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Management of Anaphylaxis
Controversial dogmaControversial dogma
Dr Peter Arkwright
Senior Lecturer in Paediatric Allergy ...
• Adrenaline
– Position
– Number
• Avoidance
Dogma in the dock
• Avoidance
– versus exposure
– gut versus skin
• first line treatment for anaphylaxis
• for food and venom associated
anaphylaxis, recommended route is
Adrenaline
anaphy...
Concern
increase obesity in society
with the increasing levels of obesity will auto-
injectors still deliver adrenaline in...
2011 Overweight or obese Obese
>30 kg/m2
Men 65 24
Women 58 26
Children 30 16
• skin to muscle depth was measured by ultrasound at set
distances down the thigh and leg in 93 children attending the
pae...
• age 1 to 16 years old, median 6 years
• 56% male
• 64% White, 24% Asian
• overweight 9%, obese 17%
Results
• overweight ...
20
30
40
musclethickness>needlelength
12 (9–17)mm
9 (7–13)mm
% children with SC thickness > needle length
0
10
20
1/4fromh...
50
75
100
% of children with skin to muscle thickness > needle length
Green – healthy weight
Yellow – overweight (85-94th ...
• 120 adults, aged 18 - 55 years old
• mid-thigh measurements only
• mean BMI 29.2 kg/m2
• 31% potential failure risk (wom...
• review of records 4 New England Hospitals 2001
– 2006 of ED patients presenting with allergic
reactions
• 18% overweight...
• Obesity in both children and adults is
associated with an increased risk that
adrenaline will not be injected into the m...
• AC is recommending TWO devices
• clinicians vary in the number of auto-injectors
they prescribe
Number of prescribed aut...
Number of pens in
children with food allergy
Mt Sinai Hospital
New York
RMCH
Manchester
number of children 413, median 4.5...
• auto-injectors should never be prescribed
without concomitant training on how and
when to use the device
• decision on t...
• Is strict avoidance of foods that children are
partly tolerant to making their food allergies
– more severe?
Controversy...
Egg
NATURAL HISTORY OF CHILDREN WHO TOLERATE BAKED MILK AND EGG
0
Milk
Probabilityofdevelopingtolerance
Challenge: baked m...
Probabilityofdevelopingtolerance
Milk Egg
Baked food
Complete avoidance
CURING MILK AND EGG ALLERGY WITH BAKED FOODS
Baked...
Standard advice
• Children with immediate cow’s milk or egg
allergy should avoid these foods in all forms
unless otherwise...
• Addition of dietary baked milk and egg is safe,
convenient and well-accepted by many
patients with milk and egg allergy
...
Palmar hyperlinearity
(excessive lines on palms)
filaggrin
Filaggrin – gene involved in skin barrier
Clinical Associations
Atopic dermatitis*
0% (0/13) no mutation
44% (13/29) one m...
Tolerance
Allergy
GUT SKIN
• Age
• Severe asthma
• Genetic factors
Risk factors for severe and complex
allergies
• Genetic factors
• Unnecessary food...
• Adrenaline auto-injectors
– increasing obesity in the community is increasing the
potential for more injections not bein...
Allergy arkwright ac anaphylaxis controversies finer points
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Allergy arkwright ac anaphylaxis controversies finer points

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Allergy arkwright ac anaphylaxis controversies finer points

