10/1/2012

1

Improving Self Care

with Allergy New Zealand

and ASCIA Resources

Dr Kylie Morse, Wellington GP

Allergy NZ Board Member

Associate Member ASCIA

1

• Allergy New Zealand for providing the depth of information

and support that many families need to manage allergies,

including mine

• My children, who have provided me with the impetus to

improve allergy education, and not let multiple allergies affect

their development

• ASCIA for use of their slides and resources

Acknowledgements

2

10/1/2012

2

• What patients want to know:

• What is allergy?

• Why is it increasing and changing?

• How to manage anaphylaxis – immediate and long

term

• Who would benefit from adrenaline auto-injectors?

• Action plans

• The role of the GP

• Further information, resources and training

Overview

3

Mechanism of IgE mediated allergy

4

10/1/2012

3

Signs and symptoms of mild or moderate allergic

reactions

• Swelling of lips, face, eyes

• Hives or welts

• Tingling mouth

• Abdominal pain, vomiting (these may be signs of anaphylaxis especially in insect allergy)

5

Any acute onset of hypotension or bronchospasm or upper airway obstruction where anaphylaxis is considered possible, even if typical skin features are not present

OR

Any acute onset illness with typical skin features (urticarial rash or erythema/flushing, and/or angioedema), PLUS involvement of respiratory and/or cardiovascular and/or persistent severe gastrointestinal symptoms

Ref: ASCIA 2010

What is anaphylaxis?

6

10/1/2012

4

Cutaneous symptoms

Urticaria, erythema and angioedema may be transient,

subtle and easily overlooked

In 1 out of 6 fatal food induced

anaphylaxis cases, severe

cardiovascular symptoms

developed without skin or

respiratory symptoms

Ref: Sampson et al. 1992; Brown, Mullins, Gold. 2006 7

Food allergy

Whilst 90% of food allergic reactions are caused by allergic reactions to

these foods, any food can cause an allergic reaction

8

10/1/2012

5

Risk of anaphylaxis and quality of life

• Risk of anaphylaxis can:

– impair QOL

– induce great anxiety

– lead to significant social and family disruption

• QOL in child with severe food allergy has been

reported as worse than child with diabetes

• Insect sting anaphylaxis may lead to fear of outdoors

Ref: Noone. 2010 9

Hospital admission rates for anaphylaxis in

Australia

Ref: Mullins, Dear, Tang. 2009 10

10/1/2012

6

11

Why the rise in food allergy?

Proposed explanations include:

• Hygiene hypothesis

• Delayed versus early

introduction of allergenic foods

• Methods of food processing

• Development of allergy to food

by skin exposure (especially in

severe eczema)

This area requires further research

Fatal anaphylaxis - associations

• Asthma

• Delayed or no administration of adrenaline

• Age:

– Teenagers and young adults (food allergy)

– Adults (insect and drug allergy)

• Upright posture during anaphylaxis

• Food allergic individuals eating away from home

• Initial misdiagnosis

• Systemic mastocytosis

Previous mild/moderate reactions may not rule out subsequent severe or fatal reactions

Ref: Bock. 2010; Liew, Williamson, Tang. 2008; Bock. 2007; Pumphrey. 2003; Bock. 2001 12

10/1/2012

7

Cause of Allergic ReactionPercent

Peanut 60% 0.190968 37

Tree nut 27% 0.087742 17

Fish 2% 0.005161 1

Milk 8% 0.025806 5

Shrimp 3% 2

62

0% 10% 20% 30% 40% 50% 60% 70%

Peanut

Tree nut

Fish

Milk

Shrimp

Percent of Cases

Cause of Fatal Anaphylaxis

Common causes of fatal food anaphylaxis

Ref: Pumphrey, Garland. 2007 13

Shrimp (prawn)

Key information that assists diagnosis:

• Nature of symptoms

• Exposure to potential triggers

• Timing of reaction in relation to exposure

• Response to treatment

Clinical history

14

10/1/2012

8

Allergy testing: use and limitations

Use:

• Useful to confirm clinical suspicions

• Single allergen testing; avoid mixes

Limitations:

• Positive test alone does not = allergy

• Does not correlate well with severity

• Not available for all triggers (e.g. ticks, NSAID, most

antibiotics, anaesthetics)

• SPT – false positives and negatives may occur

15

Allergic reactions may occur on the first

known exposure

Sensitisation may occur through:

• Oral exposure in other foods

• Cutaneous exposure - creams containing unrefined

nut oils, direct contact of food to skin especially in

children with eczema

16

10/1/2012

9

Serum tryptase

Ref: Simons, Camargo. 2010; Yunginger, Squillace et al. 1989; Sampson, Menderson et al. 1992.

