managing common presentations of allergy in primary care
TRANSCRIPT
MANAGING COMMON PRESENTATIONS
OF ALLERGY IN PRIMARY CARE
Helen Bourne
Consultant Immunologist
AIMS
⢠Presentation of Allergic Disease in Adults
⢠Rhinitis/ Rhinoconjuctivitis
⢠Urticaria and Angioedema
⢠Food Allergy
⢠Anaphylaxis
⢠Management
Rhinitis
⢠Common
⢠Affects 20% UK population
⢠Significant impact on quality of life
⢠Affects school and work attendance
Rhintis
⢠Symptoms
⢠Sneezing
⢠Nasal itching
⢠Nasal blockage
⢠Nasal discharge
⢠Post nasal drip
⢠Causes
⢠Infective
⢠Allergic
⢠Non Allergic
Diagnosis of Rhinitis
⢠History ⢠Seasonal or perennial
⢠At home or at work
⢠Pets
⢠Discharge ⢠Green â infective
⢠Clear/yellow â allergic/non allergic
⢠Unilateral â nasal blockage
⢠Nasal crusting â staph carriage/ autoimmune conditions
â˘
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
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
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)
Urticaria and Angioedema
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
Management Of Urticaria and Angioedema
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
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
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
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)
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
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)
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 ânettle rashâ)
Plan: ⢠Get help â someone to stay with you ⢠Chew Cetirizine 20mg (2x 10mg tablets) immediately ⢠Take Prednisolone 20mg if available
Moderate Reaction Symptoms: As in a mild reaction plus any one of the following: ⢠Abdominal pain ⢠Vomiting ⢠Diarrhoea ⢠Coughing ⢠Mild wheeze ⢠âLumpâ in the throat sensation Plan: ⢠Get help â 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
Severe Reaction Symptoms: As in a mild reaction plus any one of the following: â˘Swelling of the tongue or airway â˘Persistent vomiting or diarrhoea â˘Dizziness or confusion â˘Collapse â˘Breathing difficulty, severe wheeze or chest tightness â˘Difficulty speaking or swallowing â˘Persistent coughing or choking Plan: â˘Get help â someone to stay with you â˘Phone 999 (and say ANAPHYLAXIS) â˘Use adrenaline pen (JEXT / Epi-Pen / Emerade) if available on the upper outer thigh. Repeat with 2nd pen if no better in 5-10 minutes â˘Lie down (or sit down if unable) â˘If not already taken: chew Cetirizine 20mg (2x 10mg tablets) & take Prednisolone 20mg if available
Acute Management of Anaphylaxis
Adrenaline Autoinjectors
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)
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, 1258â1280
How to use an adrenaline pen
Allergy Referral Guidelines
WHAT TO REFER* WHAT NOT TO REFER*
Known or suspected primary
immunodeficiency
HIV/AIDS [known or suspected]
Recurrent major infection Recurrent minor infection
Recurrent severe boils [failed initial
therapy; deep seated abscesses]
Recurrent superficial abcess/boil;
hidradenitis suppurativa
Vasculitis/Connective tissue disease
Arthritis
Anaphylaxis
Recurrent angioedema in people NOT on
ACE Inhibitors including hereditary or
acquired angioedema
Angioedema in people taking ACE Inhibitors
single episode of self-limiting angioedema
Seasonal or perennial rhinoconjunctivitis
resistant to usual therapy
Eczema; Periorbital oedema with scaly rash
Asthma
Drug Allergy
Latex allergy
Asplenic patients
Recurrent shingles
Food allergy â known or suspected Food intolerance; irritable bowel syndrome
Urticaria if severe and prolonged Urticaria if single episode, recent onset
and/or mild
Chronic Fatigue Syndrome
Primary Care Guidelines
⢠BSACI website
⢠www.bsaci.org
⢠Primary Care Allergy Training Days
⢠NICE Guidelines
⢠Anaphylaxis
⢠Food allergy
⢠Drug allergy
⢠Milk Allergy