GP Information

PDF Version: ALL04001(D) Food Allergy vs Intolerance (GP).pdf [pdf] 165KB

Having to avoid certain foods in your diet can be difficult. But there are a few simple things you can do to help you manage your food allergies - allowing you to stay safe, continue to participate in fun activities and enjoy your food.

What is the difference between food allergy and food intolerance?

For some people, eating certain foods can lead to an unpleasant and sometimes dangerous physical reaction.

The term used to describe all types of reactions to foods is ‘food hypersensitivity’. A 'food allergy' is a reaction involving the immune system (the body’s defence against foreign bodies). Those that do not involve the immune system are often called a ‘food intolerance’. 

It is important to identify and manage foods that trigger any symptoms in an appropriate way.

Food allergy

Proteins within foods can trigger immediate (within two hours) or delayed symptoms (up to several days later).

Immediate food allergy (IgE mediated food allergy)

Immediate reactions to foods occur when your immune system reacts to a normally harmless protein in food, due to the creation of
Immunoglobulin E (IgE).

This results in the release of chemicals (e.g. histamine) which trigger allergic symptoms. These symptoms are usually in the skin
(itching/swelling), or gut (vomiting, diarrhoea).

Other symptoms can include breathing problems and in rare cases an extreme allergic reaction called anaphylaxis.

Delayed food allergy (non IgE mediated food allergy)

Delayed reactions to foods still involve your immune system, but there is a different type of immune reaction involved. Symptoms
typically occur in the gut (vomiting, diarrhoea, constipation) and/or the skin (atopic eczema).

Which foods are involved?

The most common foods to be involved in children are:

1. cow’s milk

2. hen’s egg

3. peanuts

4. tree nuts e.g. hazelnuts, almonds, walnuts, Brazil nuts, cashew and pistachio nuts

5. wheat

6. soya

7. fish

8. shellfish, especially prawns

9. sesame

In adults, the most common type of food allergy is to raw fruits and raw vegetables. It is known as pollen food syndrome. Fish,
shellfish, legumes and seeds are also common causes of allergy in adults.

Food allergy testing

If you think you have a food allergy, you will need specialist input to diagnose your allergy and help you manage it. For more
information see the Food Allergy and Intolerance Testing fact sheet.

There are many different types of ‘food intolerance’. Food intolerances do not involve your immune system. Reactions often show
a vast range of symptoms, and can be individual to you.

The onset of reactions could be immediate or delayed and the symptoms range in severity. If you think you have a food
intolerance, you will need a detailed clinical history by an experienced healthcare professional to diagnose and help you manage
these reactions.

Lactose intolerance

This is one of the most common food intolerances. It occurs when you have either too little or no lactase. This is the enzyme which
helps to digest lactose, the sugar found in milk and dairy products from all types of animals (such as cow, goat and sheep). If you are lactose intolerant you should avoid or reduce these foods. Replace them with lactose-free milk and dairy products or fortified plant-based alternatives.

Histamine intolerance

This is a reaction to certain naturally occurring substances in foods called vaso-active amines – such as histamine. Common trigger foods include red wine, strong and blue cheeses, tuna, mackerel, pork products, tomatoes and various other preserved foods.

Salicylate sensitivity

Salicylates are substances, chemically similar to aspirin, found in a wide variety of plant foods. Some fruits, vegetables, nuts, herbs
and spices are high in salicylates. Most people can tolerate small amounts of these foods.

Other sensitivities

Some people can have reactions to caffeine or theobromine - found in chocolate.

There are also many reactions to foods with unknown mechanisms such as intolerance to food additives benzoate and sulphite,
preservatives and monosodium glutamate.

In all these examples avoidance of foods or reduced intake may improve the symptoms. Often there can be other factors that also
need to be considered.

Food labelling

Under UK law, food businesses must inform you if they use any of the 14 allergens as ingredients in the food and drink they provide. The 14 allergens are: celery, cereals containing gluten (such as rye, wheat, barley and oats), crustaceans (such as prawns, crabs and lobsters), eggs, fish, lupin, milk, molluscs (such as mussels and oysters), mustard, peanuts, sesame, soybeans, sulphur dioxide and sulphites and tree nuts (such as almonds, hazelnuts, walnuts, brazil nuts, cashews, pecans, pistachios and macadamia nuts).

Prepacked food - Allergens must be emphasised within the ingredients list of pre-packed food or drink, for example on tins you buy in the supermarket. This could be done by using bold, italic or coloured type.

Non-prepacked (loose) food - Food businesses such as a bakery, butchers or delicatessen, must provide you with allergen information for any loose item you buy that contains any of the 14 allergens.

Foods prepacked for direct sale (PPDS) – These are foods packed and prepared on the same site, such as in a café, sandwich shop, deli or food outlet preparing food in their own kitchen. From 1 October 2021, PPDS food must have a label that displays a full ingredients list. The 14 allergens must be emphasised within it.

Eating out – A restaurant or café must provide you with allergen information in writing. This could be allergen information on their menu or a written notice explaining how you can get this information. Ask a member of staff about the allergen content of a dish you wish to order.

Food delivery & takeaway food - If you are ordering food online or by phone, allergen information must be provided before purchase is completed and when the food is delivered (in writing or verbally). If ordering through a food delivery company you must contact the restaurant directly.

Precautionary allergen labelling - ‘May contain’ statements are often used on food packaging to state that a food may be contaminated with one of the common allergens. There is no law to say when these statements should be used. This type of labelling is used on many foods, so it is important to discuss the safest approach with your doctor or dietitian.

Top tips

• When a food hypersensitivity reaction involves the immune system, it is called a ‘food allergy’. If it does not involve the immune system, it is often called a ‘food intolerance’ or an ‘adverse reaction’.

• If you have to cut out complete food groups from your diet such as dairy or wheat, try to make sure the foods you replace them with have enough of the nutrients you need.

• Look out for, and try, new ‘free from’ products as this will help add variety and enjoyment to your diet. These are clearly labelled and are common foods made without the standard ingredients.

• Develop your cooking skills! Adapt your favourite recipes using suitable alternative ingredients.

• Plan ahead. For special occasions or meals out, let your host or chef know your dietary requirements.

• Prepare in advance for holidays abroad. This includes emergency medication, translation cards and making your airline and accommodation aware.

• Be aware of the ingredients used in cuisines from different countries.

• Know your level of food avoidance. Find out if you have to avoid tiny ‘trace’ amounts of food allergens or if you can have small amounts without triggering a reaction. Be aware of the risk of cross-contamination on surfaces and utensils.

• Always carry the emergency medication recommended by your doctor. Make sure your family and friends know what to do in an emergency.

• If you are unsure about which foods you can and can’t eat and need further dietary advice, ask your doctor to refer you to a dietitian.

PDF Version:  ALL04002(D) Anaphylaxis Action Plan with Adrenaline (GP).pdf [pdf] 572KB

Anaphylaxis Action Plan

For use with Epipen® adrenaline autoinjectors

• Anaphylaxis (severe allergic reaction)

• Mild to moderate allergic reaction

• How to give Epipen®

• More information on anaphylaxis

 

Anaphylaxis (severe allergic reaction)

Any one of these symptoms:

Airway:

• Swelling of tongue

• Swelling/tightness in throat

• Difficulty talking/hoarse voice

Breathing:

• Difficult/noisy breathing

• Wheeze or persistent cough

Circulation:

• Persistent dizziness or collapse

• Loss of consciousness

Action plan

1. Lie flat with your feet up until help arrives. If breathing is difficult you can sit, but do not stand or walk.

2. Call 999 for an ambulance* and say you are having anaphylaxis (“ana-fil-ax-is”).

3. Use your Epipen®.

4. If there is no improvement over 5 minutes use your second Epipen®.

If in doubt, use your Epipen®

*You can dial 999 from any phone, even if there is no credit left on a mobile phone.
Medical observation in hospital is recommended after anaphylaxis

 

Mild to moderate allergic reaction

• Swelling of lips, face, or eyes

• Hives or welts

• Tingling mouth

• Abdominal pain/vomiting

Action plan

1. Locate your Epipen®

2. Take antihistamines as prescribed:

3. Phone family/emergency contact

4. Watch for worsening symptoms

 

How to give Epipen®

1. Form fist around Epipen® and pull off blue safety cap.

2. Position orange end about 10cm away from outer mid-thigh (either clothed, or unclothed, avoiding seams and pocket areas).

