Top Tips for managing Allergic conditions

Transcription

1 Top Tips for managing Allergic conditions Dr David Cremonesini Specialist Paediatrician Allergy / Respiratory interest American Hospital cdavid@ahdubai.com

2 Clinic!! 2 allergy specialists!! Appointment same week!! Skin Prick Tests and Blood tests!! Oral Food challenges on the ward!! Anaphylaxis training!! Sublingual immunotherapy service

3 Why is it important?

4 !"#$%& '%()*()+!,#')-. )$%'),%&/ ~20% of Americans have atopic disease ~ 1 in 5 infants develop atopic dermatitis Prevalence (% Children) Asthma Allergic rhinitis Ninan TK, Russell G. BMJ. 1992;304: NIAID Website. Accessed April Atopic dermatitis

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6 What can we do to prevent allergy?!! For all infants!! No special diet during pregnancy or lactation!! Breastfeed exclusively for 4-6 months!! Avoidance of solids until 4-6 months!! NO BENEFIT re allergy waiting until 6 months!! Vitamin D levels normal!! For infants high risk for allergy!! Supplement with extensively hydrolyzed or amino acid formula for first 4 months then introduce diary

7 Allergic March

8 History is key!! What s important to ask about?!! Vital to ascertain which foods consistently cause symptoms!! Targeted allergy testing VITAL!! Other allergy history!! Family History!! How do you differentiate between!! IgE-mediated food allergy!! Non-IgE mediated food allergy

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11 Key points in history!! Age of onset of symptoms? Infancy? At introduction in the diet?!! What foods? Think of common foods!! Time course of symptoms!! How much food to trigger a reaction?

12 Skin symptoms IgE!! Rapid onset!! Pruritis!! Erythema!! Acute urticaria!! Angioedema Non - IgE!! Delayed onset!! Pruritis!! Erythema!! Atopic eczema

13 Gastro-intestinal symptoms IgE!! Angioedema of lips, tongue and palate!! Oral pruritis!! Nausea!! Colicky abdominal pain!! Vomiting!! Diarrhoea Non IgE!! Gastro-oesophageal reflux!! Loose or frequent stools!! Blood or mucus in stools!! Abdominal pain!! Infantile colic!! Food refusal or aversion!! Constipation!! Perianal redness!! Pallor and tiredness!! Faltering growth with one or more GI symptoms or significant atopic eczema

14 Respiratory symptoms IgE!! Nasal itching, sneezing, rhinorrhoea or congestion (with or without conjunctivitis) Non IgE!! Cough, chest tightness, wheeze and shortness of breathe!! Cough, chest tightness, wheeze and shortness of breath!! Anaphylaxis and systemic allergic reactions

15 When to suspect food allergy!! Immediate reaction to food!! Non response to standard therapy in:!! Eczema!! Gastro-oesophageal reflux disease!! Constipation!! Chronic gut symptoms!! Asthma!! BUT check r taking standard therapy properly

16 IgE or Non-IgE mediated

17 Common food allergens

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19 Prevalence of food allergy

20 Natural History!! Milk and egg outgrow 80% by 5 years!! May tolerate BAKED products beforehand!! Encourage eating these to bring on tolerance to raw/lightly cooked foods!! Wheat and soya outgrow 80% by 5 years!! Peanuts / Tree Nuts outgrow 20% by 5 years!! Much more likely life long

21 Impact of Food Allergy Diagnosis!! 39% longer to shop!! Significantly greater expense!! Quality of life scores worse than Type I IDDM!! Risk of compromised nutrition!! Risk of fatal reaction!! Long term impact on feeding behaviours

22 Diagnosis of IgE mediated food allergy!! History can your child eat a whole helping?!! At best only 50% positive challenge with good history!! Outgrowing allergy!! Incorrect identification of food!! Non-allergic cause of reaction!! Allergy testing!! Help to show evidence of Sensitivity, history key to determine likelihood of Reactivity!! Food challenges

