Allergies and treatment Presented by Dr Shubha Agrawal (MD Chest & TB)

1. Allergies &
Treatment
Presented By
Dr Shubha Agrawal
(MD CHEST & TB)

2. Allergy – a multi-headed monster

3. What Is An Allergy?
Allergies are caused by an abnormal response
of the immune system. The immune system
reacts to a usually harmless substance in the
environment. This substance can be pollen,
mold, dust, animal dander, certain foods, insect
stings, etc. and is referred to as an allergen.

4. What Is An Allergic Reaction?
A person is exposed to an allergen by inhaling it,
swallowing it, or getting in on their skin. After a
person is exposed, there is a sequence of events
that create an
allergic reaction:
The body produces an antibody, IgE, to bind the allergen
These antibodies attach to a mast cell, which can be found in
the airways, intestines, and elsewhere
Allergens bind to the IgE, which is attached to the mast cell,
which causes the mast cells to release a variety of chemicals
into the blood such as histmamine. Histamine causes most of
the symptoms of an allergic reaction

5. Types of Allergies

6. When the body encountes an allergen
An allergen is a protein different from the body

7. The body reacts
Favourable result ---immunity

8. If the body over-reacts----harmful
allergy

9. Atopic dermatitis

11. Tell tale signs of allergy

12. Rhinitis
Very common
AR in children
May predicit asthma

13. Allergic cold

16. Eye lid allergy

19. Drug allerg: Isonex (SJ) / methotrexate
Drug allergy

20. Insulin allergy

21. Pressure urticaria

22. Contact dermatitis

23. Nickel allergy
Nickel / copper allergy

24. Insect allergy

25. What does this slide project ?
House dust mite

27. Pollen
allergy

28. pollens
Rage weed
Chrysanthemum
POLLENS

29. Systems not restricted to single system
• Gastrointestinal
• Respiratory
• Skin
• Cardiovascular
• General-Anaphylaxis

30. • General
• Itching, tingling,
swelling lips, mouth
• Tongue & Throat
swelling
• Angio-oedema
(swelling, puffiness)
• Nausea
• Vomiting
• Diarrhoea
• Abdominal pain,
cramps
• Colic , reflux
Respiratory
Throat tightness
Wheezing, asthma
Shortness of breath
Repetitive coughing
Cyanosis- turning blue
Nasal congestion
Runny nose
Cough

31. • Skin reactions
• Pruritus – itching
• Flushing
• Urticaria – rash
• Angio-oedema- tissue
swelling
• Eczema/dermatitis
• Itchy eyes and ears
• Hypotension
• Shock
• Syncope- fainting
• Arrhythmia
• Chest pain

32. Most common allergenic foods
• Milk
• Wheat
• Egg
• Soy
• Peanut
• Tree nuts
• Fish & shellfish
• Any foods can theoretically trigger allergies

33. Cross-reactions may occur
• Wheat and other grains
• Soy and other legumes
• Cow’s milk & horse, sheep, goat’s milk
• Different tree nuts
• Nuts and peanuts
• Pollen & some fruit
• Latex and avocado, kiwi, chestnut, banana

34. Anaphylaxis –food induced
Foods most commonly implicated
• Eggs
• Wheat
• Milk
• Peanuts
• Fish
• Shellfish
• Nuts
Celery
Seeds
Legumes
Guar gum
Rice
Many others

35. petsPet a

36. Hoarse voice - anaphylaxis

37. FIRES IN THE GARBAGE
• 1. DECOMPOSING WASTE MATTER
• 2. MAN MADE
FOR RECYCLABLE MATERIAL
(30% OF GARBAGE IN CAIRO)
environment

38. genes pregnancy
smoking viral infections in infancy
small
baby

39. Cold urticaria – 2 cases

41. Chronic wheeze

42. Do the right thing
• Don’t just restrict your freedom of eating a wide
variety of foods
• Do seek professional help to investigate the
symptoms you have
• The cause may not always be what you think!
• Remember- it can take up to 36-48 hours for
some reactions to develop – even longer in some
conditions