3. Swing and jab orange tip into thigh at 90° angle and hold in place for 10 seconds.

4. Remove Epipen®. Massage injection site for 10 seconds (after use the orange needle cover automatically extends to cover the injection needle)

 

More information on anaphylaxis

• Visit Allergy UK

• Visit Anaphylaxis Campaign

• Keep your Epipen® at room temperature, and away from direct sunlight. For more information on your Epipen® and to register for a free Expiry Alert Service go to Epipen UK

PDF Version: ALL04003(D) Anaphylaxis Action Plan without Adrenaline (GP).pdf [pdf] 1MB

Anaphylaxis Action Plan

For patients without adrenaline autoinjectors

• Mild to moderate allergic reaction

• Anaphylaxis (severe allergic reaction)

• More information on anaphylaxis

 

Mild to moderate allergic reaction

• Swelling of lips, face, or eyes

• Hives or welts

• Tingling mouth

• Abdominal pain/vomiting

Action plan

1. For insect stings, flick out the sting if visible.

2. Take antihistamines as prescribed:

3. Phone family/emergency contact

4. Watch for worsening symptoms

 

Anaphylaxis (severe allergic reaction)

Any one of these symptoms:

Airway:

• Swelling of tongue

• Swelling/tightness in throat

• Difficulty talking/hoarse voice

Breathing:

• Difficult/noisy breathing

• Wheeze or persistent cough

Circulation:

• Persistent dizziness or collapse

• Loss of consciousness

Action plan

1. Lie flat with your feet up until help arrives. If breathing is difficult you can sit, but do not stand or walk.

2. Call 999 for an ambulance* and say you are having anaphylaxis (“ana-fil-ax-is”).

3. Use injectable adrenaline if one is available.

4. If there is no improvement over 5 minutes use you can use a second dose of adrenaline.

*You can dial 999 from any phone, even if there is no credit left on a mobile phone.
Medical observation in hospital is recommended after anaphylaxis

 

More information on anaphylaxis

• Visit Allergy UK

• Visit Anaphylaxis Campaign

PDF Version: ALL04004(D) House dust mite avoidance (GP).pdf [pdf] 138KB

House dust mites (HDM) are an important cause of symptoms for patients with asthma, eczema, rhinitis, and many other conditions.

They thrive in warm, humid conditions and are invisible to the naked eye. HDM feed on the tiny scales of skin that we constantly shed. They breed in carpets, upholstered furniture, fabrics (especially our beds and bedding) and furry toys.

The allergen that triggers the immune system is mainly in the HDM droppings. These tiny particles become airborne as they dry and are then easily inhaled.

Controlling HDM Allergens

It is not possible to eliminate HDM completely however some patients find that the following measures help reduce their symptoms. Avoidance measures will need to be repeated regularly to get the maximum benefit.

• Use allergen-proof barrier covers on all mattresses, duvets and pillows which are breathable and completely enclose the item.

• Replace feather duvets and woollen blankets with synthetic ones. If possible, replace an old mattress with a new one.

• Wash all bedding every week at 60°C.

• Remove all carpeting where possible and vacuum floors regularly with a high filtration vacuum cleaner. (HEPA filter, S-class filter or similar)

• Concrete floors under carpets trap moisture allowing dust mites and mould spores to thrive. Carpets should be removed, the floor sealed with a vapour barrier then covered with vinyl or linoleum. If carpets cannot be removed, vacuum regularly with a high filtration vacuum cleaner, and use a high-temperature steam-cleaner to kill mites effectively.

• Damp wipe all surfaces weekly.

• Wash curtains regularly and reduce soft furnishings.

• Vacuum all surfaces of upholstered furniture at least twice a week.

• Toys should be washed frequently at 60°C or placed in a plastic bag in the freezer for at least 12 hours once a month and then washed at the recommended temperature.

• Reduce humidity by increasing ventilation. A dehumidifier can also be useful.

Visit Allergy UK for further support

Contact details

The Eden Unit

Clinical Immunology and Allergy

University Hospitals Plymouth NHS Trust

Derriford Road

Plymouth

PL6 8DH

Tel: 01752 431672/5

Email: plh-tr.eden@nhs.net

PDF Version: ALL04005(D) Peanut Allergy (GP).pdf [pdf] 1MB

Peanut Allergy Dietary Advice for Adults

Written by the Food Allergy Specialist Group (FASG) of The British Dietetic Association 2020.

• Signs and symptoms of peanut allergy

• Diagnosis

• Will peanut allergy ever go away?

• Should other nuts be avoided?

• What about...?

• Checking food labels

• Common peanut containing foods to avoid

• Non-food sources of nuts

• Advice for managing a peanut allergy

• Tips for eating out

• Travel Tips

• Useful Contacts

• Useful websites

• Top tips for living with a nut allergy

 

Signs and symptoms of peanut allergy

Symptoms can occur within minutes or up to 2 hours after eating peanuts or foods containing peanuts. They range from mild to severe and may include:

• Sudden onset itchy eyes, ears, runny nose and sneezing

• dry repetitive coughing

• itching or tingling of the lips, tongue or throat

• red, raised itchy rash (hives) on face or body

• stomach ache, nausea or vomiting

• swelling of face, eyes, lips, tongue or throat

• difficulty swallowing or talking

• difficult or noisy breathing

• drop in blood pressure that can lead to dizziness, collapse or loss of consciousness.

Everyone has different reactions, so you should have been given specific advice on how to deal with an allergic reaction by your Doctor or a member of the allergy team. You should also be given a written emergency plan.

It is difficult to predict who will have a severe (anaphylactic) reaction but the risk tends to be higher in people who have asthma. However, anyone who has a peanut allergy has the potential to have a severe allergic reaction even if previous reactions have been mild. The amount of peanut needed to cause a reaction will also vary; even trace amounts of peanut can cause severe reactions in some people.

Some people might be prescribed an adrenaline auto-injector (AAI) (such as Epipen, Jext or Emerade). If you have been prescribed on of these devices, make sure you know how to use it, and also that you have it with you at all times. Some people are prescribed one AAI and others two; if you have been given two adrenaline devices you must carry both of them with you. 

Diagnosis

It is important that a peanut allergy is diagnosed by a healthcare professional with the right training. They will ask questions about the history of any allergic reactions and may perform tests. The type of tests will depend on the type of reactions and the symptoms experienced.

Skin prick tests or blood tests that measure ‘specific IgE antibodies’ may be used to help with the diagnosis. These test results can be difficult to interpret without an allergy specialist. Sometimes, a food challenge (where increasing amounts of the suspected food are given and symptoms monitored) may be needed to make a diagnosis. This will only be carried out in a safe hospital setting.

Some companies offer food allergy or intolerance tests that measure IgG antibodies. These are not a safe or reliable way of diagnosing nut allergies. Other tests such as hair analysis, kinesiology testing and vega testing have also been found to be unreliable and have no scientific basis, and therefore should not be used.

Will peanut allergy ever go away?

We know that about 20% (1 in 5) of peanut allergic children will grow out of their allergy. However, we really do not know much about adult peanut allergy, or how many years you are likely to have this problem. It could be life-long; so you should not try to reintroduce nuts into your diet without medical guidance or supervision.

Should other nuts be avoided?

We know that 30% (1 in 3) of peanut allergic people will react to one or more tree nuts.

If you are avoiding tree nuts but don’t know whether you can eat them or not, you should discuss this with your Doctor or the allergy team. Many people with peanut allergy can eat all tree nuts, but you will need to have allergy tests and might need to have a food challenge in hospital to find out whether you can eat some or all tree nuts. So if you are currently avoiding all nuts, it is very important that you do not try introducing tree nuts into your diet without medical supervision.

