Transcript Don`t perform food IgE testing without a history consistent with

FOOD ALLERGY UPDATE
2016
GIRISH VITALPUR, MD, FAAP,
FAAAAI
ASSISTANT PROFESSOR OF CLINICAL PEDIATRICS, RILEY
CHILDREN’S HOSPITAL, INDIANA UNIVERSITY SCHOOL OF
MEDICINE, INDIANAPOLIS, IN USA
COMMERCIAL DISCLOSURES
• NONE.
OBJECTIVES
• Review a case that convey different
presentations of food allergies
• Discuss diagnosis of IgE-mediated food allergies
• Discuss management options
PreTest Question 1
• A 4 yr old girl presents with issues of recurrent rashes over
the past year. A food allergy blood test panel is done. Peanut
IgE is 1.35 kU/L. Your next step should be to:
• A) Advise the family to avoid peanuts only, in all forms
• B) Ask the family about the child’s history with peanut items
• C) Tell the family to avoid peanuts, tree nuts, and all skin care
products that may have nut oils.
• D) Prescribe emergency epinephrine injectors.
Pretest Question 2
• A 7 yr old child is having difficulty in school. The family had
labs drawn from a behavioral specialist. IgG is detected to
milk, wheat, corn, and oranges. Your next step should be to:
• A) Advise the family that IgG testing is not a validated method
of allergy assessment, per the guidelines of the American
Academy of Allergy
• B) Have the child follow a diet free of all milk, gluten, corn and
citrus items, and monitor his response.
• C) Choice B + prescribe emergency epinephrine
• D) Have the family eliminate one of these foods every 2 weeks
at a time, and then monitor his response
Pretest Question 3
• A 15 yr old has a history of anaphylaxis to peanut and walnut.
His mother reports the teen does not want to carry his
epinephrine injector. Which of the following is not true?
• A) Tell the family that a past reaction cannot predict the type
or severity of a future reaction
• B) Peanuts and tree nuts are among the most common
reasons for fatal food anaphylactic reactions
• C) Oral antihistamines will likely suffice as a first step with
future reactions
• D) Adolescents with asthma have the highest risk of fatal
outcomes from food allergic reactions.
CASE
• Alex is 2, and has had mild eczema since infancy.
• Parents question if he has peanut allergy.
Why may families question if the
child has a food allergy?
•
•
•
•
Actual Symptoms
Family history
Fear
Other reasons
DEFINITIONS OF FOOD ALLERGY
• Food allergy=“An immunologically mediated
hypersensitivity reaction to any food, including
IgE-mediated and/ or non-IgE-mediated
reactions.” (Greer, 2008)
• Food allergy: An adverse health effect arising
from a specific immune response that occurs
reproducibly on exposure to a given food.
– Requires sensitization to a food AND
development of specific signs and symptoms.
(Boyce 2010)
Other important definitions
• Food intolerance: Non-immunologically
mediated adverse reactions
• Sensitization: Allergen-specific IgE is present to
an allergen, but no clinical symptoms occur on
exposure to that food.
• Allergy: Allergen-specific IgE is present to an
allergen, and clinical symptoms DO occur on
exposure to that food
Boyce, 2010
More Important Definitions
• Cross reactivity: An antibody reacts not only
with the original allergen, but also with a
similar allergen.
• Cross sensitization: An antibody is present to
a similar allergen, but there is no reaction to
that allergen.
Boyce, 2010
STUDIES IN FOOD ALLERGY:
METHODOLOGY ISSUES
• Gold standard for diagnosis of food allergy=
double-blind, placebo-controlled oral food
challenge (DBPCFC).
• Studies limited by:
– Self-report data
• Only 40% of pts’ histories of food-induced allergic
reactions can be verified through DBPCFC.
– Variations in definition of food allergy
– Population variations
--Sicherer & Leung, 2008; Kim JS, 2008.
SPECTRUM OF FOOD ALLERGY
•
•
•
IgE-mediated disorders (Nearly always occur within two hours)
– Anaphylaxis
– Acute urticaria and angioedema
– Oral allergy syndrome/ Pollen-food allergy syndrome
– Immediate-type gastrointestinal hypersensitivity
– Acute bronchospasm
Non IgE-mediated disorders
– Dietary protein-induced enterocolitis
– Celiac disease
– Dermatitis herpetiformis
Mixed IgE-mediated and non-IgE-mediated disorders
– Eosinophilic esophagitis and gastroenteritis
– Atopic dermatitis (AD)
---Food proteins may also produce delayed, non-IgE-mediated responses, in the
skin and the gut.
