value)| in the naming (as opposed to delayed onset in case of the red meat allergy) It seems that 788802000 |Allergy to cetuximab (finding)| is the only concept of type: << 609328004 |Allergic disposition (finding)|: 263502005 |Clinical course (attribute)| = 385315009 |Sudden onset (qualifier value)| so we don't have similar concepts to consider as template for terming.

• Allergy to cetuximab and the alpha-gal syndrome.pptx

5

Adjourn

@Bruce Goldberg

• Any other topics for discussion?

  • Improving Immune hypersensitivity disorder content in SNOMED CT, need to set up call with Drs. Corriger and almedia

• April business meeting call:

Friday, April 12, 2024 (Online Only) (Time in UTC)
17:00-19:00 UTC    
Working Group
Open to all 
Allergy/Hypersensitivity and Intolerance CRG
Chairs: Bruce Goldberg and Marie-Alexandra Lambot
Online- Zoom Only