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24 Sensitization!! Huge problem leading to over diagnosis and unnecessary dietary restriction!! Avoid panels for food testing!! Food causing eczema positive tests reflect real allergy only 30-65% of the time!! 85% of eczema patients have specific IgE!! Food diary looking for associations first!! Some benefit testing for common foods pre weaning!! NEGATIVE tests suggest no food allergy >95% of the time

25 Skin Prick Testing

26 Skin Prick Testing!! Requires specific training!! Immediate results in 15mins!! Does a positive skin test imply allergy?!! No but it makes it more likely!! Can be sensitised but not allergic!! Does a negative skin test exclude allergy?!! No but it makes it less likely!! If high clinical suspicion consider sige or OFC!! > 95% PPV for egg/milk/peanut 7-8mm+!! Size of wheal correlates with likely allergy NOT reaction

27 Specific IgE!! Measure levels of food-specific IgE!! Not influenced by drugs, skin disease and is safe!! Time consuming but tests for > 200 foods available!! Does a positive sige imply allergy?!! No but it makes it more likely!! Can be sensitised but not allergic!! Does a negative sige exclude allergy?!! No but it makes it less likely!! Values available for common foods PPV > 95%!! Phadia ImmunoCAP only validated sige test and other technologies NOT comparable

28 Specific IgE and PPVs

29 Diagnosis!! Consider allergy tests giving 3 possible results!! LOW!! Skin Prick Test 0-2mm!! Specific IgE < 0.7kU/l!! MEDIUM!! Skin Prick Test 3-7mm!! Specific IgE up to 95% PPV!! HIGH!! Skin test! 8mm!! Specific IgE > 95% PPV

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32 UK Paediatric Allergy Clinics / / / / / / /US / // 22% had used CAM / // /diagnostic tests / // 18% used CAM therapies / // 49% didn t tell doctor /Michaelis L, 2006 Ko et al. Use of CAM by food allergic patients. /Annals ofallergy,asthma & Immunology 2006.

33 Types of CAM Ancient Wisdom Blinding with science / / / / Kinesiology / Homeopathy / Ayuverda / Acupuncture / Snake Oil, John Diamond 2001, Vintage Antibody tests Leucocytotoxic test Bioenergetic /medicine (VEGA) / ALCAT

34 IgG testing Use IgG4 levels to specific foods as a marker of intolerance (not allergy) Recommended for patients suffering from wide variety of complaints inc lethargy, joint pains, migraine, bloating, eczema Available from many providers, mainly postal kits via internet Screening test 20, extended panels

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36 Does it work? IgG4 to foods higher in IBS patients but also high in many healthy volunteers Controversial role of excluding foods identified by IgG in IBS more research needed No published data in children or in other conditions Clear statements from numerous international societies Atkinson W et al, 2004: Food elimination based on IgG antibodies in irritable bowel syndrome: a randomised controlled trial. Gut 53, Zuo et al. Alterations of food antigen-specific serum immunoglobulins G and E antibodies in patients with irritable bowel syndrome and functional dyspepsia. Clin ExpAllergy Jun;37(6): Zar S et al. Food-specific IgG4 antibody-guided exclusion diet improves symptoms and rectal compliance in irritable bowel syndrome. Scand J Gastroenterol Jul;40(7):800-7.

37 Position statements The significance of IgG anti-food antibodies is particularly uncertain since the sera of many children with such antibodies in their serum tolerate the foods in question perfectly well. (AAAAI, 2006) IgG antibodies to food are commonly detectable in healthy adult patients and children, independent of the presence of absence of food-related symptoms. There is no credible evidence that measuring IgG antibodies is useful for diagnosing food allergy or intolerance, nor that IgG antibodies cause symptoms. (ASCIA) We recommend further research into the relevance of IgG antibodies in food intolerance and...urge [health professionals] not to endorse the use of these products until conclusive proof of their efficacy has been established (House of Lords Report: Allergy 2007)

38 Case 1!! 12 year old boy!! Symptoms of itchy throat when ate peanut!! Asthma!! Eats nutella ok!! Hay fever symptoms!! Never had allergic reaction before!! Blood test sige 25!! What do you do?

