MANAGING COMMON PRESENTATIONS OF ALLERGY IN PRIMARY CARE. Helen Bourne Consultant Immunologist

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1 MANAGING COMMON PRESENTATIONS OF ALLERGY IN PRIMARY CARE Helen Bourne Consultant Immunologist

2 AIMS Presentation of Allergic Disease in Adults Rhinitis/ Rhinoconjuctivitis Urticaria and Angioedema Food Allergy Anaphylaxis Management

3 Rhinitis Common Affects 20% UK population Significant impact on quality of life Affects school and work attendance

4 Rhintis Symptoms Sneezing Nasal itching Nasal blockage Nasal discharge Post nasal drip Causes Infective Allergic Non Allergic

5 Diagnosis of Rhinitis History Seasonal or perennial At home or at work Pets Discharge Green infective Clear/yellow allergic/non allergic Unilateral nasal blockage Nasal crusting staph carriage/ autoimmune conditions

6 Causes of Non Allergic Rhinitis Vasomotor Rhinitis Triggered by physical/chemical agents Drugs ACE inhbitors Rhinitis medicamentosa Hormonal Pregnancy Hypothyroidism Food Alcohol/spicy foods NARES Associated with aspirin sensitivity

7 Management of Rhinitis Topical Nasal Steroid Antihistamines Cetirizine 10-20mg BD Saline nasal douching Allergen avoidance If failure of maximal medical therapy Consider referral to allergy unit for Immunotherapy

8 Immunotherapy Can be delivered by an Injection or subcutaneous route Indicated in UK for venom allergy and inhalant allergy in patients who have failed maximal medical therapy Need evidence for IgE mediated disease (SPT or Specific IgE) Is effective only for the specific allergens administered Requires treatment monthly for three years Can cause both local and systemic reactions (anaphylaxis)

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10 Urticaria and Angioedema

11 Urticaria and Angioedema Common Affects 2-3% of individuals (lifetime prevalence) Significant impact on QoL Clinical Diagnosis History is key Exclude precipitating factors Physical Infection Stress NSAIDs ACE inhibitors and angioedema

12 Management Of Urticaria and Angioedema

13 Could it be food allergy? Food related symptoms are common Up to 20% of population Not all food related symptoms = allergy Can affect 1-3% pop Overlap with IBS True food allergy is mediated by IgE

14 Everyone has had experience My dad has very severe symptoms of IBS. Has anyone found something they enjoy eating with no symptoms. Has anyone found any help from alternative medicine? My wife was ill with similar symptoms as your dad by the sounds of it. She went to Holland and Barrett in town where they can do intolerance tests without invasive methods. This was a couple of years ago but might be worth a try. I had terrible IBS for years until i went for a food allergy test which was the best 30 i spent. I was apparently intolerant to wheat products and dairy products and since i have cut them out of my diet i have been tons better. I only have these occasionally. Good luck - I sympathise

15 Symptoms of Food Allergy Oral Tingling of lips, swelling, lump in throat Respiratory Hoarse voice, chest tightness, asthma Cardiovascular Syncope, light headedness Cutaneous Flushing, urticaria, itching Gastrointestinal Diarrhoea, vomiting, nausea

16 Are the symptoms likely to be food allergy The history is critical! Key features Time from consuming food to symptoms occurring Reproducibility Are symptoms consistent with food allergy Has the patient already decided (and discounted evidence to the contrary)

17 When to refer to the allergy clinic Life threatening Allergic Features/ Severe Food Allergy (Anaphylaxis) hypotension, laryngospasm, bronchospasm Suspected Reactions to Foods Previous high street allergy tests Dietary restrictions

18 What can we offer in the allergy clinic Confirmatory testing SPT RAST Food Challenge Acute Management Plans Adrenaline Autoinjector Training Medic Alert After acute anaphylaxis, an adrenaline auto-injector should be prescribed in the Emergency Department or primary care and an allergy referral immediately triggered (NICE guidance)

19 Mild Reaction Symptoms: Any one of the following: Tingling or itch in the mouth Swelling of the face Hives or an itchy, raised, red rash (like a nettle rash ) Plan: Get help someone to stay with you Chew Cetirizine 20mg (2x 10mg tablets) immediately Take Prednisolone 20mg if available

20 Moderate Reaction Symptoms: As in a mild reaction plus any one of the following: Abdominal pain Vomiting Diarrhoea Coughing Mild wheeze Lump in the throat sensation Plan: Get help someone to stay with you Chew Cetirizine 20mg (2x 10mg tablets) immediately Take Prednisolone 20mg if available If your symptoms fail to improve or you remain concerned please ring 111 for further advice

21 Severe Reaction Symptoms: As in a mild reaction plus any one of the following: Swelling of the tongue or airway Persistent vomiting or diarrhoea Dizziness or confusion Collapse Breathing difficulty, severe wheeze or chest tightness Difficulty speaking or swallowing Persistent coughing or choking Plan: Get help someone to stay with you Phone 999 (and say ANAPHYLAXIS) Use adrenaline pen (JEXT / Epi-Pen / Emerade) if available on the upper outer thigh. Repeat with 2 nd pen if no better in 5-10 minutes Lie down (or sit down if unable) If not already taken: chew Cetirizine 20mg (2x 10mg tablets) & take Prednisolone 20mg if available

22 Acute Management of Anaphylaxis

23 Adrenaline Autoinjectors

24 Anaphylaxis Definitions Rapid, generalised immunologically mediated reaction to certain substances in previously sensitised persons (WHO) Severe life threatening, generalised or systemic hypersensitivity reaction. Characterised by rapidly developing, life threatening problems involving the airway and /or breathing and /or circulation (RESUS Council/NICE)

25 Who should carry an adrenaline autoinjector? A severe (anaphylactic) reactions where the allergen cannot be easily avoided Risk Assessment Reaction Severity Ability to avoid allergen Cofactors e.g asthma Social circumstances/geographic factors Cautions Drugs Tricyclic antidepressants, beta blockers, ACE inhibitors Cardiovascular disease BSACI Guideline; Prescribing An Adrenaline Autoinjector Clinical & Experimental Allergy (2016) 46,

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27 How to use an adrenaline pen

28 Allergy Referral Guidelines WHAT TO REFER* Known or suspected primary immunodeficiency Recurrent major infection Recurrent severe boils [failed initial therapy; deep seated abscesses] Anaphylaxis Recurrent angioedema in people NOT on ACE Inhibitors including hereditary or acquired angioedema Seasonal or perennial rhinoconjunctivitis resistant to usual therapy Drug Allergy Latex allergy Food allergy known or suspected Urticaria if severe and prolonged Chronic Fatigue Syndrome WHAT NOT TO REFER* HIV/AIDS [known or suspected] Recurrent minor infection Recurrent superficial abcess/boil; hidradenitis suppurativa Vasculitis/Connective tissue disease Arthritis Angioedema in people taking ACE Inhibitors single episode of self-limiting angioedema Eczema; Periorbital oedema with scaly rash Asthma Asplenic patients Recurrent shingles Food intolerance; irritable bowel syndrome Urticaria if single episode, recent onset and/or mild

29 Primary Care Guidelines BSACI website Primary Care Allergy Training Days NICE Guidelines Anaphylaxis Food allergy Drug allergy Milk Allergy