Schools are quite paranoid about giving any medication on their watch. The liability for giving sunscreen when you don’t need it? Zero. This is very similar to the use of epinephrine in a school aged child with food allergy. You certainly don’t want to withhold epi and risk anaphylaxis or death, when the risk of giving the EpiPen is negligible even if you don’t need the drug. Maybe our policies in schools will change after a large malpractice case gets media attention for NOT giving epinephrine at the appropriate time for peanut allergy.
Ok, another study about the dangers of food allergy (yesterday in USA Today). You would think the occurrence of food allergy to KNOWN allergens (peanut & milk) would decrease given all the attention given to accidental ingestion. Evidently, this is not the case. Explanations? Maybe we’re afraid of giving epinephrine. In my personal experience, giving epinephrine is analogous to “waving the white flag.” It doesn’t have to be nor should it be when treating children with suspected food allergy. As I tell my nurses, “give the epi, then call the doctor!”
Milk allergy may cause life-threatening anaphylaxis in children & adults. Wouldn’t it be nice if milk allergy could be “cured?”
The adverse immune reactions to cow’s milk proteins can range from immediate, potentially life-threatening reactions to chronic disorders. Cow’s milk allergy (CMA) is the most common food allergy in infants and young children, affecting 2–3% of general population. That’s a lot of kids! Most studies have shown the prognosis for developing tolerance to cow’s milk to be good, with the majority outgrowing their allergy by age 3 years.
Because no treatments are available to cure or provide long-term remission from food allergy, allergen-specific treatments and strategies that attempt to alter the allergic response to specific food allergens are expected. The approach that attracts a significant interest in the scientific community, as well as the public and media, is oral immunotherapy (OIT).
To begin treatment for food allergy, your doctor should do the following:
- IgE must be demonstrated to the food in question. That means skin testing or blood tests.
- Who wants to be cured? That’s what desensitization accomplishes. If you gradually increase the amount of offending food (milk powder for instance), sensitive patients will no longer react to an accidental ingestion. Pretty cool…but wait, that’s not all!
- Permanent tolerance, as illustrated, means are you protected from ingestion of milk when you haven’t had exposure for say 2 months? Because it’s not known how to predict whether patients develop tolerance, this procedure of OIT is not recommended for clinical use at this time.
Almost all children receiving oral desensitization (OIT) experienced allergic symptoms during the protocol that primarily involved urticaria and angioedema. That’s mild and treatable.
Table 1. Oral food desensitization for IgE-mediated cow’s milk allergy
|Study||Patients (N)||Success rate||Comments|
|Staden et al. , CM and egg||CM 14; egg 11; control group 20; age 0.6–12.9 years||9/35 (36%) permanent tolerance; 3/25 (12%) tolerance with regular intake (desensitization); 4/25 (16%) achieved partial tolerance||The first randomized clinical trial of OIT. The rate of spontaneous food allergy resolution in the control group (7/29, 35%) was similar to the treatment group.|
|Longo et al. , CM||CM 60; 30 active group; 30 control group; age 5–17 years||11/30 (37%) tolerated 150 ml f CM; 13/30 (53%) tolerated 5–150 ml||The first study including children with previous anaphylaxis to cow’s milk; 3 children 10% discontinued the study because of severe systemic reaction. 17/30 children of active group reported side-effects at home.|
|Skripak et al. , CM||CM 20; active to placebo; ratio 2 : 1; age 6–21 years||12 (92%) of active group reached the dose 5140mg of CM (range 2540–8140 mg); no change in the placebo group||The first double-blinded, placebo-controlled clinical trial for OIT; the median frequency of side-effect was 35% in the active group compared with 1% of the placebo group.|
|Pajno et al. [19•], CM||CM 30; active to placebo; ratio 1 : 1; age 4–13 years||10 (76%) of active group tolerated 200 ml CM; no change in the placebo group||The first blinded trial with the weekly up-dosing regimen carried out in 18 weeks. Two children (15%) of active group discontinued the trial because of systemic reaction.|
Legend for the above table: CM, cow’s milk; OIT, oral immunotherapy.