If you have been advised by your Doctor that it is safe to eat some or all tree nuts, we recommend that they are only eaten if you are confident that they are not contaminated with peanut and they are only eaten at home with emergency medication to hand.

What about...?

Chestnut, water chestnut, coconut, palm nuts, nutmeg and butternut squash: Despite all containing the word “nut”, none are related to peanuts. Therefore, they should not be avoided unless they are known to cause a problem.

Shea nut

Shea nut butter and oil are mostly found in moisturising creams, toiletries and cosmetics but are increasingly found as an ingredient in chocolate-based confectionery. They contain minimal protein and the risk of allergic reactions to products containing shea nut is very low. Shea nut is a tree nut so if you can eat tree nuts you do not need to worry about avoiding these products, but if you have eczema it is probably sensible not to use skin creams containing shea nut butter or tree nut extracts.

Sesame seeds and pine nuts

These seeds share some similar allergens to peanut but there is no need to avoid them unless you have also been diagnosed with a sesame or pine nut allergy. Usually in adults, sesame is a stand-alone allergy and does not involve reactions to other foods.

Other Legumes (pulses)

Peanuts belong to the legume family, which includes: peas, kidney beans, chick peas, white beans, baked beans, bean sprouts, lentils, soya beans (including soya products), lupin and fenugreek. The vast majority of people with a peanut allergy can eat all legumes and none of them should be avoided unless you have specifically had reactions to them. Usually people with a legume allergy react primarily to lentils, chick peas and kidney beans, and often can eat peanuts and other beans without any difficulties. A small number of adults with peanut allergy (particularly those of South Asian decent) may react to another legume. If you are not sure whether you also need to avoid legumes, discuss this with your Doctor or allergy team, before cutting them out of your diet.

Lupin and fenugreek are both legumes which might be found in small quantities in foods. Lupin seed flour may be used instead of wheat or soya flour in French breads, biscuits, cakes, pastry, pancakes, pizza, pasta, wheat and gluten free foods and some vegetarian products. Lupin is only used as an ingredient in a few UK foods. It is more widely used in mainland Europe, Brazil and the Middle East.

Fenugreek is a spice often present in curries and curry spices mixes. Both of these legumes may be more likely to cause reactions in people with a peanut allergy, so if you are having reactions but know you have not eaten peanuts, check the ingredients list of any foods you have had reactions to. 

Nut Oils

Refined peanut oil has had the protein removed, which is the part of the nut that causes allergic reactions. Therefore, it is highly unlikely to cause a reaction in the majority of peanut allergic people. Some medicines e.g. Abidec baby vitamins contain refined peanut oil. Whilst the risk of an allergic reaction is very low, the Committee on Safety of Medicines has recommended that patients known to be allergic to peanuts should not use medicines containing peanut oil.

Unrefined, crude or cold pressed peanut oil (also called groundnut oil) may contain small amounts of nut protein and is more likely to cause reactions so should always be avoided. Unrefined peanut oil is most commonly found in Indian or Oriental food products in dishes such as curries or stir-fries.

Note: In the UK, both refined and unrefined peanut oil must be labelled as containing peanut. However, it is not a legal requirement for manufacturers to say whether their peanut oil is refined or unrefined. Therefore, the safest approach is to avoid all foods that contain peanut or groundnut oil.

Vegetable oil and products containing vegetable oil that are sold in the UK must state if they contain any peanut or nut oil. Therefore, all products containing vegetable oil are safe to eat unless peanut or tree nuts are listed in the ingredients.

Checking food labels

European Union (EU) food allergen labelling law requires that common food allergens used as ingredients or processing aids must be declared on the packaging or at the point of sale. The list of 14 common food allergens includes tree nuts, peanuts, lupin and sesame. Any products that contain peanut should use the term ‘peanut’ on the ingredient label and those containing tree nuts should list each type of nut (e.g. cashew, walnut, almond etc).

These laws apply to all packaged and manufactured foods and drinks sold throughout the EU. They also apply to foods sold loose (e.g. from a bakery, delicatessen, butcher or café) and foods packed or pre-packed for direct sale (e.g. café, sandwich bar, food outlet, market stall, some catering products). If you travel outside the EU, be aware that labelling laws are different so check ingredients carefully.

For pre-packed products (e.g. made in a factory) allergens must be listed in one place on the product label (i.e. in the ingredients list) and highlighted (e.g. in bold or underlined). 

Example of food label:

---

Satay Sauce:

Ingredients: water, peanuts (28%), coconut milk (7%) (coconut extract, water, stabiliser (guar gum, sodium carboxy methyl cellulose) emulsifier (sucrose esters of fatty acids), brown sugar, Soy Sauce (water, soya beans, wheat, salt), garlic, tamarind extract (1.5%),
lemongrass (1.5%), galangal (1.0%), sesame seed oil, modified maize starch, acidity regulator (lactic acid), salted chilli (chilli, salt), sunflower oil.

Allergy Advice: For allergens, see ingredients in bold.

---

For more information on food allergy labelling go to NHS Food allergy information

There are different rules for:

• foods which are pre-packed on the same site where they are sold (pre-packed for direct sale) such as in a café, sandwich shop, deli or food outlet preparing food in their own kitchen. For these foods, allergen information has to be provided either in writing or verbally. However, the law is changing and from Autumn 2021 labelling with the full list of ingredients will be required. 

• foods sold without packaging such as in a bakery, café or pub. For these foods, allergen information has to be provided either in writing or verbally. If provided verbally, the business must be able to provide further written information if requested (in the UK only).

Food Allergy Notice: If you have a food allergy please ask a member of staff for further information. Thank you

Be aware that food manufacturers change their ingredients from time to time e.g. ‘new improved recipe’. Therefore, it is always safer to check the ingredients every time you buy.

May contain…’ or ’Made in a factory…’ labelling

These warnings are used by food manufacturers to highlight a possible risk of an otherwise nut free product being accidentally contaminated by nuts during manufacturing. There is currently no law to say how or when this type of labelling should be used but it appears on a wide variety of products. The way these statements are worded does not indicate their level of importance, e.g, ‘not suitable for….’ does not mean there is a greater risk of contamination than ‘made in a factory….’. Tolerance to foods with a ‘may contain’ labelling does not always mean that trace amounts of allergen are tolerated.

It is important to take these warnings seriously and consider the following points:

Just because a particular food with a nut warning has been eaten safely in the past, does not mean that it will always be safe; it may contain nut traces next time. Recipes and manufacturing processes can change.

All nut warnings should be treated with the same level of risk regardless of the wording used.

Patients may be more sensitive to nut protein if they are unwell, have been doing strenuous exercise or drinking alcohol, so having a nut trace during these times is more risky.

Sweet and savoury snacks (e.g. cakes, biscuits, cereal bars, and crackers), confectionary and breakfast cereals are the foods most likely to be contaminated with peanuts and should be avoided if they have a ‘May contain’ warning.

Chocolate and chocolate covered items pose a higher risk of nut contamination because chocolate dripping off one product may be used on another during manufacturing. Therefore, chocolate with nut warnings should always be avoided (lists of peanut free or all nut free
products are available from chocolate manufacturers).

The safest approach is to avoid all foods with “may contain” nut warnings. However, if a food with a nut warning is to be eaten the following advice should always be followed:

• Always have in-date emergency medication to hand

• be within easy reach of a phone or mobile that has charge and reception

• only eat if someone is with you who can help if a reaction occurs

• avoid if in a remote location, far from emergency services

• avoid if unwell or asthma is not well controlled

• avoid after strenuous exercise or drinking alcohol

• avoid if you have had a previous anaphylactic reaction to nut traces or “may contain” products.

Discuss your approach to managing “may contain nut” products with your Dietitian or allergy team as they can give you specific advice.