43. Allergy Diagnosis
• CLINICAL EXAMINATION
• BLOOD TEST
• XRAY CHEST PA
• LUNG FUNCTION TEST
• ALLERGY SKIN PRICK TEST
• BLOOD ALLERGY TEST

44. The skin Prick test

45. SPTs / patch tests

47. Allergy Treatment
There are two types of allergy treatment:
1.Medication – Decongestants
2. Antihistamines
3. Corticosteroids
4. Nasal spray
5. Antibiotics
6. Nebulization
7.Immunotherapy – A preventive treatment for allergic reactions that
involves giving gradual increase doses of the allergen. The slow
increase of the allergen allows the immune system to become less
sensitive to the allergen.
8.IgE Monoclonal Antibody
injections-OMALIZUMAB etc

48. Definition
• Allergen specific immunotherapy :
- administering gradually increasing doses of
the specific allergen to reduce the clinical
reaction
- the only treatment focusing the causes of
hypersensitivity
Marseglia G L, Incorvaia C, Rosa M L, Frati F & Marcucci F. Sublingual immunotherapy in
children : facts and needs. Italian Journal of Pediatrics 2009, 35:31

49. Definition
• Subcutaneous immunotherapy ( SCIT)
- traditional route but risk for systemic
reaction
• Sublingual immunotherapy ( SLIT)
- non injection route for specific immuno-
therapy
Marseglia G L, Incorvaia C, Rosa M L, Frati F & Marcucci F. Sublingual immunotherapy in
children : facts and needs. Italian Journal of Pediatrics 2009, 35:31

50. Sublingual Immunotherapy (SLIT)
Sublingual immunotherapy is an alternative
way to treat allergies without injections. An
allergist gives a patient small doses of an
allergen under the tongue to boost tolerance
to the substance and reduce symptoms.
.

51. MONOCLONAL ANTIBODY
• Omalizumab
• MISCELLANEOUS – PDE4 inhibitors,
CRth2 antagonists, Endothelin
antagonists, NO synthase inhibitors,
Chemokine receptor antagonists,
Protease inhibitors etc…

52. Omalizumab
• MOA
• 1) inhibits the binding of IgE to mast cells and
basophils.
• 2) inhibits the activation of IgE already bound to
mast cells and thus prevent their degranulation.
• 3) down-regulates Fc€R-1 receptor present on
mast cells and basophils.

53. Omalizumab
• Dose of 150 to 375 mg subcutaneously every 2 to 4
weeks
• Dose determined by levels of serum IgE
•
• Should be treated for a minimum of 12 weeks
• Pregnancy - Category B
• Lactation - caution should be exercised

54. • PATIENT’S SELECTION FOR OMALIZUMAB THERAPY
• Multiple documented severe asthma exacerbations.
• Symptomatic despite high dose ICS and LABA therapy.
• Frequent daytime symptoms or night-time awakenings.
• Reduced lung function (FEV1 < 80%)
• Body weight between 20-150 Kg and total IgE 30-1500 IU/ml

55. Other MONOCLONAL ANTIBODIES In
Asthma Therapy
• Mepolizumab
• Anti TNF-α MAb
• AntiTGF-β MAb − Fresolimumab
• Pitrakinra
Infliximab
Golimumab

56. MEPOLIZUMAB (Anti IL -5Ab)
• IL -5 -- cytokine in eosinophil function at sites of
allergic inflammation.
• Recent studies confirm that in patients with
eosinophilic asthma, mepolizumab therapy had
some clinical benefit.
• However, many patients with asthma do not
have eosinophilia, and even in patients with
eosinophilic asthma, mepolizumab had no effect
on other physiological and clinical factors.

57. Anti TNF- alpha in Asthma Therapy
• Infliximab - occurrence of neutralizing
antibodies against is a common event,
• may compromise drug efficacy.
• Incidence of anti-TNF induced tuberculosis in
treated patients.
• Studies with golimumab did not demonstrate
a favorable risk– benefit profile

58. Anti-TGF beta MAb
• Neutralisation of TGF-b1 with specific
antibody had no significant effect on airway
inflammation and eosinophilia
• It suppressed pulmonary fibrosis.