Desensitization state can be achieved by approximately 36–92% of the children treated with specific immunotherapy; the rate of permanent tolerance is unknown.
An alternative route of allergen delivery is through an epicutaneous patch (EPIT). CMA was confirmed by an oral food challenge at baseline. Children received three 48-h applications (1mg of skimmed milk powder or 1mg of glucose as placebo) through a skin patch each week for 3 months. EPIT-treated children had a trend toward an increased threshold dose in the follow-up oral milk challenge. There was no change in the placebo group. The most common side-effects were local pruritus and eczema at the site of EPIT application.
The possibility of the appearance of adverse events or reactions during OIT is quite frequent. Side-effects have been reported by patients in all trials.
Severe systemic side-effects have been reported with either rush schedule or weekly up-dosing regimen. The frequency of serious events and the severity of reactions are greatest on the initial days and least on the days following desensitization when high doses of cow’s milk intake are reached by patients.
Mild reactions such as abdominal pain, throat pruritus, gritty eyes, watery eyes, transient erythema and sneezing usually do not require stopping desensitization. On the contrary, when rhinitis, dyspnea, asthma, generalized urticaria and hypotension occur as a single symptom or in combination, OIT should be postponed or stopped.
A life-threatening asthma reaction caused by desensitization to milk was described by Nieto et al. Adverse events are largely unpredictable, and they can occur during home dosing. Several systemic reactions have occurred at previously tolerated doses in the setting of exercise,viral illness and suboptimally controlled asthma.
Of note, these reactions had been well controlled by antihistamines, steroids or epinephrine. Because desensitization( s) place patients at risk for systemic reactions, it is not appropriate to implement OIT in clinical practice settings at this time. Therefore, OIT can be performed for research purposes or as ‘avant-garde’ and modern therapy for IgE-mediated food allergy in specialized pediatric centers.
- Patriarca G, Nucera E, Roncallo C,et al. Oral desensitizing treatment in food allergy: clinical and immunological results. Aliment Pharmacol Ther 2003; 17:459–465.
- Nieto A, Fernandez-Silveira L, Mazon A, Caballero L. Life-threatening asthma reaction caused by desensitization to milk. Allergy 2010; 65:1342–1343.
My transcriptionists are not only good at what they do, but when they hear me talk as much as I do, it’s almost family.
I am reading a book called, Don’t Kill the Birthday Girl by Sandra Beasley, and I thought of you.
- It’s a memoir about the author’s life with food allergies, what it was like growing up with allergies, etc. She has a variety of food allergies along with environmental allergies.
- It’s not very long but it seemed like a book parents who have kids with allergies or individuals suffering from allergies in general would really be able to relate to. Good advice Stephanie!
- The author is really honest about what it’s like living with allergies but she’s humorous about it at the same time.
- The one thing that shocked me is that when the author was a teenager she thought about overdosing on Benadryl because she was tired of living with allergies. Don’t kid yourself, the quality of life in patients with allergy isn’t very good….much worse than heart disease or even diabetes.
- I think this book could help people with allergies, so they don’t feel alone. I don’t feel alone but I know I’m the only one in my family with allergies and none of them get what an allergic reaction is really like so I’m really enjoying this book.
Stephanie, thanks for the suggestion and I’m sure many of our readers will also enjoy the book. You’ll have to ask her permission to “friend”, but here’s her link—>profile.php?id=1192230038&sk=photos
Here’s the link from Amazon about further information on the book: Book on Allergies from Amazon
From Medscape Allergy & Immunology by Marrecca Fiore
Ever wonder what other allergists are reading? After sorting through the long list of articles published on Medscape during the past year, it seems our member audience of allergists and clinical immunologists was most interested in:
- Food allergies
The top 10 articles list is comprised of the most-read content of 2011. If you missed any of these articles, please take a look at them now. Thanks Marrecca for your work on compiling the list.
The List–I’ll comment when appropriate!
10. Office-Based Oral Food Challenge Safely Diagnoses Food Allergy
A letter published August 11th in the Journal of Allergy and Clinical Immunology said that food challenges can be safely done in a physician’s office as long as certain precautions are taken.