• Serum tryptase should be measured within 4 hours after anaphylaxis

• Serum tryptase is often normal after food anaphylaxis

17

Action for anaphylaxis in clinical settings

• Remove allergen (if still present)

• Call for assistance

• Lay patient flat (if breathing difficult allow to sit but not

stand or walk)

• Give IMI ADRENALINE without delay– 1:1000 IMI into mid lateral thigh

– Repeat every 5 minutes as needed

– If multiple doses required or a severe reaction consider adrenaline

infusion if skills and equipment available

• Call ambulance to transport patient,

state “anaphylaxis need adrenaline”

18

10/1/2012

10

Is it anaphylaxis or asthma?

If patient is known to be at risk of anaphylaxis and is

unsure if they are experiencing anaphylaxis or asthma

follow their ASCIA Action Plan for Anaphylaxis:

• Give adrenaline autoinjector first

• Then give asthma reliever medication

• Call ambulance

• Continue asthma first aid

19

Why is adrenaline effective?

• Inhibits the release of inflammatory mediators

• Reverses the physiological effect of mediators by:

– Reducing airway mucosal oedema

– Inducing bronchodilatation

– Inducing vasoconstriction (thus increasing HR & BP)

– Increasing strength of cardiac contraction

Lasts ~ 15-20 minutes; repeated doses may be needed after 5 minutes if no response

Ref: Tole, Lieberman. 2007 20

10/1/2012

11

IMI into outer mid thigh is recommended

• IMI into mid-anterolateral thigh provides rapid plasma

and tissue concentrations of adrenaline

• IM formulation of adrenaline contains 1 mg/mL and may

also be labelled as 1:1000 or 0.1%

• If using adrenaline ampoules ensure appropriate needle

length for IMI

21

Adrenaline ampoule dosages

Dose 0.01 mg per kilogram (up to 0.5 mg per dose)

Source: Adapted from the Australian Immunisation Handbook 9th Edition22

10/1/2012

12

Adrenaline - possible adverse effects

• Well tolerated in children as well as adults

• Transient adverse effects include anxiety, fear, restlessness, headache, dizziness, palpitations, pallor and tremor

IV boluses of adrenaline are NOT recommended

23

Medical observation

• Relapse, protracted and/or biphasic reactions may occur

• Observe patient for at least 4 hours after last dose of adrenaline

• Observe overnight if patient:– had a severe reaction (hypotension or hypoxia) or– required repeated doses of adrenaline or – has a history of asthma or biphasic/protracted

anaphylaxis or– has other concomitant illness or– lives alone or is remote from medical care

24

10/1/2012

13

Biphasic reactions

Ref: Tole, Lieberman. 2007 25

Antihistamines

• Ineffective for treating anaphylaxis

• Oral non-sedating antihistamines may be useful for

treating itch and urticaria

• Side-effects of oral sedating antihistamines may be

similar to signs of anaphylaxis

• Injectable promethazine should not be used in

anaphylaxis as it can worsen hypotension and cause

muscle necrosis

26

10/1/2012

14

Adrenaline autoinjectors...

• are spring-loaded automatic injector devices

• contain a single pre-measured fixed dose of adrenaline

• are designed for self-injection or bystander use

• should be injected into the outer mid-thigh muscle

• can be administered through a single layer of clothing

• should be stored in easily accessible, unlocked location with ASCIA Action Plan for Anaphylaxis

27

How to give EpiPen with orange needle end and blue safety

release

28

10/1/2012

15

How to give Anapen or Anapen Junior

29

Availability of adrenaline autoinjectors to patients

EpiPen and Anapen:

• Are not currently reimbursed by Pharmac in NZ

• are available without a prescription at full retail price

• are available on PBS authority prescription in Australia

• have different administration techniques and are not

brand substitutable

30

10/1/2012

16

Guidelines for prescribing an adrenaline autoinjector

Always recommended if…

• History of anaphylaxis (and continued risk)