39 Questions from mother?!! Will reactions get worse?!! Depends on amount/alcohol/asthma!! Must he avoid all nuts?!! Easier to do that but in own home carry on what eats at moment. Can test!! Never do mixed nuts RAST which is it??!! Does he need epipen!! YES, all food allergy with asthma needs a pen. Who s going to show how to use it?

40 Case History 2

41 Case History 3

42 Case 4!! 4 month old!! Exclusively breastfed!! Mother started introducing formula!! Describes rash round face, lip swelling, crying 10 mins after sucking on bottle!! Known eczema!! What would you do? What type of allergy?!! Can you test for this?

43 Case 5!! 4 month old!! Exclusively breastfed!! Mother started introducing formula!! Seems more upset, loose stools, crying++!! Mother thinks (not so) silent reflux!! Hydrocortisone not working for eczema!! What would you do? What type of allergy?!! Can you test for this?

44 Key points in milk allergy!! Is it IgE or non-ige mediated?!! IgE mediated should be tested to confirm!! Non-IgE mediated is a community problem!! Is it severe CMPA?!! Faltering growth, severe eczema, bloody stools, anaphylaxis, exclusive breast fed infant!! Persistent symptoms not responding to treatment!! Moderate-severe eczema!! Reflux!! Constipation

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48 Which formula?!! First choice extensively hydrolysed formula!! Neutramigen!! Pepti (better palatability maybe)!! Avoid other animal milks!! Soya milk > 6 months!! Rice milk > 5 yrs!! Consider Amino acid formula (> 2x price of ehf)!! Failure to thrive!! Anaphylaxis (10% ehf allergic too)!! Severe eczema!! Severe GI symptoms bloody stools, irritable ++!! Symptoms in breastfed infant / no response to ehf

49 Which formula?!! First choice extensively hydrolysed formula!! Avoid other animal milks!! Soya milk > 6 months!! Rice milk > 5 yrs!! Consider Amino acid formula (Neocate or Elecare)!! Failure to thrive!! Anaphylaxis (10% ehf allergic too)!! Severe eczema!! Severe GI symptoms bloody stools, irritable ++!! Symptoms in breastfed infant / no response to ehf

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51 Re-challenge if non-ige!! Symptoms will improve within 4 weeks!! Majority not severe CMPA!! At home, increase proportion of formula in feeds gradually over few days look for return of symptoms!! If return:!! Continue cows milk free diet until 9-12 mths or for at least 6 mths THEN rechallenge!! BUT does child have eczema/other allergies!! If tolerates soya in weaning diet, consider changing to soya formula from 9 mths!! Involve dieticians to help with weaning/alternatives

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54 Rapid progression of symptoms

55 3*-2 B2 &*8()/ Asthma Angioedema Shock DIC Drug Venom Food Pumphrey 2004 Curr Op Allergy & Clin Immunol 4:285

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57 Initial Treatment!! Immediately give ADRENALINE im!! Phone 999 and start oxygen!! WHEEZE!! Sit up right!! Give salbutamol 5 mg neb if wheeze!! Give adrenaline 5mls of 1:1000 ned if stridor!! COLLAPSE!! Lie down with legs elevated!! Recovery position if vomit (common!)

