Food Allergy ECHO: High Yield Summary - PowerPoint Presentation

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Food Allergy ECHO:High Yield Summary

Yale University ECHO SeriesSession 6Stephanie Leeds, MD FAAAAI

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Disclosure

The following individuals have no conflicts of interest to disclose relevant to this activity:Stephanie Leeds, MD - PresenterGunjan Tiyyagura, MD - ReviewerSandra Selzer, MSHQ - PlannerKris Samara - Planner

Theresa Barrett, PhD, CMP, CAE - Planner

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Accreditation

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the New Jersey of Academy of Family Physicians and Hezekiah Beardsley Connecticut Chapter of the American Academy of Pediatrics. The New Jersey Academy of Family Physicians is accredited by the ACCME to provide continuing medical education for physicians.

The New Jersey Academy of Family Physicians designates this live activity for a maximum of 1.0

AMA PRA Category 1 Credit(s)™

.

Physicians should claim only the credit commensurate with the extent of their participation in the activity.

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Learning Objectives

Review the typical presentation of conventional food allergy.

Review the typical workup for conventional food allergy.

Review diagnosis and treatment of anaphylaxis.

Review preventative measure for food allergy through early introduction.

Review interventional measures for food allergy through oral immunotherapy.

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Clinical Cases?

What cases do you all want to discuss?

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Questions to Ask Food Allergy Patient:

Has patient had food before or since reaction? Is the food a major allergen? If they are eating food again without issue, no need for testing or evaluation. Remember pitfalls of testing!

What were the symptoms of reaction?

If the symptoms are not typical (hives, swelling, wheeze, vomiting), don’t jump to testing and perhaps refer for evaluation instead.

How soon after ingestion did the patient have the reaction?

If reaction was not within minutes to hours after ingestion, not likely an

IgE

mediated food allergy.

Are parents worried/afraid to give food again?

If family is strictly avoiding food regardless of whether or not reaction is convincing, refer to allergist for (at minimum) an educational appointment.

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What Is the Role of Pediatrician?

If you plan on starting the allergy evaluation, please always remember the following:NEVER ORDER FOOD ALLERGY PANELS.

JUST DON’T DO IT.

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What Do We Do with Allergy Tests?We triangulate information to better counsel our families on management of individual foods:

Avoid foodOral food challengeHome introduction*Select families may make joint decision to think about proactive intervention, like oral immunotherapy (OIT).

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Definition of AnaphylaxisAnaphylaxis is an acute, life-threatening, systemic reaction resulting from the sudden release of mediators from mast cells and basophils. Common triggers include food, medications, exercise, and venoms- but anaphylaxis can also be idiopathic.

Manifestations:Cutaneous (85-90%): pruritus, urticaria, angioedema, flushingRespiratory (45%): bronchoconstriction, wheeze, cough, shortness of breathCardiovascular (30%): tachycardia, hypotension, shockGastrointestinal (25%): nausea, emesis, abdominal pain, diarrhea

Other: conjunctival injection, sense of doom, seizure, etc.

Lieberman P, et al. J Allergy

Clin

Immunol

. 2010.

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Anaphylaxis Factors

Turner, PJ et al. Allergy 2016.

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Risk Factors for Severe Anaphylaxis

AsthmaIncreasing age (teenagers)Male genderUnderlying comorbidities (especially cardiovascular disease)*Biphasic anaphylaxis is not that common, but risk factors include prior history of anaphylaxis, unknown food trigger, and epinephrine given 60 minutes or more after reaction begins.

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When Should Epinephrine Be Prescribed?

Most commonly prescribed for food, sting, or drug reactions if:There is a history of anaphylaxis or serious reactionThere is risk of anaphylaxis or serious reaction in the judgement of the clinician *Alternative treatments, such as antihistamines, steroids, and inhaled treatments have failed to prevent or relieve severe anaphylactic reactions.

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Misconceptions About Anaphylaxis/Epinephrine

Severe attack will always be preceded earlier/milder warning reactionThere is always time to get medical attention, so patients do not have to worry about administering epinephrine quickly Medications, especially epinephrine, will always work when needed, even if use is delayed to make sure patient “really needs it”Epinephrine is dangerous because of its cardiovascular effects in pediatric population

AAAAI Position Statement, 2002.

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Epinephrine Autoinjectors

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Epinephrine Autoinjectors and Temperature

Manufacturer’s recommendation: store at 68-77 F, can tolerate temperatures at 59-86 F.Studies have shown variable stability of epinephrine (1 mg/mL) at high temperatures (ie well above 100 F), but continuous heat exposure seems worse than intermittent heat exposure. Most “real world” study looking at epinephrine in EMS vehicles in Southern California showed no significant degradation of drug. Autoinjector device may be affected. Studies have shown consistent stability of epinephrine (1 mg/mL) at low temperatures, including study that did multiple cycle of freezing/thawing. Autoinjector device usually not affected.

Gill et al, Am J Health

Syst

Pharm, 2004

Beasley, Wilderness and

Env

Med, 2015

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Early Peanut Introduction: Risk Stratification

Togias

et al, JACI 2017

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Togias

et al, JACI 2017

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Barriers to Early Peanut Introduction

Misinformation and/or conflicting medical adviceFear of introducing allergenic food at homeFinding the right peanut product that is age appropriate Other family members at home with peanut allergy

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Oral Immunotherapy Model

Nowak A. J Allergy

Clin

Immunol 2011.

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Palforzia- FDA Approved Peanut Oral Immunotherapy

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Oral Immunotherapy and Adverse Reactions

Adverse reactions range from mild to life-threateningMajority of patients will have some adverse reaction from OITStudy drop out rates can be as high as 25-30%Adverse reactions are more common during build up phase, but can also happen during maintenance phaseAdverse reactions often decrease in frequency with longer duration of therapy

Biggest concerns: anaphylaxis and induction of eosinophilic esophagitis

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Take Home Points

Pediatricians should ask detailed questions about food reaction when deciding whether or not to refer to an allergist: symptoms, timing, and subsequent exposures.Skin and blood allergy testing is valid only for IgE mediated reactions, and NEVER ORDER FOOD PANELS.

First line treatment for anaphylaxis is epinephrine, and this can be repeated if symptoms do not improve. Delay to epinephrine is a predictor of poorer outcomes in anaphylaxis.

Epinephrine should be stored at room temperature, but exposure to hot and cold (especially cold) temperatures likely does not affect drug stability significantly.

“Expired” epinephrine autoinjectors are not bad and likely retain most of their efficacy well beyond their expiration date.

Patients with severe eczema, egg allergy, or both disease are most likely to avoid peanut allergy with early introduction (4-6 months) compared to other risk groups. 

Peanut is the only food for which FDA approved oral immunotherapy exists.

Patients may experience adverse reactions, including anaphylaxis, when going through build up and maintenance stages of oral immunotherapy.

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Thank you all for your participation and engagement!