Improving Self Care with Allergy New Zealand and ASCIA Resources Dr Kylie Morse, Wellington GP Allergy NZ Board Member Associate Member ASCIA 1 Acknowledgements Allergy New Zealand for providing the depth of information and support that many families need to manage allergies, including mine My children, who have provided me with the impetus to improve allergy education, and not let multiple allergies affect their development ASCIA for use of their slides and resources 2 1
Overview What patients want to know: What is allergy? Why is it increasing and changing? How to manage anaphylaxis immediate and long term Who would benefit from adrenaline auto-injectors? Action plans The role of the GP Further information, resources and training 3 Mechanism of IgE mediated allergy 4 2
Signs and symptoms of mild or moderate allergic reactions Swelling of lips, face, eyes Hives or welts Tingling mouth Abdominal pain, vomiting (these may be signs of anaphylaxis especially in insect allergy) 5 What is anaphylaxis? Any acute onset of hypotension or bronchospasm or upper airway obstruction where anaphylaxis is considered possible, even if typical skin features are not present OR Any acute onset illness with typical skin features (urticarial rash or erythema/flushing, and/or angioedema), PLUS involvement of respiratory and/or cardiovascular and/or persistent severe gastrointestinal symptoms Ref: ASCIA 2010 6 3
Cutaneous symptoms Urticaria, erythema and angioedema may be transient, subtle and easily overlooked In 1 out of 6 fatal food induced anaphylaxis cases, severe cardiovascular symptoms developed without skin or respiratory symptoms Ref: Sampson et al. 1992; Brown, Mullins, Gold. 2006 7 Food allergy Whilst 90% of food allergic reactions are caused by allergic reactions to these foods, any food can cause an allergic reaction 8 4
Risk of anaphylaxis and quality of life Risk of anaphylaxis can: impair QOL induce great anxiety lead to significant social and family disruption QOL in child with severe food allergy has been reported as worse than child with diabetes Insect sting anaphylaxis may lead to fear of outdoors Ref: Noone. 2010 9 Hospital admission rates for anaphylaxis in Australia Ref: Mullins, Dear, Tang. 2009 10 5
Why the rise in food allergy? Proposed explanations include: Hygiene hypothesis Delayed versus early introduction of allergenic foods Methods of food processing Development of allergy to food by skin exposure (especially in severe eczema) This area requires further research 11 Fatal anaphylaxis - associations Asthma Delayed or no administration of adrenaline Age: Teenagers and young adults (food allergy) Adults (insect and drug allergy) Upright posture during anaphylaxis Food allergic individuals eating away from home Initial misdiagnosis Systemic mastocytosis Previous mild/moderate reactions may not rule out subsequent severe or fatal reactions Ref: Bock. 2010; Liew, Williamson, Tang. 2008; Bock. 2007; Pumphrey. 2003; Bock. 2001 12 6
Common causes of fatal food anaphylaxis Cause of APercent eanut 60% 0.190968 Cause 37of Fatal Anaphylaxis ree nut 27% 0.087742 17 ish 2% 0.005161 1 Milk 8% 0.025806 5 Shrimp Shrimp (prawn) 3% 2 62 Milk Fish Tree nut Peanut 0% 10% 20% 30% 40% 50% 60% 70% Percent of Cases Ref: Pumphrey, Garland. 2007 13 Clinical history Key information that assists diagnosis: Nature of symptoms Exposure to potential triggers Timing of reaction in relation to exposure Response to treatment 14 7
Use: Allergy testing: use and limitations Useful to confirm clinical suspicions Single allergen testing; avoid mixes Limitations: Positive test alone does not = allergy Does not correlate well with severity Not available for all triggers (e.g. ticks, NSAID, most antibiotics, anaesthetics) SPT false positives and negatives may occur 15 Allergic reactions may occur on the first known exposure Sensitisation may occur through: Oral exposure in other foods Cutaneous exposure -creams containing unrefined nut oils, direct contact of food to skin especially in children with eczema 16 8
Serum tryptase Serum tryptase should be measured within 4 hours after anaphylaxis Serum tryptase is often normal after food anaphylaxis Ref: Simons, Camargo. 2010; Yunginger, Squillace et al. 1989; Sampson, Menderson et al. 1992. 17 Action for anaphylaxis in clinical settings Remove allergen (if still present) Call for assistance Lay patient flat (if breathing difficult allow to sit but not stand or walk) Give IMI ADRENALINE without delay 1:1000 IMI into mid lateral thigh Repeat every 5 minutes as needed If multiple doses required or a severe reaction consider adrenaline infusion if skills and equipment available Call ambulance to transport patient, state anaphylaxis need adrenaline 18 9
Is it anaphylaxis or asthma? If patient is known to be at risk of anaphylaxis and is unsure if they are experiencing anaphylaxis or asthma follow their ASCIA Action Plan for Anaphylaxis: Give adrenaline autoinjector first Then give asthma reliever medication Call ambulance Continue asthma first aid 19 Why is adrenaline effective? Inhibits the release of inflammatory mediators Reverses the physiological effect of mediators by: Reducing airway mucosal oedema Inducing bronchodilatation Inducing vasoconstriction (thus increasing HR & BP) Increasing strength of cardiac contraction Lasts ~ 15-20 minutes; repeated doses may be needed after 5 minutes if no response Ref: Tole, Lieberman. 2007 20 10
IMI into outer mid thigh is recommended IMI into mid-anterolateral thigh provides rapid plasma and tissue concentrations of adrenaline IM formulation of adrenaline contains 1 mg/ml and may also be labelled as 1:1000 or 0.1% If using adrenaline ampoules ensure appropriate needle length for IMI 21 Adrenaline ampoule dosages Dose 0.01 mg per kilogram (up to 0.5 mg per dose) Source: Adapted from the Australian Immunisation Handbook 9 th Edition 22 11
