Referral Guidelines for Allergy in General Practice

Allergy in 10 minutesDETECTIVE WORK

Presenting episode

Previous episodes

Consistent trigger or pattern to episodes

Contacts/Foods in previous 4 hours (most begin within 30

minutes)

Co-factors - exercise/alcohol/NSAIDS/intercurrent illness

Other drugs

Atopic medical history - CONCURRENT ASTHMA

Assess severity

GRADE Brown et al 2006

1 MILD Skin and subcutaneous tissues only: Generalised erythema, urticaria, periorbital oedema or angioedema

2 MODERATE Respiratory, cardiovascular or gastrointestinal symptoms: Dyspnoea, stridor, hoarseness, wheeze

Nausea, vomiting

Dizziness (presyncope), diaphoresis

Chest or throat tightness, abdominal pain

3 SEVERE Hypoxia, hypotension or neurological compromise: Cyanosis or SpO2≤92%

Systolic blood pressure<90mmHg in adults

Confusion, collapse, loss of consciousness

GRADING SYSTEM FOR GENERALISED HYPERSENSITIVITY REACTIONS

Management of AnaphylaxisRESCUE KIT:

MILD: Anti-histamine high dose

INTRAORAL SWELLING:ADD Soluble prednisolone

30mg (0.5mg/kg)

SEVERE: ADD Adrenaline auto injector300mcg over 30kg150mcg 15-30kg

AnaphylaxisRefer suspected severe anaphylaxis symptoms:

Any combination of: Bronchospasm Laryngeal/pharyngeal oedema Hypotension USUALLY with flushing, urticaria, angioedema

If blood sample taken: Gold top marked: ‘HOLD- allergens to be advised’

Urticaria & AngioedemaNon –allergic cause suggested if:

Spontaneous/overnight/early morningPhysical triggersSeveral days durationNo consistent relationship with food

(ingestion/contact)In Food Allergy:

Symptoms usually within 30 minutes of ingestion Delay of more than 2 hours is rare

ACE-I with angioedema

Treatment: Urticaria only

Check not following NSAIDPotent long acting antihistamine Up to 4 x standard dose+/- Montelukast 10mg nocte+/- H2 BlockerRefer if symptoms intolerable despite Rx

Treatment: Angioedemawith or without urticaria

Rx as for urticariaCheck not on ACE-IIsolated angioedema:

check C3, C4, C1-inhibitor and electrophoresisIf intraoral swelling:

Add soluble prednisolone 30mg as stat PRN dose Consider need for adrenaline auto-injector REFER

Hay feverStart 2 weeks prior to earliest symptomsContinue daily treatment throughout season‘Itchy –Sneezies’: Potent antihistamine

up to 2 bdNasal congestion: Intranasal Steroids up to

2 bdOcular symptoms: opticrom/optilastConsider montelukastREFER: Rescue steroids/SLIT/IT

Eczema in AdultsAdult patients often keen to find a dietary

allergic causeMany demonstrate apparent sensitisationRoutine blood testing not advised in the

absence of symptoms of food allergyContact eczema: Skin PATCH testing-

Dermatology

SUMMARY: When to Refer

Insect venom anaphylaxisSymptoms do not respond to treatment/avoidanceConfirmed IgE mediated food allergy with asthmaTests are negative but a strong suspicion of

allergy Anaphylaxis of uncertain causeReview of condition/for retesting/management