- Precautions include having resuscitative equipment in office during the challenge.
- What foods do you challenge to? I’d start out with egg, milk, wheat to name a few.
- Some exciting potential for “desensitization” and oral tolerance as well.
9. Pathophysiology of Itch and New Treatments
As highlighted in this paper, the pathophysiology of itch is diverse and involves a complex network of cutaneous and neuronal cells. The article explains current treatments as well as experimental and promising therapies.
- Patients would rather have ANY symptom except itching.
- Be careful! Itching can be a result of correctable causes….like elevated bilirubin. Don’t miss this one.
Dr. Matthew Fenton from NIAID and Dr. Hugh Sampson, past president of AAAAI, review the food allergy guidelines and discuss how these principles should guide clinical practice.
- The most important guideline to follow–please avoid a food “panel” which misleads many patients to think they have a food allergy & you may just have an irrelevant positive test.
7. The Itch That Rashes
A 2-year-old presents with a persistently itchy rash. What is the most appropriate management?
6. Common Variable Immunodeficiency at the End of a Prospering Decade: Towards Novel Gene Defects and Beyond
This review highlights the most important publications of the past year, with an emphasis on novel findings in genetics and the immunophenotype of CVID.
5. Molecular Diagnosis of Peanut and Legume Allergy
Peanut- and legume-induced allergic reactions can be fatal and can significantly impair the quality of life of patients and their families. This paper reviews and discusses recent studies on the molecular diagnosis of peanut and other legume allergy.
4. I’m Struggling to Live on $160,000 a Year: MD Lament
Most people who don’t have “MD” or “DO” after their name would assume that $160,000 is a good annual income. However, many physicians find it a challenge to live on that amount. Why can some manage easily while others are struggling to pay the bills?
3. Hymenoptera Venom Immunotherapy
Hymenoptera stings can induce allergic systemic and occasionally fatal reactions. What is the best treatment?
- Bee sting shots are >90% effective & I’ve learned much about allergy shots for pollens based on research for bee stings.
2. Influenza Vaccine: Guidelines for Those With Egg Allergy
Vaccine expert Paul A. Offit, MD, explains the new influenza guidelines for individuals with egg allergy.
- The bottom line: Flu shot is probably safe even in patients with egg allergy. This was taboo only 5 years ago….the more you know, the less you know!
1. New Test for Peanut Allergy a Step Forward
Measuring antibody levels of 2 peanut protein components in patients may be a better predictor of allergic reactions than current diagnostics.
These articles did not make our Top 10, but they came close.
Can Inhaled Corticosteroids Prevent Asthma Exacerbations?
ICS therapy is the mainstay of asthma treatment, but can it also be used as a preventive measure?
Helping Families Manage Food Allergy in Schools
School can be a frightening place for food-allergic children and their parents. Are physicians providing the best information to help them?
Food allergy is an increasing problem in homes and schools. How do we determine who is at increased risk for anaphylaxis?
As always, if you have difficulty reading or obtaining any of these articles, let me know–I’ll be glad to help.
“I’m allergic to everything!” Ah, you’re smiling. Is this really possible to be allergic to multiple drugs? Evidently this is true according to a recent study published in Ann Allergy Asthma Immunol 108 (2012) 88–93.
Multiple drug intolerance syndrome: prevalence, clinical characteristics, and management byEric Macy, MD and Ngoc J. Ho, PhD.
So what is this condition? Multiple drug intolerance syndrome (MDIS) is generally defined as intolerance to 3 or more unrelated medications. This can be antibiotics, ibuprofen, or high blood pressure medication. The problem with adverse drug reactions is that intolerances are typically recorded in the “allergy” field of the medical record. This makes doctors and patients alike worry about anaphylaxis with any accidental use. Relax….most adverse drug reactions are not going to result in a severe reaction without warning. The authors of this paper use the word “allergy” in quotes throughout this paper to remind us that most of the drug “allergy” reports in the medical record are not immunoglobulin (IgE)-mediated.
Now don’t misunderstand, a true IgE-mediated allergy requires sensitization, and every systemic exposure in a sensitized individual can potentially result in anaphylaxis and death. But this is not the type of reaction we’re dealing with in this study.
