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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