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Allergy: Acute Care

Allergy: Acute Care. Lisa Katz Buglino, DO ProHEALTH. Environmental Allergies. CAUSES Spring pollen: grass pollen, tree pollen (oak, elm, birch, maple), spring weeds Fall pollen: ragweed, fall weed (pigweed, cocklebur, mugwort) Perennial allergens: cat, dog, dust, mold SYMPTOMS

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Allergy: Acute Care

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  1. Allergy: Acute Care Lisa Katz Buglino, DO ProHEALTH

  2. Environmental Allergies • CAUSES • Spring pollen: grass pollen, tree pollen (oak, elm, birch, maple), spring weeds • Fall pollen: ragweed, fall weed (pigweed, cocklebur, mugwort) • Perennial allergens: cat, dog, dust, mold • SYMPTOMS • Rhinorrhea, nasal congestion, sneezing • Itchy/watery eyes • Cough, wheeze, shortness of breath • Eczema

  3. Environmental Control Measures • Dust mite • Vacuum carpet weekly • Wash bedding in hot water weekly • Dust mite encasements • Stuffed animals off the bed • Humidity <50% • Dander • Wash pet weekly • Keep the pet out of the bedroom • HEPA Filter • Spring Pollen • April-July 1 • Fall Pollen • August 15th-First Frost • Windows Closed • Air conditioning on • Sunglasses outside • Shower at night

  4. Treatment of Allergic Rhinitis • Nasal corticosteroids-Nasacort, Rhinocort, Flonase, Xhance • Anti-histamines-Allegra, Xyzal, Zyrtec, Claritin • Double the standard doses • Give more than one daily (for example: Allegra - AM, Zyrtec - PM) • Give a combination of the two • Allergy immunotherapy

  5. Treatment • Mast Cell stabilizers • Zaditor (Ketotifen), Cromolyn • Opthalmic antihistamines • Epinastine, Azelastine, Patanol (Olopatadine), Pataday, Pazeo, Bepreve • Opthalmic corticosteroids • Alrex, Lotemax, FML

  6. Why is it getting worse? • 8% of Americans have allergic rhinoconjunctivitis and the number is increasing • Global warming • Higher CO2 counts causes increased pollen • Higher pollen counts affecting patients without AR

  7. Who to Refer? • Children requiring topical steroids for allergic conjunctivitis • Children with chronic sinusitis or otitis media • Children with asthma exacerbations

  8. Environmental Allergy Testing

  9. Eczema • Pruritis, erythematous and scaly skin • Flexural surfaces • Affects 2-20% of the population • 90% of patients are diagnosed prior to 5 years of age • Caused by history of atopy and/or environmental allergies (dust mite) • 80% of patients with atopic dermatitis have an elevated IgE level

  10. Treatment • Skin care-MOISTURIZERS/EMOLIENTS • Ointments ->creams->lotions • Topical steroids • Calcineurin inhibitors • Wet wraps • Bleach baths • Antibiotics

  11. New Eczema Treatments Eucrisa Dupixent • PGE-4 inhibtor • Inhibits IL-4 and TNF alpha • Topical • Works best for mild to moderate eczema • Side effect: BURNING • Inhibits IL-4 and IL-13 • Indicated for 12 and above • Subcutaneous every 2 weeks • at home • Best for severe eczema • Side effect: conjunctivitis

  12. Dupixent

  13. Contact Dermatitis • Increased prevalence in adults with chronic atopic dermatitis • Presentation: rash around the eyes or mouth • Development of rash is delayed • Diagnosis: Patch testing • Treatment: Topical or PO steroids

  14. Eczema and Food Allergy • Key to treatment of eczema is skin care • If parents employ diligent skin care and eczema persists, then consider allergy testing (first to environmental aeroallergens) • Less that 20% of patients who have eczema have eczema secondary to food allergy • Patients with eczema have higher levels of IgE, increasing the likelihood of false positive food allergy testing • Avoid food panel testing

