food allergy assessment - poma.memberclicks.net · food protein-induced enterocolitis syndrome...

“Food Allergy Assessment”James N. DeAngelo, DO

POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31, 2019-February 3, 2019 1

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Food Allergy Assessment

James DeAngelo, D.O., FAAAAI, FACOI

With special thanks for teaching slide contributions from David Fleischer, MD, Anna Nowak-Węgrzyn, MD, & Michael C. Young, MD through the AAAAI

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Disclosures

• Independent Contractor for AstraZeneca Pharmaceuticals, LP,

GlaxoSmithKline, Gossamer Bio, Inc., and Novartis

Pharmaceuticals Corp.

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• Eosinophilic esophagitis (EoE)

• Eosinophilic gastritis

• Eosinophilic gastroenteritis

• Atopic dermatitis

Immunologic (Allergic) Adverse Food Reactions

• Systemic (Anaphylaxis)

• Oral Allergy Syndrome

• Immediate gastrointestinal allergy

• Asthma/rhinitis

• Urticaria

• Morbilliform rashes and flushing

• Contact urticaria

IgE-Mediated Non-IgE Mediated

Cell-Mediated

• Food Protein-Induced Enterocolitis

• Food Protein-Induced Enteropathy

• Food Protein-Induced Proctocolitis

• Dermatitis

herpetiformis

• Contact dermatitis

Sampson HA. J Allergy Clin Immunol 2004;113:805-9.

Chapman J, et al. Ann Allergy Asthma Immunol 2006;96:S51-68.

Mixed IgE/Non

IgE

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Cutaneous

• Flushing, hives, angioedema, eczema

Respiratory

• Rhinitis, laryngeal edema, wheezing, coughing

Gastrointestinal

• Abdominal cramping, nausea, vomiting, diarrhea

Cardiovascular

• Hypotension, tachycardia, arrhythmias

IgE-Mediated Food Allergy Presentation

Central Nervous System

• Lightheadedness, syncope

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Mixed IgE/ Non-IgE-Mediated Food Allergy

Eosinophilic Esophagitis, Gastritis, Gastroenteritis

• Vomiting, nausea, abdominal pain, diarrhea, failure to thrive,

weight loss, dysphagia, food impaction

Atopic Dermatitis

• Itchy, erythematous papulo-vesicular rash localized to flexor

areas, in infants rash can be generalized; chronic lesions-

hypertrophy, lichenification, hyperpigmentation

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Food Protein-Induced Allergic Proctitis / Proctocolitis• Gross blood in stool + other symptoms, usually well-appearing infant

Food Protein-Induced Enterocolitis Syndrome (FPIES)

• 2-4 hours after ingestion: repetitive projectile vomiting + diarrhea

that can lead to severe dehydration, onset usually in the 1st year of

life

Celiac Disease

• Diarrhea, steatorrhea, malabsorption, abdominal distention,

flatulence, + nausea & vomiting, failure to thrive, oral ulcers

Non IgE-Mediated Food Allergy Presentation

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Non-Immunologic Adverse Food Reactions

• Bacterial food poisoning

• Heavy metal poisoning

• Scombroid fish poisoning

• Caffeine

• Alcohol

• Histamine

Toxic / Pharmacologic Non-Toxic / Intolerance

• Lactase deficiency

• Galactosemia

• Pancreatic insufficiency

• Gallbladder / liver disease

• Hiatal hernia

• Gustatory rhinitis

• Anorexia nervosa

• Idiosyncratic

• Carbohydrate malabsorption

Sicherer SH, Sampson HA. J Allergy Clin Immunol 2006;117:S470-475.#POMAD8

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Estimated Prevalence of Food Allergy

Food Children (%) Adults (%)

Cow’s milk 2.5 0.3

Egg 1.5 0.2

Wheat, Soy 0.4 0.3

Peanut 2.0 0.6

Sesame 0.1 0.1

Tree nut 0.5 0.6

Crustacean 0.1 2.0

Fish 0.1 0.4

Overall 6 2-3.5

Sicherer SH, Sampson HA. J Allergy Clin Immunol 2010;125:S116-125.

