Doctors talk about allergy

At the recent Anaphylaxis Campaign Healthcare Professionals Conference Dr Matt Doyle talked about the increased awareness of allergy in primary care and Dr Paul Turner talked about anaphylaxis to food, and its management.

As all too many readers will know to their cost, the average GP is no allergy expert. Indeed, all too often in the past, the patient has been far better informed about allergy than their healthcare professional. However, Dr Matt Doyle believes that things are improving.

Traditionally GPs have had very little, if any, training in allergy and what training they have had has been via specific diseases or conditions – asthma/respiratory allergy; eczema/skin allergy etc. So what they have learnt they have learnt 'on the hoof'. Moreover, although they have 'permission' to prescribe management drugs (Salbutimol, autoinjectors, steroid injections, hydrolysed formulae etc) they have been given no training on what/how much to prescribe or how the medications should be used.

Ten years ago a GP's training did cover, briefly, hay fever and eczema, but there was no mention of allergy. Now, ten years later, the relevant 343 pages include 12 mentions of allergy, 24 of asthma, 8 of eczema and one of anaphylaxis (how to recognise it) – although still nothing on food allergy.

However, for those practitioners who wish to learn more, there is now, relatively speaking, a wealth of material for them to study.

NICE have produced a range of guidelines for the diagnosis and management of:

• Food allergy
• Anaphylaxis
• Drug allergy
• Cow's Milk Allergy

Meanwhile the following now all offer allergy courses:

• Allergy Academy
• BSACI, Primary care days
• BSACI webinars
• Pulse Learning
• Southampton University, MSc in allergy
• Guidelines in Practice
• Royal College General Practitioners

Within Primary Care a new system to alert GPs if they are over prescribing is also forcing GPs to think about what they are prescribing in terms of allergy medication, especially autoinjectors. None the less, it remains extremely difficult to get both GPs and patients to actually use trainer pens. This is especially important if pens are changed as both the users and the medical professionals need to be retrained, but they rarely get that training. There can be further confusion as regards pharmacies and both pharmacies and doctor will assume that the other will train – and then neither does!

So there is still a long way to go, but, it is a much more encouraging picture than it was ten years ago.

Dr Paul Turner who is currently investigating mechanisms of food-triggered anaphylaxis at Imperial College made a number of interesting points with reference to anaphylaxis to food.

* The LEAP study did suggest that the early introduction of potential allergens could reduce the incidence of allergy, but despite the early introduction1.9% of the children remained allergic. So although we may be able to reduce the incidence, we cannot, at this stage anyhow, get rid of food allergy.

* The impact of food allergy is significant:

• It takes 30% longer to shop
• The cost of food is significantly higher
• The Quality of Life scores for those with food allergy are worse than for people with diabetes
• There is a significant risk of compromised nutrition

* Anaphylaxis.

Published data on 12-20 year olds suggests that one in ten may report an allergic reaction but only one in every ten of those will actually have suffered anaphylaxis.
On the other hand, those suffering wheeze may often be mistreated as the wheeze may in fact be unrecognised anaphylaxis.
However, the likelihood of anaphylaxis being fatal is very small.
The issue is that there is currently no way of predicting which reactions will, or will not, be serious.

* Failure to treat anaphylaxis appropriately

• 83% of teenagers did not use their autoinjectors or their asthma medication when they had a reaction.
• Even worse, the majority went off somewhere alone when they had a reaction. You should never go off alone if you are reacting as if the reaction develops you may pass out and not be found until it is too late.
• Even when they have been trained to use the autoinjector pen, most teenagers do not use adrenaline if they think they are having a reaction - nor do many doctors!
• Even after intensive training, only 4% of mothers used the pens correctly while, in a study in Melbourne, only 2% of doctors were found to use the pens correctly!

* Sensitivity versus allergy

'Sensitisation is a poor marker of clinical sensitivity.' Only around 50% of those who are sensitive to a food are actually allergic to it.

* Diagnosis/testing

• Skin prick tests are better than blood tests as diagnosing peanut allergy but still not totally reliable.
• Component Resolved Diagnostic (CRD) testing is no more accurate than skin tests.
• Basophil Activation test - good for diagnosing allergy but far too complicated for practical use.
• Food challenge tests remain gold standard.
• Food challenge tests have very positive effect on Quality of Life, even when reactions occur.
• Sub-lingual mucosal challenge - photographing the blood flow through the lip to assess severity of allergy – shows promise.

December 2016

For more articles on the management and treatment of food allergy and intolerance, see here.

For more reports an Anaphylaxis Campaign conferences see here.

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