How will we manage food allergy in 2026

Transcription

1 How will we manage food allergy in 2026 Paul Turner MRC Clinician Scientist & Honorary Consultant in Paediatric Allergy & Immunology, Imperial College London; Honorary Clinical Lecturer, University of Sydney

2 Will we all be out of a job? Du Toit et al, JACI 2016

3 Will we all be out of a job?

4 Will we all be out of a job? >50% age 5 yrs

5 Will we all be out of a job? >50% age 5 yrs

6 Will we all be out of a job? >50% age 5 yrs 15.3%

7 Will we all be out of a job? 8.5% already 4-6 months of age

8 Will we all be out of a job? Food allergy is likely to continue to remain a significant healthcare issue although new prevention strategies are likely to have some impact Infant eczema likely to remain a significant risk factor

9 Thousands of prescriptions Adrenaline auto-injector devices mcg 300+mcg TOTAL 50 0 Data: NHS Prescription Cost Analysis for England,

10 Hospital admissions Admissions per 100,000 population Age 0-14 Age Age 60+ FOOD

11 Hospital admissions Admissions per 100,000 population Age 0-14 Age Age 60+ FOOD?

12 Impact of a Food Allergy Diagnosis 39% longer to shop Significantly greater expense Quality of life scores worse than Type 1 DM Risk of compromised nutrition Risk of fatal reaction Avery NJ, Assessment of quality of life in children with peanut allergy. Ped All Immunol 2003;14: Fox AT et al. Food Allergy as a risk factor for Nutritional Rickets. Ped All Immunol 2004 Dec;15 (6): Bock SA et al Fatalities due to anaphylactic reactions to food. J Allergy Clin Immunol. 2001;107(1):191-3.

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14 IS ANAPHYLAXIS ALWAYS SEVERE?

15 Risk of food-induced anaphylaxis Umasunthar et al, Clin Exp Allergy. 2013;43:

16 83% of (245) teenagers with anaphylaxis don t use their AAI

17 Anaphylaxis is not uncommon, but death from anaphylaxis is very rare Brown et al., MJA (2007)

18 Anaphylaxis is not uncommon, but death from anaphylaxis is very rare but also unpredictable Turner et al, Allergy (2016

19 Perceptions Fatal anaphylaxis rare but unpredictable

20 Perceptions Fatal anaphylaxis rare but unpredictable Food allergy common Allergen labelling widespread

21 You might tell me that the chance of dying is 1 in a million

22 You might tell me that the chance of dying is 1 in a million my child is that 1 in a million

23 Management vs treatment There is currently no treatment for food allergy in routine clinical practice Management Treatment

24 Current management NOW & THEN Dietary Avoidance Rescue treatment Immunotherapy

25 Current management NOW & THEN Dietary Avoidance Rescue treatment Immunotherapy

26 Dietary avoidance

27 Allergen Labelling Allergen disclosure required under law: key allergens in ingredients of prepacked foods

28 Allergen Labelling Allergen disclosure required under law: Australia & NZ UK and Europe USA Wheat Wheat Wheat Other gluten: rye, barley, Other gluten: rye, barley, oats, spelt oats, spelt, kamut Egg Egg Egg Milk Milk Milk Peanuts Peanut Peanut Tree nuts Tree nuts Tree nuts and coconut (!) Soy Soy Soy Fish Fish Fish Crustaceans Crustaceans Crustaceans Molluscs Celery Mustard Sesame Sesame Lupin Sulphur dioxide (>10ppm) Sulphur dioxide (>10ppm)

29 Allergen Labelling Allergen disclosure required under law: key allergens in ingredients of prepacked foods Mandatory disclosure applies only to allergens in ingredients

30 Allergen Labelling Allergen disclosure required under law: key allergens in ingredients of prepacked foods Mandatory disclosure applies only to allergens in ingredients Since December 2014, there are now statutory requirements in terms of labelling: but not for potential allergen presence due to cross-contamination

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32 Turner et al, 2011 Turner et al, BMJ 2011

33 Unnecessary avoidance? Sensitisation is a poor marker of clinical reactivity: Osborne et al. JACI 2011; 127: Ball et al. PAI 2011; 22:

34 Unnecessary avoidance? Sensitisation is a poor marker of clinical reactivity: Should peanut-allergic patients avoid all nuts? 31% of 94 peanut-allergic children were sensitised to a tree nut Only 7 (of 29) were allergic at formal OFC Osborne et al. JACI 2011; 127: Ball et al. PAI 2011; 22:

35 Improved diagnostics? New in vitro diagnostics: Component resolved diagnostics (CRD) Basophil activation test

36 Improved diagnostics? New in vitro diagnostics: Component resolved diagnostics (CRD) Dang et al. JACI 2012;129:

37 Improved diagnostics? New in vitro diagnostics: Component resolved diagnostics (CRD) Basophil activation test

38 Don t underestimate the power of a food challenge Food Allergy Quality of Life Reduced adverse impact Self-efficacy assessment Improvement in self-efficacy In child, self-reported In child, reported by parent In parent In child, self-reported In child, reported by parent Change in HRQL pre- and post challenge

39 Diagnosis: The future?

40 Back to avoidance Turner et al, 2011 Turner et al, BMJ 2011

41 Turner et al, BMJ 2011

42 Not helpful to allergic consumers Helpful to allergic consumers Product with PAL 1. Product with PAL with a real risk of inducing an allergic reaction i.e. unsafe to consume Proper risk assessment by the food manufacturer Conclusion that the allergen may be present in the product (despite allergen management and Good Manufacturing Practice). Product without PAL 4. Product without PAL with low or no risk of inducing an allergic reaction i.e. safe to consume Proper risk assessment by the food manufacturer Conclusion that the allergen is not present in the product at a level that is likely to cause an allergic reaction 2. Product with PAL with unknown risk of inducing an allergic reaction i.e. may be safe or unsafe to eat No proper risk assessment No conclusion about allergen presence can be drawn 3. Product with PAL with low or no risk of inducing an allergic reaction i.e. safe to consume Proper risk assessment undertaken Manufacturer uses PAL nonetheless No conclusion about allergen presence can be drawn 5. Product without PAL, with unknown risk of inducing an allergic reaction i.e. may be safe or unsafe to consume No proper risk assessment No conclusion about allergen presence can be drawn

43 Not helpful to allergic consumers Helpful to allergic consumers Product with PAL 1. Product with PAL with a real risk of inducing an allergic reaction i.e. unsafe to consume Proper risk assessment by the food manufacturer Conclusion that the allergen may be present in the product (despite allergen management and Good Manufacturing Practice). Product without PAL 4. Product without PAL with low or no risk of inducing an allergic reaction i.e. safe to consume Proper risk assessment by the food manufacturer Conclusion that the allergen is not present in the product at a level that is likely to cause an allergic reaction 2. Product with PAL with unknown risk of inducing an allergic reaction i.e. may be safe or unsafe to eat No proper risk assessment No conclusion about allergen presence can be drawn 3. Product with PAL with low or no risk of inducing an allergic reaction i.e. safe to consume Proper risk assessment undertaken Manufacturer uses PAL nonetheless No conclusion about allergen presence can be drawn 5. Product without PAL, with unknown risk of inducing an allergic reaction i.e. may be safe or unsafe to consume No proper risk assessment No conclusion about allergen presence can be drawn

44 Do foods with PAL contain allergen? FSA, 2014 (n=508) UK Robertson et al, 2013 (n=38) Eire Zurzolo et al, 2013 (n=43) Australia Remington et al, 2013 (n=352) USA FSAI, 2011 (n=108) Eire Crotty et al, 2010 (n=81) USA Ford et al, 2010 (n=228) USA Pele et al, 2007 (n=569) Europe Hefle et al, 2007 (n=179) USA } 0% Peanut Hazelnut Milk Egg Soya % pre-packed food products with PAL containing allergen

45 So Most foods with PAL don t contain the allergen but some do, and enough to trigger reactions Snack/confectionery items at particular risk (nut contamination) Some foods without PAL do contain the allergen

46 UK FSA Survey (2014) 508 products Remington et al. Allergy. 2015;70:813-9.

47 UK FSA Survey (2014) 508 products Remington et al. Allergy. 2015;70:813-9.

48 The reality: Wide inconsistencies in labelling Significant increase in awareness of the hazards posed by food allergens but understanding is still far from complete Foods can become contaminated with residues of allergenic foods at multiple points: Harvesting on farms Storage & transportation Manufacture: shared equipment Measures to reduce cross-contamination not uniform across manufacturers

49 The future

50 The future: Aids to avoidance

51 Hypoallergenic foods Not a novel concept: e.g. hydrolysed cow s milk-based formula

52 Current management NOW & THEN Dietary Avoidance Rescue treatment Immunotherapy

53 Accidental/inadvertent reactions are common: 1 in 8 peanut-allergic children experienced at least one accidental reaction every year 1 Over 50% of 512 infants had at least one reaction over 3 years follow-up 2 Avoidance is, therefore, inadequate on its own 1 Nguyen-Luu et al, PAI 2012; 23: Fleischer et al. Pediatrics 2012; 130:e25 32.

