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.