6/5/2018. Asthma. What is Asthma? Asthma effects 8.1 million children in the United States and rising

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1 ASTHMA Asthma Statistics in the United States In 2016, an estimated 25.9 million people suffered from asthma 1 In comparison, approximately: 27 million had heart disease 2 * 25.8 million had diabetes million had cancer 4 In 2016, asthma prevalence was % in African Americans 8% in Caucasians 7.2% in Hispanics Marc W. Cromie, Sr.,M.D. Pediatric and Adult allergy, Asthma &Immunology Chattanooga Allergy Clinic Asthma costs the U.S. economy more than $80 billion annually in medical expenses, missed work days and death, according to new research published in the Annals of the American Thoracic Society. *Heart disease includes coronary heart disease, angina pectoris, heart attack, or any other heart condition or disease in patients aged 18 and older. Includes any person alive on January 1, 2009, who had been diagnosed at any sites with active disease and those who were cured. 1. American Lung Association, Epidemiology and Statistics Unit, Research and Program Services Division. Trends in Asthma Morbidity and Mortality. September Accessed April 17, Pleis JR et al. Vital Health Stat. 10(249) Accessed April 17, US Centers for Disease Control and Prevention. Accessed April 17, National Cancer Institute Surveillance Epidemiology and End Results. Accessed April 17, Barnett SB et al. Costs of Asthma in the United States: J Allergy Clin Immunol. 2011;127(1): Asthma Remains a Serious Health Risk in the United States 14.4 million missed school days due to asthma 14.2 million missed work days due to asthma 11.7 million asthma-related healthcare visits 2.1 million asthma-related emergency department visits *Data represented ranges from Annually in the US, approximately...* 439,000 asthma-related hospitalizations 3,388 deaths due to asthma Asthma Asthma effects 8.1 million children in the United States and rising Most common chronic disease in kids and most common cause of school absenteeism Most children with asthma develop asthma symptoms before age 5 American Lung Association, Epidemiology and Statistics Unit, Research and Program Services Division. Trends in Asthma Morbidity and Mortality. September Accessed April 17, What is Asthma? A Chronic, Obstructive, Reversible airways disease characterized by Inflammation, Mucus Secretion, and Bronchoconstriction. 1

2 Pathophysiology Symptoms Cough, wheeze, SOB, increase respiratory rate or work of breathing, chest tightness Fatigue- the child will stop playing, slow down, avoid certain activities Infant may have difficulty feeding, grunt during sucking Symptoms are worse at night and early morning Worse with viral infections, exposure to allergens and irritants (smoke), exercise, emotions, and changes in weather or humidity Worse with activity The Dreaded Cough How do you diagnose asthma? COUGHING ALONE CAN BE ASTHMA!!!! -The patient may NEVER wheeze -Think asthma when the parents say. he coughs at night all the time when she gets a normal cold, she gets such a bad cough, and keeps it longer after running and playing, he seems to start coughing and comes inside she coughs when she s at her grandma s There is no perfect test for diagnosing asthma Can be quite difficult History Physical exam Pulmonary Function Testing FENO (Fractionated Exhaled Nitric Oxide) Response to medications Spirometry FeNO Testing as a Tool to Aid in Implementing Asthma Treatment Guidelines Diagnosis and Initiating Therapy Circassia Pharmaceuticals

