Can we identify patients at risk of life-threatening allergic reactions to food? Fecha: Lunes 19 de Noviembre de 2018
Can we identify patients at risk of life-threatening allergic reactions to food?
Authors:
P J Turner 1 , J L Baumert 2 , K Beyer 3 , R J Boyle 1 , C-H Chan 4 , A T Clark 5 , R W R Crevel 6 , A DunnGalvin 7 , M Fernández-Rivas 8 , M H Gowland 9 , L Grabenhenrich 10 , S Hardy 4 , G F Houben 11 , J O'B Hourihane 12 , A Muraro 13 , L K Poulsen 14 , K Pyrz 7 , B C Remington 11 , S Schnadt 15 , R van Ree 16 , C Venter 17 18 , M Worm 19 , E N C Mills 20 , G Roberts 18 21 , B K Ballmer-Weber 22
1 Section of Paediatrics (Allergy and Infectious Diseases) & MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, Imperial College London, London, UK.
2 Food Allergy Research and Resource Program, Department of Food Science and Technology, University of Nebraska, Lincoln, NE, USA.
3 Department of Pediatric Pneumology and Immunology, Charité Universitätsmedizin, Berlin, Germany.
4 Food Standards Agency, London, UK.
5 Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
6 Safety and Environmental Assurance Centre, Unilever, Colworth Science Park, Sharnbrook, Bedford, UK.
7 Applied Psychology and Paediatrics and Child Health, University College Cork, Cork, Ireland.
8 Servicio de Alergia, Hospital Clínico San Carlos, IdISSC, Madrid, Spain.
9 Allergy Action, Farnborough, UK.
10 Institute for Social Medicine, Epidemiology and Health Economics, Charité - Universitätsmedizin Berlin, Berlin, Germany.
11 TNO, Zeist, The Netherlands.
12 Paediatrics and Child Health, University College Cork, Cork, Ireland.
13 Department of Paediatrics, Centre for Food Allergy Diagnosis and Treatment, University of Padua, Veneto, Italy.
14 Allergy Clinic, Copenhagen University Hospital at Gentofte, Copenhagen, Denmark.
15 German Allergy and Asthma Association (Deutscher Allergie- und Asthmabund (DAAB)), Mönchengladbach, Germany.
16 Departments of Experimental Immunology and of Otorhinolaryngology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
17 School of Health Sciences and Social Work, University of Portsmouth, Portsmouth, UK.
18 The David Hide Asthma and Allergy Research Centre, St Mary's Hospital, Isle of Wight, UK.
19 Allergy-Center Charité, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Berlin, Germany.
20 Institute of Inflammation and Repair, Manchester Academic Health Science Centre, Manchester Institute of Biotechnology, The University of Manchester, Manchester, UK.
21 NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust and Human Development and Health Academic Unit, University of Southampton Faculty of Medicine, Southampton, UK.
22 Allergy Unit, Department of Dermatology, University Hospital, University Zürich, Zürich, Switzerland.
Abstract:
Anaphylaxis has been defined as a 'severe, life-threatening generalized or systemic hypersensitivity reaction'. However, data indicate that the vast majority of food-triggered anaphylactic reactions are not life-threatening. Nonetheless, severe life-threatening reactions do occur and are unpredictable. We discuss the concepts surrounding perceptions of severe, life-threatening allergic reactions to food by different stakeholders, with particular reference to the inclusion of clinical severity as a factor in allergy and allergen risk management. We review the evidence regarding factors that might be used to identify those at most risk of severe allergic reactions to food, and the consequences of misinformation in this regard. For example, a significant proportion of food-allergic children also have asthma, yet almost none will experience a fatal food-allergic reaction; asthma is not, in itself, a strong predictor for fatal anaphylaxis. The relationship between dose of allergen exposure and symptom severity is unclear. While dose appears to be a risk factor in at least a subgroup of patients, studies report that individuals with prior anaphylaxis do not have a lower eliciting dose than those reporting previous mild reactions. It is therefore important to consider severity and sensitivity as separate factors, as a highly sensitive individual will not necessarily experience severe symptoms during an allergic reaction. We identify the knowledge gaps that need to be addressed to improve our ability to better identify those most at risk of severe food-induced allergic reactions.
DOI: 10.1111/all.12924
P J Turner 1 , J L Baumert 2 , K Beyer 3 , R J Boyle 1 , C-H Chan 4 , A T Clark 5 , R W R Crevel 6 , A DunnGalvin 7 , M Fernández-Rivas 8 , M H Gowland 9 , L Grabenhenrich 10 , S Hardy 4 , G F Houben 11 , J O'B Hourihane 12 , A Muraro 13 , L K Poulsen 14 , K Pyrz 7 , B C Remington 11 , S Schnadt 15 , R van Ree 16 , C Venter 17 18 , M Worm 19 , E N C Mills 20 , G Roberts 18 21 , B K Ballmer-Weber 22
1 Section of Paediatrics (Allergy and Infectious Diseases) & MRC and Asthma UK Centre in Allergic Mechanisms of Asthma, Imperial College London, London, UK.
2 Food Allergy Research and Resource Program, Department of Food Science and Technology, University of Nebraska, Lincoln, NE, USA.
3 Department of Pediatric Pneumology and Immunology, Charité Universitätsmedizin, Berlin, Germany.
4 Food Standards Agency, London, UK.
5 Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
6 Safety and Environmental Assurance Centre, Unilever, Colworth Science Park, Sharnbrook, Bedford, UK.
7 Applied Psychology and Paediatrics and Child Health, University College Cork, Cork, Ireland.
8 Servicio de Alergia, Hospital Clínico San Carlos, IdISSC, Madrid, Spain.
9 Allergy Action, Farnborough, UK.
10 Institute for Social Medicine, Epidemiology and Health Economics, Charité - Universitätsmedizin Berlin, Berlin, Germany.
