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 – infective

• Clear/yellow – allergic/non allergic

• Unilateral – nasal blockage

• Nasal crusting – staph carriage/ autoimmune conditions

•

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 ‘nettle rash’)

Plan: • Get help – 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 • ‘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

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 2nd 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

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, 1258–1280

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 — 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