58 Still no ambulance!!! REPEAT Adrenaline in 5-10 mins if No improvement or still resp distress!! Monitor for change in symptoms re positioning!! May need 3 rd dose:!! Adrenaline not in muscle (needle length issue)!! Wrong dose ideal dose 0.01mg / kg = adult need 2!! Wrong technique

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60 Food allergy deaths UK

61 !! 40% had been provided adrenaline pens!! Only 50% used!! >50% of deaths had previously mild reactions that didn t warrant an adrenaline pen!! One teenager ate chocolate bar thinking the pen would save her!! >50% had not received professional advice on their food allergy!! 43/48 took daily treatment for asthma

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65 Which children need adrenaline pen!! If they have had confirmed anaphylaxis!! If they have asthma and on regular preventer!! If they have difficulty accessing healthcare!!? Teenagers? All nut allergy!!? If parents request it all cases should discuss

66 !! Dose 0.01mg/kg!! Only 2 doses available 0.15 / 0.3!! Check weight!! Change from 0.15 to 0.3 at 25Kg or perhaps sooner if asthmatic or previous reaction needing 0.3

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69 If you prescribe Epipen!! Must prescribe it appropriately!! Must show how to use it!! 2015 study, 146 patients using Epipen were asked how they use device!! 16% used device properly!! Common errors!! Not holding for 10 seconds!! Failure to place needle end on thigh!! Not using enough force to activate injection!! Do you know how to use it?

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71 Is it allergy doctor?!! It must be, do some tests!

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73 Yes there is a link!! Infants with eczema by 12 months!! 6 x more likely have egg allergy!! 11 x more likely peanut allergy!! First focus on comprehensive skin care:!! Bathing and moisturisers!! Topical steroids and other medications!! Bleach baths (recurrent infections)!! Wet wraps / nightime petroleum jelly!! Need to get skin better FIRST before looking for effect of restriction diet

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76 Yes but am sure it is allergy!!! Proper skin care not working?!! SEVERE eczema difficult to treat!! Eczema flares consistently associated with specific food or trigger (better when away from cat?)!! If food might be hours or days later!! V rare to think 1 food is the problem!! Food most likely egg, wheat and peanut!! Poor growth in child

77 Allergy testing!! Targeted Targeted Targeted!! What happens when eat the food!! Did poor control coincide with introduction of food!! Is it a common food allergy cause!! Get basics right!! Empower families!! No panels, positive test confirm with restriction and reintroduction if no IgEmediated reaction

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79 Acute asthma

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83 Location of death!! 45% of all died from asthma without any medical help during final episode!! 11% tried to get help but died before any help arrived!! 80% of < 10yrs!! 72% of 10-19yrs!! Died before reaching hospital

84 Personal asthma action plan!! Only 23% of the 195 patients that died was there a record of them having a PAAP!! Only 4/28 children had a PAAP!! RECOMMENDATION!! All people with asthma should have PAAP that mentions: 1.! Triggers and current treatment 2.! How to spot symptoms getting worse and what to do then 3.! What to do in emergency and when to call for help

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87 Typical case!! John, 12 year old boy with asthma!! Taking seretide puffs twice a day!! Presents to GP with 24 hour history of wheeze and breathlessness.!! Taking ventolin 2 puffs every 3 hours at home!! Last course of prednisolone 6 weeks ago!! Missed last asthma review with nurse

88 What are you priorities in 10 minutes?

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90 !! Resp rate!! Heart rate!! Saturations in air!! PFR (> 5yrs) + predicted!! Comment on communication!! Auscultation!! Respiratory distress!! DOCUMENTATION

91 !! Assign a child to most severe grade in which any feature occurs!! If child has received treatment prior to assessments may need to assign a more severe grade

92 NICE asthma quality standards" Feb 2013!! Children who present with asthma should have an assessment of severity

93 Take the opportunity!!! Children who present with an exacerbation should be assessed and control determined BEFORE acute deterioration!! Children aren t brought when they are well!! No children DNA, they should be classified as WNB Was Not Brought (Appleton 2012)!! Back to basics.