59. PITRAKINRA
• A mutated interleukin- -4
• binds to IL -4Rα and blocks the effects of both
IL- 4 and IL- 13.
• A phase II trial in mild to moderate asthmatics
showed that inhaled pitrakinra reduced the
late phase decline in lung function.

60. Other potential Mabs in Asthma
therapy
A phase 1 study evaluating the
pharmacokinetics, safety and tolerability of a
human IL -13 antibody (CAT- 354) revealed
an acceptable safety profile.
Specific inhibition of tissue kallikrein 1 with a
human monoclonal antibody(DX- 2300 )
revealed a potential in vitro and in vivo role in
airway diseases.

61. Other potential Mabs in Asthma
therapy
• A Mab against TIM- 1 (Tcell Immunoglobulin
Mucin gene) protein influenced activated T
cells and blocked the development of disease
in a humanized mouse model of allergic
asthma suggesting that it may provide potent
therapeutic benefit in asthma.

62. What is Anaphylaxis?
Anaphylaxis is a serious, life-threatening allergic
reaction. The most common anaphylactic
reactions are to food, insect stings,
medications, and latex.
Anaphylaxis requires immediate medical
treatment, including an injection of epinephrine
along with a trip to an emergency room. If not
treated properly, anaphylaxis can be fatal.

63. Anaphylaxis Symptoms
Symptoms of anaphylaxis typically start within 5-
30 minutes of coming into contact with the
allergen. Warning signs may include:
Red rash, with hives/welts, usually itchy
Swollen throat or areas of the body
Wheezing
Passing out
Chest tightness
Trouble breathing
Hoarse voice
Vomiting
Diarrhea
Stomach Cramping
Pale or red color to the face or body
Trouble swallowing

64. Anaphylaxis Treatment
The best way to manage anaphylaxis is:
Avoid allergens
Be prepared for an emergency
If you are at risk for anaphylaxis, carry auto-
injectable epinephrine (often referred to as an
epi-pen).

65. Epipen (Inj adrenaline)

68. INSTRUCTIONS REGARDING ORAL
IMMUNOTHERAPY VACCINES
• Dear Friend,
• You are about to embark upon a noval method of treatment, namely “Oral immunotherapy”. This is a special
from of treatment for “Allergic Diseases”. Please read the following instructions carefully before starting the vaccines.
Please do not hesitate to contact your physician in case of any difficulties.
• Please ensure that the vaccine is always refrigerated.
•
• Always shake the vial well before use.
•
• Please check the dose you need to take as per the accompanying
• time- table before you actually administer it to yourself.
•
• The vaccine drops should be administered below the tongue, before
• breakfast “on an empty stomach”, retained in the mouth for 2 minutes
• and then swallowed.
•
• Please wait for 15 to 20 minutes after swallowing the vaccines before you eat or drink anything else.
•
• Please ensure that you do not miss any doses. If for any reason, you miss out on any dose, please take the very next day.
However, you must consult your physician before you take the next dose, If more that one day has elapsed, because the
dose may need to be re-adjusted r the vaccines may even need to be restarted.

69. • Undesirable effects during treatment are very rare. Fatigue, cold, skin rash, mouth or lip
itching are possible and must be immediately reported, first to your physician then to me.
Your doctor may have to administer appropriation anti-allergy therapy which may consist of
oral or intramuscular medication. Kindly also inform your physician of any adverse effect you
may experience other than those listed above.
•
• Please do not exceed the dose recommended since this may lead adverse reactions.
•
• Please ensure that you adhere to the “schedule” prescribed. The only contraindications for
taking a dose of oral vaccines high fever and an acute attack of asthma.
•
• Your vaccines are not known to have interactions with any other drugs.
•
• Please note that these vaccines have been found to be safe during “pregnancy” and should
not be discontinued in a pregnant patient.
•
• It is extremely important to continue and complete the full course of “oral vaccines”. Please
do not discontinue this treatment without consulting your physician.
•
• Please ensure that you report to your physician’s clinic when the next order is due.
Continuity is very important during vaccine treatment. Any break ion continuity would result
in having to result the vaccines.
• You are requested to follow all the above instructions very carefully.
•