3 LOW FeNO level FeNO Interpretation 1 INTERMEDIATE/ INCREASING FeNO level* HIGH FeNO level Inhaled steroids. <25 ppb in adults <20 ppb in children Eosinophilic inflammation less likely Symptomatic patients unlikely to benefit from trial of or additional ICS therapy; consider other possible etiologies ppb in adults ppb in children Cautious interpretation; based on clinical judgment, consider initiating trial of or increasing ICS therapy/adherence and monitor change in FeNO levels >50 ppb in adults >35 ppb in children Eosinophilic inflammation likely Symptomatic patients likely to benefit from trial or increase in ICS/anti-Th2 therapy; investigate allergen exposure Treats the Inflammation and Mucus Secretion in Asthma Remember, albuterol does not treat inflammation at all! Zero! Nothing! Preventative medication FeNO, fractional exhaled nitric oxide; GERD, gastroesophageal reflux disease. *Increasing defined as >40% increase from previous stable FeNO level. Chronic cough and/or wheeze and/or shortness of breath for >6 weeks. For example, rhinosinusitis, bronchiectasis, primary ciliary dyskinesia, anxiety-hyperventilation, cardiac disease, GERD, or vocal cord Circassia dysfunction. Pharmaceuticals Dweik et al. Am J Respir Crit Care Med. 2011;184: Other meds Rescue Inhalers Montelukast ICS/LABA combo LAMA Biologics/monoclonal Abs Omalizumab=Xolair Mepolizumab=Nucala Reslizumab=Cinqair Benralizumab=Fasenra Bronchodilators Ventolin, ProAir, Proventil, Xopenex Relax muscles around the airway Rescue medication only Puffers should be used with a spacer Can be nebulized as well Albuterol How to administer albuterol I write for 2-4 puffs every 4-6 hours as needed 1 puff every 30 seconds ER studies suggest 6-8 puffs equals 1 nebulizer treatment 1 puff of albuterol = 90 mcg 1 nebulizer vial = 2.5 mg albuterol 3

4 Patients, % (Weighted Prevalence) % of Patients With Uncontrolled Asthma Side effects Jittery, increased heart rate, nervous feeling Should help in about 5 minutes Can use a spacer or not Are Patients in the United States Achieving Asthma Control on Their Current Therapy? Asthma Control of Adults in Primary Care Objective To evaluate the level of uncontrolled asthma in adult patients Study Design Cross-sectional, epidemiological survey administered at 35 geographically distributed primary care provider (PCP) sites across the US 2238 adults ( 18 years of age) with a self-reported physician diagnosis of asthma Brief, self-administered questionnaire included: The validated ASTHMA CONTROL TEST and Questions about demographics, health behaviors, medical history, current asthma medication use, and reason for current PCP visit Survey was conducted from January 25, 2008, to May 2, 2008 Asthma Control of Adults in Primary Care Age (Years), Mean (SD) 46.7 (15.7) 46.3 (15.9) 46.7 (15.7) Female n (%) 1601 (72%) 602 (70%) 935 (73%) Race/ethnicity n (%) Caucasian 1483 (68%) 557 (66%) 877 (69%) African American 262 (12%) 97 (11%) 154 (12%) Hispanic 246 (11%) 119 (14%) 118 (9%) Others 206 (9%) 74 (9%) 119 (9%) Patient-described severity n (%) Mild 1061 (49%) 324 (39%) 708 (56%) Moderate 971 (45%) 434 (52%) 497 (40%) Severe 137 (6%) 79 (9%) 51 (4%) Body mass index Overall N=2238 Respiratory Visits N=861 Nonrespiratory Visits N=1289 <20 kg/m 2 63 (3%) 29 (4%) 33 (3%) kg/m (48%) 388 (47%) 607 (49%) >30 kg/m (49%) 410 (50%) 598 (48%) ASTHMA CONTROL TEST is a trademark of QualityMetric Incorporated. Mintz M et al. Curr Med Res Opin. 2009;25(10): SD=standard deviation Mintz M et al. Curr Med Res Opin. 2009;25(10): % of Adults With Asthma Visiting a PCP for Any Reason Had Uncontrolled Asthma Nearly Half of Patients With Asthma Visiting a PCP for a Nonrespiratory Reason Had Uncontrolled Asthma % 80% 72% 70% % 60% 50% 58% 48% 30 40% 20 30% 10 20% 0 Controlled Uncontrolled 10% Results are from a cross-sectional epidemiological survey conducted between January 25 and May 2, 2008, among patients in PCP offices, regardless of reason for visit. Data are presented for 2238 adults with a self-reported physician diagnosis of asthma. Patient asthma was classified as uncontrolled if ASTHMA CONTROL TEST score was 19. 0% Total Respiratory Reason Nonrespiratory Reason Results are from a cross-sectional epidemiological survey conducted between January 25 and May 2, 2008, among patients in PCP offices, regardless of reason for visit. Data are presented for 2238 adults with a self-reported physician diagnosis of asthma. Patient asthma was classified as uncontrolled if ASTHMA CONTROL TEST score was 19. Mintz M et al. Curr Med Res Opin. 2009;25(10): Mintz M et al. Curr Med Res Opin. 2009;25(10):