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Natural History of Food Allergy

• ~ 80% of milk, soy, egg, wheat allergy remit by teenage years

– Declining/low levels of specific-IgE predictive

– Milk and egg: tolerance to extensively heated proteins precedes development of tolerance to unheated

• High likelihood of developing further allergic disease:

• other foods >30%

• allergic rhinitis >90%

• asthma 50 – 90%

• Non-IgE-mediated GI allergy [e.g., allergic proctocolitis, FPIES]:

– Infant forms resolve in 1-3 years.

– Toddler/adult forms more persistent!

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Evaluation: History & Physical Exam

• History: very important

– Symptoms, timing, amount, raw vs. cooked food,

reproducibility, treatment, and outcome

– Concurrent exercise, medications, alcohol

• Diet details / symptom diary

• Physical exam: assess for other disorders

• Identify general mechanism

– Allergy vs. intolerance; IgE vs. non-IgE mediated

Boyce J, et al. JACI 2010; 126(6 Suppl):S1-S58.

Sampson HA, et al. JACI 2014; 134(5):1016-25.e43

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“Allergic” vs. “Sensitized”

• The presence of allergen specific IgE (sIgE) only indicates that

the patient is sensitized and that they have the potential to react.

• A positive test DOES NOT EQUAL and allergy!

• An allergic reaction requires not only the presence of sIgE but

also mast cell and basophil degranulation with the release of

mediators such as histamine, leukotrienes, prostaglandins,

platelet activating factor and many others followed by the

activation and migration of effector cells such as the eosinophil.

#POMAD8#ChoosePOMAJournal of Allergy and Clinical Immunology 2013 131, 972-976DOI: (10.1016/j.jaci.2012.12.1569)

Copyright © 2013 American Academy of Allergy, Asthma & Immunology Terms and Conditions

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http://www.elsevier.com/termsandconditions



Evaluation:

Interpretation of Laboratory Tests

• Positive skin prick test or food-specific IgE

– Indicates presence of IgE antibody NOT clinical reactivity

– ~90% sensitivity; ~50% specificity

– ~50% asymptomatic sensitization

– Larger skin tests/higher sIgE levels correlate with

increased likelihood of reaction but not severity

• Negative skin prick test or food-specific IgE

– Essentially excludes IgE antibody (>95% specific)

Sampson and Ho. J Allergy Clin Immunol 1997;100:444-51.

Sampson HA, J Allergy Clin Immunol 2001, 891-96.

Celik-Bilgili S, et al. Clin Exp Allergy 2005;35:268-73.

Boyce J, et al. JACI 2010; 126(6 Suppl):S1-S58; Sampson HA, et al. JACI 2014; 134(5):1016-25.e43

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Evaluation: Skin testing Skin testing is performed in steps: skin prick (epicutaneous)

Photos courtesy of Paige Wickner, Brigham and Women’s Hospital

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Evaluation: Skin testing

• Avoid antihistamines for a minimum of 5 days

prior to skin testing

– Benadryl/ diphenhydramine, Allegra/fexofenadine,

Claritin/loratadine, etc.

– Tricyclic antidepressants may also interfere with test

results

• Hold beta-blockers for 1 day prior to skin testing

– blunts response to epinephrine should an anaphylactic

reaction occur

• Results are available immediately (15-20 minutes)

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IgE Blood Tests are Immunoassays

• Measure the level of IgE specific to a particular allergen and include:

– Enzyme-linked immunosorbent assays (ELISAs)

– Fluorescent enzyme immunoassays (FEIAs)

– Radioallergosorbent assays (RASTs)

• Most commercial laboratories use one of three autoanalyzer systems to

measure specific IgE:

– ImmunoCAP (Phadia AB, Uppsala, Sweden)

– Immulite (Siemens AG, Berlin, Germany)

– HYTEC-288 (Hycor/Agilent, Garden Grove, CA).

Hamilton RG. Clinical laboratory assessment of immediate-type hypersensitivity. J Allergy Clin Immunol 2010; 125(suppl 2):S284–S296.

