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Managing allergies

Food allergies are becoming more and more common in the UK. Here's the many hurdles those who suffer face and some top tips for pharmacy teams to pass on.

In May 2022, Allergy UK called on the Government to address the needs of the allergic community as part of the Queen’s 2022 speech

The charity highlighted that the UK has some of the highest rates of allergy in the Western world, and that there has been a shocking 615 per cent increase in hospital admissions related to potentially life-threatening allergic reactions (anaphylaxis) in the last 20 years. 

Eating out can feel impossible for food allergy sufferers at times and is a common source of stress and worry. In February 2022, the Allergy to Peanuts ImPacting Emotions And Life (APPEAL) study, published in PLOS ONE, revealed that most people with peanut allergy, or their carers, experience uncertainty (79 per cent), stress (71 per cent) and feeling anxious (75 per cent) due to their allergy, and more than a third reported feeling worried in situations that don’t involve food. Among children and teenagers, just over half reported experiencing bullying or teasing because of their peanut allergy.

“Peanut allergy is often lifelong and, as these data from the UK and Ireland show, can be very difficult for children, their parents or caregivers,” says Simon Williams, chief executive officer at Anaphylaxis Campaign. “This study clearly indicates that the whole family is impacted, not only from the stress and anxiety of peanut allergy itself, but also from restrictions on social activities and even the potential for bullying and harassment. These findings reinforce our understanding of the substantial burden that peanut allergy has on young people and their families and highlight the importance of having new treatment options and ongoing advice and support available for those living with this condition.”

About food allergies

A food allergy occurs when the body’s immune system overreacts to a normally harmless substance by producing IgE antibodies specific to that particular food. When the body comes into contact with that food substance again, immune system cells produce various chemicals, including histamine, which trigger swelling and inflammation. This can cause symptoms that range from minor itching and sickness to breathing problems and collapse. In severe cases, a food allergy can be fatal.

“With most allergies, the first exposure sensitises our body to a particular allergen”, says Quinton Fivelman, chief scientific officer at London Medical Laboratory, “so that the second or third time we come into contact with particular foods or are stung, for example, the reaction could be far worse. However, in the case of adult-onset food allergies, the patient may have come into contact many hundreds of times previously without showing any symptoms of a reaction”.

The most common foods that may trigger allergies are celery; cereals containing gluten; crustaceans; eggs; fish; lupin; milk; molluscs; mustard; tree nuts; peanuts; sesame seeds; soya; sulphur dioxides (sulphites). Food allergy symptoms tend to appear within a few minutes of eating the trigger food, these are called immediate or IgE-mediated reactions. Occasionally they can be delayed by a couple of hours, known as delayed or non-IgE mediated reactions. Classic allergy symptoms can affect the gut (pain, nausea and/or vomiting), skin (itching and rashes) and respiratory system (runny nose, sneezing, wheezing and/or cough).

Exploring allergens

Here are some common food allergies and which food items may trigger them. Customers should be reminded to always check food labels carefully, even if they have eaten the food before, as ingredients can change.

Getting a diagnosis

If customers are worried that they, or their child, has developed a food allergy, they should speak to their GP. Food allergies may initially be attributed to something else, such as food poisoning, a skin condition or a digestive problem. If anyone is having a severe allergic reaction (e.g., causing fainting, breathing problems or swallowing difficulties), they should seek help straightaway by calling an ambulance.

To aid the diagnosis of food allergies, pharmacy customers should keep a diary of their (or their child’s) symptoms, which includes:

  • What the symptoms are
  • How often these occur
  • How long they last
  • If they had any particular foods or drinks beforehand (and how much they ate/drank)
  • How soon the symptoms appeared after eating/drinking
  • Whether the symptoms improved after antihistamines or other medicines
  • Whether they went to A&E or another healthcare service.

It may also help if they take photos or videos of any symptoms. If a food allergy is suspected, their GP should be able to refer them to a specialist allergy service, although this may not be local. Allergy testing involves skin prick tests (usually on the forearms or back) and/or specific-IgE blood tests, which measure levels of IgE antibodies to specific food allergens in the blood. 

Non-IgE allergic reactions are diagnosed with ‘elimination and reintroduction’ diets instead – the suspected culprit food is removed from the diet for two to four weeks and then slowly reintroduced. This should be supervised by a specialist dietitian. 

Management advice

Being diagnosed with a food allergy can be a worry, especially while people learn how to manage their symptoms and avoid their triggers. Peanut allergy in particular, due to the high risk of anaphylaxis, can affect all aspects of daily life, from eating out and travelling to education, socialising and work.

In May 2022, Allergy UK launched a new resource pack (supported by Reckitt Benckiser) for parents whose child has been diagnosed with cow’s milk allergy. “They may have often already had a lengthy and difficult time getting a diagnosis for their baby as many of the typical symptoms are common in well babies,” says Amena Warner, head of clinical services at Allergy UK. “Post diagnosis, their anxiety shifts to worries about how to best manage the condition and what it means for their child’s wellbeing now and in the future.”