Allergy Alerts

Sometimes food products have to be withdrawn or recalled if they pose a risk to customers. This may be because the allergy labelling is missing, wrong or if there is any other food allergy risk. You can get allergy alerts from the Food Standards Agency website or when
you subscribe to a free email or SM text message alert system. Subscribe to get food and allergy alerts.

Alternatively, you can view product alerts online. Sign Up for Allergy Alerts.

For more information on food allergy labelling go to NHS Food allergy. 

Cross contamination

Cross contamination is a risk for people with a nut allergy. It occurs when a nut free food accidentally comes into contact with nut protein during storage, manufacturing or food preparation. Even tiny traces of nut can cause an allergic reaction if eaten. Skin contact with a contaminated item may cause a local skin irritation but will not cause a severe (anaphylactic) reaction.

Examples of Cross Contamination

• Using the same spoon to serve peanut containing and peanut free dishes (e.g. ice cream), or using the same cooking pan or oil previously used to cook a nut based meal (e.g. Chinese or Indian restaurant or takeaway food).

• Eating only the raisins from a packet of nuts and raisins.

• Food touching at a buffet, deli-counter, self-service salad bar or on a barbeque (e.g. satay chicken next to a plain burger).

Tips to Reduce Cross Contamination

• Take extra care with hand washing and cleaning of food preparation areas and equipment. Wipe down surfaces with hot soapy water.

• Always use clean dishes and cutlery. Never use the same knife for peanut butter, margarine and jam. Use separate labelled containers for the allergic person if other people in the household are eating peanut butter or nuts.

• Consider having one agreed place in the kitchen where nuts are prepared and consumed or make your home a nut free zone.

• Don’t drink from cups used by other people that may have been eating nuts.

• Avoid kissing or holding hands with someone who has eaten nuts until they have thoroughly cleaned their hands, face and mouth.

Common peanut containing foods to avoid

Please note: this is not an exhaustive list – always check labels.

• Breakfast cereals: crunchy nut cornflakes, muesli or granola with nuts, honey nut cereals, nut Cheerios™, Krave™.

• Cereal bars: Tracker™ bar, Jordans™ bar, Eat Natural™, Nakd™ and Trek™ bars.

• Bread & crackers: Speciality breads topped with or containing nuts (e.g. Peshwari & Kashmiri naan bread).

• Biscuits, pastries and cakes: peanut cookies, boasters, chocolate brownies, Dundee or Christmas cake, Stollen cake).

• Chocolates and Sweets: Snickers™, Reese’s™ peanut butter cups, Revels™, peanut M&Ms™, Celebrations™, Quality Street™, Roses™, speciality chocolates or mixed selections with praline, nut brittle, halva.

• Desserts, ice cream and cheese: Snickers™ ice cream, ice cream sundae topped with nuts, ice cream scooped from ice cream counter where risk of cross contamination is high, Crediou or Rambol cheese coated in nuts.

• Take-away/ready meals: Indian, Chinese, Thai, Indonesian, Middle Eastern, and African dishes - many are contaminated with or contain nuts or unrefined nut oils or sauces thickened with peanut flour (e.g. bhajis, samosas, tikka and korma curries, spring rolls, stir fries with

  cashew or peanut, chicken satay, pad Thai, couscous or tagine with roasted almonds or pistachios).

• Vegetarian foods: nut cutlets, veggie burgers, nut roast.

• Salads: nut-based salads, peanut sprouts and peanut shoots - now being sold in some supermarkets.

• Soup, sauces & spreads: peanut soup, satay sauce, Chinese and curry sauces (e.g. hoi sin, korma), pesto (often contains cashew or other nuts as well as pine nuts), peanut butter.

• Savoury snacks: peanuts, mixed nuts and raisins, Bombay mix, trail mix, Bamba snacks, Chinese rice crackers, pop corn cooked in ground nut oil.

• Drinks: nut flavoured milk shakes, peanut punch.

• Oils: Peanut oil, groundnut oil, Arachis oil.

Suitable foods and foods to avoid

The following tables provide a list of foods that are usually nut free and those that sometimes contain nuts and should always be checked. This list may not be complete as products change, so you must always check the ingredients list on the package. Remember to discuss with your Dietitian how to approach ‘may contain’ labelling.

Suitable foods and foods to avoid

Type	Nut Free Foods	Foods that may contain nut
Milk and Dairy Products	Cow/goat/sheep milk.	Ice cream, ice cream wafers.
	Soya/rice/coconut/oat milk	Flavoured milk.
	Plain yoghurts, fromage frais.	Cheesecake
	Fresh cream.	Cheese spreads
	Plain cheese, plain cream cheese & cottage cheese.	Speciality and loose unpackaged cheese.
Meats and fish	Fresh or frozen unprocessed meat or fish.	Indian, Chinese, Thai, Indonesian, Mexican, Middle Eastern, African dishes.
	Plain tinned fish e.g. tuna, salmon, sardines etc.	Processed meat and fish dishes (e.g. pate, sausages, burgers, breaded chicken, fish fingers, meat pies & pastries, coronation chicken, and meat or fish in sauces or marinades).
Breakfast Cereals	Plain breakfast cereals without nut warnings e.g. Weetabix™, cornflakes, porridge oats, Shredded Wheat™ etc.	Breakfast cereals (e.g. fruit & fibre, muesli, granola, oat crunch and flavoured cereals).
Breads, pastries, cakes and biscuits	Plain breads & rolls (white, brown or wholemeal).	Loose products (e.g. from bakery or deli) for cross contamination.
	Plain bread products. e.g. pitta bread or baguettes.	Naan bread, speciality breads.
	Cream crackers.	Bread sticks, rice cakes, crackers.
	Plain cakes and biscuits with no nut warnings.	Cereal/muesli bars, flapjacks.
	Home-made or purchased bread, cakes and biscuits known to be nut free.	Fruit cakes, and other Middle Eastern cakes and pastries.
	*Check for lupin if relevant	Sponge cakes, pastries, pies, gateaux, cookies and biscuits.
Fruit, vegetable and pasta	Fresh, plain frozen, stewed, tinned or dried fruit and vegetables.	Mixed salads, rice/pasta/noodle salads, coleslaw and fruit dishes.
		Vegetarian dishes (e.g. Veggie burgers, cutlets & sausages, pate).
		Pasta dishes with pesto sauce (may contain cashew) and nut fillings in tortellini and ravioli
Desserts, sweets and chocolate	Jelly.	Chocolate, fudge or toffee bars.
	Milk puddings, custard, egg custard, rice pudding.	Mixed chocolate selections
	Sweets known to be nut free e.g. boiled sweets.	Asian, Greek, Turkish, Middle Eastern sweets.
	Chocolate guaranteed to be nut free.	Instant desserts, trifle toppings, mousse, ice cream and ice lollies, meringues, pavlova.
	Home-made or purchased desserts known to be nut free.	Sponge puddings, crumbles and fruit pies.
Snacks, soups, sauces, condiments and spreads	Plain crisps.	Flavoured crisps and snacks.
	Home-made and ready-made soups known to be nut free.	Dried fruit.
	Salt, pepper.	Salad dressings & mayonnaise.
	Fresh herbs and spices.	Dips, hummus.
	Vinegar.	Stuffing mixes
	Soy sauce.	Oriental and Indian sauces (e.g. for curries and stir-fries).
	Marmite™,Bovril™.	Popcorn cooked in groundnut oil.
Drinks		Instant chocolate drinks and milkshakes
Fats and Oils	Olive/rapeseed/corn/soya/sunflower/palm and vegetable oils.	Fried foods and Indian or oriental dishes cooked in groundnut, peanut or other nut oils.
	Butter, ghee, lard, and margarines made from the from the above oils.	Salad dressings using unrefined nut oils (e.g. walnut, almond, groundnut oil).

 

Non-food sources of nuts

Bird food, pet food and other animal feed may contain nuts. So, remember to check the ingredients if you are handling these products.

