putting it together: niaid- sponsored 2010 guidelines for ......putting together diagnosis and...
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American Academy of Allergy, Asthma and
Immunology
FIT Symposium # 1011
Putting It Together: NIAID-
Sponsored 2010 Guidelines for
Managing Food Allergy
Scott H. Sicherer, MD Mount Sinai School of Medicine
Jaffe Food Allergy Institute
Pediatric Allergy & Immunology
New York, NY February 22, 2013 11:45 AM
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Putting Together Diagnosis
and
Putting Together
Management
Boyce JA, Assa'ad A, Burks AW, Jones SM, Sampson HA, Wood RA et al. Guidelines for
the diagnosis and management of food allergy in the United States: report of the NIAID-
sponsored expert panel. J Allergy Clin Immunol 2010; 126(6 Suppl):S1-58.
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Major Points for Successful
Diagnosis
• Pathophysiology
• Epidemiology
• Careful history
• Understanding utility of tests
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Step 1: Pathophysiology
Adverse reactions
(not hypersensitivity)
Non-Allergic
Allergy (Immune-mediated)
IgE-Mediated “Non-IgE” mediated
•Bacterial food poisoning
•Scombroid fish poisoning
•Lactase deficiency
•Galactosemia
•Anaphylaxis
•Urticaria
•Isolated
gastrointestinal
reactions
•Skin rashes
IgE?
•Atopic Dermatitis
•Eosinophilic
gastroenteritis
Expect Positive
Skin Test
Accept Negative
Skin Test
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Step 2: Epidemiology
• Of foods
• Of disorders
Common in Children
-egg -peanut
-milk -tree nuts
-soy -seafood
-wheat
Common in Adults
-peanut
-tree nuts
-seafood
-(fruits/vegetables)
Not usually associated with food
-chronic asthma
-chronic allergic rhinitis
-chronic urticaria
Often associated with food
-anaphylaxis
-urticaria (acute)
-atopic dermatitis (~35%)
-syndromes of gastrointestinal allergy
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Step 3: Careful History
• Symptoms
• Food(s) ingested
• Frequency of ingestion (ever tolerated?)
• Timing of symptoms
• Co-ingestion of ASA, alcohol
• Association with exercise
• Diet records
• Labels
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Step 4: Incorporation of Tests
• IgE-mediated acute symptoms
– Tests positive eliminate
– Tests negative reintroduce (possibly as oral challenge)
• IgE-Mediated chronic symptoms (Atopic dermatitis, eosinophilic gastroenteropathies)
– Screening tests by history and a priori, elimination diet, if resolved do oral challenges
• Non-IgE (enterocolitis, enteropathies)
– Elimination diet and oral challenges
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Food-Specific IgE Antibody
Concentrations Correlate with
Risk of Clinical Reactivity
0
10
20
30
40
50
60
70
80
90
100
Food-specific IgE Antibody Concentration
Pro
bab
ilit
y o
f a r
eact
ion
(%
) Curve varies by:
•Food
•Disease
•Age
•Other
~95% Predictive
Values (CAP-System):
Egg-7 kIU/L
Milk-15 kIU/L
Peanut-14 kIU/L Negative test does not guarantee no reaction!
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Diagnostic Decision Points
(Food-specific IgE in kU/L)
Sicherer & Sampson JACI Primer 2006 (based mostly on US studies)
Food Mean age
5 years
~50%
react
Mean age
5 yrs
~95%
react
Age <2 yrs
~95%
react
Egg 2 > 7 > 2
Milk 2 > 15 > 5
Peanut 2-5 > 14 --
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Component Resolved Diagnosis Pollen cross-
reactive
components*
LTP Pollen non-cross-reactive
components**
Peanut Ara h 8 Ara h 9 Ara h 1; Ara h 2; Ara h 3
Arah 4; Ara h 6; Ara h 7 Ara h 5
Hazelnut Cor a 1 Cor a 8 Cor a 9
Cor a 11 Cor a 2
Soybean Gly m 4 Gly m 1 Gly m 5
Gly m 6 Gly m 3
Wheat Tri a 12 Tri a 14 Tri a 19 (ω-5 gliadin)
Tri a 21 - alfa gliadin
Tri a 26 - HMW glutenin
Tri a 28 - AAI dimer 0.19
*Birch tree pollen, Timothy grass pollen for wheat
** Storage seed proteins, albumins and globulins
PRP-10
Profilin
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LR(+)=sens/(1-spec)
•Must estimate pre-
test probability
(history, prior tests)
•Use simple,
additional tests with
(hopefully) strong
predictive accuracy
•Decide upon further
testing that may be
definitive but more
costly/risky/invasive
Prior Probability and Likelihood Ratios
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From Sicherer SH, Wood RA. Advances in
diagnosing peanut allergy. J Allergy Clin Immunol:
In Practice. 2013;1:1-13
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• CASE PRESENTATIONS