Sellge ,2008.
IGE-MEDIATED REACTIONS
 Mild to moderate reactions
 Hives/ itching
 Swelling of the lips, eyes, or face
 Vomiting
 Severe reactions





Shortness of breath/ wheezing
Combination of vomiting, coughing, and angioedema
Low blood pressure
Any report of anaphylaxis
Reported in @38% of children with food allergy
Gupta, 2011
Case : Symptoms
• Alex had hives and wheezing associated with peanut butter
two months ago. No other immediate food reactions.
• Questions:
– How soon after consumption?
– How did the reaction progress?
– How long did symptoms last?
– How were symptoms treated?
– Prior peanut exposures?
– Any medications or other illnesses?
FOOD ALLERGY: EPIDEMIOLOGY & IMPACT: How
Common Is It?
.
1 out of every 25 children in the US have a food allergy—2008
.
1 in 13 children in the US affected by IgE-mediated food allergy—2011.
(@6 million children)
Overall prevalence of food allergy in the US: 2.5%
Negative impact on health-related quality of life, compared with other
allergic conditions
$120.5 BILLION/ YEAR, TO FAMILIES
– Special foods
– Lost labor productivity/ lost opportunity
– Out-of-pocket medications
200,000 ER visits annually
Deaths: @150/ year.
– Most common among adolescents with asthma.
– Most associated with peanut, tree nut or shellfish
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•
•
•
Branum & Lukacs, 2008; Gupta, 2011; Liu, 2010; Ostblom 2008; Branum & Lukacs, 2008; Munoz-Furlong & Weiss,
2009; Clark 2011
PREVALENCE OF COMMON FOOD ALLERGIES
FOOD
CHILDREN
ADULT
MILK
1.8%a
0.4%a
EGG
1.8%a
0.2%a
PEANUT
1.4-1.8%b,d
0.6-1.3%a,d
TREE NUT
1.1%d
0.5-1%b,c,d
SOY
0.4%f
<1%e
WHEAT
0.4%f
<1%e
FISH
0.2%b; 0.5%f
0.5%b
SHELLFISH
0.5%b; 1.4%f
2.5%b
0.1%d
SESAME
a=Liu, 2010;
b=Boyce, 2010;
OVERALL POPULATION
c=Sicherer, 2011;
d=Sicherer, 2010
e=Zuidmeer, 2008
f=Gupta, 2011
FOOD ALLERGEN TRAITS
 Major food allergens
◦ Water soluble glycoproteins
◦ Fairly stable to heat, acid and proteases
 Peanut—allergens identified thus far (Ara h 1-14)
[COMPONENTS]
◦ ARA H 2—Fairly specific for anaphylaxis
 Soy—@6 allergenic
 Wheat—multiple allergenic components
 Milk—@8 allergenic
 Egg white—@6 allergenic
FOOD ALLERGY:
METHODS OF DIAGNOSIS?
•
•
•
•
HISTORY, HISTORY, HISTORY
SKIN PRICK TESTING
SPECIFIC IGE STUDIES
COMPONENT DIAGNOSTICS
ALLERGY SKIN PRICK TESTING
SKIN PRICK TESTING
ALLERGY SKIN PRICK TESTING
DIAGNOSIS OF FOOD ALLERGY
Skin Prick Testing
• Negative predictive value > 90%
• Positive predictive value < 50%
• Low specificity
– Ex: False + skin tests to wheat can occur in those with
grass pollen allergy
• Large wheals and flares may have more predictive value.
• Standardized extracts not available for all allergens
• Can be done on infants
DIAGNOSIS OF FOOD ALLERGY
Specific IgE studies
• Negative predictive value>90%
– As sensitive as, or less sensitive than, skin prick tests, depending on the
food.
• Positive predictive value<50%
 Higher specific IgE levels may suggest more likelihood of a
reaction, but not the severity of that reaction.
 Specific IgE values may also vary by age, in terms of
relevance
 Circulating IgE may not quantitatively correlate well with
the specific IgE bound at the target tissue.
• Random food allergy panels not recommended
• “Class” not as helpful as actual specific IgE value.
• Can be done on infants
There are many other disorders associated
with elevated total serum IgE
• Infections
– Virus: Ex: HIV, RSV
– Fungal
• Allergic bronchopulmonary aspergillosis
– Bacterial: Ex: Staphylococcus
– Parasites
• Immune deficiency: Ex: Hyper IgE Syndrome
• Skin disorders
– Atopic Dermatitis
– Impetigo
– Contact dermatitis
CLINICALLY IRRELEVANT SPECIFIC
IgE LEVELS (aka, FALSE POSITIVES)
• Peanut, soy, wheat and other grains are plants
• Share cross-reactive plant proteins with allergenic plants/
pollens
• Profilins
• Storage proteins
• Non-specific lipid transfer proteins
• PR-10 protein, homologue to a birch antigen, etc.