94 Levels of Asthma Control ( Characteristic Controlled (All of the following) Partly controlled (Any present in any week) Uncontrolled Daytime symptoms None (2 or less / week) More than twice / week Limitations of activities Nocturnal symptoms / awakening Need for rescue / reliever treatment None None None (2 or less / week) Any Any More than twice / week 3 or more features of partly controlled asthma present in any week Lung function (PEF or FEV 1 ) Normal < 80% predicted or personal best (if known) on any day

95 Back to Basics!! Vast majority of children with asthma should improve on a decent dose of seretide/ symbicort!! Children who are struggling, think of the basics round asthma management

96 Clinical Features that increase probability it is asthma?

97 Assessing control!! Used closed questions.!! NOT how is your asthma = I am ok thanks!! YES do you use your blue inhaler everyday?!! Primary care monitoring should include (BTS)!! Symptom score eg Asthma Control Test!! Number of exacerbations / days off school!! Inhaler technique!! Adherence review prescription frequency!! Do they have an asthma plan?!! Tobacco exposure parents need treatment?!! Growth

98 Risk factors for life threatening asthma!! Using 2 or more ventolin every month!! Admission to hospital past 12 months!! Repeated exacerbations!! Did not attend (should be WNB!)!! Learning difficulty (in parents too)!! History of child abuse!! Previous near fatal asthma!! Need alerts for patients

99 Low adherence!! Very common but difficult to assess!! One study < 15% of children collected sufficient prescriptions!! One study of severe asthmatics at RBH:!! < 50% of children picked up >80% of required meds!! 1/3 rd of children picked up < 50% of meds!! 25% at home visit unable to show a complete set of accessible and in date medications!! Supervision key also:!! 20% of 7yr olds, 50% of 11yr olds left to own devices!! Send printout of collected prescriptions with referral

100 Low adherence!! Review print out of prescriptions!! Mainly ventolin??!! Ask why low adherence, don t be afraid to confront!! Understanding of meds!! Unsupervised!! Time pressures school / double evening dose?!! Don t like spacer -?turbohaler!! Anxiety concerns!! Child taking control? Why? Family dynamics?

101 Inhaler Technique!! First things to check in poor control!! ALWAYS use spacer for inhaled steroids!! Use a mouthpiece in children > 3yrs!! Check if using dry powder device!! Always use combined LABA/ICS!!! asthma deaths when LABA without ICS!! Ensures ICS delivery in children who feel benefit from LABA

102 !! Always use a spacer Steroid inhaler

103 Environment!! The clinic lie never smoke in the house doc!! Remains on clothes!! Passive smoking undoubtedly aggravates symptoms and likely induces steroid resistance!! Aeroallergen avoidance can be helpful so worth referring for SPT or doing RAST esp if pets and suspect allergy.!! Where do they keep inhalers at home?!! HOME VISIT and remember the clues are there as we go through the keyhole.

104 Atopic children are sensitised to allergens present in their local environment Grass pollen HDM Tree pollen Cat Alternaria Horse Dog 377 children aged 6-18 years Leech 2001

105 House dust mite allergy House Dust Mite

106 Practical Dust Mite avoidance Written information BSACI HDM reduction information sheet Remove carpets wooden / lino / laminate floors Vacuum carpets daily - or as often as practical Separate out bunk beds Air bedroom during the day - Open the windows - Remove duvet and hang over banister Wash bedlinen weekly at 60oC Avoid drying clothes over radiators Keep bedrooms clutter free Remove old sofas replace with leather

107 Stuffed animals Freezing for 24 hours kills HDM but doesn t reduce allergen Dodin A & Rak H J Med Entemol 1993;30: Remove wherever possible Keep in a toy box

108 Allergen Avoidance - Pets!! Cats and dogs are a major source of allergens in the home.!! People are not allergic to an animal's hair!! But to an allergen found in the saliva, dander (dead skin flakes) or urine of an animal with fur Although the amount of allergen released can vary between breeds, there are no hypoallergenic breeds.