Some cosmetics, creams, toiletries, pharmaceutical products (e.g. ear drops, lip balm, throat spray) and vitamin supplements may contain nut or seed oils, but these oils are likely to be refined and therefore very unlikely to cause allergic reactions. Some sensitive individuals may need to avoid skin products containing nut oils, if they develop any localised skin reactions such as an itchy rash. Any nut-containing products taken orally should be avoided by those with a nut allergy.

Cosmetics, pharmaceutical products and supplements are required by EU law to have any nut ingredients listed using the Latin name for peanut - Arachis hypogaea. 

 

Advice for managing a peanut allergy

• It is important that everyone, whatever their age, always carries rescue medication including adrenaline, if this has been described.

• If you have been prescribed an adrenaline autoinjector, you need to feel confident about how and when to use it.

• Tell your friends, work colleagues and employers that you have a peanut allergy, and what to do if they have an allergic reaction.

• Alcohol can affect judgement and a combination of alcohol and heavy exercise can increase the severity of a reaction.

• Be careful when kissing or drinking from the cup or glass of someone who has eaten nuts, as nut protein can be present in saliva for several hours and could cause a reaction.

• Keep asthma well controlled – see GP for help if required.

 

Tips for eating out

• Thai, Indonesian, Chinese, Indian, Middle Eastern and African meals have a high risk of nut contamination and should be avoided unless you are sure they are nut free as most severe reactions happen with this type of food. If you cannot avoid this then make sure you order your own peanut-free meal, rather than sharing dishes or choosing from a banquet.

• Whichever cuisine you choose, make sure you have all your in date medication with you

• Check out the restaurant’s website – many now contain nutritional and allergy information.

• Ring the restaurant in advance to ask if they can cater for your allergy. Try to call at off-peak times when the staff will have more time to deal with your query.

• Speak to the waiter/waitress or the chef as soon as you are seated to ensure that they are all aware of your peanut allergy. You may find it helpful to use a ‘chef card’ to ask the chef to confirm that the food you have requested is completely nut free. Print off a chef card.

• Get to know the chef in your favourite local restaurant.

• Avoiding the busiest meal times may help to give staff more time to check ingredients properly. If in doubt, go elsewhere.

• Keep to “simple” foods on the menu. Sauces and gravies contain many ingredients that can’t always be remembered by staff. Peanuts may not be mentioned in the description of a dish so, check for hidden sources (e.g. in bread, pastry, salads and desserts). If you do not understand the description of a menu item, it is safer not to order it.

• Self-service areas, buffets and salad bars are also at risk of cross contamination from one dish to another.

• Make sure those you are dining with know about your allergy and know what to do if you have a reaction.

• If eating at a friends house or at a party, remember to tell the host about your nut allergy in advance so they can prepare nut free dishes.

 

Travel tips

If you are travelling abroad, check in advance how to describe your allergies in the local language. There are several websites that provide useful phrases and eating out translation cards in different languages: Allergy Action, Allergy Free Passport and Allergy UK.

If you are flying, speak to your airline well in advance to check if they can accommodate your dietary needs. On boarding, notify flight attendants of your nut allergy and ask for an ingredient list to check the correct airline meal is given.

Try to choose an airline that doesn’t serve complementary peanut and nut snacks. Some will agree to give alternative nut free snacks on your flight if requested well in advance.

Consider taking snacks for the journey in case your flight is delayed or the requested meal is not available. Try to obtain a letter from your Doctor or Dietitian explaining why you need to take special food items on board. Any items not needed for the flight should be packed in your suitcase. Do not pack fruit, vegetables or meat as you will not be allowed to take these through customs at your destination.

Also check if the airline has any restrictions on the amount of liquid you can take on board. Some will want a Doctor’s letter confirming an allergy before allowing you to take more than 100 ml of liquid (e.g. antihistamine) or an adrenaline auto-injector.

Keep all emergency medication (e.g. antihistamines, adrenaline auto-injector) and action plan close to hand and check they are in date. If flying, do not store auto- injectors in overhead lockers.

Make sure any people you are travelling with know about your allergies and what to do if a reaction occurs.

If you are staying in a hotel, try to get a room with a kitchen in case there are no safe places to eat out.

Wherever you are staying, make sure you have the telephone number of the local hospital or emergency services and keep your medical insurance number handy in case you need it.

Ensure you wear an allergy ID bracelet or card. These and travel containers to protect emergency medicines are available from a variety of websites:. MedicAlert, Medical Bracelets UK, FRIO UK and Anaphylaxis UK.

 

Useful Contacts

Anaphylaxis UK

A charity organisation providing information & support for people with severe allergies including information on the availability and use of adrenaline auto-injectors. Tel: 01252 542 029.

 

Allergy UK

A charity organisation providing support for people with allergies. Tel: 01322 619 898.

 

The British Dietetic Association

Provides fact sheets on food allergy and intolerance, autistic spectrum & allergy testing. Tel: 0121 200 8080.

 

British Society for Allergy and Clinical Immunology

Allergy information for patients.

 

NHS food allergy and intolerance advice.

 

NHS Anaphylaxis advice.

 

Useful websites

Free From Food Awards. Useful resources about allergy and intolerance.

Nut Free Products

The following companies have dedicated nut free production lines and factories. No product can be guaranteed to be 100% nut free but these companies aim to control all possible sources of nut contamination and therefore may have safer products. These products are available on-line and in health food shops or supermarkets:

• Nut free chocolates at Kinnerton

• Birthday cakes made to order and available in supermarkets at Just Love Food Company

• Vegetarian marshmallows at Freedom Mallows

• Cookies, crisp breads and cereals at Orgran

• Toasted soya spread at Wow Butter

• Freenut butter, sunflower spread at Eskal Foods

• Vegan, milk, egg, nut, and sugar free products at Plamil Foods

Nut Free Food Lists

Many supermarkets and food companies will provide information on their own-brand nut free products. Your Dietitian can provide a separate list of contact numbers and websites if required.

 

Top tips for living with a nut allergy

• Even small traces of peanut can trigger an allergic reaction. Households where nuts are eaten, extra care is needed in food preparation, cooking and storage in order to minimise the risk of cross contamination.

• Only eat foods you are certain don’t contain peanuts and if you are unsure, leave it out!

• Avoid foods without labels (e.g. from a bakery or delicatessen) and high-risk foods such as Indian and oriental curries and stir-fries, and Italian dishes with pesto sauce that may contain peanut.

• Read food ingredient labels to check for peanuts every time you buy, as product ingredients or manufacturing processes may change.

• All food products with “may contain” warnings are best avoided. However, if you choose to take a calculated risk, only eat foods with these warnings if you have your emergency medication to hand and are within easy reach of a hospital. Avoid: if unwell or asthma poorly controlled; if previously reacted to trace amounts of nut; or after strenuous exercise or drinking alcohol.

• If you do not know whether you can eat tree nuts safely, avoid them until you can discuss this with your Doctor.

• Make sure your emergency plan and medication is always up-to-date and carried at all times.

• Ensure that friends, relatives and work colleagues, are given a copy of your emergency treatment plan and know what to do if an allergic reaction should occur.

• Ensure you and relevant family members feel confident giving emergency medication if required.

PDF Version: ALL04006(D) Steroid Nasal Spray Information Sheet (GP).pdf [pdf] 226KB

Hay Fever? Are you making the most of your nasal spray?

A steroid nose spray is commonly used to treat allergies of the nose such as hay fever and persistent rhinitis. Steroid sprays reduce inflammation in the nose, and usually work well. There are different brands.

Some points about steroid nose sprays

• It takes several days for a steroid spray to build up to its full effect. Therefore you will not have an immediate relief of symptoms when you first start it. In some people it can take up to three weeks or longer to get the maximum benefit.

• If you use the spray for hay fever, it is best to start using it at least 2 weeks before the hay fever season starts.

• Once symptoms are gone, you are still likely to need to take it regularly to keep symptoms away.

• Your doctor may advise that you reduce the dose to a lower ‘maintenance’ dose once symptoms have gone. The aim is to find the lowest dose that controls symptoms, e.g. once a day or every other day.