5 How Much Rescue Medication Are Asthma Patients Using? Use of SABA >2 days a week for symptom relief (not prevention of exerciseinduced bronchospasm) generally indicates inadequate control and the need to step up treatment. 1 Use of a SABA several times per day may indicate very poorly controlled asthma. 1 Overuse of SABA is a risk factor for subsequent exacerbations. Requiring ED visits, hospitalizations, and/or oral corticosteroid dispensing 2,3 Most albuterol inhalers have 200 puffs per canister, equaling 100 doses* If a patient uses 2 doses per week, a canister will last approximately 1 year If a patient uses 1 dose per day, the patient would use approximately 4 canisters per year 2007 National Heart, Lung, and Blood Institute Asthma Guidelines SABA = short-acting beta 2-agonists *Calculation for canister containing 200 inhalations, with patient using 2 inhalations per dose. Additional puffs may be required for priming of the canister. 1. National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program. asthgdln.htm. Accessed April 17, Schatz M et al. Chest. 2006;130: Schatz M et al. J Allergy Clin Immunol. 2006;117(5): Definitions: Severity, Control, and Responsiveness Assessment and monitoring of asthma are closely linked to the concepts of severity, control, and responsiveness Severity Control Responsiveness The intrinsic intensity of the disease process; most easily and directly measured in a patient who is not currently receiving long-term control medications (eg, ICSs) The degree to which the manifestations of asthma (symptoms, functional impairments, and risks of untoward events) are minimized and the goals of therapy are met The ease with which control is achieved by therapy The Goals of Asthma Therapy Reduce Impairment Prevent chronic and troublesome symptoms Require infrequent use ( 2 days/week) of short-acting beta 2 -agonists (SABA) for symptom relief Maintain (near) normal pulmonary function Maintain normal activity levels Meet patients and families expectation of, and satisfaction with, asthma care Reduce Risk Prevent recurrent exacerbations of asthma and minimize the need for emergency department visits or hospitalizations Prevent progressive loss of lung function; for children, prevent reduced lung growth Provide optimal pharmacotherapy with minimal or no adverse effects ICS=inhaled corticosteroid. National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program. Accessed April 17, National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program. Accessed April 17, Assessing Asthma Severity and Control Assessing Severity (Patients Aged 5 Years) Patients not currently taking long-term asthma control medications (eg, ICSs) Assess asthma severity Initiate/maintain/adjust asthma therapy Patients taking long-term asthma control medications (eg, ICSs) Assess asthma control Assess Impairment (based on patient s/caregiver s recall of previous 2 to 4 weeks and spirometry) Symptoms Nighttime awakenings SABA use for symptom control (not prevention of EIB) Interference with normal activity Lung function FEV 1, FEV 1/FVC Risk Exacerbations requiring oral systemic corticosteroids Classifying Severity Assign to the most severe category in which any feature occurs Intermittent Mild Persistent Moderate Persistent Severe Persistent EIB=exercise-induced bronchospasm; FEV 1=forced expiratory volume in 1 second; FVC=forced vital capacity. Adapted from: National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program. Accessed April 17, National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program. Accessed April 17,