Cox L, Williams B, Sicherer S, et al; American College of Allergy, Asthma and Immunology Test Task Force; American Academy of Allergy, Asthma and

Immunology Specific IgE Test Task Force. Pearls and pitfalls of allergy diagnostic testing: report from the American College of Allergy, Asthma and

Immunology/American Academy of Allergy, Asthma and Immunology Specific IgE Test Task Force. Ann Allergy Asthma Immunol 2008; 101:580–592.

Hamilton RG, Franklin Adkinson N. In vitro assays for the diagnosis of IgE-mediated disorders. J Allergy Clin Immunol 2004; 114:213–225.

Siles, R.I. & Hsieh, F.H. Allergy blood testing: A practical guide for clinicians. Cleveland Clinic Journal of Medicine. 2011 September;78(9):585-592.#POMAD8

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IgE Blood Tests are Immunoassays cont.

• Utilize a solid-phase polymer (cellulose or avidin) in which the antigen is

embedded.

1. The polymer facilitates binding of IgE.

2. Allergen specific IgE binds to the allergen embedded in the polymer.

3. Unbound antibodies are washed off.

• Despite the term “RAST,” these systems do not use radiation.

• Instead, a fluorescent antibody binds to the patient’s IgE.

• The amount of IgE present is determined by the amount of fluorescence.

– Reported in kilounits of antibody per liter (kU/L) or nanograms per milliliter (ng/mL).

– Usually considered positive if the allergen-specific IgE level is greater than 0.35 kU/L

Hamilton RG. Clinical laboratory assessment of immediate-type hypersensitivity. J Allergy Clin Immunol 2010; 125(suppl 2):S284–S296.

Cox L, Williams B, Sicherer S, et al; American College of Allergy, Asthma and Immunology Test Task Force; American Academy of Allergy, Asthma and

Immunology Specific IgE Test Task Force. Pearls and pitfalls of allergy diagnostic testing: report from the American College of Allergy, Asthma and

Immunology/American Academy of Allergy, Asthma and Immunology Specific IgE Test Task Force. Ann Allergy Asthma Immunol 2008; 101:580–592.

Hamilton RG, Franklin Adkinson N. In vitro assays for the diagnosis of IgE-mediated disorders. J Allergy Clin Immunol 2004; 114:213–225.

Siles, R.I. & Hsieh, F.H. Allergy blood testing: A practical guide for clinicians. Cleveland Clinic Journal of Medicine. 2011 September;78(9):585-592. #POMAD8#ChoosePOMA

Just what is a positive allergy blood test?

NEW REFERENCE RANGES for

sIgE* (IMMUNOCAP®)

RANGE

(kU/L**)CLASS

INTERPRETATIO

N

< 0.10 0 Undetectable

0.10 - 0.35 0/1 Detectable, low

0.36 - 0.69 1 Low

0.70 - 3.49 2 Moderate

3.50 - 17.40 3 High

17.50 - 49.0 4

Very high- 99.0 5

> 100.00 6

OLD REFERENCE RANGES for sIgE*

(IMMUNOCAP®)

RANGE

(kU/L**)CLASS INTERPRETATION

< 0.35 0 Undetectable

0.35 - 0.69 1 Low

0.70 - 3.49 2 Moderate

3.50 - 17.40 3 High

17.50 - 49.0 4

Very high- 99.0 5

> 100.00 6

*sIgE (allergen specific IgE in kU/L) where one kU/L equals 2.4 ng/ml. The kU/L or IU/L for IgE was developed express

the level of IgE in peripheral blood to alleviate the inconvenience in expressing the very low levels of serum IgE.

**Seagroatt V, Anderson SG. J Biol Stand. 1981 Oct; 9(4):431-7.#POMAD8

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Predictive value of food-specific IgE testing in positive and negative OFC

Food >95% Positive ~50% Negative

Test sIgE, kIU/L SPT, mm sIgE, kIU/L SPT, mm

Peanut >14 >8<2, + prior rxn

<5, no prior rnx

<3

Milk (age <2 yr) >5>8

<2 <2

Milk >15 >8

Egg (age <2 yr) >2>7

<2 <3

Egg >7 >8

Fish >20 ? ? ?