• An occasional forgotten dose should not be a problem, buy symptoms usually return after a few days if you stop taking the spray.

• Some people only need a nose spray for the hay fever season. If you have a persistent rhinitis, you may have to take treatment long-term to keep symptoms away. Long-term use of a steroid nose spray is thought to be safe but it is ideal to take ‘holidays’ off treatment for a few weeks during periods when symptoms are less active if you can. Also see points about ‘maintenance’ dosing.

• Steroid nose sprays occasionally cause dryness, crusting, and bleeding of the nose. If this occurs, stop it for a few days and then restart. Check your administration technique, most side-effects relate to incorrect technique. Other side-effects or problems are rare (read the packet leaflet for details).

How to use your steroid nasal spray

• Blow your nose and shake the bottle.

• Tilt your head forward. It is very important to tilt your head well forward.

• Hold the spray bottle upright.

• Insert the tip of the spray bottle just inside one nostril and apply one or two sprays as prescribed.

• Breath as you spray (but do not sniff hard as the spray then travels past the nose to the throat).

• Do not angle the canister towards the middle or side of the nose, but straight up. With your head tilted forward the spray should go to the back of your nose.

• Repeat in the other nostril. 

What if my nose is very blocked or runny?

Sometimes a very blocked or runny nose will prevent the steroid spray from getting through to work. A decongestant nose spray which you can buy at pharmacies may then be useful. A decongestant spray has an immediate effect to clear a blocked nose. You can then use
the steroid spray once the nose is clear.

Please Note: Decongestant sprays are not usually advised for more than a few days. If you use one for more than 5 to 7 days, a ‘rebound’, more severe congestion of the nose may develop. In contrast, steroid sprays work well to clear symptoms, and can be used for long periods.

 

Adapted from ‘The Medicines Management Team’ (University Hospitals Plymouth) Hayfever/Nasal Spray leaflet, April 2011.

GP Guide to Allergic Rhinitis (Hayfever management)

The following is intended as a guide to the non-specialist management of seasonal and perennial rhinitis. If the following steps are ineffective in controlling symptoms or there are other complications, then referral to the Peninsula Specialist Immunology and Allergy Service is appropriate and this will also be discussed. Please refer to Clinical Referral Guideline.

PDF Version: ALL04007 GP Guide to Allergic Rhinitis (Hayfever management).pdf [pdf] 141KB

Seasonal Rhinitis

Typical symptoms of nasal congestion, nasal discharge, sneezing and watery or itchy eyes occur secondary to allergy to pollen. The timing of symptoms throughout the year can indicate the likely pollen allergen however identifying the pollen definitively does not change initial management and therefore testing is not recommended at this stage. Below are the recommended actions.

1) Start regular treatments at least 4 weeks before symptoms normally begin, to limit extent of mucosal inflammation.

2) Regular long acting non-sedating antihistamine, (eg, cetirizine 10mg OD), if ineffective change to a different agent (eg, fexofenadine 180mg OD). The dose of antihistamine can be doubled to BD if required for severe symptoms.

3) Regular topical nasal steroid spray; different preparations are available with no clear advantage of any particular device. Correct spray technique is critical to increase effectiveness and reduce side effects. Inform the patient to insert the spray nozzle into their nostril aiming for the outside of the nostril, put chin on chest, activate the device and breathe in gently. Repeat on other side.

Watch a video on How to Use Nasal Spray

If first line spray (eg beconase) is not tolerated, alternatives include Avamys or Nasonex nasal sprays. It is important to try more than one nasal spray as patients will have different preferences for different steroids/devices.

If good control is achieved with licensed dose, dose may be reduced in frequency to maintain effect and limit risks.

4) Eye drops used liberally and regularly; there are numerous preparations available with no clear advantage to a particular preparation.

5) Pollen avoidance is difficult to achieve but the following may help;

• Wrap-around sunglasses

• Changing clothes after being outside

• Applying Vaseline to nostrils to try to trap the pollen

6) Nasal douching/saline rinse e.g. NeilMed. Appropriate sterile solution must be used to avoid the risk of infection.

7) Reminders throughout the season – Hay fever management often fails because patients do not maintain the regularity of their medications. Reminders and motivation throughout the season can be helpful, for example via a nurse-led telephone clinic.

If the above measures are used correctly and regularly but fail to achieve good symptom control refer to the Peninsula Specialist Immunology and Allergy Service for allergen identification and assessment for pollen desensitization. 

Desensitization is available for certain pollens in injectable and sub-lingual forms. It is not suitable for everyone and requires significant commitment from the patient. Desensitization aims to reduce rhinitis symptoms from severe to moderate and therefore traditional therapies as described above will still be necessary. If a patient has multiple pollen allergies, desensitization may not provide complete benefit. If desensitization is appropriate, it is important that any asthma and hypertension are well controlled and that the patient is not taking any beta-blockers or ACE-I.

Perennial Rhinitis

Perrenial rhinitis can be caused by allergy to a large variety of aeroallergens which are present all year round. Perennial and seasonal rhinitis can coexist and patients can have multiple allergies to aeroallergens. Common perennial aeroallergens include house dust mite, mould and pet dander and can be difficult to avoid or control in the environment.

Treatment is with regular long acting non-sedating antihistamines and topical nasal steroids as described above. A referral to the Peninsula Specialist Immunology and Allergy Service can help identify the allergens which in turn can help target avoidance techniques. If standard treatment techniques fail to adequately control symptoms, treatments are not isolated, or there is an occupational impact from symptoms.

It is important to optimise any concomitant asthma and eczema care.

Desensitization for perennial rhinitis is available for house dust mite allergy. It is not without risk and is not suitable for everyone.

GP Guide to Chronic Spontaneous Urticaria and Angioedema (CSU&A)

This guide is intended to provide advice on the recognition and non-specialist management of Chronic Spontaneous Urticaria and Angioedema (CSU&A). Severe cases not responding to first line therapy or cases where the diagnosis is in doubt may benefit from a referral to the Peninsula Specialist Immunology and Allergy Service. Please see the clinical referral guideline.

PDF Version: ALL04008 GP Guide to Chronic Spontaneous Urticaria & Angioedema.pdf [pdf] 154KB

CSU&A

Diagnosis: CSU&A, also known as chronic idiopathic urticaria and angioedema, is a relatively common and often under-recognised condition of frequent, recurrent urticarial rashes with or without angioedema. Urticaria and angioedema can occur simultaneously or
separately. A minority of patients can also suffer anaphylaxis; if there has been suggestion of airway swelling in the past the patient should be prescribed 2 self-injectable adrenaline pens and educated in their use. Under these circumstances referral to the Peninsula
Specialist Immunology and Allergy service at Derriford would be appropriate. Symptoms are caused by spontaneous histamine release from mast cells and as such will be at least partially responsive to antihistamines. It is important to differentiate this condition from Type 1 hypersensitivity reactions with the release of histamine and other mast cell mediators triggered by specific, reproducible and reliable triggers, eg food, drugs, stings. Such differentiation is usually clear from the history; the following are features suggestive of CSU&A;

• Frequent symptoms (multiple times per week)

• Protracted symptoms (lasting >24hours)

• No discernible pattern to symptom onset, eg, not always within 1 hour of food, patients wake up in the morning with symptoms

• No specific triggers linked to every episode of symptoms

• Exacerbated during intercurrent illness, fever, heat, cold, with NSAIDS, alcohol, stress, oestrogens

Investigation:

CSU&A can be associated with undiagnosed or poorly controlled systemic illness, the likelihood of which is related to the standard risk factors for each associated condition, eg, autoimmune thyroid disease, diabetes, H.Pylori, malignancy. Screening tests can be organised in primary care accordingly. If the patient has had symptoms suggestive of anaphylaxis measure a baseline Mast Cell Tryptase (MCT).

