4/7/15
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
1
4/7/15
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
2
4/7/15
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
5
4/7/15
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
6
4/7/15
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
7
4/7/15
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
8
4/7/15
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
9
4/7/15
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
11
4/7/15
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
12
4/7/15
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
13
4/7/15
Questions?
14