Sampson HA, et al. JACI 2014; 134(5):1016-25.e43#POMAD8

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Molecular Diagnosis of Food Allergy

• Major allergens identified in certain foods

• Birch cross-reactive allergens: Ara h 8 in peanut, Cor a 1 in

hazelnut-mild oral symptoms or no symptoms upon

ingestion, consider challenge

• Storage seed proteins: Ara h 1, 2, 3 in peanut, Cor a 9 and

14 in hazelnut-associated with systemic reactions,

recommend strict avoidance, defer challenge

Sicherer SH, Wood RA. JACI in Practice 2013;1:1-13.


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Basophil Activation Test (BAT)

• Requires fresh blood and uses flow cytometry.

• Is a “functional” test that goes beyond “quantitative” detection of IgE.

• Measures “qualitative” activation of live basophils.

– Basophil & mast cell, activation depends not only sIgE levels but also on IgE

epitope specificity & affinity.

• “Allergic” patients demonstrate a dose-dependent expression of activation markers: CD63,

CD203c and others.

• The basophils of “sensitized-tolerant” patients lack significant expression of activation

markers.

• Enhanced specificity with conserved sensitivity.» Good luck with insurance!

Santos, A. F., & Brough, H. A. (2017, 03). Making the Most of In Vitro Tests to Diagnose Food Allergy. The Journal of Allergy and Clinical Immunology: In Practice, 5(2), 237-248.

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#POMAD8#ChoosePOMASteiner, Markus & Harrer, Andrea & Himly, Martin. (2016). Basophil Reactivity as Biomarker in Immediate Drug Hypersensitivity Reactions—Potential and Limitations. Frontiers in Pharmacology. 7. 10.3389/fphar.2016.00171 .

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Ratios: allergen-specific/total IgE and allergen-specific IgG4/IgE

• Food-specific IgG4/IgE ratios have been studied!

– Sensitized-tolerant children tend to have higher allergen-specific

IgG4/IgE ratios than allergic children.1

– A higher peanut-specific IgG4/IgE ratio has also been observed in

peanut allergic patients treated with peanut oral immunotherapy

(OIT).2

– Allergic patients tend to show a higher food sIgE/IgG4 ratio.1

• Diagnostic utility has not been established.1

1. Santos, A. F., & Brough, H. A. (2017, 03). Making the Most of In Vitro Tests to Diagnose Food Allergy. The Journal of Allergy and

Clinical Immunology: In Practice, 5(2), 237-248.

2. Santos AF, James LK, Bahnson HT, Shamji MH, Couto-Francisco NC, Islam S, et al. IgG4 inhibits peanut-induced basophil and mast cell

activation in peanut-tolerant children sensitized to peanut major allergens. J Allergy Clin Immunol 2015;135:1249-56.

Unproven / Experimental Tests

• Intradermal skin test with foods

– Risk of systemic reactions and death;

high false positive rate

• Atopy patch testing with foods

– No standardized reagents

• Provocation/neutralization

• Cytotoxic tests

• Hair analysis

• Electrodermal testing

• Applied kinesiology (muscle

response testing)

– See Dr. Swindler for demonstration of

applied kinesiology

https://www.youtube.com/watch?v=Hlv8

Wrb_2YI

• Food-specific IgG or IgG4 (IgG

“RAST” or “ELISA)

– No way to determine what constitutes a

“positive”!

Lockey RF. Allergy Proc 1995;16:293-6.



