ALLERGIES vs INTOLERANCES JOANNE WALSH GENERAL PRACTITIONER CASTLE PARTNERSHIP NORWICH

Transcription

1 ALLERGIES vs INTOLERANCES JOANNE WALSH GENERAL PRACTITIONER CASTLE PARTNERSHIP NORWICH

2 BMJ 2013;346:f529 Bad medicine: food intolerance Published 30 January 2013 (Des Spence BMJ)

3 Plan Definitions Symptoms Possible mechanisms Management in primary care

4

5 FOOD (HYPER)SENSITIVITY Food Related Symptom FOOD INTOLERANCE Reproducible reaction on repeat exposure FOOD ALLERGY Form of intolerance involving immune system

6 Food allergy in children and young people February 2011 NICE clinical guideline 116

7 NICE CG 116 Food allergy may be confused with food intolerance, which is a non-immunological reaction that can be caused by enzyme deficiencies, pharmacological agents and naturally occurring substances. Food intolerance will not be covered in this guideline.

8 The Gastrointestinal System Angioedema of the lips, tongue and palate Gastro-oesophageal reflux disease Oral pruritus Nausea Colicky abdominal pain Vomiting Diarrhoea Loose or frequent stools Blood and/or mucus in stools Abdominal pain Infantile colic Food refusal or aversion Constipation Perianal redness Pallor and tiredness Faltering growth in conjunction with at least one or more gastrointestinal symptoms above (with or without significant atopic eczema)

9 What do we mean by food allergy? Food allergy is an adverse IMMUNE response to a food. It can be classified into: IgE-mediated non-ige mediated reactions

10 What do we mean by Food Intolerance? Non-immunological reaction: Enzyme deficiencies Lactose Intolerance Pharmacological agents Salicylates Natural Substances Benzoates

11 European Academy of Allergy and Clinical Immunology Classification of Adverse Reactions to Foods (Allergy ; 56 : ) Adverse Reactions to Foods Toxic Non-Toxic Immune-mediated Food Allergy Non-immune-mediated Food Intolerance IgE mediated Non-IgE mediated Enzymatic Pharmacological Undefined

12 Milk Allergy vs Lactose Intolerance Milk Allergy immune response to the PROTEIN in milk Lactose Intolerance malabsorption of lactose - SUGAR

13 Lactose Intolerance Congenital Lactase deficiency very rare (Russian, Scandinavian) Primary Lactase Deficiency Lactase levels fall very rare below 3yrs Secondary Lactose Intolerance Temporary damage to brush border post infection or as a result of e.g. cow s milk allergy

14 Lactose Intolerance Symptoms Malabsorption of SUGAR (LACTOSE) Onset within 30min to 2 hours Loose stools Abdominal Pain Flatulence Bloating Nausea Settle within 48 hours on Lactose Free Diet

15 Except after a gastrointestinal infection, infants with gastrointestinal symptoms on exposure to cow s milk are more likely to have cow s milk allergy than lactose intolerance. Ludman S, Shah N, Fox AT Managing Cow s Milk allergy in Children BMJ 2013;347:f5424

16 INTOLERANCES

17 vast range of symptoms, individual to each patient. The onset of reactions could be immediate or very delayed and the symptoms range in severity. (BDA fact sheet- food allergy and intolerance)

18 Salicylates Those with severe reactions to aspirin / asthma can usually eat high levels of salicylates in foods Aspirin acetyl group Natural Salicylates non acetylated Tea, coffee, cherries, liquorice

19 Benzoates Preservatives e.g. in sugar free coca-cola Naturally occur in prunes, cinnamon, tea

20 Vasoactive amines Histamine, Tyramine and Phenylethylamine Reduced ability to break down lack of diamine oxidase Headaches, rashes, flushing, blocked or runny nose, nausea, vomiting, abdominal pain. allergy symptoms 30mins. after ingestion Wine, beer, cheese, chocolate, cheeses, tuna, cured meats, oranges, peanuts Respond to antihistamine

21 Symptoms of Food Allergy

22 The Allergic Jumble GASTROINTESTINAL RESPIRATORY SKIN

23 The Gastrointestinal System Angioedema of the lips, tongue and palate Gastro-oesophageal reflux disease Oral pruritus Nausea Colicky abdominal pain Vomiting Diarrhoea Loose or frequent stools Blood and/or mucus in stools Abdominal pain Infantile colic Food refusal or aversion Constipation Perianal redness Pallor and tiredness Faltering growth in conjunction with at least one or more gastrointestinal symptoms above (with or without significant atopic eczema)

24 The Skin Pruritus Erythema Acute urticaria localised or generalised Pruritus Erythema Atopic eczema Acute angioedema most commonly of the lips, face and around the eyes

25 Eczema Early onset eczema risk factor for food allergy Eczema may be worsened by certain food proteins in diet 6 8 week trial of an extensively hydrolysed protein formula or amino acid formula in place of cow s milk formula for bottle-fed infants aged under 6 months with moderate or severe atopic eczema that has not been controlled by optimal treatment with emollients and mild topical corticosteroids (December 2007)

26 Respiratory System (usually in combination with one or more of the previous symptoms and signs) Upper respiratory tract symptoms (nasal itching, sneezing, rhinorrhoea or congestion [with or without conjunctivitis]) Lower respiratory tract symptoms (cough, chest tightness, wheezing or shortness of breath) In addition, take note of any other signs and symptoms of systemic allergic reaction or anaphylaxis.