• These patients should be referred to a clinical immunology/allergy

specialist

May be recommended if…

• History of a generalised allergic reaction and one or more risk factors:

– Asthma

– Age (children >5 yrs, adolescents, young adults)

– Specific allergic triggers

– Co-morbidity (e.g. ischaemic heart disease)

– Geographical remoteness from emergency medical care

• These patients should be referred to a clinical immunology/allergy

specialist31

ASCIA Action Plans:

Should be:

• provided to each patient who is prescribed an adrenaline autoinjector

• completed and signed by the doctor

• reviewed annually or if patient’s medical condition changes

• stored with adrenaline autoinjector

Can be printed in colour from ASCIA or Allergy New Zealand websites or colour hard copies ordered from ASCIA

Advise patient to keep their Action Plan with their autoinjector and provide a copy to their school, childcare or workplace

32

10/1/2012

17

Patient’s

photo and

personal

details

Confirmed

allergens

Contact details

for family and

doctor

Adrenaline

autoinjector

brand name

Signs, symptoms,

action for mild or

moderate

allergic reactions

Instructions

on how to

use the

device

Signs, symptoms,

action for

anaphylaxis

Additional

information

33

ASCIA Action Plan for Anaphylaxis (personal) - Red

Original EpiPenNew look EpiPen Anapen

34

10/1/2012

18

Provided to

patients with

known mild to

moderate allergies

who have NOT

been prescribed an

adrenaline

autoinjector

ASCIA Action Plan for Allergic Reactions - Green

35

• Provides

documentation for

patient to carry

adrenaline

autoinjector in

aircraft cabin

• Can be printed from

the ASCIA website

ASCIA Travel Plan for Anaphylaxis

36

10/1/2012

19

Role of GP after INITIAL allergic

reaction/anaphylaxis

• Provide specialist referral

• Prescribe initial adrenaline autoinjector if required• Provide ASCIA Action Plan

• Educate patient/carers in recognition/management of reactions• Advise on appropriate allergen avoidance measures

• Teach patient/carer how to use adrenaline autoinjector using trainer

– Demonstration results in 5-fold increase in ability to use the device

– Training must be brand specific as the devices have different methods of administration

• Educate patient on carrying and storage of adrenaline autoinjector• Review and optimise asthma management

• Provide resource materials

37

• Be aware of NZ Allergy Guidelines for Schools 2011. All school and ECE

children should have an appropriate action plan completed and education

around this

• Ensure yearly follow up, update Action plans, medications, education, +/-

allergy tests (to assess if they have grown out of some of the allergies)

• Look for and treat other atopic co-morbidities

-optimising allergic rhinitis Mx improves asthma

-treating eczema and improving the skin barrier function reduces

sensitisations

- improves QOL: “no one would hold my hand”, nasal congestion

• Be aware of immune dysregulation: offer varicella vaccination, be alert for

eczema herpeticum, recurrent staph and widespread molluscum

• Support family teaching how to be safe but not anxious, letting go.

Encourage them to join Allergy New Zealand for support and education.

Role of GP in long term management

38

10/1/2012

20

Eczema and allergic rhinitis plans

39

Further Information – Allergy NZ

41

10/1/2012

21

Further information - ASCIA

Australasian Society of Clinical Immunology and Allergy

The peak professional body of allergy and clinical immunology

specialists in Australia and New Zealand

ASCIA website www.allergy.org.au

Includes:

• Anaphylaxis resources (ASCIA Action Plans, Travel Plans,

FAQ, Guidelines), other Action Plans, Immunotherapy

treatment plans

• ASCIA education resources and patient information

(including allergen avoidance strategies)

• ASCIA anaphylaxis, food allergy and allergic rhinitis and immunotherapy e-training (CME being applied for)

39

• Goodfellow Allergy Toolkit under development

• NZ Paediatric Allergy Management guidelines

• Graduate Certificate in Allergic Diseases via

University of Western Sydney for GPs and

Paediatricians2 year mainly online part time course with a practical component in

second year working with Immunologists in NZ

• Professional Certificate of Allergy Nursing,

University of south Australia 16 week online course and 1 week clinical

Further Resources and Training

42