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•AAL Reference Laboratories (AALRL)

•Aeron Life Cycle Labs

•Affinity Laboratory Technologies,

•Altess Medical Laboratory

•Age Diagnostic Laboratories

•American Medical Testing Laboratories

•Amscot Medical Labs

•Anamol Laboratories (acquired by another company in 2008)

•Antibody Assay Laboratories

•Bio-Center Laboratory (BCL)

•BioHealth Diagnostics

•Biolab Medical International (Australia)

•Biolab Medical Unit (UK)

•Cellmate Wellness Systems (formerly Carbon Based Corporation)

•Center for Complex Infectious Diseases

•Dental DNA (Colorado Springs, CO)

•Diagnos-Techs

•Fry Laboratories (Scottsdale, AZ)

•Great Plains Laboratory

•Genova Diagnostics (formerly Great Smokies Diagnostic Laboratory)

• BodyBalance and Its Test Kits

• Genovations

• Aetna Coverage Policy Bulletin

•Immuno Laboratories

•Immunosciences Lab (CLIA accreditation revoked, 6/12/07)

•Individual WellBeing Diagnostic Laboratories

•International Center for Metabolic Testing (ICMT)

•Intracellular Diagnostics

•King James Medical Laboratory (closed following death in 2012 of owner James Frackelton, MD)

•Labrix Clinical Services

•Laboratiore Phillippe Auguste

•Liberty Testing Laboratory (closed 6/30/99)

•Maxillofacial Center for Diagnostics & Research

•Meridian Valley Clinical Laboratory

•MetaMetrix Medical Research Laboratory

•Optimum Health Labs

•Pantox Laboratories

•RealTime Laboratories (Dallas, Texas)

•Sage Medical Laboratory

•Serammune Physicians Lab

•Scientific Health Solutions

•SpectraCell Laboratories

•Trace Elements

•Trace Minerals International

•US BioTek Laboratories

•YorkTest Laboratories

•Your Future Health

•ZRT Laboratory (formerly Zava Laboratories

This article was revised on May 28, 2017.

Laboratories Doing Nonstandard Laboratory TestsStephen Barrett, M.D

Most of the laboratories listed below cater to practitioners who engage in nonstandard practices. All of these labs perform one or more nonstandard tests. Most also

perform various standard tests. When evaluating practitioners, we would regard routine use of any of these laboratories as an unfavorable sign.

Slide adapted from: https://www.quackwatch.org/01QuackeryRelatedTopics/Tests/nonstandard.html

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0.25

0.29

0.22

0.32

0.27

0.25

1.05

0.7

6.51

1.12

3.12

2.33

1.45

2.27

BEEF

CHICKEN

EGG

MILK

PEANUT

SOY

WHEAT

Personal Food Allergy Profile

IgE kU/L IgG4 mg /dL

2 3 4 5 7 8 9

TAU

1

Total Allergy Units = TAU#POMAD8

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https://www.quackwatch.org/11Ind/kindness.html

https://www.quackwatch.org/01QuackeryRelatedTopics/Tests/bodybalance.html

https://www.quackwatch.org/01QuackeryRelatedTopics/Tests/genomics.html

http://www.aetna.com/cpb/data/CPBA0608.html

https://www.quackwatch.org/01QuackeryRelatedTopics/Tests/serum.html

https://www.quackwatch.org/01QuackeryRelatedTopics/Tests/nonstandard.html

https://www.quackwatch.org/01QuackeryRelatedTopics/Tests/healthprints.html



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“The world is flat, and resting on the backs of four elephants who, in turn, stand upon the back of a giant, space-faring turtle!”*

*Stewart, I. (2013, July 16). The Science Behind Discworld's Flat Earth on the Back of a Turtle. GIZMODO Retrieved from https://io9.gizmodo.com/the-science-behind-discworlds-flat-earth-on-the-back-o-802628932

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Evaluation:

Elimination Diets & Food Challenges

• Elimination diets (1-6 weeks) most useful for chronic disease (eg. AD, GI syndromes)– Eliminate suspected food(s) or– Prescribe limited “few food” diet or– Elemental (free amino acid) diet

• Oral food challenge – physician supervised, emergency meds available– Open– Single-blind– Double-blind, placebo-controlled (DBPCFC)-gold standard– Usually full serving of food administered in divided,

increasing doses over 1 hour, followed by observation

Nowak-Wegrzyn A, et al. JACI 2009;123:S365-83.



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* Unless convincing history warrants supervised challenge!