109 Cat allergen Fel d 1: Salivary protein Preened onto fur and dried into flakes Hormonal control

110 If parents insist on keeping pets: Restrict animal to one area of the house Keep out of bedroom HEPA or electrostatic air filters Especially in the bedroom Remove carpets and reservoirs for allergen collection Especially in bedroom Mattress and pillow covers should be used routinely Tannic acid modest reduction in cat allergen levels but effects short lived when cat is present Cat washing Transient benefit and should be done at least twice a week alongside other methods (Castrate a male / get a female)

111 Practical pet avoidance 1. Test for allergic sensitisation 2. Discuss removal if appropriate - How long have you had the pet? 3. Restrict pet to one part of house 4. Wooden floors / leather sofas etc. If wish to get a new pet: consider contingency plan for rehousing if child develops symptoms

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114 Allergy tests!! History key any test might just show sensitisation so corroborate history!! House dust mite!! Grass pollen May to August!! Tree Pollen Feb - June!! Cat!! Dog!! Should diagnose 90% of allergy component!! Other tests damp / occupation

115 Common case!! Emma 15 years old with allergic rhinitis!! Dropped a grade during mock school exams!! Stops playing sports 2 months a year!! Itchy eyes, runny nose, poor sleep!! Previous eczema!! Pet dog at home!! Lots of runny nose over winter!! On regular piriton + nasal steroid!! How would you manage her?

116 To address!! What are the triggers?!! Does she have seasonal asthma?!! Trial of asthma medication!! Winter symptoms perennial rhinitis or viral colds?!! Skin prick tests / sige!! On a sedating antihistamine change!!! Is she compliant? Technique?!! Check prescriptions / technique

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118 PREVALENCE OFALLERGIC RHINITIS AND ASTHMA Allergic Rhinitis Asthma UK Australia Canada Brazil USA South Africa Germany France Argentina Algeria China Russia UK Australia Canada Brazil USA South Africa Germany France Argentina Algeria China Russia % prevalence % prevalence Study of worldwide prevalence of atopic diseases in 463,801 children years of age. Children self-reported symptoms over 12 months using questionnaires. Adapted from the International Study of Asthma and Allergies in Childhood (ISAAC) Steering Committee. Lancet 1998;351:

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120 !! Prevalence!! Co-morbidities!! Complications!! Quality of Life!! Costs

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125 Newer INS: low bioavailability Bioavailability of currently used steroid sprays % bioavailability % Fluticasone furoate 0.5% Fluticasone propionate 0.5% Mometasone furoate 11% Budesonide 20% Flunisolide Bryson HM, Faulds D. Drugs 1992;43: Daley-Yates PT, Baker RC. Br J Clin Pharmacol 2001;51: Daley-Yates PT et al. Eur J Clin Pharmacol 2004;60: Allen A et al. Clin Ther 2007;29:

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130 Monosensitization Monoallergy Polysensitization Polyallergy Stop Specific Immunotherapy Stop Allergic Rhinitis Allergic Asthma!"#$

131 Sublingual Immunotherapy!! Patient selection:!! Moderate/severe AR affecting daily life!! Confirmed allergy diagnosis!! Adhering to maximum treatment!! Tried allergy avoidance!! Pollen induced rhinitis!! Animal dander / House Dust Mite allergy!! NO perennial asthma!! Advantage over subcut: Noninvasive!! Home delivery!! Much safer

132 2011 SLIT: most common adverse events (children & adults) The majority of reported adverse events were mild to moderate 132 and did not require any treatment.

133 Staloral in practice 2 min under the tongue before swallowing First dose of under the supervision of the doctor : patient education and safety assessment.

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135 Acute Exacerbations/Year Before SLIT 39 children with asthma and rhinitis, allergic to house dust mite were treated for 3 years with HDM SLIT After 3 years of SLIT Complete clinical remission of asthma was recorded in 37 (95 %) patients. Similarly, complete clinical remission of allergic rhinitis was recorded in 32 (82 %) patients. No significant side effects were reported.

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138 Allergy Tips!! Use appropriate tests that are validated and focused on the history!! Over-diagnosis leads to unnecessary worry and dietary restriction!! Nothing beats getting the basics right of care

139 Thank You