27 Which foods? Milk Soya Eggs Wheat Nuts Shell fish

28 What is Milk? Cow s milk (fresh, UHT) Evaporated milk Condensed milk Milk powder Skimmed milk powder Milk protein Milk sugar Milk solids Butter milk, butter oil Cream/ artificial cream Whey, whey solids Whey protein Casein (curds), caseinates Calcium caseinate Sodium caseinate Lactoglobulin Lactoalbumin Yogurt, fromage frais Cheese Margarine Butter, Ghee Ice cream

29 15% IgE react to soya 60% Non IgE react to soya Identifying and managing cow's milk protein allergy George du Toit, Rosan Meyer, Neil Shah, et al. Arch Dis Child Educ Pract Ed published online August 5, 2010 doi: /adc

30 Mechanisms

31 IgE mediated

32 Non IgE mediated

33 Asthma or Eczema of the Bowel?

34 Asthma / Eczema of the Bowel?

35 Eosinophils?

36 Eosinophilic Oesophagitis Eosinophilic Gastroenteritis Eosinophilic Colitis Eosinophilic Proctocolitis Eosinophilic Myenteric Ganglionitis associated with functional gastrointestinal obstruction (Schappi Gut )

37 Gastrointestinal Manifestations of Cow s Milk Protein Allergy and Gastrointestinal Motility (Vandenplas 2012) Foundation Acta Paediatrica p

38 Neuromuscular / Neuroimmune Allergic Constipation normal stool but strains Balloon distension Pressure in rectum 25mm (normal) 70mm Stool softeners not working? Mast Cells degranulate close to nerve endings pain and motility (tricyclics) Borrelli et al Neuroimmune Interaction and Anorectal Motility in Constipation Am J Gastroenterol advance online publication, 20 January 2009; doi: /ajg

39 Gastroesophageal Reflux Reflux triggered by milk protein not acidic Gastric Pressure greater, decreased gastric compliance, outflow obstruction? No difference in efficacy between lansoprazole and placebo for symptoms attributed to reflux in 1-12 months Stop the PPI express: They don t keep babies quiet (Putnam J paediatri )

40 NICE Guideline Reflux in Infants Advise Thicken Alginates Acid Suppressing drugs Red flags- with chronic diarrhoea? cow s milk protein allergy

41 What About Adults? NOT RECOGNISED or NOT HAPPENING??

42 Wheat / Gluten Immediate IgE mediated wheat allergy Exercise induced (omega 5 gliadin) Coeliac Self Reported non Coeliac Gluten Sensitivity Gluten Enteropathy

43 Irritable Bowel Syndrome Food Sensitivity in X% Genetics (Family History) IgE Non IgE Gut flora birth, time in hospital, DIET

44 FODMAPS Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols

45 Food-Pollen Syndrome Birch Bet v 1 apple, hazelnut, carrot, potato, cherry, pear, celery, peach Grass Pollen melon, orange, tomato, wheat Ragweed melon, banana Latex avocado and banana

46 MANAGEMENT

47 Testing Immediate Allergy (IgE) Specific IgE (Blood or Skin Prick Tests) Delayed Allergy (non IgE) Elimination and Reintroduction Intolerances

48 Testing - NICE Do not use the following alternative diagnostic tests in the diagnosis of food allergy: vega test applied kinesiology hair analysis Do not use serum-specific IgG testing in the diagnosis of food allergy.

49 Food Sensitive Food Insensitive Food Partial Sensitive

50 Spectrum? Mild Diet Moderate Diet and Drugs Severe Immunosuppressants +/- Diet

51 Patient Support (Dairy Council) (British Dietetic Association) The Complete Guide to Food Allergy and Intolerance (Brostoff and Gamlin) 2008

52 Allergy UK Anaphylaxis Campaign Families Affected By Eosinophilic Disorders Little Refluxers

53 (RCPCH - Information for parents) NICE guidance for patients food allergy, eczema, anaphylaxis

54 Where do I find out more? Allergy Academy Academy for Paediatric Gastroenterology British Society for Allergy and Clinical Immunology RCPCH allergy pathway project (food and gastrointestinal allergy) Food Hypersensitivity: Diagnosing and Managing Food Allergies and Intolerance (Skypala, Venter) The Complete Low FODMAP Diet Shepherd and Gibson

55 Take Home Messages Do you know Allergists and Paediatric Gastroenterologists definitions of allergy and intolerance? Do you know the difference between Lactose Intolerance and Milk Allergy? How much of a problem is Gastrointestinal Allergy in adults?

56 THANK YOU