Adrenaline - possible adverse effects Well tolerated in children as well as adults Transient adverse effects include anxiety, fear, restlessness, headache, dizziness, palpitations, pallor and tremor IV boluses of adrenaline are NOT recommended 23 Medical observation Relapse, protracted and/or biphasic reactions may occur Observe patient for at least 4 hours after last dose of adrenaline Observe overnight if patient: had a severe reaction (hypotension or hypoxia) or required repeated doses of adrenaline or has a history of asthma or biphasic/protracted anaphylaxis or has other concomitant illness or lives alone or is remote from medical care 24 12
Biphasic reactions Ref: Tole, Lieberman. 2007 25 Antihistamines Ineffective for treating anaphylaxis Oral non-sedating antihistamines may be useful for treating itch and urticaria Side-effects of oral sedating antihistamines may be similar to signs of anaphylaxis Injectable promethazine should not be used in anaphylaxis as it can worsen hypotension and cause muscle necrosis 26 13
Adrenaline autoinjectors... are spring-loaded automatic injector devices contain a single pre-measured fixed dose of adrenaline are designed for self-injection or bystander use should be injected into the outer mid-thigh muscle can be administered through a single layer of clothing should be stored in easily accessible, unlocked location with ASCIA Action Plan for Anaphylaxis 27 How to give EpiPen with orange needle end and blue safety release 28 14
How to give Anapen or Anapen Junior 29 Availability of adrenaline autoinjectors to patients EpiPen and Anapen: Are not currently reimbursed by Pharmac in NZ are available without a prescription at full retail price are available on PBS authority prescription in Australia have different administration techniques and are not brand substitutable 30 15
Guidelines for prescribing an adrenaline autoinjector Always recommended if History of anaphylaxis (and continued risk) These patients should be referred to a clinical immunology/allergy specialist May be recommended if History of a generalised allergic reaction and one or more risk factors: Asthma Age (children >5 yrs, adolescents, young adults) Specific allergic triggers Co-morbidity (e.g. ischaemic heart disease) Geographical remoteness from emergency medical care These patients should be referred to a clinical immunology/allergy specialist 31 ASCIA Action Plans: Should be: provided to each patient who is prescribed an adrenaline autoinjector completed and signed by the doctor reviewed annually or if patient s medical condition changes stored with adrenaline autoinjector Can be printed in colour from ASCIA or Allergy New Zealand websites or colour hard copies ordered from ASCIA Advise patient to keep their Action Plan with their autoinjector and provide a copy to their school, childcare or workplace 32 16
Patient s photo and personal details Confirmed allergens Contact details for family and doctor Instructions on how to use the device Adrenaline autoinjector brand name Signs, symptoms, action for mild or moderate allergic reactions Signs, symptoms, action for anaphylaxis Additional information 33 ASCIA Action Plan for Anaphylaxis (personal) - Red New look EpiPen Original EpiPen Anapen 34 17
ASCIA Action Plan for Allergic Reactions - Green Provided to patients with known mild to moderate allergies who have NOT been prescribed an adrenaline autoinjector 35 ASCIA Travel Plan for Anaphylaxis Provides documentation for patient to carry adrenaline autoinjector in aircraft cabin Can be printed from the ASCIA website 36 18
Role of GP after INITIAL allergic reaction/anaphylaxis Provide specialist referral Prescribe initial adrenaline autoinjector if required Provide ASCIA Action Plan Educate patient/carers in recognition/management of reactions Advise on appropriate allergen avoidance measures Teach patient/carer how to use adrenaline autoinjector using trainer Demonstration results in 5-fold increase in ability to use the device Training must be brand specific as the devices have different methods of administration Educate patient on carrying and storage of adrenaline autoinjector Review and optimise asthma management Provide resource materials 37 Role of GP in long term management Be aware of NZ Allergy Guidelines for Schools 2011. All school and ECE children should have an appropriate action plan completed and education around this Ensure yearly follow up, update Action plans, medications, education, +/- allergy tests (to assess if they have grown out of some of the allergies) Look for and treat other atopic co-morbidities -optimising allergic rhinitis Mx improves asthma -treating eczema and improving the skin barrier function reduces sensitisations - improves QOL: no one would hold my hand, nasal congestion Be aware of immune dysregulation: offer varicella vaccination, be alert for eczema herpeticum, recurrent staph and widespread molluscum Support family teaching how to be safe but not anxious, letting go. Encourage them to join Allergy New Zealand for support and education. 38 19
Eczema and allergic rhinitis plans 39 Further Information Allergy NZ 41 20
Further information - ASCIA Australasian Society of Clinical Immunology and Allergy The peak professional body of allergy and clinical immunology specialists in Australia and New Zealand ASCIA website www.allergy.org.au Includes: Anaphylaxis resources (ASCIA Action Plans, Travel Plans, FAQ, Guidelines), other Action Plans, Immunotherapy treatment plans ASCIA education resources and patient information (including allergen avoidance strategies) ASCIA anaphylaxis, food allergy and allergic rhinitis and immunotherapy e-training (CME being applied for) 39 Further Resources and Training Goodfellow Allergy Toolkit under development NZ Paediatric Allergy Management guidelines Graduate Certificate in Allergic Diseases via University of Western Sydney for GPs and Paediatricians 2 year mainly online part time course with a practical component in second year working with Immunologists in NZ Professional Certificate of Allergy Nursing, University of south Australia 16 week online course and 1 week clinical 42 21