Dr Tim Jefferies Dr Tom Townend General Practitioner Paediatrician Onslow Medical Centre Christchurch Hospital Wellington Christchurch

8:30 - 10:30 WS #4: Training GPs to Manage Allergic Disease 11:00 - 13:00 WS #10: Training GPs to Manage Allergic Disease (Repeated) Training GPs to manage Allergic Disease

•Dr Tim Jefferies •GP with a Special Interest in Allergy •Onslow Medical Centre, Wellington

•Dr Tom Townend •Paediatrician •Christchurch Training GPs to manage Allergic Disease

•Dr Tim Jefferies •GP with a Special Interest in Allergy •Onslow Medical Centre, Wellington

•Dr Tom Townend •Paediatrician •Christchurch

Allergic Disease

 Allergic rhinitis NOT (Hayfever) General toxin reactions  Allergic asthma (eg alcohol, snake bites)  Allergic eczema Coeliac disease  Food allergy Lactose Intolerance  Venom allergy Other food intolerance  Drug allergy (IBS) Chronic Urticaria?

Plan for the session

 Basic Management of Asthma, Eczema, and Hayfever (brief!)

 Food allergy, specifically advice on management of Childhood food allergy

 Management of anaphylaxis

 Role of Immunotherapy Part 1: Basic Management of Asthma, Eczema, and hayfever

 Asthma  Symbicort now funded with no Special Authority

 Eczema  Hydrocortisone 1%

 Hayfever  Cetirizine  Flixonase  Patanol (Oloptadine) Part 2: Managing food allergy Why is food allergy difficult for GPs?

 Wide range of presentations  A lot of information about allergy that is contradictory  Testing can be difficult and services are variable  Difficult to fit into 15 minutes  A lot of differences between doctors in how food allergy is managed  Emotional overlay Common presentations Case 1: A five-month old with eczema or ‘colic’

 Fully breast fed  Mum restricting her diet  Concerned about food allergy Tips for management

 How bad is the eczema? Thriving?  Mild to moderate eczema has a low risk of being due to a food allergy.  No strong role for allergy testing  Possible risk of causing a food allergy from food restriction on the part of the mother or the infant  Recommend normal diet with early introduction of peanut, egg etc. LEAP study, BEAT study  Possible room for short (2 week) restriction?? Case 2: 9 month old with milk allergy

 Breast fed, but hives with introduction of milk formula  Mum wondering about weaning advice Tips for management

 SPT indicated to confirm. Might guide management down the track

 Extensively hydrolysed formula for under 6 months – (eg Pepti- Junior)

 Soy formula for over 6 months

 Amino Acid formula if anaphylaxis (eg Elecare, Neocate)

 If the first choice formula is not tolerated, an alternative formula can be trialed

 Other formula such as goats’ milk-based, lactose-free and partially hydrolysed formula are not suitable for CMPA Case 3: 10 month old with minor rashes to foods

 Difficult situation as this is Primarily a GP issue  Is the rash in a contact area? Dribble area?  Is it getting worse with each exposure?  What is the offending food?  Judgement call – keep on with the food and review? Case 4: 1 year old with widespread hives to peanut butter  SPT and probably ssIgE (RAST) warranted.  Avoidance advice  Allergy action plan (ASCIA)  Discuss Epipen. Difficult area!

 Safety vs anxiety  Look to retest  Introduction of related allergens (ie other nuts)

 Safety vs pragmatism Resources ASCIA Action Plans

* Allergic reactions * Anaphylaxis

The Future?

 Subunit testing, eg Ara h3  More on early introduction  Probiotics?  Immunotherapy?  ASCIA Conference, Auckland 13-15 September Questions, then

Time for a stretch Part 3: Management of Anaphylaxis

 ABC

 Adrenaline  0.5mg IM  0.3mg IM (Age 6- 12)  0.15mg (Aged <6)

 Epipen dose 0.3mg

 Epipen Junior dose 0.15mg

 Anapen no longer available Part 4: Introduction to Allergen Immunotherapy

 Allergic rhinitis NOT

 Some allergic asthma Food allergy

 Sometimes allergic Other asthma eczema Mild or moderate eczema  Venom allergy generally

 Salicylate sensitivity Cancer Background to Allergen Immunotherapy

 Based on the idea that tolerance to an allergen can be brought about by continued exposure to small amounts of the allergen.

 Been around for a long time

 Been difficult to study

 Different approaches to administration

 Differing production methods

 Lack of standardised measures of clinically meaningful efficacy

 Single allergen vs multiple allergen immunotherapy

 Different delivery systems – SCIT, SLIT Why haven't GPs got in to Immunotherapy?

 General sense of inertia

 Difficult to understand the different products.

 Section 29

 Concerns about anaphylaxis/reactions

 Possibly some politics at play – eg 'Patch protection' What I hope to achieve for GPs and Immunotherapy

 Gain a sense of familiarity with the different Immunotherapy products available, and how they are given

 Understand risk factors for reactions to immunotherapy

 Find your place on the 'Immunotherapy ladder'

 Understand what is involved in 'stepping up the ladder' Two general types of Immunotherapy

Sub-Cutaneous Sub-Lingual Immunotherapy (SCIT) Immunotherapy (SLIT)

 More experience in NZ • More convenient

and around the world • Safer

 Cheaper with multiple • Similar price with a allergens single allergen Immunotherapy Ladder

 No immunotherapy

 Continuing already established Immunotherapy

 Starting Sublingual Immunotherapy (SLIT)

 Starting Sub-Cutaneous Immunotherapy (SCIT) Things to check before a patient has ongoing Immunotherapy at your Practice

 Who is 'Managing' the Immunotherapy?

 Asthma – especially 'brittle asthma'

 B-blockers

 Previous anaphylaxis to Immunotherapy

 Pregnancy

 Are they otherwise well? Starting Sublingual Immunotherapy

 Grass or HDM would be 90% of Immunotherapy patients

 Have peer support / friendly specialist

 Pick the right patients

 Review your ability to manage adverse reactions

 Start at the right time

 Antihistamine

 Review

 Aim to treat 3-5 years Starting Sub-Cutaneous Immunotherapy

 Have appropriate support – GPSI?

 Know the product and the build-up phase

 Make sure the nurses have experience, and an appropriate protocol

 Again – review your ability to manage reactions

 Check right patient, right dose, right allergen Questions