If you have Multiple Drug Intolerance Syndrome, what can you do?
Most individuals with a record of any drug “allergy” have only 1 implicated medication, and they simply avoid that drug or class of medication. Individuals with multiple drug “allergies” are a special case.
Antibiotic overuse probably accounts for a significant proportion of the antibiotic “allergy” reported. Not only should antibiotics be avoided to prevent resistance, but overuse of antibiotics contributes to MDIS.
Challenge testing has typically shown tolerance to most medications in patients with MDIS. Schiavino et al performed 1,808 challenges on 480 patients, 84.4% female, most ages 40 to 60, with histories of ADRs to at least 3 unrelated medications.
All of these patients were evaluated at a specialized drug allergy clinic in Rome between January 1, 2000 and December 31, 2005. Two hundred twenty-four (12.4%) positive challenges were seen. In virtually all patients, either the index medication was tolerated on rechallenge or an acceptable alternative was identified.
Multiple drug “allergy” is relatively uncommon in children, and most adverse drug reactions (ADRs) in children are associated with antibiotic use. Park et al provided demographic information on 97 children with 2 or more antibiotic “allergies” seen in a specialized drug allergy center in Canada. The accompanying editorial concluded that rare individuals may truly have allergic reactions to unrelated antibiotics, but it also might just be opportunity and bad luck.
One often may stop multiple medications safely in the elderly. This may be the most important way to reduce the incidence of MDIS. In the presence of a life-threatening condition that would benefit from a particular medication associated with a historical reaction, based on a careful history, one may possibly safely test or rechallenge most individuals with MDIS.
So is there anyone who should NOT be challenged with a drug they suspect is causing MDIS?
Individuals who have experienced drug-associated toxic epidermal necrolysis, Stevens-Johnson syndrome, blistering, desquamation. These reactions are usually MORE severe after the second exposure!
Here’s what this type of reaction looks like:
Severe hepatitis, nephritis, or hemolytic anemia should not be rechallenged. The risk of inducing severe reactions is just too great. Fortunately, these severe reactions are rare.
Angiotensin-converting enzyme inhibitor–associated angioedema can be lethal, and rechallenge is not recommended.
If I have MDIS, when would a challenge be appropriate?
- Urticaria or angioedema associated with NSAID use outside of aspirin-exacerbated respiratory disease is often transient, and rechallenge often can be safely performed.
- Individuals with aspirin-exacerbated respiratory disease can be challenged with aspirin and desensitized.
- Appropriate skin testing or in vitro IgE measurements can be used to evaluate individuals with MDIS who experienced classic IgE-mediated reactions such as anaphylaxis, shortness of breath, or hives. If negative, they can be rechallenged under observation.
- If positive, they can be desensitized for 1 therapeutic course.
- Multiple drug intolerance syndrome subjects with most other mild ADRs such as macular papular rashes, fixed drug eruptions, nausea, vomiting, gastrointestinal upset, diarrhea, drug fevers, other mild symptoms, or unknown symptoms can generally be safely rechallenged.
In closing, what’s the bottom line for patients with multiple drug “allergies?”
Multiple drug intolerance syndrome may be considered partially an iatrogenic condition.
Multiple drug intolerance syndrome is most prevalent in elderly women with high overall health care and pharmaceutical utilization.
Multiple drug intolerance syndrome is associated with anxiety but not with life-threatening illnesses or IgE-mediated allergy.
Coordinated efforts to reduce poly-pharmacy may be helpful in reducing iatrogenic MDIS.
Drug hypersensitivity testing or drug challenges can be used safely to help manage many individuals with MDIS.
Call me with questions; I’d be happy to help you out!
So how much can we hear about food allergy? As unfortunate as it is to have a severe food allergy, what bothers patients most is lack of reliable information about their condition and the lack of concern about a potentially fatal reaction. Just look on Facebook to find hundreds of stories about the tragedy of food allergy or anaphylaxis. Here’s an example of the anxiety that results from a child with food allergy—>
If you’re going to treat food allergy, you have to know it’s there–duh. But not so fast….most kids never get the appropriate food challenges to make the diagnosis. Consider this:
- Oral food challenges are the gold standard for diagnosing food allergies in children, but only a small fraction of kids in the United States are getting them.
