Update in the Understanding and Treatment of Food Anaphylaxis

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Update in the Understanding and Treatment of Food
Anaphylaxis

• James P. Rosen, MD, FAAAAI, FAAP
• Connecticut Asthma and Allergy Center LLC

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Definition of Anaphylaxis

• Meaning the opposite of prophylaxis, without or
  against protection
• Defined as an acute systemic allergic reaction
  that is potentially fatal
• Results from IgE-antibody triggered release of
  mediators from mast cells
• Skin, respiratory, cardiovascular and
  gastrointestinal systems are primary organ
  systems affected
• Very unpredictable in its clinical presentation
  and outcome

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IgE-Mediated Food AllergySigns and Symptoms

• SKIN
• Hives/angioedema
• Flushing
• Papular rash
• Pruritis

• GASTROINTESTINAL
• Itching or swelling of lips, tongue, mouth
• Nausea
• Vomiting or reflux
• Abdominal cramping
• Diarrhea

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IgE-Mediated Food AllergySigns and Symptoms

• RESPIRATORY
• Congestion, itching, sneezing, runny nose
• Laryngeal edema, cough, hoarseness,
• Wheezing, shortness of breath, chest tightness

• CARDIOVASCULAR
• Feeling of faintness
• Syncope
• Hypotension/shock
• Arrhythmias

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N Engl J Med Vol. 346, No 17
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N Engl J Med Vol. 346, No. 17
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Clinical Characteristics

• It is not known why foods provoke different
  constellations of symptoms in different
  individuals
• Food allergy can be very unpredictable in its
  clinical presentation in the same individual at
  different times

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Predisposing Factors forSevere Food Reactions

• Patients who have asthma, especially if it is
  poorly controlled
• Having an allergy to peanuts, tree nuts, fish, or
  shellfish (although any food is capable of
  causing a severe reaction)
• Patients with a history of a prior severe
  reactions to foods
• Patients on beta-blockers or ACE-inhibitors

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Features of Food-induced Anaphylaxis

• Onset of symptoms within seconds to 2 hours
  following ingestion of a food to which an
  individual is sensitized
• Typically, the later the onset of symptoms, the
  less severe the reaction and vice versa
• Skin reactions (hives, swelling) may be absent
  during an anaphylactic reaction to a food
• Prior reactions to the food (esp. peanuts/tree
  nuts) may have been much milder

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Food-dependent Exercise-induced Anaphylaxis

• Requires food ingestion followed by exercise to
  occur
• Anaphylaxis occurs when patient exercises within
  2 to 4 hours of ingesting a food
• Can be a specific food (celery, shellfish, wheat)
  or any food
• Twice as common in women, 60 of cases in
  individuals lt30 years of age
• Management Identifying specific foods, if
  possible, and avoiding exercise for 4 hrs after
  eating

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Most Common Foods Associated with Food Allergy in
Children

• Milk
• Eggs
• Peanuts
• Tree Nuts
• Soy
• Sea Food (Shellfish and bony fish)

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Clinical Characteristics of Food Allergy

• Life threatening reactions most often associated
  with ASTHMA and
• Peanuts
• True Tree Nuts
• Shellfish
• Bony Fish

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Patterns of Anaphylaxis

• Uniphasic
• Symptoms resolve within hours of treatment
• Biphasic
• Symptoms resolve after treatment but return
  between 1 and 72 hours later (usually 1-3 hours)
• Protracted
• Symptoms do not resolve with treatment and may
  last gt24 hours

Lieberman, 2004
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Uniphasic Anaphylaxis
Treatment
Initial Symptoms
Time
0
Antigen Exposure
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Biphasic Anaphylaxis
Treatment
Treatment
Second-Phase Symptoms
Initial Symptoms
1-8 hours
Time
0
Classic Model
1-72 hours
Antigen Exposure
New Evidence
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Protracted Anaphylaxis
Initial Symptoms
Time
0
Possibly gt24 hours
Antigen Exposure
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Biphasic Anaphylaxis

• Biphasic reactions comprise 1-30 of attacks and
  are usually characterized by an initial
  symptomatic period followed by an asymptomatic
  period of 1-8 hours, but the asymptomatic phase
  may last longer than 24 hours
• No predictive characteristics (age, gender) for
  biphasic reactions
• These patients may require additional epinephrine

Stark and Sullivan, J Allergy Clin Immunol, 1986
Lieberman, Allergy Clin Immunol Int, 2004 Ellis
and Day, Curr Allergy Asthma Rep, 2003
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Factors Affecting Incidence of Biphasic
Anaphylaxis

• A delay of 30 minutes or more after antigen
  before onset of symptoms (Sullivan)
• Hypotension in first phase (Brady)
• Ingested antigen
• Severity of first phase
• Delay in administration of epinephrine (Lee)
• Failure to give epinephrine or diminished dose
  (Brazil)
• Failure to administer lower doses of
  corticosteroid