The aim of treatment is to prevent allergic reactions occurring in the first place to improve quality of life. This involves avoiding the trigger food(s) and being ready to respond if an allergic reaction occurs. Non-sedating antihistamines (such as cetirizine, loratadine or acrivastine) are recommended for mild or early allergy symptoms, rather than sedating antihistamines (such as chlorphenamine).

“A non-anaphylactic reaction should be treated with oral antihistamines,” says Aneta Ivanova, paediatric allergy nurse consultant at Midlands Allergy Service. “The pharmacist should be able to assist in purchasing oral antihistamines and help with clarifying the instructions that are well written on the medication. There are no other products for the management of true allergic reaction except adrenaline auto injectors (AAI) in event of anaphylaxis.”

Advice for eating out

Allergy UK’s consumer survey in 2015 revealed that 92 per cent of those living with allergy are scared to eat out. “The most important advice when eating out is to firstly inform the establishment about the child’s allergies,” says Aneta. “Where possible, ask for a list of ingredients included in the food they are planning to order. If the food is pre-packed, read the label carefully. With Natasha’s Law in power since October 2021, all food manufacturers are required to provide a full ingredients list and display all major allergens in bold on pre-packed food for direct sale.”

The pharmacy team can pass these ‘eating out’ tips on to customers with food allergies:

  1. Research the restaurant carefully, check out the menu options online and call the restaurant in advance
  2. Watch out for potential cross-contamination and avoid buffets or salad bars, in particular
  3. Check the recipe ingredients with the chef at each visit as recipes can change
  4. Where possible, avoid eating out in a busy restaurant when it may be more difficult to speak to the chef or manager and the chefs may be more likely to make a mistake when preparing food
  5. When the meal arrives, check it carefully to make sure it’s exactly what was ordered – don’t be afraid to send it back if there’s any doubt
  6. Carry two AAIs and make sure these are easily accessible; ideally, at least one other person eating at the table should know how to use them.

Using an AAI

If someone is at risk of a severe allergic reaction, they should carry two AAIs at all times and use these immediately if a reaction occurs. Possible symptoms of anaphylaxis include feeling faint, breathing difficulties, wheezing, a fast heartbeat, clammy skin, confusion and collapse.

Epipen, Jext and Emerade are three brands of AAI licensed in the UK. These all work slightly differently, so anyone who carries them, including family and friends, should obtain a trainer auto-injector from the manufacturer and practise using it. 

In an emergency, if someone is having a severe allergic reaction, it’s important to follow these steps:

  1. Use the AAI immediately if there are any signs of anaphylaxis. If in doubt, use them anyway. Don’t delay
  2. Dial 999 – saying ‘anaphylaxis’ – straight after using an AAI
  3. Lie them down and raise their legs
  4. Sit them up if they are struggling to breathe but don’t change their position suddenly
  5. Lie them down again as soon as they can
  6. Keep them lying them down even if they are feeling better. They must not stand up even if someone encourages them to do so
  7. Use their second AAI if they haven’t improved after five minutes.

Treatment advances

In March 2022, Palforzia, a peanut desensitisation (oral immunotherapy) product, received regulatory approval by the Medicines and Healthcare products Regulatory Agency (MHRA) for children aged four to 17 with proven peanut allergy who fit specific requirements. The treatment needs to be given under medical supervision at specialist allergy centres and should be used with a peanut-avoidant diet.

Clinical trial evidence shows that Palforzia improves tolerance to peanut protein compared with placebo when precise amounts are used in a food challenge test and is likely to improve people’s quality of life once they are having a stable dose. 

“This is an exciting new opportunity to improve the quality of life and reduce the risk of severe reactions in our young patients,” says Aneta. “Nevertheless, the Palforzia protocol follows strict criteria based on an assessment that takes place in a specialist paediatric allergy clinic. In brief, it takes into account the severity of the symptoms, test results and any co-morbidities. Only the future can tell how many patients will meet the inclusion criteria and have the immunotherapy.”

'tis the sneeze-on!

Hayfever (pollen allergy) tends to be worse in March to September when tree and plant pollen levels are high. Key symptoms are sneezing, a runny or blocked nose, coughing, itchy, red or watery eyes, generalised itching, headaches, loss of smell, earache and fatigue. Hayfever can affect sleep and concentration and may make asthma worse.

The main way to treat mild hayfever is to take daily antihistamines (tablets, liquids or nasal sprays). If the nose is blocked, or the symptoms are moderate to severe, add in a corticosteroid nasal spray and cromoglycate eye drops, if necessary. Pollen avoidance is also very important, such as wearing wraparound sunglasses, changing clothes after being outdoors, smearing petroleum jelly or a barrier balm around the nostrils to trap pollen, keeping windows and doors shut as much as possible, vacuuming regularly and buying pollen filters for cars and a vacuum cleaner with a HEPA filter.

If over the counter (OTC) medicines aren’t working, GPs can prescribe stronger antihistamines and nasal sprays. Severe hayfever may be treated with immunotherapy – giving small amounts of pollen as an injection or sublingual tablet to slowly build up immunity. This treatment is usually started around three months before the hayfever season begins.

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