American Academy of Allergy, Asthma and

Immunology

FIT Symposium # 1011

Putting It Together: NIAID-

Sponsored 2010 Guidelines for

Managing Food Allergy

Scott H. Sicherer, MD Mount Sinai School of Medicine

Jaffe Food Allergy Institute

Pediatric Allergy & Immunology

New York, NY February 22, 2013 11:45 AM

Putting Together Diagnosis

and

Putting Together

Management

Boyce JA, Assa'ad A, Burks AW, Jones SM, Sampson HA, Wood RA et al. Guidelines for

the diagnosis and management of food allergy in the United States: report of the NIAID-

sponsored expert panel. J Allergy Clin Immunol 2010; 126(6 Suppl):S1-58.

Major Points for Successful

Diagnosis

• Pathophysiology

• Epidemiology

• Careful history

• Understanding utility of tests

Step 1: Pathophysiology

Adverse reactions

(not hypersensitivity)

Non-Allergic

Allergy (Immune-mediated)

IgE-Mediated “Non-IgE” mediated

•Bacterial food poisoning

•Scombroid fish poisoning

•Lactase deficiency

•Galactosemia

•Anaphylaxis

•Urticaria

•Isolated

gastrointestinal

reactions

•Skin rashes

IgE?

•Atopic Dermatitis

•Eosinophilic

gastroenteritis

Expect Positive

Skin Test

Accept Negative

Skin Test

Step 2: Epidemiology

• Of foods

• Of disorders

Common in Children

-egg -peanut

-milk -tree nuts

-soy -seafood

-wheat

Common in Adults

-peanut

-tree nuts

-seafood

-(fruits/vegetables)

Not usually associated with food

-chronic asthma

-chronic allergic rhinitis

-chronic urticaria

Often associated with food

-anaphylaxis

-urticaria (acute)

-atopic dermatitis (~35%)

-syndromes of gastrointestinal allergy

Step 3: Careful History

• Symptoms

• Food(s) ingested

• Frequency of ingestion (ever tolerated?)

• Timing of symptoms

• Co-ingestion of ASA, alcohol

• Association with exercise

• Diet records

• Labels

Step 4: Incorporation of Tests

• IgE-mediated acute symptoms

– Tests positive eliminate

– Tests negative reintroduce (possibly as oral challenge)

• IgE-Mediated chronic symptoms (Atopic dermatitis, eosinophilic gastroenteropathies)

– Screening tests by history and a priori, elimination diet, if resolved do oral challenges

• Non-IgE (enterocolitis, enteropathies)

– Elimination diet and oral challenges

Food-Specific IgE Antibody

Concentrations Correlate with

Risk of Clinical Reactivity

0

10

20

30

40

50

60

70

80

90

100

Food-specific IgE Antibody Concentration

Pro

bab

ilit

y o

f a r

eact

ion

(%

) Curve varies by:

•Food

•Disease

•Age

•Other

~95% Predictive

Values (CAP-System):

Egg-7 kIU/L

Milk-15 kIU/L

Peanut-14 kIU/L Negative test does not guarantee no reaction!

Diagnostic Decision Points

(Food-specific IgE in kU/L)

Sicherer & Sampson JACI Primer 2006 (based mostly on US studies)

Food Mean age

5 years

~50%

react

Mean age

5 yrs

~95%

react

Age <2 yrs

~95%

react

Egg 2 > 7 > 2

Milk 2 > 15 > 5

Peanut 2-5 > 14 --

Component Resolved Diagnosis Pollen cross-

reactive

components*

LTP Pollen non-cross-reactive

components**

Peanut Ara h 8 Ara h 9 Ara h 1; Ara h 2; Ara h 3

Arah 4; Ara h 6; Ara h 7 Ara h 5

Hazelnut Cor a 1 Cor a 8 Cor a 9

Cor a 11 Cor a 2

Soybean Gly m 4 Gly m 1 Gly m 5

Gly m 6 Gly m 3

Wheat Tri a 12 Tri a 14 Tri a 19 (ω-5 gliadin)

Tri a 21 - alfa gliadin

Tri a 26 - HMW glutenin

Tri a 28 - AAI dimer 0.19

*Birch tree pollen, Timothy grass pollen for wheat

** Storage seed proteins, albumins and globulins

PRP-10

Profilin

LR(+)=sens/(1-spec)

•Must estimate pre-

test probability

(history, prior tests)

•Use simple,

additional tests with

(hopefully) strong

predictive accuracy

•Decide upon further

testing that may be

definitive but more

costly/risky/invasive

Prior Probability and Likelihood Ratios

From Sicherer SH, Wood RA. Advances in

diagnosing peanut allergy. J Allergy Clin Immunol:

In Practice. 2013;1:1-13

• CASE PRESENTATIONS

Tests:

Diagnosis:

OFC?:

Risk Monitor

Modality Dose

Location Post care

Prep

• 6 week old, breast fed

• Mucousy bloody stools

• No vomit

• Good growth

• Mother on regular diet

Tests:

Diagnosis:

OFC?:

Risk Monitor

Modality Dose

Location Post care

Prep

• 6 week old, breast fed

• Mucousy bloody stools

• No vomit

• Good growth

• Mother on regular diet

Tests: not

relevant

Diagnosis:

proctocolits

OFC?:not yet

Risk Monitor

Modality Dose

Location Post care

Prep

• 6 week old, breast fed

• Mucousy bloody stools

• No vomit

• Good growth

• Mother on regular diet

• Mother off milk-all better

• Returns age 11 months still off milk…

Tests:

Diagnosis:

OFC?:

Risk Monitor

Modality Dose

Location Post care

Prep

• 6 week old, breast fed

• Mucousy bloody stools

• No vomit

• Good growth

• Mother on regular diet

• Mother off milk-all better

• Returns age 11 months still off milk…

Tests:

Diagnosis:

OFC?:

Risk Monitor

Modality Dose

Location Post care

Prep

Interval Hx:

No atopic disease

Regular diet except

no milk…

• 6 week old, breast fed

• Mucousy bloody stools

• No vomit

• Good growth

• Mother on regular diet

• Mother off milk-all better

• Returns age 11 months still off milk…

Tests:

maybe

Diagnosis:

proctocolitis

OFC?:yes

Risk low Monitor

Modality openDose

Location homePost care

Prep

Interval Hx:

No atopic disease

Regular diet except

no milk…

• 37 year old with ragweed AR

• Banana ingestion, within minutes…

• Itchy throat

• Numb hands

• Generalized urticaria

• Took diphenhydramine

• Trouble breathing, LOC awoke and went to

ER, stable

Tests:

Diagnosis:

OFC?:

Risk Monitor

Modality Dose

Location Post care

Prep

• 37 year old with ragweed AR

• Banana ingestion, within minutes…

• Itchy throat

• Numb hands

• Generalized urticaria

• Took diphenhydramine

• Trouble breathing, LOC awoke and went to

ER, stable

Tests:

Banana extr

SPT neg

sIgE-neg

RW-PST 9mm

Diagnosis:

OFC?:

Risk Monitor

Modality Dose

Location Post care

Prep

• 37 year old with ragweed AR

• Banana ingestion, within minutes…

• Itchy throat

• Numb hands

• Generalized urticaria

• Took diphenhydramine

• Trouble breathing, LOC awoke and went to

ER, stable

Tests:

Banana extr

PST neg

sIgE-neg

RW-PST 9mm

Diagnosis:

Banana Ana?

OAS-panic?

OFC?:

Risk Monitor

Modality Dose

Location Post care

Prep

• 37 year old with ragweed AR

• Banana ingestion, within minutes…

• Itchy throat

• Numb hands

• Generalized urticaria

• Took diphenhydramine

• Trouble breathing, LOC awoke and went to

ER, stable

Tests:

RAW Banana

PST 13 mm

Diagnosis:

Banana Ana?

OAS-panic?

OFC?:

Risk Monitor

Modality Dose

Location Post care

Prep

• 3 years old

• Tried scrambled egg at age 11 months

• Generalized urticaria, vomit, cough

• Age 2, accident with mayonnaise, small

amount, facial urticaria

Tests:

PST 8 mm

sIgE 10 kIU/L

Diagnosis:

Current vs.

Resolved egg

allergy

OFC?:

Risk Monitor

Modality Dose

Location Post care

Prep

• 3 years old

• Tried scrambled egg at age 11 months

• Generalized urticaria, vomit, cough

• Age 2, accident with mayonnaise, small

amount, facial urticaria

Tests:

PST 8 mm

sIgE 10 kIU/L

Diagnosis:

Current vs.

Resolved egg

allergy

OFC?: NO

Risk Monitor

Modality Dose

Location Post care

Prep

• 3 years old

• Tried scrambled egg at age 11 months

• Generalized urticaria, vomit, cough

• Age 2, accident with mayonnaise, small amount, facial urticaria

• RETURNS age 4, mild asthma

• No interval reactions, tolerated baked egg

Tests:

PST 3 mm

sIgE 1.5 kIU/L

Diagnosis:

Current vs.

Resolved egg

allergy

OFC?:

Risk Monitor

Modality Dose

Location Post care

Prep

• 3 years old

• Tried scrambled egg at age 11 months

• Generalized urticaria, vomit, cough

• Age 2, accident with mayonnaise, small amount, facial urticaria

• RETURNS age 4, mild asthma

• No interval reactions, tolerated baked egg

Tests:

PST 3 mm

sIgE 1.5 kIU/L

Diagnosis:

Current vs.

