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Objectives

What’s new in Allergy?

v  Know the available treatment options for allergic rhinitis v  Understand clinical features, diagnostic testing and natural

history of IgE mediated food allergy v  Become familiar with the recent LEAP study on the

Tara Federly, M.D. Pediatric and Adult Allergy

prevention of peanut allergy v  Know the available treatment options for chronic urticaria v  Understand clinical features, diagnostic testing and natural

history of IgE mediated penicillin allergy

Allergic Rhinitis

Allergic Rhinitis

Allergic Rhinitis

Allergic Rhinitis

v  10-30% of children and adults have environmental

allergies

v  Treatment v  Allergen avoidance

v  Allergic rhinitis has a significant impact on quality of

life

v  Oral antihistamines, oral leukotriene inhibitors, nasal

antihistamines, nasal steroids v  Short courses of oral steroids

v  Direct and indirect costs are high v  Estimated 3.5 million lost workdays per year

v  Injections of steroids are not recommended

v  Nasal irrigation

Nathan, 2007 Marshall et al, 2000 Cuffel et al, 1999

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Allergic Rhinitis v  Treatment v  Subcutaneous immunotherapy v  Sublingual immunotherapy v  1 year ago the FDA approved sublingual tablets for

Sublingual Immunotherapy v  Ragweed allergy v  Ragweed pollen is one of the most common allergens v  26% of people in the U.S.

v  Symptoms occur in the fall

ragweed and grass allergy

Sublingual Immunotherapy v  Ragweed allergy

Sublingual Immunotherapy v  Ragwitek

v  Ragwitek v  Indicated for ages 18-65 years v  Dissolve tablet under tongue daily from May-November v  Fist dose given in physician’s office

Sublingual Immunotherapy v  Grass allergy v  Timothy grass is one of the most common grasses in

the U.S. v  Symptoms occur in the summer

Sublingual Immunotherapy v  Grass allergy v  Grastek v  Indicated for ages 5-65 years v  Dissolve tablet under tongue daily from February-July v  Fist dose given in physician’s office

v  Year round treatment for 3 years provided sustained

benefit 2 years after cessation of treatment

Didier et al, 2011

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Sublingual Immunotherapy v  Grastek

Sublingual Immunotherapy v  Grass allergy v  Oralair v  Indicated for ages 10-65 years v  Dissolve tablet under tongue daily from January-July v  If >18 years old, first dose given in physician’s office v  If 95%

v  Specific food IgE testing or skin testing

v  Positive predictive value is 30-50% v  Larger size increases likelihood of clinical allergy

v  Oral food challenge

v  Intradermal Testing v  Not predictive and high risk for systemic reactions

Peters et al, 2013

IgE Mediated Food Allergy v  Serum IgE Testing

IgE Mediated Food Allergy v  Serum IgE Testing

v  10-25% of patients with negative IgE levels may have

clinical reactions

v  To reduce the risk of over-diagnosis and unnecessary

dietary elimination

v  Elevated serum IgE alone is not diagnostic v  Higher levels increase likelihood of clinical allergy v  Level does not correlate with severity

v  Allergy testing should be limited to specific foods that

have temporal relation to acute symptoms v  Large panels should NOT be used v  Allergy testing for atopic dermatitis could include only

commonly associated foods which the child is eating v  Milk, egg, soy, wheat, peanut and tree nuts

Boyce et al, 2010

Bird et al, 2015

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IgE Mediated Food Allergy v  Unproven allergy tests

IgE Mediated Food Allergy v  Unproven allergy tests

v  Serum IgG testing

v  NAET (Nambudripad’s Allergy Elimination

v  Sign of a normal functioning immune system

Technique) v  Evaluates changes in muscle strength as foods are placed

v  Cytotoxic and ELISA/ACT testing

in contact or close proximity with the body

v  Evaluates changes to WBCs in the presence of allergens v  Scientific studies have determined that WBCs change by