Other medication:

ACE inhibitors should be avoided in patients with a history of angioedema, NSAIDS are not absolutely contraindicated but can cause exacerbation of CSU&A in some patients and should be used with caution

Treatment:

The mainstay of treatment is regular long acting non-sedating antihistamines used at high dose. These medications are licenced for once daily use however there is good  safety data for more frequent dosing and their use up to QDS is recommended in this
condition by the BSACI (except in Pregnancy and Breastfeeding).

The following treatment can be initiated in primary care, each step should be tried for at least 1 month;

1. Single agent long acting non-sedating antihistamine eg Cetirizine 10mg up to QDS to achieve complete symptoms control

2. If ineffective, change agent, eg to fexofenadine 180mg up to QDS

3. Montelukast 10mg ON and consider referral.

4. An emergency pack of prednisolone 15-20mg OD for up to 3 days can be considered for slowly resolving episodes. If the patient requires this emergency pack more than once then the background medication should be escalated and referral considered.

5. H2 blockers may help some patients.

Referral:

Refer to the Peninsula Specialist Immunology and Allergy Service if;

• Step 3 of the treatment plan is attempted and condition not under control.

• If the patient has had symptoms suggestive of anaphylaxis in the past.

• There is a raised baseline MCT

There are a number of specialist treatments available on a case by case basis including immune suppression and immunomodulation. Such treatments are not without risk and are not suitable for all patients.

If there is any coexistent eczema, management should be optimised. If there is isolated eyelid erythema and swelling with or without rash, especially if that rash is not typically urticarial, a referral to dermatology may be more appropriate. Consider sending photos
for advice and guidance.

Angioedema without Urticaria

Angioedema without urticaria can be histamine mediated in which case it should respond at least partially to antihistamines and/or steroids. If this is the case the same advice as for CSU&A applies.

Angioedema without urticaria and which does not respond to antihistamines is suggestive of bradykinin-mediation. The following steps should be taken;

• Stop ACE-I (if patient on one) – if symptoms persist 3-4 months after the ACE-I has been stopped refer to the Peninsula Specialist Immunology and Allergy Service

• Blood tests for Complement C4 level. If low, further testing for Complement C1Inhibitor level and function may be required, however specific sampling requirements mean that these tests must be undertaken in secondary care.

• Assess clinically for autoimmune disease and haematological malignancy

• Identify any first degree family history of angioedema without urticaria.

Referral:

Once ACE-I related angioedema has been excluded, most of the above patients will benefit from a specialist referral to the Peninsula Specialist Immunology and Allergy Service.

GP Guide to Anaphylaxis, Food Allergy and Food Intolerance

The following is intended as a guide to the non-specialist management of anaphylaxis, food allergy and food intolerance. Please refer to the Clinical Referral Guideline for information on referral criteria to the Peninsula Immunology & Allergy Service.

PDF Version: ALL04009 GP Guide to Anaphylaxis, Food Allergy & Food Intolerance.pdf [pdf] 150KB

Anaphylaxis

Current NICE guidelines recommend that any patient who has experienced anaphylaxis to an unknown trigger should be offered referral to a specialist centre. If the causative trigger (eg a specific food) has been identified, referral may not be required as long as the patient
has a clear emergency plan for future symptoms, as follows;

• Avoid specific identified trigger

• Education on symptom recognition in case of accidental exposure

• Knows to call 999 and use keyword ‘Anaphylaxis’ if develops severe allergic symptoms (difficulty breathing, dizziness, airway compromise)

• Self-injectable adrenaline (2 devices to be carried at all times) for use against anaphylactic symptoms (airway, respiratory, or cardiovascular compromise) if trigger difficult to avoid, unavoidable, or unknown, i.e. not for drug reactions.

• Supply of long acting non-sedating antihistamines (e.g. cetirizine 10mg)

If anaphylaxis occurred to an identified drug trigger, primary and secondary care records should be updated with this information and the patient advised to wear a medical alert bracelet. A home supply of self-injectable adrenaline in this context is not usually
required.

If risk of subsequent anaphylaxis, and particularly if prescribing self -injectable adrenaline, ensure the patient is not on a non cardio selective beta-blocker and that cardio-selective beta-blockers are changed to alternative medications if possible. Asthma care should be optimised. Any patient with a tendency to angioedema should avoid ACE-I.

Food Allergy

It is important to differentiate between food allergy and food intolerance.

Food allergy can develop at any age although is more common in children and it can develop to any food, although some foods are more allergenic than others. Food allergy is characterised by a Type 1 Hypersensitivity reaction and therefore symptoms are rapid in
onset and histamine mediated. Check the clinical history for foods and drinks ingested within 1-2 hours of symptom onset and for the presence of typical immediate symptoms such as urticarial rash, angioedema, anaphylaxis and GI upset in context of the other symptoms. Multiple allergies can develop although this is less common. Any suspected food triggers would lead to similar symptoms after every exposure and symptoms would not be expected to occur unless exposure to that trigger had occurred, meaning that if the patient has eaten a suspected food SINCE the original episode without a problem, that food is excluded as the allergen.

If the allergen is not easily identified on clinical history further investigation is recommended via referral to the Peninsula Specialist Immunology and Allergy Service, Derriford Hospital where skin prick testing and challenge testing can be considered. While waiting for the appointment the following actions are helpful;

1. Consider performing Specific IgE blood tests but only to foods specifically suspected from the history; there is no role for screening foods not implicated in the index reaction. However the presence of Specific IgE does not diagnose allergy and the results can often be difficult to interpret if the patient is atopic.

2. Prescribe self-injectable adrenaline if there has been any suggestion of airway or cardiorespiratory compromise during previous reactions (have a lower threshold for prescribing in asthmatics). If self-injectable adrenaline is prescribed (2 devices to be carried at all times), it is important the patient is taught how and when to use them (see above).

3. Optimise asthma care

Food Intolerance

Food intolerance is a benign, although unpleasant, condition. Patients typically develop isolated and sometimes non-specific-gastrointestinal symptoms some hours after eating varied food groups. Patients will be able to tolerate small amounts of the foods and will find that the amount tolerated will vary day to day; this is the main differentiating factor from food allergy. No specific investigations are required and the mainstay of treatment is to exclude offending food groups. Reintroduction of those food groups periodically is useful as intolerance can resolve. It is essential that a patient maintain a balanced diet and if multiple exclusions are necessary the patient may benefit from a dietician review. The Peninsula Specialist Immunology and Allergy Service has a dedicated allergy-specialist dietician who accepts appropriate referrals; outside of this context there is little utility in a specialist allergy review unless Type 1 hypersensitivity to food has not been excluded (see above).

Food allergy and food intolerance do not contribute to eczema in adults. Testing for food allergy (with specific IgE blood tests) without a supporting clinical history suggestive of type one hypersensitivity as described above will not be beneficial.

PDF Version: ALL04010 GP Guide to Large Local Reactions after Insect Stings.pdf [pdf] 141KB

Referral Guidelines

If a patient has experienced a systemic reaction following an insect sting, refer them to the Peninsula Specialist Immunology and Allergy Service for potential venom immunotherapy (available for bee and wasp venom).

Acute management - a short course of antihistamines and/or low-dose steroids may be considered depending on the severity and duration of symptoms.

Risk of Progression to Systemic Reactions

• The risk of developing a systemic reaction for patients with a history of large local reactions is generally no more than 10%.

• Certain high-exposure individuals (e.g., beekeepers, pest controllers) may face a slightly higher risk due to increased exposure – consider referral to Peninsula Specialist Immunology and Allergy Service for these patients.

• Most patients with large local reactions tend to have similar reactions after future stings. It is a myth that reactions progressively worsen with each sting.

• The severity of a reaction is influenced by multiple factors, including:

• Temperature

• Stress

• Alcohol consumption

• Current illness or medication

• Amount of venom injected

• Further allergy testing or SpIgE blood testing is unnecessary at this stage. Unless the patient develops a systemic reaction in the future, they are not candidates for venom immunotherapy.

Patient Emergency Plan for Future Stings

Patients with a history of large local reactions should have a clear emergency plan in case of future stings:

1) Remove the stinger as soon as possible.