• Wheat and other grains are members of the grass family
@20-30% of those with grass pollen allergy can show IgE to
wheat, corn, and other grains.
• Peanut and soy share plant proteins with birch.
FOOD ALLERGY PANELS/ PROFILES
•
IgE allergy testing for:
Almond (f20)
Cashew Nut (f207)
Codfish (f3)
Cow's Milk (f2)
Egg White (f1)
Hazelnut (f17)
Peanut (f13)
Salmon (f41)
Scallop (f338)*
Sesame Seed (f10)
Shrimp (f24)
Soybean (f14)
Tuna (f40)
Walnut (f256)
Wheat (f4)
Bird JA, Crain M, & Varshney P. Food allergen panel testing often results in
misdiagnosis of food allergy. J Pediatrics. 2015;166:97-100.
• Site: Food Allergy Center, Southwestern Medical Center,
Dallas
• Timeframe: 9/2011-12/2012
• Subjects: New patient referrals in timeframe
– N=797. 284 of the 797 (35%) came in having had panels
done
– 274 used for analysis (omitted 10 EoE patients)
– 90/274 (32.8%) had clinical history that warranted
evaluation for IgE-mediated food allergy.
– 184/274 (67.2%) DID NOT HAVE A RELEVANT HISTORY.
Bird JA, Crain M, & Varshney P. Food allergen panel testing often results in
misdiagnosis of food allergy. J Pediatrics. 2015;166:97-100.
• Of those who did not have a relevant history
(n=184), only 4 were found to have an
unknown food allergy.
– Positive predictive value = 2.2%
• Reasons for ordering panels
– Allergic rhinitis
– Atopic dermatitis, often mild
– Hives, acute or chronic
SO….
•
•
•
•
•
One allergist
15 months
Texas Medicaid
@$80,000 in medical expenditures
HOW MUCH ARE PANELS CONTRIBUTING TO
UNNECESSARY MEDICAL COSTS AND SOCIAL
STRESSES OVERALL???
DIAGNOSIS OF FOOD ALLERGY
• A POSITIVE SKIN OR IMMUNOCAP TEST IS ASSOCIATED
WITH CLINICAL REACTIONS ONLY 50% OF THE TIME.
• Tests may also stay + for some time AFTER clinical
reactivity has resolved.
• Trial elimination diets may be needed to determine
relevance.
• Oral food challenges in the office may be needed to
determine reactivity or resolution.
COMPONENT DIAGNOSTICS/ MOLECULAR ARRAYS
• ISAC test, from Phadia/ uKNOW test
• Quantifies IgE to a single allergen protein, ex:
Ara h 2
• Assesses for antibodies towards
– Allergens
– Cross-reactive proteins, eg,
• Profilins
• Storage proteins
• Non-specific lipid transfer proteins
• PR-10 protein, homologue to a birch antigen, etc.
Vieira, 2011
Case: Alex
• Food allergy profile test done:
– Milk IgE-2.01ku/ l;
– Egg IgE—0.85ku/l;
– Peanut IgE—1.50ku/l
– All other foods are negative.
• How do you advise the family?
CASE
• Egg and milk now removed from Alex’s diet.
– No known reactions to egg or milk ever.
– Stressful for the entire family
• Family questions why peanut IgE is lower than
milk IgE
• Family questions need for Epipen Jr.
MANAGEMENT OF FOOD ALLERGY
AVOIDANCE, AVOIDANCE, AVOIDANCE
LABEL READING
HAVE SELF-INJECTABLE EPINEPHRINE AVAILABLE IN
MULTIPLE PLACES(HOME, SCHOOL, DAYCARE, ETC.)
PT/ ALL CAREGIVERS SHOULD KNOW HOW TO USE
EPINEPHRINE DEVICES
CALL 911/ GO TO ER IF EPINEPHRINE IS USED.
(BIPHASIC ANAPHYLAXIS—20%)
OBSERVE IN ER FOR FOUR HOURS AFTER RXN.
Boyce 2010
CASE 1
• Skin prick tests were + to peanut (and tree
nuts).