6 Classifying Asthma Severity: Children 5 to 11 Years of Age Components of Severity Classification of Asthma Severity: Children 5 11 Years of Age Who Are Not Currently Taking Long-Term Asthma Control Medication Persistent Classifying Asthma Severity: Youths 12 Years of Age and Adults Components of Severity Classification of Asthma Severity: Youths 12 Years of Age and Adults Who Are Not Currently Taking Long-Term Asthma Control Medication Persistent Impairment Intermittent Mild Moderate Severe >2 days/week Symptoms Daily Throughout the day but not daily > 1x/week Nighttime awakenings 2x/month 3 4x/month Often 7x/week but not nightly Short-acting beta 2-agonist >2 days/week use for symptom control Daily Several times per day but not daily (not prevention of EIB) Interference with normal activity None Minor limitation Some limitation Extremely limited Normal FEV between FEV 1= 60%-80% 1 exacerbations FEV 1= >80% predicted predicted FEV 1 < 60% predicted Lung function FEV 1>80% predicted FEV 1/FVC >80% FEV 1/FVC = FEV 1/FVC <75% FEV 1/FVC >85% 75% 80% Impairment Normal FEV 1/FVC: 8 19 y 85% y 80% y 75% y 70% Intermittent Mild Moderate Severe >2 days/week Symptoms Daily Throughout day (not daily) >1 time/week Nighttime awakenings 2 times/month 3 to 4 times/month Often 7 times/week (not nightly) SABA use for symptom >2 days/week control (not prevention Daily Several times daily (not daily and not more of EIB) than 1x on any day) Interference with normal activity None Minor limitation Some limitation Extremely limited Normal FEV 1 between FEV 1 <60% FEV 1 >60% but <80% exacerbations FEV 1 >80% predicted predicted Lung function predicted FEV >80% predicted FEV 1/FVC normal FEV 1/FVC 1 FEV 1/FVC reduced 5% FEV 1/FVC normal reduced >5% 0 1/year* 2/year* Exacerbations requiring oral Consider severity and interval since last exacerbation Risk systemic corticosteroids Frequency and severity may fluctuate over time for patients in any severity category Relative annual risk of exacerbations may be related to FEV 1 Level of severity is determined by both impairment and risk. Assess impairment domain by patient's/caregiver's recall of the previous 2 to 4 weeks and spirometry. Assign severity to the most severe category in which any feature occurs. Adapted from the NIH guidelines. *At present, there are inadequate data to correspond frequencies of exacerbations with different levels of asthma severity. In general, more frequent and intense exacerbations (eg, requiring urgent, unscheduled care, hospitalization, or ICU admission) indicate greater underlying disease severity. For treatment purposes, patients who had 2 exacerbations requiring oral systemic corticosteroids in the past year may be considered the same as patients who have persistent asthma, even in the absence of impairment levels consistent with persistent asthma. National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program. Accessed April 17, to 1/year* 2 /year* Exacerbations Consider severity and interval since last exacerbation Risk requiring oral systemic Frequency and severity may fluctuate over time corticosteroids Relative annual risk of exacerbations may be related to FEV 1 Level of severity is determined by both impairment and risk. Assess impairment domain by patient s/caregiver s recall of the previous 2 to 4 weeks and spirometry. Assign severity to the most severe category in which any feature occurs. Adapted from the NIH guidelines. *At present, there are inadequate data to correspond frequencies of exacerbations with different levels of asthma severity. In general, more frequent and intense exacerbations (eg, requiring urgent, unscheduled care, hospitalization, or ICU admission) indicate greater underlying disease severity. For treatment purposes, patients who had 2 exacerbations requiring oral systemic corticosteroids in the past year may be considered the same as patients who have persistent asthma, even in the absence of impairment levels consistent with persistent asthma. National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program. Accessed April 17, Assessing Control (Children Aged 5-11 years) Assess Impairment (based on patient s/caregiver s recall of previous 2 to 4 weeks and spirometry) Symptoms Nighttime awakenings Interference with normal activity SABA use for symptom control (not prevention of exercise-induced bronchospasm [EIB]) Lung function FEV 1 or peak flow; FEV 1/FVC Risk Exacerbations requiring oral systemic corticosteroids Reduction in lung growth Treatment-related adverse effects Classifying Control Assign to most severe category in which any feature occurs Well Controlled Not Well Controlled Very Poorly Controlled Assessing Control (Patients Aged 12 years) Assess Impairment (based on patient s recall of previous 2 to 4 weeks and spirometry) Symptoms Nighttime awakenings Interference with normal activity SABA use for symptom control (not prevention of exercise-induced bronchospasm [EIB]) Validated questionnaire ATAQ, ACQ, ASTHMA CONTROL TEST Lung function FEV 1 or peak flow Risk Exacerbations requiring oral systemic corticosteroids Progressive loss of lung function Treatment-related adverse effects Classifying Control Assign to most severe category in which any feature occurs Well Controlled Not Well Controlled Very Poorly Controlled National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program. Accessed April 17, ATAQ=Asthma Therapy Assessment Questionnaire; ACQ=Asthma Control Questionnaire. National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program. Accessed April 17, Classifying Asthma Control: Children 5 to 11 Years of Age Components of Control Symptoms Classification of Asthma Control: Children 5 11 Years of Age Well Controlled Not Well Controlled Very Poorly Controlled but not more than once on each day >2 days/week or multiple times on Throughout the day Nighttime awakenings 1x/month 2x/month 2x/week Classifying Asthma Control: Youths 12 Years of Age and Adults Components of Control Symptoms Classification of Asthma Control: Youths 12 Years of Age and Adults Well Controlled Not Well Controlled Very Poorly Controlled but not more than once on each day >2 days/week Throughout the day Nighttime awakenings 2 2 times/month 1 to 3 times/week 4x/week Interference with normal activity None Some limitation Extremely limited Impairment Interference with normal activity None Some limitation Extremely limited Short-acting beta 2-agonist use for >2 days/week Several times per day symptom control (not prevention of EIB) Impairment SABA use for symptom control (not prevention of EIB) FEV 1 or peak flow 2 >2 days/week Several times per day >80% predicted/ 60% to 80% predicted/ <60% predicted/ 80% Lung function: FEV 1 or peak flow FEV 1/FVC >80% predicted or >80% predicted 60% 80% predicted or 75% 80% predicted <60% predicted or <75% predicted Validated questionnaires Asthma Therapy Assessment Questionnaire Asthma Control Questionnaire ASTHMA CONTROL TEST * 20 1 to to 19 3 to 4 NA 15 Risk Exacerbations requiring oral systemic corticosteroids Reduction in lung growth Treatment-related adverse effects 0 1/year 2/year Consider severity and interval since last exacerbation Evaluation requires long-term follow-up Medication side effects can vary in intensity from none to very troublesome and worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk. Risk Exacerbations requiring oral systemic corticosteroids Progressive loss of lung function Treatment-related adverse effects 0 to 1/year 2/year Consider severity and interval since last exacerbation Consider severity and interval since last exacerbation Evaluation requires long-term follow-up care Medication Evaluation side effects requires can long-term vary in intensity follow-up care from none to very troublesome and worrisome. The level of intensity does not Medication side effects can vary in intensity from none to very troublesome correlate and worrisome. to specific The level levels of intensity of control does not but correlate should to be specific considered levels of control but should in the be overall considered assessment in the overall of assessment risk. of risk. Adapted from the NIH guidelines. National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program. Accessed April 17, Values of 0.76 to 1.4 are indeterminate regarding well-controlled asthma. Adapted from the NIH guidelines. National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program. Accessed April 17,