Diagnostic Approach:

Suspicion of IgE-Mediated Allergy

• If test for food-specific IgE is

– Negative: reintroduce food*

– Positive: food avoidance recommended

• If elimination diet is associated with

– No resolution: reintroduce food*

– Resolution

• Open / single-blind challenges to “screen”

• DBPCFC for equivocal open challenges


Sampson HA, et al. JACI 2014; 134(5):1016-25.e43 #POMAD8#ChoosePOMA

Diagnostic Approach: Non-IgE-Mediated

Disease or Those with Unclear Mechanism

• Elimination diets (may need elemental amino acid-based diet)

• Physician-supervised Oral Food Challenges

– Timing/dose/approach individualized for disorder

• Enterocolitis syndrome can induce shock

• Eosinophilic gastroenteritis may need prolonged feedings before symptoms develop

– Blinded challenges may be necessary

– May require ancillary testing (endoscopy/biopsy)

Sampson HA. JACI 2004;113:805-19.

Sicherer SA. JACI 2005;115:149-56.

Järvinen KM, Nowak-Węgrzyn A. JACI in Practice 2013;1(4):317-22. #POMAD8#ChoosePOMA

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General Principles of Management

• Avoidance of the food allergen

• Ensure nutritional needs for children are met

• Education

• Written individualized healthcare plans (IHP) and emergency

action plans (EAP)

• Quick access to emergency medications including self-injectable

epinephrine (SIE)

Boyce JA, et al. J Allergy Clin Immunol 2010;126:S1-S58. #POMAD8#ChoosePOMA

Introduction of Complementary Foods

• Complementary foods, including cow’s milk protein (except for

whole cow’s milk), egg, soy, wheat, peanut, tree nuts, fish, and

shellfish, can be introduced between 4-6 months of age

• New data suggest that early introduction of highly allergenic

foods (e.g. peanut) may reduce the risk of food allergy

• If a patient has difficult to control moderate-severe AD or a food

allergy, referral to an allergist for possible testing is

recommended before introduction of highly allergenic foods

Fleischer DM et al. J Allergy Clin Immunol: In Practice. 2013;1:29-36

Du Toit G, et al. N Engl J Med. 2015; 372: 803-13 #POMAD8#ChoosePOMA

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LEAP Study: “Learning Early About Peanut”

• Randomized 640 infants with severe eczema, egg allergy, or both,

to either consume or avoid peanuts until 60 months of age.

• At the end of the study the researchers found:

– Prevalence of peanut allergy in the peanut-avoidance group was 17.2%

vs. only 3.2% in the consumption group.

– Children already sensitive to peanuts reflected a 35.3% prevalence of

peanut allergy in the avoidance group vs. 10.6% in the consumption

group.

– Early introduction of peanut dramatically decreases the risk of developing

a peanut allergy 70-80%.

Du Toit, G. et. al, Randomized Trial of Peanut Consumption in Infants at Risk for Peanut Allergy. New England Journal of Medicine, 372(9), pp.803-813.

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#POMAD8#ChoosePOMADu Toit G et al. N Engl J Med 2015;372:803-813

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“In 2015, findings from the landmark Learning Early About Peanut Allergy

(LEAP) study—the first randomized trial to study early allergen

introduction as a preventive strategy—showed that early introduction of

peanut-containing foods to infants at high risk of developing peanut allergy

was safe and led to an 81 percent relative reduction in the subsequent

development of peanut allergy. Based on the size of the observed effect and

the statistical significance of this result, the National Institute of Allergy and

Infectious Diseases (NIAID), part of the National Institutes of Health

(NIH), established a coordinating committee and convened an expert panel

to develop clinical guidelines to address the prevention of peanut allergy.

These guidelines are an Addendum to the 2010 Guidelines for the Diagnosis

and Management of Food Allergy in the United States.”

National Institute of Allergy and Infectious Diseases Addendum Guidelines

for the Prevention of Peanut Allergy in the United States

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Summary of Addendum Guidelines: National Institute of Allergy and Infectious Diseases

Addendum Guideline Infant Criteria RecommendationsEarliest Age of Peanut

Introduction

1Severe eczema, egg allergy,

or both

Strongly consider evaluation

with peanut specific IgE

and/or skin prick test and, if

necessary, an oral food

challenge. Based on test

results, introduce peanut

containing foods.