Lee and Greenes, Pediatrics, 2000 Brady et al,
Acad Emerg Med, 1997 Douglas et al, J Allergy
Clin Immunol, 1994 Brazil and MacNemara, J Accid
Emerg Med, 1998
Slide courtesy of Phil Lieberman, MD
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Factors associated with severe food anaphylaxis

• Lack of cutaneous symptoms (hives, itch,
  swelling)
• Delayed administration of epinephrine
• Symptom denial or a lack of early recognition
• Failure to understand or appropriately treat
  biphasic reactions
• Food allergy can be very unpredictable in its
  clinical presentation and progression

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Treatment of Food Anaphylaxis

• There is no cure for food allergy
• Complete and strict avoidance is the only way to
  prevent a reaction
• All patients must be educated as to the
  seriousness of the disorder
• Label education and diligent label reading
• All patients mush have a food allergy treatment
  form which reviews symptoms and treatment of
  anaphylaxis

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Treatment of Anaphylaxis

• Successful treatment depends on early recognition
  of signs symptoms
• The longer initial therapy is delayed, the
  greater the incidence of complications
• Early treatment with IM epinephrine is essential
  and associated with the best outcomes
• Rapid assessment of extent and severity of
  symptoms
• Prompt reversal of respiratory and cardiovascular
  complications of prime importance

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Treatment of Anaphylaxis

• Epinephrine Drug of choice and first drug
  used to treat anaphylaxis
• Reverses signs symptoms of anaphylaxis alpha1?1
  ?2
• Inhibits mast cell degranulation ?2
• Self administered Epi readily available 2
• Train patients for indications and technique

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Epinephrine Dosing

• Intramuscular injection in lateral thigh produces
  most rapid rise in blood level
• 0.01 mg/kg in children, 0.3-0.5 mg in adults
• Patients who receive Epinephrine and have
  symptoms other than hives should be lying down
  when they get Epinephrine with feet above head
  empty heart syndrome

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IM vs SQ Epinephrine
8 2 minutes

-
(Epipen)
34 14 (5 120) minutes p lt 0.05

-
Time to Cmax after injection (minutes)
Simons J Allergy Clin Immunol 113838, 2004
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Treatment of Anaphylaxis

• Side Effects of Epinephrine
• Tachycardia
• Tremor
• Pain at injection site
• Nausea
• Vomiting

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Treatment of Anaphylaxis

• Use of Antihistamines
• Only prevents further hives
• Never reverses signs or symptoms of anaphylaxis
• Never to be used by itself to treat anaphylaxis
• Benadryl 1-2 mg/kg P.O.

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Endogenous Compensatory Mechanisms for Hypotension
ACE
Phil Lieberman Anaphylaxis, a clinicians manual
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Twinject Product Overview
There are no absolute contraindications to the
use of epinephrine in a life-threatening allergic
reaction
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Twinject Product Features
Twinject should be used with extreme caution in
people who have heart disease. Side effects of
Twinject may include fast or irregular heartbeat,
nausea, and breathing difficulty. Certain side
effects may be increased if Twinject I used
while taking tricyclic antidepressants or
monoamine oxidase inhibitors (MAOIs)
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Twinject Product Photos
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Anaphylaxis Management

• Everyone makes mistakes
• Accidents are never planned
• Create a plan for managing a reaction before you
  need it
• Educate others on what to do in case you need
  their help

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Risk Factors for Adolescents

• More likely to eat meals and snacks outside the
  home
• More likely not to carry their epinephrine
  autoinjector on their person
• Take more chances with fooddo not think about
  mortality
• Keep their food allergy issues to themselves
• Are afraid to use their epinephrine
  autoinjector-less empowered

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Anaphylaxis Management Plan

• Create an emergency plan of action including
• What symptoms to look for
• What medications to use
• Medication dosage instructions
• Where will medications be kept
• What teachers, students, etc. should do
• Allergy emergency practice drills

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Food Allergy Facts

• Size of skin test and CapRast test do not predict
  severity of clinical reaction or the organ
  systems involved
• Quality of food ingested does not predict
  severity of reaction only a little bite can
  hurt
• There is no peanut protein in the aroma of peanut
  butterthe smell is all fat
• A CapRast test of lt0.35Ku/L is not necessarily
  negative, but rather the lowest level that the
  assay can measure
• Patients can have food reactions with CapRast
  levels of lt0.35Ku/L
• Topical exposure contact allergy does not cause
  an allergic reaction unless the allergic patient
  licks the topical exposure

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Peanut Protein in Schools

• Soap and water removes peanut protein from hands
  and surfaces
• Hand sanitizers do not remove peanut protein from
  a surface, they only move the protein around
• Airborne peanut protein was not found in the
  school air even when peanut butter and peanuts
  were consumed in the school where the air was
  sampled
• Roasting peanuts can aerosolize peanut protein

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Key Steps in Anaphylaxis Management

• Written treatment plan from a doctor
• Early recognition of symptoms
• Early administration of epinephrine and other
  medications
• Transport to hospital for follow-up