7 Clinical Assessments Before Stepping Up or Stepping Down Asthma Therapy Regular follow-up contacts at 1- to 6-month intervals, depending on the level of control Consider 3-month intervals if a step down in therapy is anticipated Step up if necessary; step down if possible Stepping Up Stepping Down Assessing Asthma Control in Children, Adolescents, and Adults Symptoms Nighttime awakenings Interference with normal activity NIH Criteria for Well-Controlled Asthma: Impairment Domain SABA use for symptom control (not prevention of EIB) 2 times/month (youths 12 years and adults) 1 time/month (children 5 to 11 years) None Review adherence, inhaler technique, environmental control, and comorbid conditions. If alternative* treatment option is used in a step, and asthma is still uncontrolled, discontinue and use preferred* medication before stepping up If a clear and positive response for 3 months:. Attempt a careful step down to identify the lowest dose required to maintain control FEV 1 or peak flow FEV 1/FVC Validated questionnaires (adults and adolescents only) Asthma Therapy Assessment Questionnaire Asthma Control Questionnaire ASTHMA CONTROL TEST Patients with asthma need to meet all criteria to be considered well controlled. * Values of 0.76 to 1.4 are indeterminate regarding well-controlled asthma. >80% predicted/ >80% (children aged 5 to 11 years) * 20 *For NIH definitions, see Figure 4-1a, Figure 4-1b, and Figure 4-5 of the Guidelines. National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program. Accessed April 17, EIB=exercise-induced bronchospasm; SABA=short-acting beta 2-agonist. National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program. Accessed April 17, Assessing Asthma Control in Children, Adolescents, and Adults Asthma Goals Exacerbations requiring oral systemic corticosteroids NIH Criteria for Well-Controlled Asthma: Risk Domain Progressive loss of lung function (youths 12 years and adults) or reduction in lung growth (children aged 5 to 11 years) Treatment-related adverse effects 0 to 1/year. Consider severity and interval since last exacerbation Evaluation requires long-term follow-up care Medication side effects can vary in intensity from none to very troublesome and worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk NIH Asthma Guidelines recommended actions for well-controlled asthma include the following: Schedule regular follow-ups every 1 to 6 months to maintain control Consider step down if well controlled for at least 3 months Your clinical judgment is important in considering whether patients asthma is well controlled; consider both impairment and risk domains. Lead a happy, healthy normal life Participate in any sport (except SCUBA) Be active, run around and play Be able to sleep through the night without coughing No missed school or work Normal lung functions National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program. Accessed April 17, Allergy Central Allergic Diseases Marc W. Cromie Sr,, M.D. Chattanooga Allergy Clinic N e 7