Tests:
Diagnosis:
OFC?:
Risk Monitor
Modality Dose
Location Post care
Prep
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• 6 week old, breast fed
• Mucousy bloody stools
• No vomit
• Good growth
• Mother on regular diet
Tests:
Diagnosis:
OFC?:
Risk Monitor
Modality Dose
Location Post care
Prep
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• 6 week old, breast fed
• Mucousy bloody stools
• No vomit
• Good growth
• Mother on regular diet
Tests: not
relevant
Diagnosis:
proctocolits
OFC?:not yet
Risk Monitor
Modality Dose
Location Post care
Prep
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• 6 week old, breast fed
• Mucousy bloody stools
• No vomit
• Good growth
• Mother on regular diet
• Mother off milk-all better
• Returns age 11 months still off milk…
Tests:
Diagnosis:
OFC?:
Risk Monitor
Modality Dose
Location Post care
Prep
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• 6 week old, breast fed
• Mucousy bloody stools
• No vomit
• Good growth
• Mother on regular diet
• Mother off milk-all better
• Returns age 11 months still off milk…
Tests:
Diagnosis:
OFC?:
Risk Monitor
Modality Dose
Location Post care
Prep
Interval Hx:
No atopic disease
Regular diet except
no milk…
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• 6 week old, breast fed
• Mucousy bloody stools
• No vomit
• Good growth
• Mother on regular diet
• Mother off milk-all better
• Returns age 11 months still off milk…
Tests:
maybe
Diagnosis:
proctocolitis
OFC?:yes
Risk low Monitor
Modality openDose
Location homePost care
Prep
Interval Hx:
No atopic disease
Regular diet except
no milk…
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• 37 year old with ragweed AR
• Banana ingestion, within minutes…
• Itchy throat
• Numb hands
• Generalized urticaria
• Took diphenhydramine
• Trouble breathing, LOC awoke and went to
ER, stable
Tests:
Diagnosis:
OFC?:
Risk Monitor
Modality Dose
Location Post care
Prep
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• 37 year old with ragweed AR
• Banana ingestion, within minutes…
• Itchy throat
• Numb hands
• Generalized urticaria
• Took diphenhydramine
• Trouble breathing, LOC awoke and went to
ER, stable
Tests:
Banana extr
SPT neg
sIgE-neg
RW-PST 9mm
Diagnosis:
OFC?:
Risk Monitor
Modality Dose
Location Post care
Prep
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• 37 year old with ragweed AR
• Banana ingestion, within minutes…
• Itchy throat
• Numb hands
• Generalized urticaria
• Took diphenhydramine
• Trouble breathing, LOC awoke and went to
ER, stable
Tests:
Banana extr
PST neg
sIgE-neg
RW-PST 9mm
Diagnosis:
Banana Ana?
OAS-panic?
OFC?:
Risk Monitor
Modality Dose
Location Post care
Prep
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• 37 year old with ragweed AR
• Banana ingestion, within minutes…
• Itchy throat
• Numb hands
• Generalized urticaria
• Took diphenhydramine
• Trouble breathing, LOC awoke and went to
ER, stable
Tests:
RAW Banana
PST 13 mm
Diagnosis:
Banana Ana?
OAS-panic?
OFC?:
Risk Monitor
Modality Dose
Location Post care
Prep
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• 3 years old
• Tried scrambled egg at age 11 months
• Generalized urticaria, vomit, cough
• Age 2, accident with mayonnaise, small
amount, facial urticaria
Tests:
PST 8 mm
sIgE 10 kIU/L
Diagnosis:
Current vs.
Resolved egg
allergy
OFC?:
Risk Monitor
Modality Dose
Location Post care
Prep
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• 3 years old
• Tried scrambled egg at age 11 months
• Generalized urticaria, vomit, cough
• Age 2, accident with mayonnaise, small
amount, facial urticaria
Tests:
PST 8 mm
sIgE 10 kIU/L
Diagnosis:
Current vs.
Resolved egg
allergy
OFC?: NO
Risk Monitor
Modality Dose
Location Post care
Prep
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• 3 years old
• Tried scrambled egg at age 11 months
• Generalized urticaria, vomit, cough
• Age 2, accident with mayonnaise, small amount, facial urticaria
• RETURNS age 4, mild asthma
• No interval reactions, tolerated baked egg
Tests:
PST 3 mm
sIgE 1.5 kIU/L
Diagnosis:
Current vs.
Resolved egg
allergy
OFC?:
Risk Monitor
Modality Dose
Location Post care
Prep
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• 3 years old
• Tried scrambled egg at age 11 months
• Generalized urticaria, vomit, cough
• Age 2, accident with mayonnaise, small amount, facial urticaria
• RETURNS age 4, mild asthma
• No interval reactions, tolerated baked egg
Tests:
PST 3 mm
sIgE 1.5 kIU/L
Diagnosis:
Current vs.