11 TNO, Zeist, The Netherlands.
12 Paediatrics and Child Health, University College Cork, Cork, Ireland.
13 Department of Paediatrics, Centre for Food Allergy Diagnosis and Treatment, University of Padua, Veneto, Italy.
14 Allergy Clinic, Copenhagen University Hospital at Gentofte, Copenhagen, Denmark.
15 German Allergy and Asthma Association (Deutscher Allergie- und Asthmabund (DAAB)), Mönchengladbach, Germany.
16 Departments of Experimental Immunology and of Otorhinolaryngology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
17 School of Health Sciences and Social Work, University of Portsmouth, Portsmouth, UK.
18 The David Hide Asthma and Allergy Research Centre, St Mary's Hospital, Isle of Wight, UK.
19 Allergy-Center Charité, Department of Dermatology and Allergy, Charité - Universitätsmedizin Berlin, Berlin, Germany.
20 Institute of Inflammation and Repair, Manchester Academic Health Science Centre, Manchester Institute of Biotechnology, The University of Manchester, Manchester, UK.
21 NIHR Respiratory Biomedical Research Unit, University Hospital Southampton NHS Foundation Trust and Human Development and Health Academic Unit, University of Southampton Faculty of Medicine, Southampton, UK.
22 Allergy Unit, Department of Dermatology, University Hospital, University Zürich, Zürich, Switzerland.
Abstract:
Anaphylaxis has been defined as a 'severe, life-threatening generalized or systemic hypersensitivity reaction'. However, data indicate that the vast majority of food-triggered anaphylactic reactions are not life-threatening. Nonetheless, severe life-threatening reactions do occur and are unpredictable. We discuss the concepts surrounding perceptions of severe, life-threatening allergic reactions to food by different stakeholders, with particular reference to the inclusion of clinical severity as a factor in allergy and allergen risk management. We review the evidence regarding factors that might be used to identify those at most risk of severe allergic reactions to food, and the consequences of misinformation in this regard. For example, a significant proportion of food-allergic children also have asthma, yet almost none will experience a fatal food-allergic reaction; asthma is not, in itself, a strong predictor for fatal anaphylaxis. The relationship between dose of allergen exposure and symptom severity is unclear. While dose appears to be a risk factor in at least a subgroup of patients, studies report that individuals with prior anaphylaxis do not have a lower eliciting dose than those reporting previous mild reactions. It is therefore important to consider severity and sensitivity as separate factors, as a highly sensitive individual will not necessarily experience severe symptoms during an allergic reaction. We identify the knowledge gaps that need to be addressed to improve our ability to better identify those most at risk of severe food-induced allergic reactions.
DOI: 10.1111/all.12924
Asistentes: Dr. Ricardo Cardona Villa, Dr. Carlos Fernando Chinchilla, July Ospina, Susana Uribe, Luis Carlos Santamaria, Liliana Guevara, Ana Calle.
ResponderEliminarLas tasas de anafilaxia secundaria a alimentos es baja, sin embargo continuan siendo impredesibles. Se propone utilizar el término de anafilaxia como un evento “potencialmente fatal”, aproximadamente el 80% de las anafilaxias por alimentos resuelve espontáneamente. El metabolismo de las catecolaminas endógenas podrian jugar un papel en esta autorregulación al igual que los cofactores.
Los casos de mortalidad relacionados con anafilaxia por alimentos son bajos (<0.0001%), siendo mas frecuente en adultos.
Aspectos relevantes:
- Impacto de la matriz alimentaria en el desarrollo de reacciones anafilácticas como la presencia de grasas y como ingrediente adicional el trigo parecen inhibir la unión a IgE específica para el alimento.
- La dosis puede ser un factor modificable importante para cualquier tipo de anafilaxia, pero la relacion entre la dosis y la gravedad de la reacción anafiláctica no esta clara.
- La identificación de epitopes específicos podrían predecir con mayor precisión el riesgo de anafilaxia y su gravedad a diferencia de la determinación de IgE específica por medios in vitro o in vivo que predicen solo el riesgo de presentar una reacción más no su gravedad.
- Hasta el 50% de los pacientes con sindrome de alergia oral podrían presentar síntomas sistémicos, sin embargo en nuestro medio, aunque la prevalencia es baja, no se documentan síntomas sistémicos con tanta frecuencia.
- La indicacion de adrenalina autoinyectada siempre debe ir acompañada de la educación sobre las situaciones específicas en cuales deben ser aplicada.
- IgE específica para Ara h 2 se asocia tanto con sensbilización a mani como gravedad en las reacciones, por lo tanto se sugiere solicitar este recombinante específico pera orientar manejo y predecir un fenotipo de severidad.
- La duda que se genera a partir del concepto que cofactores como IECAS y betabloqueadores debido al efecto sinérgico que resulta en activcación de mastocitos.
- El antecedente de asma no es por si mismo un predictor fuerte de anafilaxia fatal, sin embargo, un episodio anafiláctico previo y el antecedente de asma mal controlada son factores de riesgo.
Prescripción de autoinyector de adrenalina en alergia alimentaria:
- Anafilaxia previa documentada
- Alergia maní con determinación de IgE específica para Ara h 2
- Casos especiales como niños en estado de vulnerabilidad ( bajo nivel socioeconómico, hijos de padres con alcoholismo, enfermedades psiquiátricas)