8 Objectives Review diseases that can be allergic Describe allergy testing Discuss groups of allergens Review common allergy medicines Discuss treatment of allergic disease Answer questions Allergic Diseases Hay fever Asthma Anaphylaxis Eczema Hives Food reactions Drug reactions Insect sting reactions What is Allergy? Allergic reactions are marked by a very specific reaction by the immune system Triggered by otherwise harmless substances Characterized by release of histamine and other inflammatory chemicals Many physical reactions are not allergic Allergic Diseases For each of these diseases, some people have allergy as a trigger, some don t Evaluation by an allergist can help to identify allergies and assess their significance Allergy Diagnosis History Physical Exam Allergy Testing if indicated Skin testing Blood Testing Other tests as needed Spirometry Skin Testing Skin prick testing Intradermal testing Allergy Diagnosis 8

9 Pollens Common Allergens Fungi or Molds Common Allergens Trees Grasses Weeds Spring Summer Fall Common Allergens Indoor allergens Foods Common Allergens Dogs Cockroach Peanut Shrimp Egg Milk Cats Dust Mite Soy Fish Wheat Tree Nuts Common Allergens Common Allergens Drugs Penicillin Sulfa antibiotics Aspirin Insect Stings Hornet Fire Ant Yellow Jacket Paper Wasp 9