Resolved egg
allergy
OFC?: needed if..
Risk Mod Monitor
Modality open Dose slow
Location ? Post care
Prep ?no IV
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• 10 year old ate cashew anaphylaxis
• Tolerates peanut, walnut and almond
but stopped eating them after this
reaction 3 weeks ago
• Mild atopic history (resolved AD, mild
SAR)
Tests:
Diagnosis:
OFC?:
Risk Monitor
Modality Dose
Location Post care
Prep
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• 10 year old ate cashew anaphylaxis
• Tolerates peanut, walnut and almond but stopped eating them after this reaction 3 weeks ago
• Mild atopic history (resolved AD, mild SAR)
• Family would be interested in adding peanut/”allowed” nuts
Tests (IgE):
Cashew-11.7
Peanut-1.4
Almond-3.4
Walnut < 0.35
Diagnosis:
TNA-but
what to instruct?
OFC?:
Risk Monitor
Modality Dose
Location Post care
Prep
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• 3 year old, asthma, anaphylaxis X 5
• Severe reactions to egg, milk, peanut
and high IgE to these
• Diet restricted to turkey, soy, 3 fruits,
rice, oat, 3 vegetables (no other beans)
and amino acid formula
Tests:
Diagnosis:
OFC?:
Risk Monitor
Modality Dose
Location Post care
Prep
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• 3 year old, asthma, anaphylaxis X 5
• Severe reactions to egg, milk, peanut
and high IgE to these
• Diet restricted to turkey, soy, 3 fruits,
rice, oat, 3 vegetables (no other beans)
and amino acid formula
Tests serum/skin):
Beef-3.7/ 4 mm
Pea-2.8/ 2 mm
String bean-4.3/0 mm
Soy-19.9/ 6 mm
Wheat-15.4/ 5 mm
Pork-5.5/ 5 mm
Diagnosis:
MFA
OFC?:
Risk Monitor
Modality Dose
Location Post care
Prep
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Atopic Dermatitis Referral
• 18 month old with severe atopic dermatitis
• Pediatrician sent tests, many positives
• Left on a very limited diet
• Skin care maximized, environmental
controls, rash is moderate, still
waxes/wanes—not happy!
• You have the pre-determined tests
• You can take a history
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The tests! Eating PST (MM) IgE (kIU/L)
plum 3 0.47
peach 2 0.70
chicken 4 2.3
beef 5 44
spelt
Suspected
soy 3 8
wheat 7 >100
apple 3 <0.35
rice 3 2.0
pea 3 4.18
corn 2 3.12
barley 0 <0.35
banana 0 1.14
sweet potato 0 <0.35
Acute reaction-eliminated
milk 8 >100
egg 4 7.15
Never tried:
Peanut-67 kIU/L
Codfish-47 kIU/L
Lets vote:
Eat
Restrict
Challenge
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Management
• Avoidance advice
– Home, restaurants, school, vacation,
cross-contact, label reading, interpersonal,
anxiety, nutritional assessment , age-
related issues.
• Treatment advice
– When and how to use self-injectable
epinephrine, medical identification, dosing,
written materials, age-related issues
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Resource:
www.foodallergy.org/actionplan.pdf
Written Action Plan and Medical Jewelry
Consider cetirizine
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Treatment: Dietary Elimination
• Cross contact
• Restaurants/Hidden ingredients
• Labeling laws/advisory labeling
– Law covers milk, egg, wheat, soy, peanut, nuts,
fish, shellfish
– Advisory labeling is voluntary (may contain)
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Pediatrics. 2012;130(1):e25-32
• Followed for ~ 3 years
• Register all reactions “real time”
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Half of reactions: food not
from the parent
• Lesson- educate all caregivers and
watch siblings
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Purposeful Exposures in 11%
• Reasoning- Uncertain (suspect
misdiagnosis, small amount)
• Lesson- Education and anticipatory
guidance
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Severity of Reactions
• 11% were severe
• Lesson: Emphasize avoidance of
ingestion
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Under-treatment with
Epinephrine • Overall, 30% of severe reactions were treated
with epinephrine
– Severe=lower respiratory, cardiovascular, or combination of skin/oral/upper respiratory and GI.
• Among 65 reactions when not given but caregiver admitted “should have”- reaction not recognized (48%), medicine not on hand (23%), afraid (12%), waiting to worsen (6%).
• Lesson: emphasize safety of epinephrine, indications and technique of administration
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Summary
• Diagnosis: Synthesis of a priori
(epidemiology, pathophysiology,
history) and tests.
• Management: Education
• Resources: See Guidelines Page
S58. Includes: www.aaaai.org,
www.cofargroup.org,
www.niaid.nih.gov and others