• Recommend:
– Avoidance of peanut (and tree nuts)
– Have Epipen Jr available at all times
– MedicAlert tag
• Resumed milk and egg without complications
REFERRAL SOURCES
 WWW.FOODALLERGY.ORG
 WWW.APFED.ORG
 www.nationaleczema.org
 www.allergyhome.org
ORAL IMMUNOTHERAPY (OIT)—
PEANUT & OTHER FOODS
NOT READY FOR CLINICAL USE
Significant risks of reactions during escalation
phases
18% of patients drop out of peanut trials b/c of side
effects.
Milk OIT appears to have HIGHER risks of reactions
than peanut.
Wide variation in dosing protocols
Postdesensitization strategies—unclear.
Goals vary—cure? Raise threshold for reactions?
Adverse effects?
 Thyagarajan 2010
LEAP STUDY
DuToit et al. New England Journal of Medicine 2015; 372:803-813.
• Infants at high risk for peanut allergy (4-11mo)
– Severe eczema and/or
– Egg allergy
• SPT to peanut
– If negative, or positive, with wheal <4mm:
– Peanut challenge (2g) (Bamba, a peanut snack, or PB)
• If passed:
– Peanut avoidance, or
– Peanut, 6grams/ week, in 3 or more servings
LEAP STUDY CONCLUSIONS
DuToit et al, New England Journal of Medicine 2015; 372:803-813.
• Among infants who have severe eczema and/or egg
allergy,
• continued peanut consumption starting in the first
11 months of life, compared to peanut avoidance,
• resulted in a significantly smaller proportion of
children with peanut allergy at age 5 years.
• The reduction was 86% in those with negative
peanut skin prick tests, and
• 70% in those with positive peanut skin prick tests.
CHOOSING WISELY CAMPAIGN
http://www.choosingwisely.org/societies/american-academy-of-allergy-asthma-immunology/
• “Don’t perform unproven diagnostic tests, such as immunoglobulin
G(lgG) testing or an indiscriminate battery of immunoglobulin E(lgE)
tests, in the evaluation of allergy.
• Appropriate diagnosis and treatment of allergies requires specific IgE
testing (either skin or blood tests) based on the patient’s clinical history.
The use of other tests or methods to diagnose allergies is unproven and
can lead to inappropriate diagnosis and treatment. Appropriate diagnosis
and treatment is both cost effective and essential for optimal patient care.
• Don’t perform food IgE testing without a history consistent with
potential IgE-mediated food allergy.
• IgE testing for specific foods must be driven by a history of signs or
symptoms consistent with an IgE-mediated reaction after eating a
particular food.”
CHOOSING WISELY CAMPAIGN
http://www.choosingwisely.org/societies/american-academy-of-allergy-asthma-immunology/
• “Considering that 50 to 90 percent of presumed
cases of food allergy do not reflect IgE-mediated
(allergic) pathogenesis
• and may instead reflect food intolerance or
symptoms not causally associated with food
consumption,
• ordering panels of food tests leads to many
incorrectly identified food allergies
• and inappropriate recommendations to avoid foods
that are positive on testing.”
PostTest Question 1
• A 4 yr old girl presents with issues of recurrent rashes over
the past year. A food allergy blood test panel is done. Peanut
IgE is 1.35 kU/L. Your next step should be to:
• A) Advise the family to avoid peanuts only, in all forms
• B) Ask the family about the child’s history with peanut items
• C) Tell the family to avoid peanuts, tree nuts, and all skin care
products that may have nut oils.
• D) Prescribe emergency epinephrine injectors.
• Correct answer: B
Posttest Question 2
• A 7 yr old child is having difficulty in school. The family had
labs drawn from a behavioral specialist. IgG is detected to
milk, wheat, corn, and oranges. Your next step should be to:
• A) Advise the family that IgG testing is not a validated method of allergy
assessment, per the guidelines of the American Academy of Allergy
• B) Have the child follow a diet free of all milk, gluten, corn and citrus
items, and monitor his response.
• C) Choice B + prescribe emergency epinephrine
• D) Have the family eliminate one of these foods every 2 weeks at a time,
and then monitor his response
• Correct answer: A
Posttest Question 3
• A 15 yr old has a history of anaphylaxis to peanut and walnut.
His mother reports the teen does not want to carry his
epinephrine injector. Which of the following is not true?
• A) Tell the family that a past reaction cannot predict the type or severity of
a future reaction
• B) Peanuts and tree nuts are among the most common reasons for fatal
food anaphylactic reactions
• C) Oral antihistamines will likely suffice as a first step with future reactions
• D) Adolescents with asthma have the highest risk of fatal outcomes from
food allergic reactions.
• Correct answer: C
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