v  There are no standards for consistent testing and no

scientific studies have proven reliability

many mechanisms, whether an allergen is present or not

IgE Mediated Food Allergy v  Resolution

IgE Mediated Food Allergy v  Resolution

v  Wheat and soy

v  Egg allergy

v  85% outgrown by five years

v  53% outgrow by age 10 and 82% outgrow by age 16

v  Peanut

v  Milk allergy

v  20% outgrow

v  80% outgrow by age 5

v  7-9% redevelop allergy if peanut is avoided

v  Tree nuts v  9% outgrow

v  Seafood/Fish v  Typically lifelong Savage et al, 2007 Sampson, 1999

Sampson, 1999

IgE Mediated Food Allergy v  Heating milk and egg can denature conformational

epitopes

IgE Mediated Food Allergy v  Adding baked milk and egg to the diet v  Increases quality of life by expanding the diet

v  Many children with milk and egg allergy can tolerate

baked milk or egg over time

v  Boosts nutrition v  Promotes inclusion in social activities

v  Children should continue eating baked milk and egg if

already tolerating

Kim et al, 2011 Leonard et al, 2015

v  May hasten the development of tolerance to lesser cooked

or raw forms of milk and egg

Kim et al, 2011 Leonard et al, 2015

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IgE Mediated Food Allergy v  Baked milk versus no baked milk

IgE Mediated Food Allergy v  Baked egg versus no baked egg

IgE Mediated Food Allergy v  History of reaction

IgE Mediated Food Allergy v  Vaccines v  MMR/MMRV

v  Milk IgE or egg IgE

v  May be administered to children with egg allergy/

v  Component testing

anaphylaxis

v  Milk proteins

v  However allergy evaluation and testing is recommended if

v  Whey (alpha-lactalbumin, beta-lactoglobulin) – heat labile

gelatin allergy

v  Casein – heat resistant

v  Egg proteins v  Ovalbumin – heat labile v  Ovomucoid – heat resistant Kelso et al, 2014

IgE Mediated Food Allergy v  Vaccines

IgE Mediated Food Allergy v  Vaccines

v  Rabies Vaccine

v  Inactivated influenza vaccine

v  Imovax does not contain egg protein and can be used if

egg allergy/anaphylaxis

v  Egg allergy with hives only – administration by PCP with

30 minute observation

v  RabAvert can also be administered if egg allergy/

anaphylaxis

v  Egg anaphylaxis – administration by allergist v  28 published studies with 4315 patients with egg allergy

including 656 patients with anaphylactic reactions to egg, received influenza vaccine with no serious reactions v  Live attenuated influenza vaccine v  Recent study of 68 children with egg allergy had no

allergic reactions Kelso et al, 2014

Kelso et al, 2014

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IgE Mediated Food Allergy

Oral Immunotherapy

v  Vaccines v  Yellow Fever Vaccine v  Allergy evaluation and testing is recommended if egg

allergy/anaphylaxis

Kelso et al, 2014

Oral Immunotherapy v  Oral immunotherapy (OIT) for foods date back to

1905

Oral Immunotherapy v  Study Methods v  Retrospective record review of 5 allergy practices

v  In the United States OIT is not a standard treatment

v  More than 350 patients treated for peanut allergy with

240,000 doses

v  However a recent article proposed that practicing

allergists may consider OIT for treatment of patients with peanut allergy

Wasserman et al, 2014

Oral Immunotherapy v  Study Methods v  Initial dose of peanut flour v  Below the threshold dose for a reaction

v  Patients would continue the same dose 1-2 times daily

for a defined period of time and then return to the site for dose increases

Oral Immunotherapy v  Study Methods v  Once maintenance dose was reached the patients would

continue dose 1-2 times daily for a prolonged period v  Patients were instructed to avoid exercise for 2 hours

after the dose and call if ill for dose adjustments

v  Dose increases were administered under direct

observation

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Oral Immunotherapy

Oral Immunotherapy

v  Study Results

Our family ate in a restaurant for the first time!

v  85% reached maintenance dose v  Withdrawal was due to GI symptoms, taste aversion,

anxiety, poor adherence, mild reactions, systemic reactions or uncontrolled asthma v  95 systemic reactions required epinephrine

hday to a birt I went the first time! r party fo

v  0.2 per 1000 doses I can have the birthday treats kids bring to school!

Future Immunotherapy Options

I don’t ha ve at the pean to sit ut table any more!

I wen slum t to my fi rs ber p arty! t

We can go to the grocery store without checking every label!