  1. 1. Management of Anaphylaxis Controversial dogmaControversial dogma Dr Peter Arkwright Senior Lecturer in Paediatric Allergy and Immunology Royal Manchester Children’s Hospital
  2. 2. • Adrenaline – Position – Number • Avoidance Dogma in the dock • Avoidance – versus exposure – gut versus skin
  3. 3. • first line treatment for anaphylaxis • for food and venom associated anaphylaxis, recommended route is Adrenaline anaphylaxis, recommended route is intramuscular, not subcutaneous or intravenous
  4. 4. Concern increase obesity in society with the increasing levels of obesity will auto- injectors still deliver adrenaline into the muscle?muscle?
  5. 5. 2011 Overweight or obese Obese >30 kg/m2 Men 65 24 Women 58 26 Children 30 16
  6. 6. • skin to muscle depth was measured by ultrasound at set distances down the thigh and leg in 93 children attending the paediatric allergy clinic at RMCH • weight, height and waist circumference were measured and BMI calculated Bewick et al, JACI IP, 2013
  7. 7. • age 1 to 16 years old, median 6 years • 56% male • 64% White, 24% Asian • overweight 9%, obese 17% Results • overweight 9%, obese 17%
  8. 8. 20 30 40 musclethickness>needlelength 12 (9–17)mm 9 (7–13)mm % children with SC thickness > needle length 0 10 20 1/4fromhip midthigh 3/4fromhip midcalf %withskin-musclethickness>needlelength 8 (7–10)mm 8 (7–10)mm Needle length: Junior 12.7mm, Adult 15.9mm n = 93
  9. 9. 50 75 100 % of children with skin to muscle thickness > needle length Green – healthy weight Yellow – overweight (85-94th C) Red – obese (>95th C) gender/age specific BMI 2000 CDC growth charts %skintomusclethickness>needlelength 0 25 50 n = 93 %skintomusclethickness>needlelength 1/4 from hip mid calf3/4 from hipmid thigh age and gender are not independent determinants
  10. 10. • 120 adults, aged 18 - 55 years old • mid-thigh measurements only • mean BMI 29.2 kg/m2 • 31% potential failure risk (women 55% vs men Bhalla et al, Ohio study in adults • 31% potential failure risk (women 55% vs men 5%) Bhalla et al, Am J Emerg Med, 2013
  11. 11. • review of records 4 New England Hospitals 2001 – 2006 of ED patients presenting with allergic reactions • 18% overweight, 22% obese Rudders et al, New England retrospective review • 18% overweight, 22% obese • 321 (261 children and 60 adults) received adrenaline: 267 1 dose; 54 2+ doses • obese patients or women were no more likely to receive 2 doses • nor were those with respiratory symptoms Rudders et al, JACI, 2012
  12. 12. • Obesity in both children and adults is associated with an increased risk that adrenaline will not be injected into the muscle • Does it matter? If it did one might expect Conclusions • Does it matter? If it did one might expect more second doses, hospital admissions and deaths in obese and in women. • In more obese children consider injector in lower half of thigh
  13. 13. • AC is recommending TWO devices • clinicians vary in the number of auto-injectors they prescribe Number of prescribed auto-injectors
  14. 14. Number of pens in children with food allergy Mt Sinai Hospital New York RMCH Manchester number of children 413, median 4.5 y pea/tree nuts, milk 84% had auto-injectors prescribed 298, median 10 y pea/tree nuts, milk 100% had auto-injectors, 95% had 2+ devices Jarvinen et al, JACI, 2008 Arkwright, JACI 2009 prescribed 95% had 2+ devices Number requiring auto-injector 1 dose 71 (19%) 50% by non-meds 18 (6%) 2 doses 18 (4%) egg - restaurant 1 by non-med 0
  15. 15. • auto-injectors should never be prescribed without concomitant training on how and when to use the device • decision on the number of auto-injectors Discussion • decision on the number of auto-injectors should be based on evidence and need • variables include: peer-reviewed published evidence, family’s requirements, residential location, travel
  16. 16. • Is strict avoidance of foods that children are partly tolerant to making their food allergies – more severe? Controversy – more severe? – more prolonged?
  17. 17. Egg NATURAL HISTORY OF CHILDREN WHO TOLERATE BAKED MILK AND EGG 0 Milk Probabilityofdevelopingtolerance Challenge: baked milk muffin 1.3g of dry milk powder cooked 180C for 30 min Challenge: baked egg muffin 2.2g of dry milk powder cooked 180C for 30 min Kim JS et al, JACI, 2011, n = 88 ¾ of children tolerated baked milk challenge 8X more likely to develop tolerance to fresh milk Leonard SA et al, JACI, 2012, n = 79 Time to mean scrambled egg tolerance 3½ versus 5 years Probabilityofdevelopingtolerance MMonths following first visit
  18. 18. Probabilityofdevelopingtolerance Milk Egg Baked food Complete avoidance CURING MILK AND EGG ALLERGY WITH BAKED FOODS Baked milk muffin 1.3g of dry milk powder cooked 180C for 30 min Baked egg muffin 2.2g of egg protein cooked 180C for 30 min M Months following first visit Probabilityofdevelopingtolerance Leonard SA et al, JACI, 2012, n = 79 Children eating baked egg were 15X more likely to develop tolerance to scrambled egg Kim JS et al, JACI, 2011, n = 88 Children eating baked milk were 4X more likely to develop tolerance to fresh milk
  19. 19. Standard advice • Children with immediate cow’s milk or egg allergy should avoid these foods in all forms unless otherwise advised by an allergy specialistspecialist
  20. 20. • Addition of dietary baked milk and egg is safe, convenient and well-accepted by many patients with milk and egg allergy • Recommending baked milk and egg products Evidence-based advice • Recommending baked milk and egg products to milk and egg allergic children represents an important shift in the treatment paradigm for these allergies JACI, 2011
  21. 21. Palmar hyperlinearity (excessive lines on palms) filaggrin
  22. 22. Filaggrin – gene involved in skin barrier Clinical Associations Atopic dermatitis* 0% (0/13) no mutation 44% (13/29) one mutation 76% (16/21) two mutation Allergic asthma Severity (FEV1 & medication use) only if associated with AD (Palmer et al, JACI, 2007) 76% (16/21) two mutation (Palmer et al, Nat Genet, 2006) (Winge et al, Br J Dermatol, 2011) Peanut allergy Relative risk 5.3 (2.8 – 10.2) (Brown et al, JACI, 2011) *overall FLG mutations found in 20-40% of patients with moderate to severe AD of Northern European & Asian descent, but rare in Africans relative risk 10.1 in patients with erythema herpeticum
  23. 23. Tolerance Allergy GUT SKIN
  24. 24. • Age • Severe asthma • Genetic factors Risk factors for severe and complex allergies • Genetic factors • Unnecessary food avoidance
  25. 25. • Adrenaline auto-injectors – increasing obesity in the community is increasing the potential for more injections not being delivered into the muscle – critical to ensure that auto-injectors are only prescribed to patients and carers that are adequately training in their use, Points for discussion patients and carers that are adequately training in their use, rather than prescribing additional pens in case of misfiring because of lack of training • Avoidance – there is increasing evidence that complete avoidance of milk and egg can prolong and exacerbate these allergies – Ongoing studies e.g. LEAP will help to answer whether this is also the case for other foods e.g. peanut

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