Download Food Allergy - Devon Sessional GPs

Temporary referral criteria to Peninsula Immunology &
Allergy service
Primary Immunodeficiency (PID)

Known primary humoral (antibody), cell mediated and innate immune defects

Adults or children with unusually frequent or severe infections, or infections
with unusual organisms. Secondary causes should be excluded (eg drugs,
underlying malignancy, structural defects)

Additional information required: Results of microbiology (eg sputum/swabs),
full immunisation history (vaccine names and date administered). Radiology
(if done outside Derriford). Details of family history (especially infections)

If history strongly suggestive of immunodeficiency referral should not be
delayed pending blood results, however useful investigations include FBC
with differential, immunoglobulin levels (if recurrent bacterial infections),
sputum cultures.

If history suggestive of hereditary angioedema (angioedema, no urticaria,
often involving recurrent abdominal pain, family history) check C4 and if low
referral to PID clinic. If strongly suggestive history and normal C4, referral to
PID clinic appropriate. Otherwise treat as for spontaneous angioedema.
Allergic Rhinitis/ conjunctivitis




Adults only (>16 years)
Referral to allergy clinic only for patients with severe seasonal rhinitis
unresponsive to standard medical treatments (see below) for consideration of
desensitisation therapy. GPs referring patients to the allergy service will be
sent treatment advice and referral will only be accepted if the patient fails
after maximal standard treatment as described below.
Prior to referral patients should have been treated with regular non-sedating
antihistamines at twice the daily recommended dose and regular nasal
corticosteroid spray both starting two weeks prior to the usual onset of
symptoms. Regular sodium cromoglycate eye drops are also recommended.
It is important that the patient is trained to use nasal steroid spray
appropriately for maximum effect. If severe symptoms persist despite these
measures short courses of oral corticosteroids (10-15mg prednisolone 3-5
days) should be considered. Intra-muscular steroid injections and long
courses of oral steroids should be avoided.
Guidelines – BSACI/ ARIA guidelines for management of allergic rhinitis
Food Allergy



Adults only (>16 years)
Refer to allergy clinic patients with a history of anaphylaxis (reactions
involving cardiovascular or respiratory compromise) and those with coexisting asthma.
Patients with less severe reactions suggestive of type one hypersensitivity
should be advised to avoid the suspected allergen. Blood test for specific IgE
Drs Edward Kaminski & Claire Bethune
23.07.2010

may help to confirm an allergen, however these tests must be interpreted in
the light of the clinical presentation, a patient may have a type one
hypersensitivity to a particular allergen even if the specific IgE is negative.
All patients should be advised by their GP in the management of both mild
and severe reactions that may occur in the future.
There are a significant proportion of patients where the results are
inconclusive. These more complex patients should be reviewed in the allergy
clinic once there is adequate capacity in the service as skin prick testing and
challenge testing may be indicated.
Urticaria and Angioedema



1.
2.
3.
4.

Adults only (>16)
Refer only patients with potentially life-threatening features (cardio-respiratory
compromise)
Patients with non-life threatening urticaria and angioedema should be
managed in primary care as follows
Allergic, pseudo allergic and physical precipitants should be excluded from
the clinical history. Are there any triggers occurring prior to each episode?
Underlying systemic disorders (infection, malignancy) should be excluded
through clinical history, examination and investigations where indicated.
Angioedema with no urticaria consider ACE inhibitor and HAE (see PID
referral guidelines).
If no precipitant/underlying pathology consider regular non-sedating
antihistamine prophylaxis. Often need to go above licensed dose for control
(if normal renal/liver function and no drug interactions). Avoid corticosteroid
use in view of side effects of long term use.
Only refer consultant allergy clinic if no trigger identified and the patient not
responsive to regular antihistamines after two different antihistamines have
been tried (up to 4 times the daily recommended dose) (eg ceterizine then
fexofenadine)
Drug Allergy




Adults only (>16) (non-anaesthetic drugs)
Patients with reactions suggestive of type one hypersensitivity
Refer patients only where treatment with the implicated drug is required for
clinical management. This is due to potential risk in challenge testing and
considerable resource implications of testing. Otherwise if history suggests
type one hypersensitivity or pseudo allergic reaction the drug and other
related drugs should be avoided.
Referral must be accompanied by a detailed description of implicated drug(s)
including nature and timing of the reaction(s)
Latex allergy


Refer only patients with history suggestive of type one hypersensitivity
Clinical history needs to be taken to differentiate between potential type one
hypersensitivity (urticaria, angioedema, anaphylaxis) reactions and type four
reactions (dermatitis) where referral to dermatology for patch testing may be
appropriate.
Drs Edward Kaminski & Claire Bethune
23.07.2010
Where to refer patients with allergy
 Adult allergy (>16 years) (meeting the above inclusion criteria)
– Drs Edward Kaminski & Claire Bethune, Immunology, Derriford
Hospital
 Children with allergy (<16 years)
– local Paediatrician
 Eczema / contact dermatitis
– local Dermatologist
 Asthma
– local Respiratory Physician
 Desensitisation for bee & wasp allergy
– Dr Tim Howell, Respiratory Medicine, Derriford Hospital
 General Anaesthetic allergy
– Dr Sarah Ford / Dr Paul Sice, Anaesthetics, Derriford Hospital
Drs Edward Kaminski & Claire Bethune
23.07.2010