Food Allergy Prevention

v  Studies undergoing for sublingual food

immunotherapy and epicutaneous food immunotherapy v  Maximal dose administered is limited by the small

volume/surface area v  Small dose will protect against accidental exposures

only

Food Allergy Prevention v  In 2000 recommendations for exclusion of allergenic

foods from the diets of infants at risk for allergy and from diets of their mothers during pregnancy and lactation

Food Allergy Prevention v  In February the LEAP (Learning Early about Peanut

Allergy) study favored early introduction of peanut for infants at high risk for allergy

v  Studies have consistently failed to show that early elimination

of foods from the diet prevents food allergies

v  In 2008 the recommendations for avoidance were

withdrawn

Du Toit et al, 2015

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Food Allergy Prevention v  Study Methods v  Randomized, open-label, controlled trial of 530 infants

ages 4-11 months (Mean 7.8 months) with severe eczema, egg allergy or both

Food Allergy Prevention v  Study Methods v  Infants underwent skin testing to peanut v  >4mm were recommended to avoid peanut v  1-4mm were challenged to peanut v  If positive recommended to avoid peanut v  If negative were randomly assigned to consume peanut or

avoid

v  12 years of age symptomatic despite H1 antihistamines

v  14% last >5 years

Sheikh, 2005 Toubi et al, 2004

Chronic Urticaria

Sheikh, 2005 Toubi et al, 2004

Chronic Urticaria

v  Treatment v  Omalizumab v  Monoclonal antibody directed against IgE v  Typically 300mg SubQ every 4 weeks v  53% were hive free and 66% had suppression of hives to a

minimum level after 12 weeks v  Hives can improve within days

Maurer et al, 2013

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Penicillin Allergy

Penicillin Allergy

Penicillin Allergy

Penicillin Allergy

v  Most commonly reported medication allergy v  Up to 5-10% of patients

v  IgE mediated reaction v  Typically begins within one hour of the first dose

v  Large-scale studies found that 85-90% were negative

on penicillin skin testing and tolerated penicillin

v  May take up to one hour especially if administered with

food v  May occur later in the course of treatment if not already

sensitized v  Should be within 1 hour of the dose and symptoms

typically escalate quickly

v  Must rule out other severe drug reactions such as

Stevens-Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN) Park et al, 2006 Gadde et al, 1993

Penicillin Allergy v  Symptoms v  Pruritus, flushing, urticaria, angioedema, wheezing,

laryngeal edema, emesis, diarrhea, hypotension

Penicillin Allergy v  Diagnosis v  History v  Several studies show that IgE mediated penicillin allergy

cannot be accurately predicted based upon history alone

v  In vitro testing v  Sensitivity may be as low as 45% and specificity unknown

Wong et al, 2006 Solensky et al, 2000 Patriarca et al, 1987

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Penicillin Allergy v  Diagnosis

Penicillin Allergy v  Diagnosis

v  Skin testing v  1/3 of patients with vague reaction histories had positive

skin testing v  50% lose sensitivity 5 years after reaction

v  Graded oral challenge v  May be performed without testing depending on history v  Performed after skin testing v  Skin testing may miss 10% of penicillin allergy

v  80% lose sensitivity 10 years after reaction v  Includes both skin prick testing and intradermal testing

Consider referral

Should I refer to an Allergist?

Consider referral v  Concern for IgE mediated food allergy v  For evaluation, allergy testing and/or possible oral food

challenge

v  Known diagnosis of IgE mediated food allergy with need

for further education, testing or monitoring v  For in-depth education on food allergies v  For allergy testing to cross reactive foods

v  Monitoring for development of tolerance to baked egg or

v  Allergic rhinitis which is uncontrolled or interest in

subcutaneous immunotherapy or sublingual immunotherapy v  For evaluation, allergy testing and/or providing further

treatment

Consider referral v  Infant with high risk for food allergies v  For allergy testing

v  Chronic urticaria which is uncontrolled v  For evaluation and providing further treatment

v  History of penicillin allergy v  For penicillin testing and/or oral challenge

milk

v  Monitoring for outgrowing food allergy v  If not outgrowing food allergy considering OIT

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Questions?

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