Medicine and Me: Allergies

Meeting organised by the Royal Society of Medicine (www.roysocmed.ac.uk) in association with the National Allergy Strategy Group. www.roysocmed.ac.uk
Report by Alex Gazzola

House of Lords report
Baroness Ilora Finlay welcomed those attending with an overview of the recent House of Lords Science and Technology Committee report on allergy. The challenge for the committee, of which she was a member, was to explain how serious allergy can be, and the different allergic mechanisms and diseases there are.

They found that clinical services in the UK are fragmented and fall behind those of Europe. Key recommendations included the setting up of at least one allergy centre per strategic health authority, led by a full-time allergist, with diagnostic, education and training facilities, and which GPs could refer to for secondary care.

Other recommendations included: long-term funding of cohort studies; a disease registry; greater availability of immunotherapy (IT); better training for environmental health officers, trading standards officers and caterers; and better understanding of allergic children’s needs in schools.

She also pointed out that, despite a dearth of evidence of benefit, the UK is the only country presently recommending that pregnant women should avoid peanuts in pregnancy.

Anaphylaxis
Dr Pamela Ewan of the University of Cambridge, consultant allergist at Addenbrooke’s Hospital, said that anaphylaxis is common and becoming more so – one in 3,500 experience an anaphylactic incident annually, and one in 12 of those suffering an episode will have another within the year. It is also often misdiagnosed and unrecognised.

The matter is complicated by the fact that there is no precise definition of anaphylaxis. Hers, she said, is ‘a potentially life-threatening allergic reaction, usually sudden in onset and rapidly progressive, with airway obstruction or hypotension, possibly with cutaneous features’. Food (33%), stings (14%) and drugs (13%) were the major allergic triggers, although exercise and idiopathic causes were also common.

Acute and immediate treatment – adrenaline, antihistamines and steroids – is good, and works but the available aftercare is largely bad. A patient needs diagnosis, risk assessment, advice on allergen avoidance, rescue medication and education.

Nut allergies, of course, are the most frequent cause of near fatal reactions, and 1 in 50 children are now affected. Dr Ewan emphasised that it is possible to have a mild nut allergy, but that many nut allergic people were poorly advised on matters such as avoidance, epipen use, etc.

Although peanut allergy is the allergy with most notoriety, if you are cashew allergic – an increasing problem – you are 25 times more likely to have a severe reaction. She also expressed some concern at the rolling out of allergy blood tests into primary care.

The patient perspective
Karen Brunas, mother of a two-year-old boy with multiple severe food allergies, spoke movingly about the pressures and practicalities of parenting an infant under the constant threat of anaphylaxis – exploring issues surrounding feeding, shopping, holidaying and family acceptance. ‘How do you begin to explain egg allergy to a child who doesn’t even know what an egg is?’ she asked.

Immunotherapy
Professor Barry Kay of Imperial College began his talk by stating that that ‘Allergy is not a disease – but a mechanism’. His point being that a clear diagnosis of allergic disease needs to be made in cases where allergy is present.

European allergists, he reported, offered immunotherapy (IT) earlier rather than later, not using it as a last option as here in the UK. IT is not suitable for everyone – among those who should not receive treatment are those under five or over 50, those with autoimmune disease (including coeliac disease), pregnant women and those with multiple unrelated inhaled allergies. IT for food allergies has been tried, but was, historically, associated with fatalities. Research into oral IT treatment for nut allergies was looking good, but is not so positive now.

But why is IT so difficult to obtain in the UK? Professor Kay put this down to the ultra-conservative attitude of regulatory authorities, a paucity of allergy clinics, and a general lack of
education among GPs.

Sublingual IT (SLIT), such as the tablet Grazax for grass pollen allergy, is the major new hope, but the availability of such treatments is limited by inconsistent policies by PCTs and the usual postcode lottery. Most GPs are not aware of SLIT and continue to believe that OTC drugs are the way forward.

Need for more allergy clinics
Dr Shuaib Nasser of Addenbrooke’s and the NASG’s Mandy East (also of the Anaphylaxis Campaign) spoke of the need for more regional allergy centres, with allergists, trainee allergists, specialist nurses, dietitians and specialists in ENT, dermatology and respiratory disorders. Centres should be able to handle rare allergy, and undertake clinical research.

Mandy East reminded the meeting of some grim statistics: 20 million in the UK have allergies, around a third of which are severe enough to need care; admissions for anaphylaxis have increased seven-fold in the last decade; of 96 allergy clinics in England, only six are led by full-time staff; there are 0.04 allergy specialists per 100,000 of the population, and only eight trainees at present.

A lack of knowledge at primary care level results in multiple appointments to reach a diagnosis. This drains NHS resources and is stressful for patients. What patients wanted from their allergy centres, she said, were: a specialist-led local team, a one-stop shop for diagnosis; a service both for children and adults; ongoing advice for the allergy-affected family; support for other medical professionals, the training of future specialists, and for there to be centres of new research.

Q and A
Dr David Misselbrook, dean of the RSM, chaired a closing questions and answers. Issues raised included a lack of allergy information, IT treatments for milk allergy, and the paucity of allergy services in Wales.

First published in 2009

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