Resolved egg

allergy

OFC?: needed if..

Risk Mod Monitor

Modality open Dose slow

Location ? Post care

Prep ?no IV

• 10 year old ate cashew anaphylaxis

• Tolerates peanut, walnut and almond

but stopped eating them after this

reaction 3 weeks ago

• Mild atopic history (resolved AD, mild

SAR)

Tests:

Diagnosis:

OFC?:

Risk Monitor

Modality Dose

Location Post care

Prep

• 10 year old ate cashew anaphylaxis

• Tolerates peanut, walnut and almond but stopped eating them after this reaction 3 weeks ago

• Mild atopic history (resolved AD, mild SAR)

• Family would be interested in adding peanut/”allowed” nuts

Tests (IgE):

Cashew-11.7

Peanut-1.4

Almond-3.4

Walnut < 0.35

Diagnosis:

TNA-but

what to instruct?

OFC?:

Risk Monitor

Modality Dose

Location Post care

Prep

• 3 year old, asthma, anaphylaxis X 5

• Severe reactions to egg, milk, peanut

and high IgE to these

• Diet restricted to turkey, soy, 3 fruits,

rice, oat, 3 vegetables (no other beans)

and amino acid formula

Tests:

Diagnosis:

OFC?:

Risk Monitor

Modality Dose

Location Post care

Prep

• 3 year old, asthma, anaphylaxis X 5

• Severe reactions to egg, milk, peanut

and high IgE to these

• Diet restricted to turkey, soy, 3 fruits,

rice, oat, 3 vegetables (no other beans)

and amino acid formula

Tests serum/skin):

Beef-3.7/ 4 mm

Pea-2.8/ 2 mm

String bean-4.3/0 mm

Soy-19.9/ 6 mm

Wheat-15.4/ 5 mm

Pork-5.5/ 5 mm

Diagnosis:

MFA

OFC?:

Risk Monitor

Modality Dose

Location Post care

Prep

Atopic Dermatitis Referral

• 18 month old with severe atopic dermatitis

• Pediatrician sent tests, many positives

• Left on a very limited diet

• Skin care maximized, environmental

controls, rash is moderate, still

waxes/wanes—not happy!

• You have the pre-determined tests

• You can take a history

The tests! Eating PST (MM) IgE (kIU/L)

plum 3 0.47

peach 2 0.70

chicken 4 2.3

beef 5 44

spelt

Suspected

soy 3 8

wheat 7 >100

apple 3 <0.35

rice 3 2.0

pea 3 4.18

corn 2 3.12

barley 0 <0.35

banana 0 1.14

sweet potato 0 <0.35

Acute reaction-eliminated

milk 8 >100

egg 4 7.15

Never tried:

Peanut-67 kIU/L

Codfish-47 kIU/L

Lets vote:

Eat

Restrict

Challenge

Management

• Avoidance advice

– Home, restaurants, school, vacation,

cross-contact, label reading, interpersonal,

anxiety, nutritional assessment , age-

related issues.

• Treatment advice

– When and how to use self-injectable

epinephrine, medical identification, dosing,

written materials, age-related issues

Resource:

www.foodallergy.org/actionplan.pdf

Written Action Plan and Medical Jewelry

Consider cetirizine

Treatment: Dietary Elimination

• Cross contact

• Restaurants/Hidden ingredients

• Labeling laws/advisory labeling

– Law covers milk, egg, wheat, soy, peanut, nuts,

fish, shellfish

– Advisory labeling is voluntary (may contain)

Pediatrics. 2012;130(1):e25-32

• Followed for ~ 3 years

• Register all reactions “real time”

Half of reactions: food not

from the parent

• Lesson- educate all caregivers and

watch siblings

Purposeful Exposures in 11%

• Reasoning- Uncertain (suspect

misdiagnosis, small amount)

• Lesson- Education and anticipatory

guidance

Severity of Reactions

• 11% were severe

• Lesson: Emphasize avoidance of

ingestion

Under-treatment with

Epinephrine • Overall, 30% of severe reactions were treated

with epinephrine

– Severe=lower respiratory, cardiovascular, or combination of skin/oral/upper respiratory and GI.

• Among 65 reactions when not given but caregiver admitted “should have”- reaction not recognized (48%), medicine not on hand (23%), afraid (12%), waiting to worsen (6%).

• Lesson: emphasize safety of epinephrine, indications and technique of administration

Summary

• Diagnosis: Synthesis of a priori

(epidemiology, pathophysiology,

history) and tests.

• Management: Education

• Resources: See Guidelines Page

S58. Includes: www.aaaai.org,

www.cofargroup.org,

www.niaid.nih.gov and others