54 Accidental/inadvertent reactions are common: 1 in 8 peanut-allergic children experienced at least one accidental reaction every year 1 Over 50% of 512 infants had at least one reaction over 3 years follow-up 2 Avoidance is, therefore, inadequate on its own All food-allergic children need: Personalised Allergy Management Plan Rescue treatment (which may include AAI) 1 Nguyen-Luu et al, PAI 2012; 23: Fleischer et al. Pediatrics 2012; 130:e25 32.

55 Management of accidental reactions British Society for Allergy and Clinical Immunology Allergy Action Plan Clinic details THIS CHILD HAS THE FOLLOWING ALLERGIES: Name: DOB: Photo Mild-moderate allergic reaction: Swollen lips, face or eyes Itchy / tingling mouth Hives or itchy skin rash ACTION: Stay with the child, call for help if necessary Give antihistamine: Contact parent/carer Abdominal pain or vomiting Sudden change in behaviour (if vomited, can repeat dose) Parent / Carer details: 1)! 2)! Child s Weight: Kg Watch for signs of ANAPHYLAXIS (life-threatening allergic reaction): AIRWAY: Persistent cough, hoarse voice, difficulty swallowing, swollen tongue BREATHING: Difficult or noisy breathing, wheeze or persistent cough CONSCIOUSNESS: Persistent dizziness / Pale or floppy Suddenly sleepy, collapse, unconscious If ANY ONE of these signs are present: 1. Lie child flat. If breathing is difficult, allow to sit 2. Give EpiPen or EpiPen Junior 3. Dial 999 for an ambulance* and say ANAPHYLAXIS ( ANA-FIL-AX-IS ) If in doubt, give EpiPen After giving Epipen: 1. Stay with child, contact parent/carer 2. Commence CPR if there are no signs of life 3. If no improvement after 5 minutes, give a further EpiPen or alternative adrenaline autoinjector device, if available *You can dial 999 from any phone, even if there is no credit left on a mobile. Medical observation in hospital is recommended after anaphylaxis. Additional instructions: Keep your EpiPen device(s) at room temperature, do not refrigerate. For more information and to register for a free reminder alert service, go to Patient support groups: or The British Society for Allergy & Clinical Immunology w w w. bsaci. o r g This is a medical document that can only be completed by the patient's treating health professional and cannot be altered without their permission. This plan has been prepared by: Hospital/Clinic:! Date:

56 We need: 1. Recognition 2. Appropriate management in community 3. Appropriate management by healthcare professionals

57 1) Recognition Symptoms of anaphylaxis (DIB, LOC, pharyngeal swelling) are poorly recognized by adolescents 1 One in 7 report difficulty in knowing when to use their AAI in a US survey (n=1885) 3 1 Sampson et al. JACI 2006: 117: Simons et al JACI 2009: 124:

58 2) Appropriate Management British Society for Allergy and Clinical Immunology Name: DOB: Allergy Action Plan THIS CHILD HAS THE FOLLOWING ALLERGIES: Mild-moderate allergic reaction: Swollen lips, face or eyes Itchy / tingling mouth Hives or itchy skin rash Abdominal pain or vomiting Sudden change in behaviour Clinic details 83% of (204) teenagers with anaphylaxis don t use their AAI 1 Photo ACTION: Stay with the child, call for help if necessary Give antihistamine: Contact parent/carer (if vomited, can repeat dose) Parent / Carer details: 1)! Watch for signs of ANAPHYLAXIS (life-threatening allergic reaction): 2)! Child s Weight: Kg AIRWAY: Persistent cough, hoarse voice, difficulty swallowing, swollen tongue BREATHING: Difficult or noisy breathing, wheeze or persistent cough CONSCIOUSNESS: Persistent dizziness / Pale or floppy Suddenly sleepy, collapse, unconscious If ANY ONE of these signs are present: 1. Lie child flat. If breathing is difficult, allow to sit 2. Dial 999 for an ambulance* and say ANAPHYLAXIS ( ANA-FIL-AX-IS ) 3. Stay with child, contact parent/carer 4. Commence CPR if there are no signs of life 1 Noimark et al. CEA 2012: 42: *You can dial 999 from any phone, even if there is no credit left on a mobile. Medical observation in hospital is recommended after anaphylaxis. This BSACI Action Plan for Allergic Reactions is for children with mild to moderate allergies, who need to avoid certain allergens. Additional instructions:

59 NOT JUST PATIENTS.

60 NOT JUST PATIENTS.

61 How to use Adrenaline auto-injectors MAMA Study: Only 4 out of 10 mothers were able to successfully administer adrenaline in an anaphylaxis scenario, 6 weeks after training 30% failed to remove cap 18% insufficient time 8% wrong end

62 Only two doctors (2%) demonstrated use correctly. Most frequent errors: 57% - not holding pen in place for >5 seconds 21% - failure to apply pressure to activate 16% - self-injection into thumb 60% failed to use device correctly even after reading instructions In 37% NO adrenaline would have been administered

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64 Refractory anaphylaxis

65 What we do know: 83% of (204) teenagers with anaphylaxis don t use their AAI 1 Symptoms of anaphylaxis (DIB, LOC, pharyngeal swelling) are poorly recognized by adolescents 2 One in 7 report difficulty in knowing when to use AAI in a US survey (n=1885) 3 Adrenaline IM doesn t always work 4 1 Noimark et al. CEA 2012: 42: Sampson et al. JACI 2006: 117: Simons et al JACI 2009: 124: Pumphrey & Gowland, JACI 2007;119:

66 Do we need to shift our focus?

67 Current management NOW & THEN Dietary Avoidance Rescue treatment Immunotherapy

68 Immunotherapy to food Nowak-Wegrzyn & Sampson. JACI 2011; 127(3): Nowak-Wegrzyn & Fiocchi, Curr Opin Allergy Clin Immunol. 2010; 10:214-9.

69 Studies completed or underway Egg Milk Peanut Other Subcutaneous Baked, oral Native, oral SLIT Epicutaneous Tolerising peptides

70 Safety Desensitisation typically achieved in >80% High rate of adverse events during SOTI: 70-80% experience adverse events Rates of anaphylaxis vary Severity of anaphylaxis vary Up to 10% of patients withdraw

71 Desensitisation vs long term tolerance Nowak-Wegrzyn & Sampson. JACI 2011; 127(3):558-73

72 Desensitisation vs long term tolerance Peanut Egg Cow s Milk 12 (50%) of 24 children who completed SOTI were tolerant after 2 months 1 11 (37%) of 30 children who completed SOTI were tolerant after 2 months 2 10 (31%) of 32 children were able to tolerate at least one portion of CM daily 1-5 years after completing SOTI 3 1 Vickery et al. JACI 2014 Feb;133(2): e6. 2 Burks et al. N Engl J Med 2012; 367: Keet et al. JACI 2013; 132: ; e6.

73 Some clinical concerns How to select those suitable for SOTI Risk of increasing sensitisation? Risk of inducing a false sense of security in those only temporarily desensitised Effect on QoL of patient Potential for causing other problems e.g. EoE

74 THE FUTURE

75 THE FUTURE: Dietary avoidance Accurate diagnosis and therefore appropriate avoidance Clearer food labelling Apps to help avoid potential allergens Better understanding when eating out Hypoallergenic foods

76 THE FUTURE: Rescue treatment Recognition of symptoms More intuitive AAI Apps to aid AAI use/emergency services More training for HCPs

77 THE FUTURE: Treatment options Use of baked CM / egg More research into SOTI: Safer protocols Better understanding of long-term tolerance induction SOTI as primary prevention

78 THE FUTURE is already here? Accurate diagnosis and therefore appropriate avoidance Clearer food labelling Apps to help avoid potential allergens Better understanding when eating out Hypoallergenic foods Recognition of symptoms More intuitive AAI Apps to aid AAI use/emergency services More training for HCPs Baked CM / Egg More research into SOTI: Safer protocols Better understanding of long-term tolerance induction SOTI as primary prevention

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