10 Common Irritants Not true allergens, but can cause problems Diseases caused by Allergies Hay fever Asthma Food allergy Anaphylaxis Perfume Chemicals Smoke Pollution Hay Fever Itchy, watery eyes Runny nose Post Nasal Drip Itchy Nose Sneezing Congestion Hay Fever Usually due to Allergies Early Spring- Tree pollen Late Spring/Summer- Grass Pollen Fall- Weed Pollen (like Ragweed!) Year round (dust mite, mold, pets) Can lead to school (and work) problems Absenteeism Presenteeism, sedation, poor performance Due to lack of sleep or medicine side effects The Allergic March Starts with food allergy or eczema Child then develops hay fever Asthma follows Asthma is a bad disease Can we prevent this? Maybe! Allergy Treatments Avoidance Pets Dust Mites Foods Drugs 10

11 Hay Fever Treatments Medications Nasal steroids Antihistamines Decongestants Eye drops Montelukast Nasal saline irrigations Allergy Shots Allergy Treatments Injections of things you re allergic to with slowly increasing doses Usually requires at least 3-5 years Induces changes in the immune system away from allergic reactions Not possible with foods or drugs May halt the Allergic March Allergy Treatments Food Allergy Allergy Drops and Allergy tablets Oral treatments (either under the tongue or tablets) Tablets recently FDA approved (grass tablets and ragweed tablets) Mostly for monosensitized patients Insurance may not pay for this treatment 25% of the population thinks they have food allergy 4-6% of children actually do have food allergy Less than 2% of adults have food allergy Mostly to peanuts, tree nuts, and seafood What is Food Allergy? What is Food Allergy? A colicky baby? A child with a stomach ache, bloating, and gas after eating ice cream? An infant with prolonged loose stools after rotavirus infections? A child with vomiting and diarrhea after eating potato salad at a picnic? A wired teenager after two liters of Jolt Cola? Allergy vs. Intolerance The immune system causes allergy Eczema, hives, anaphylaxis Many factors can cause intolerance Lactose intolerance, milk protein intolerance Galactosemia Celiac Disease 11

12 Food Allergy Diagnosis Food Allergy Diagnosis If food allergy is suspected, your allergist will: Skin test to the most common foods Skin test to any other suspected foods Possibly send blood work for food allergens Skin testing is more accurate and less expensive per test than blood Diagnosis of food allergy requires a positive test AND a positive history If a child has a positive test and can eat that food without problem, they can continue to eat that food cautiously Food Allergy Symptoms Food Allergy Eczema Hives Vomiting/Diarrhea Nasal symptoms Anaphylactic Shock Many food allergies will be outgrown: ~70% milk, wheat, and egg outgrown <15% peanut allergy outgrown 5% tree nut allergy outgrown Seafood and nut allergy often persist to adulthood Frequent cause of fatal anaphylaxis Anaphylaxis Deadly Allergy Signs of Anaphylaxis Increasingly common Can be due to foods, drugs, insect stings and many more Deaths are uncommon with RAPID treatment In most fatalities, there was a delay in recognition and in giving EpiPen % have hives or swelling Wheezing Voice changes Difficulty swallowing/throat swelling Vomiting/diarrhea (common with foods) Low blood pressure Loss of consciousness 12

13 Treatment of Anaphylaxis EpiPen, EpiPen, EpiPen Same thing as adrenaline Give EpiPen Jr for children under 60 pounds Seek medical care after giving Epi Liquid Benadryl Oral or IV steroids not as important initially Key Points- Anaphylaxis Know who is at risk Severe food allergy Insect sting allergy EpiPen or EpiPen Jr should be available at all times Field trips Outside during recess (esp with insect allergy) Have liquid Benadryl on hand Works faster than pills Key Points- Anaphylaxis If a child is severely food allergic: Make sure other children wash hands after eating this food Tables, desks and toys should be thoroughly washed after meals Parents should have option of bringing a safe goody bag for the food allergic child Other parents can be asked to avoid sending that type of food to class Marc Cromie, M.D. (423) The End Thank You! N e 13