2) Move away from the hive or nest (if applicable).

3) Carry a mobile phone and be aware of their location, especially in rural areas where GPS coordinates may be necessary for emergency responders.

4) If the patient experiences severe symptoms such as:

• Throat constriction

• Difficulty breathing

• Change in voice

• Dizziness

They should:

• Lie down on the floor.

• Raise their legs.

• Call 999 and mention the keyword “anaphylaxis.”

5) If symptoms are mild (e.g., itching, swelling at the sting site):

• Take 1–2 oral antihistamine tablets.

• Rest for 30 minutes while monitoring for further symptoms.

Considerations for Prescribing Self-Injectable Adrenaline

There is no clear indication to prescribe adrenaline (self-injectable) for a patient without a history of systemic reactions. However, consider adrenaline for patients who have:

• A high risk of exposure (e.g., frequent stings).

• Significant anxiety about future stings.

• Coexisting asthma.

If adrenaline is prescribed:

• Ensure the patient carries two devices at all times.

• Provide thorough education on device use.

Additional Resources

For emergency plans with or without adrenaline read the following leaflets:

• ALL04002(D) Anaphylaxis Action Plan with Adrenaline (GP)

• ALL04003(D) Anaphylaxis Action Plan without Adrenaline (GP)

PDF Version: ALL04011 Guidelines for the Management of Latex Allergy [pdf] 187KB

Introduction

Natural rubber latex is commonly found in disposable gloves, balloons, condoms, and adhesive dressings. It is derived from the tree Hevea braziliensis, grown in Africa and Southeast Asia. Latex contains various chemicals like lipids, phospholipids, and proteins, which can trigger allergic reactions. While some chemical additives can cause localized skin reactions (such as contact dermatitis), immediate allergic reactions or anaphylaxis are usually caused by sensitization to the latex proteins themselves.

History of Reactions

Immediate Reactions: Occur within seconds to an hour after contact. Symptoms include:

• Itching

• Urticaria (hives)

• Angioedema (swelling)

• Anaphylaxis

Delayed Reactions: Appear 48-96 hours after exposure, although can occur more quickly in some cases;

• Eczematous dermatitis rash, often with vesicles

• Dry, crusting, thickening and cracking of skin can occur

Management

For Immediate (Type I) Hypersensitivity:

• Avoid all products containing latex.

• Up to half of latex-sensitive patients also have fruit allergies, especially to avocado, banana, kiwi, and sometimes nuts. Referral to Clinical Immunology & Allergy services is recommended for patients with allergies to these fruits.

• Airborne Latex Sensitivity: A small group of patients may react to latex particles in the air, which puts them at high risk of anaphylaxis.

• Management Plan:

• Antihistamines (e.g., Cetirizine 10-40mg) for mild reactions.

• Adrenaline autoinjectors for patients with severe allergic reactions or those in high-risk groups (e.g., patients with asthma).

• Referral to Clinical Immunology & Allergy services is essential for patients with a history of immediate reactions to latex. Consideration may be given to SpIgE /SPT if latex exposure required

For Delayed (Type IV) Hypersensitivity:

• Serious allergic reactions are rare, but avoidance of latex is still essential.

• Treatment: Application of topical steroid creams for skin reactions.

• Referral to a Dermatology clinic is recommended for patients suspected of delayed latex reactions for patch testing.

References

Cullinan P et al. Latex allergy. A position paper of the British Society of Allergy and Clinical Immunology. Clin Exp Allergy 2003; 33:1484–1499.

For more information or assistance, contact Clinical Immunology & Allergy or Dermatology clinic as appropriate.

 

PDF Version: ALL04012 Information Leaflet - Mast Cell Activation Syndrome (MCAS).pdf [pdf] 523KB

What is Mast Cell Activation Syndrome (MCAS)?

MCAS is a condition involving the overactivity of mast cells, part of the immune system found in all vascularized tissues. These cells secrete various proinflammatory mediators, including histamine, and are key players in anaphylaxis. There is increasing information available about an ‘alternative’ diagnosis for MCAS, encompassing a wide variety of symptoms which could be explained by various different conditions.

Diagnostic Criteria for MCAS:

To diagnose MCAS, three criteria must be met:

1) Severe and recurrent episodic symptoms consistent with mast cell activation

MCAS Clinical Criterion

Acute onset of symptoms with involvement of minimum 2 of the 4 organ systems as below

Cutaneous

• Flushing

• Pruritus

• Hives

• Angioedema

Gastrointestinal

• Vomiting

• Abdominal cramps

• Diarrhea

Respiratory

• Shortness of breath

• Laryngeal edema

• Wheezing

• Hyproxia

• Nasal congestion

• Sneezing

• Rhinorrhea

• Conjunctival injection

Cardiovascular

• Hypotension

• Syncope

• Collapse

• Incontinence

Not diagnostic for MCAS

Probable MCA-symptoms might be accompanying, but neither isolated nor such constellations are diagnostic for MCAS.

Nonspecific symptoms and conditions that do not qualify as features of MCAS:

Fatigue, fibromyalgia-like pain, chronic back pain, edema, dermographism, alopecia, warts, tinnitus, adenopathy, weight change, hypo/hyperthyroidism, metabolic syndrome, abnormal electrolytes, type 2 diabetes mellitus, gastroenterological conditions (constipation, reflux disease, irritable bowel syndrome, inflammatory bowel disease, celiac disease), neuropsychiatric disorders (headache, attention deficit/hyperactivity disorder, anxiety, depression, post traumatic stress disorder, mood disturbances, restless leg syndrome, schizophrenia), essential hypertension, pulmonary hypertension, atherosclerosis, dysautonomia symptoms (POTS), joint hypermobility (hEDS), chronic kidney disease, prostatitis, endometriosis, polycystic ovarian syndrome, autoimmune disorders, multiple chemical / food sensitivity syndrome, solid organ malignancies, anemia, polycythemia, an increased or decreased level of immunoglobulin isotypes, nonspecific peripheral blood mutations.

2) Symptom exacerbation related rise in serum mast cell tryptase (MCT): (gold standard marker for mast cell activation)
3) Response to anti-mast cell mediator drugs: primarily antihistamines

When to refer

MCAS fulfilling the above diagnostic criteria should be referred to the Allergy Clinic for further evaluation (please discuss if unable to document MCT rise in Primary Care where both other criteria are met).

Managing Symptoms Not Fulfilling Diagnostic Criteria for MCAS:

• No Specialist Referral Needed: Suggested MCAS not meeting diagnostic criteria does not require Specialist referral.

• Consider Other Conditions: Always consider other potential causes for symptoms.

• Focus on Symptom Control: Management for any symptoms sounding consistent with MCA includes a trial of antihistamines and/or mast cell stabilisers and assess response.

Medication Management Guidelines:

1) Trial Period: Use a new medication for 2-4 weeks and stop if ineffective.

2) Doses: consider starting at very low dose and increasing slowly if there is difficulty tolerating medication.

3) Consider Formulation: Different brands or forms (e.g syrup vs. tablets) may be better tolerated.

Symptom-Specific Medications:

Symptoms	Medication
Cardiovascular: Tachycardia, lightheaded, hypotension, syncope	Anti H1 (Cetirizine 10mg, Loratadine 10mg, Fexofenadine 180mg, Desloratadine, Levocetirizine 1-4xdaily); Anti H2 (Famotidine, cimetidine, nizatidine std doses); Montelukast 10mg nocte; adrenaline for anaphylaxis
Respiratory: Rhinitis, wheeze, sneezing, nasal congestion	Anti H1, Anti H2, Montelukast, nasal steroid/antihistamine, optimise asthma control if relevant
Cutaneous: Flushing, itch, urticaria, angioedema	Anti H1, anti H2, Montelukast, Ketotifen (1mg bd increasing to 2mg bd)
Gastrointestinal: Abdominal pain, diarrhoea, vomiting	Anti H2, Sodium cromoglycate tablets (100mg qds increasing to 200mg qds)