4 to 6 months

2 Mild to moderate eczemaIntroduce peanut-containing

foods.4 to 6 months

3No eczema or any food

allergy

Introduce peanut-containing

foods.

Age-appropriate and in

accordance with family

preferences and cultural

practices #POMAD8#ChoosePOMA

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Adapted from: Togias et al, Addendum guidelines for the prevention of peanut allergy in the United States: report of the National Institute of Allergy and Infectious Diseases-sponsored expert panel. Ann Allergy Asthma Immunol. 2017;118(2):166–73.

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“APPENDIX D. INSTRUCTIONS FOR HOME FEEDING OF PEANUT PROTEIN FOR

INFANTS AT LOW RISK OF AN ALLERGIC REACTION TO PEANUT”*

1. Measure 2 teaspoons of peanut buter and

slowly add 2 to 3 teaspoons of hot water.

2. Stir until peanut butter is dissolved,

thinned, and well blended.

3. Let cool.

4. Increase water amount if necessary (or

add previously tolerated infant cereal) to

achieve consistency comfortable for the

infant.

“Option 2”

*Adapted from: https://www.niaid.nih.gov/sites/default/files/addendum_guidelines_peanut_appx_d.pdf

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Emergency Treatment of Anaphylaxis

• Epinephrine: drug of choice

– Have 2 doses of self-injectable epinephrine available as 12% of children, 17 % of adults require >1 dose

– Emergency transport to hospital to monitor for possible biphasic (late phase) anaphylaxis

– Antihistamines: WILL NOT STOP ANAPHYLAXIS!

• Written Anaphylaxis Emergency Action Plan

• Emergency identification bracelet

Simons FE, JACI 2010;125(2 Suppl 2):S161-81. Kim JS, et al. JACI 2005; Jul;116(1):164-8.

Rudders S, et al. Pediatrics 2010;125:e711-8. Rudders S et al. Allergy Asthma Proc. 2010;31:308-16#POMAD8

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Respond Quickly!• Administer epinephrine quickly

• Activate EMS – 911

• Then, call emergency contacts

Images provided by: EpiPEN – Mylan, 2015. Adrenaclick – Impax Labs. Auvi-Q - Sanofi

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Future Therapies for Food Allergy

In clinical trials:

• Oral immunotherapy (OIT) for milk, egg, peanut, multiple food

combinations

• OIT in combination with anti-IgE

• Sublingual immunotherapy (SLIT)

• Epicutaneous (patch) immunotherapy for milk, egg, peanut.

• OIT with baked milk, egg for milk and egg allergy

• Chinese Herbal Formula (FAHF-2)

• Anti-IL5 & swallowed budesonide for eosinophilic esophagitis.

Nowak-Wegrzyn A, Sampson HA. JACI 2011;127:558-73. Lieberman JA, Nowak-Wegrzyn.

Curr Allergy Asthma Rep 2012;12:55-63. Berin MC. Curr Pediatr Rep 2014;2:119-26.

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Oral Immunotherapy

OIT is still investigational – not for general clinical practice

Questions remaining:

• Do risks of adverse reactions with OIT outweigh risks of accidental

exposures with avoidance diets?

• Desensitization vs. induction of tolerance?

• Standardization of extracts, protocols, and duration of treatment

Sampson HA. JACI-In Practice 2013;1:15-21. #POMAD8#ChoosePOMA

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Epicutaneous (Patch) Immunotherapy

The Viaskin Peanut Skin Patch (Source: DBV Technologies) https://www.dbv-technologies.com/viaskin-platform/#POMAD8

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#POMAD8#ChoosePOMAThe Viaskin Peanut Skin Patch (Source: DBV Technologies) https://www.dbv-technologies.com/viaskin-platform/

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food allergy assessment - poma.memberclicks.net · food protein-induced enterocolitis syndrome...

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