- At the American College of Allergy, Asthma & Immunology 2011 Annual Scientific Meeting Dr. Gupta reported from her study that oral food challenge was done in just 15.6% of children that really needed the test.
- As a result, it is likely that childhood food allergy is seriously underdiagnosed
“Food allergy guidelines just came out in March of this year from the National Institutes of Health NIAID [National Institute of Allergy and Infectious Diseases] stating that oral food challenge is the proper test to diagnose food allergy, along with medical history and positive skin and blood testing,” Dr. Gupta said.
In Dr Gupta’s study, only 47% had a skin test and 40% had a blood test for food allergy.
“Overall, what this tells us is that food allergy is not being diagnosed optimally and oral food challenges are definitely not being done enough,” she said.
What are your thoughts about food allergy? Have any readers experienced a “misdiagnosis” of food allergy? I’d love to hear from you!
Advances in allergic skin disease, anaphylaxis, and hypersensitivity reactions to foods, drugs, and insects in 2011. J Allergy Clin Immunol 2012;129:76-85
So what’s new in allergy to foods, drugs, and insects? I promise, I won’t bore you with basic science facts useful only for allergy boards, but here’s some facts for you to digest with the new year:
A US study estimates a food allergy emergency department visit every 3 minutes, on average. This is a very remarkable statistic for a condition that was “trivial” during my allergy fellowship training.
Food allergy health care costs are estimated at $500 million in 2007. Ditto the above–now you know why so much research is focused on a permanent cure for food allergy.
Severity of peanut allergy varies regionally, likely based on the source of sensitization (pollen related vs oral). Not only region variation, but also determined by culture. For instance, infants in Israel who are fed peanut early in life have less allergy than their European counterparts that withhold peanut until age 2 or 3.
Vitamin D deficiency is associated with increased risk for food sensitization (peanut). Is there anything that Vitamin D doesn’t do? Cod liver oil, here we come!
- Freezing fresh fruits for prick-prick testing does not result in a significant loss of potency. Who cares? Well, your doctor may want to test you by pricking a fresh fruit (say peaches) and then testing your skin. Don’t worry about how you’re going to get the fruit to the appointment….just freeze it for later.
Clinical studies of peanut oral and sublingual immunotherapy show promise. Why not eat small amounts of peanut and develop tolerance to it? It works and several studies are beginning in 2012 to find out more information about safety and who are the best candidates for this procedure. Want to be involved in this type of study? Call me for details.
Several studies support the use of Xolair™ for not only asthma, but also food allergy: Milk and peanut to name two. This treatment may also be useful for chronic urticaria refractory to antihistamines–>hives.
During a safety study of a food allergy herbal formula based on traditional Chinese medicine, a trend toward modulation of basophil responses was observed. This means some science exists behind the nutritional and herbal medicine “craze.”
New insights into the use of vitamin D, phototherapy, methotrexate, azathioprine, and immunoadsorption in treating severe AD were shown.
Several studies support the notion that egg content of seasonal influenza vaccines is low, that skin testing is not necessary, and that the vaccine can be safely administered to persons with egg allergy!! See my previous post on egg allergy and Flu vaccine.
A Canadian study shows only 55% with diagnosed food allergy had selfinjectable epinephrine. Folks, this is a life-threatening reaction and only 55% had the lifesaving treatment on hand?
A clinical study of children with delayed urticarial and maculopapular rashes shows a low recurrence rate and efficacy of drug rechallenge. If you’re faced with a rash occurring 4-6 hours after taking a medication, you probably won’t react with the second exposure
Is this enough to absorb in one day? Happy New Year!
HoHoHo! It’s Christmas time. Holiday safety is especially important for patients with allergies.
Regardless of whether you have asthma or food allergy, here is a great handout from the AAAAI about “Handling the Holidays!” Feel free to use this handout in your practice!
Allergy to Christmas….really?
How about those Thanksgiving dinners? Any risk for allergy?
Enjoy and eat some for me.