  15. Food Allergy • 10% of children have food allergies (~7.4 million children) • Most common food allergens • Milk, egg, wheat, soy peanut, tree nuts, shellfish • On the rise: sesame • 2% of adults have food allergies (~4.8 million) • Most common food allergy to develop as an adult: shellfish • Increased ~18% over the past 10 years

  16. Diagnosing Food Allergy • HISTORY • Timing of when they ate and when the symptoms began • Likely within 30 minutes of ingestion • New food? Had they been tolerating it previously • First sign of food allergy is generally hives • If presentation is persistent emeis – must consider Food Protein Induced Enterocolitis Syndrome (FPIES) • Consider cow's milk, soy, rice and oat

  17. Component Testing • Peanut components • AraH1, AraH2, AraH3-IgE mediated hypersensitivity • AraH8, AraH9-oral allergy • Walnut components • JugR1, JugR3-IgE mediated hypersensitivity • Hazelnut components • Cor a 9, Cor a14-IgE mediated hypersensitivity • Cor a 1-oral allergy

  18. Treatment of Food Allergy • Avoidance • Education • FARE Form

  19. Epinephrine Autoinjectors • AUVI-q 0.1 mg for infants and toddlers weighing 16.5 lbs to 33 lbs. • AUVI-Q 0.15 mg for children weighing 33 lbs to 66 lbs. • AUVI-Q 0.3 mg for anyone who weighs 66 lbs or more.

  20. Food Allergy Is Increasing-Why? • PREVIOUS THINKING: Strict avoidance of food allergens until an infant's immune system is mature may prevent food allergy • NEW THINKING: Early exposure may promote tolerance • Gideon Lack: children in Israel have less peanut allergy than USA

  21. AAP Feeding Guidelines • 2000-AAP guidelines: • Milk at 1 year, eggs at 2nd year; peanuts, tree nuts and fish at 3rd year • Prohibited pregnant mother from eating peanut and lactating mothers from eating peanut • 2008 • AAP withdrew its recommendations for maternal dietary restrictions during pregnancy or lactation • Little or no evidence that delaying time of the introduction of complementary foods beyond 4-6 months of age prevents the occurrence of atopic disease

  22. Food Allergy On The Rise • Stringent diets... • In the past children were exposed to milk and egg in baked goods, increasing their likelihood of tolerance • Now children avoid those foods increasing their likelihood of allergy • Studies show children who are able to tolerate baked egg and milk are more likely to outgrow their food allergy • Suggesting that all IgE phenotypes are not the same

  23. LEAP Study • Randomized Trial of Peanut Consumption in Infants at Risk for Peanut Allergy • Patients with egg allergy: defined as a +skin prick test to egg with a wheal diameter 3mm or greater OR a positive oral egg food challenge • Severe eczema: defined as frequently or recurring eczema with typical morphology and distribution assessed as severe by a health care provider and requiring frequent need for prescription strength topical steroids, calcineurin inhibitors or other anti-inflammatory agent despite appropriate use of emollients • A LEAP Infant is 4-11 months of age with severe eczema and/or already diagnosed egg allergy

  24. New Food Allergy Treatments • Oral Immunotherapy (OIT) • Aimmune - tablet • Off label OIT with food protein • Peanut patch • 250micrograms of peanut daily

  25. Urticaria • Pruritic plaques • Move from place to place • Last less than 24 hours • Generally worse at night • Can be worse with hot or cold temperatures • Can be aggrevated by NSAIDs, exercise, stress

  26. Urticaria • Acute Urticaria (Less than 6 weeks) • Food, Drug, Environmental or Contact Allergy • Viral infections (in the presence or absence of other symptoms) • Chronic Urticaria (Greater than 6 weeks) • 90% idiopathic

  27. Treatment • High dose oral anti-histamines • AVOID ORAL STEROIDS secondary to rebound reactions • Xolair

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