When leuprolide acetate is essential to care: A review of the literature and framework for assessing drug allergy

Gonadotropin-releasing hormone agonists are uncommonly associated with hypersensitivity reactions. To date, there have been few reports of these cases by allergists and no clear published protocols on testing. Here, we report the case of a patient who had a potential reaction to leuprolide acetate depot and a framework for assessing for drug hypersensitivity with the available literature in mind.

Food Matrix Composition Affects the Allergenicity of Baked Egg Products

BACKGROUND

Egg allergy is common and caused by sensitization to ovomucoid and/or ovalbumin. Many egg-allergic patients are able to tolerate eggs baked into other foods, such as muffins. Although heating egg extensively reduces allergens, the effect of other food ingredients on allergenicity of eggs, or the "matrix effect," is less well studied.

OBJECTIVE

We aimed to define how food matrices impact the matrix effect in egg allergenicity.

METHODS

Enzyme-linked immunosorbent assay was used to quantify ovalbumin and ovomucoid in extracts from various baked egg products: plain baked egg without a matrix, and muffins baked using either wheat flour, rice flour, or a wheat flour/banana puree mix. Allergen-specific immunoglobulin E (IgE)-blocking enzyme-linked immunosorbent assays were performed using the egg product extracts on egg-allergic patient sera to determine whether the amount of extracted egg protein in each extract correlated with how well the extracts could bind patients' egg IgE.

RESULTS

Baking eggs in any muffin matrix led to an increase in the amount of extractable ovalbumin and a decrease in the amount of extractable ovomucoid compared with plain baked egg. Compared with wheat muffins, rice muffins had more extractable ovalbumin and wheat/banana muffins had more extractable ovalbumin and ovomucoid. The egg allergens in the extracts were able to block egg-allergic patients' egg IgE.

CONCLUSIONS

Food matrices affect egg allergen availability. Patients and families should be advised that substitutions in baked egg muffin recipes can affect the amount of egg allergens in foods and potentially affect the risk of food allergic reaction.

Development of an innovative curriculum for paediatricians on peanut allergy prevention: How do we address current guidelines?

BACKGROUND

There exists strong evidence for the early introduction of peanut to at-risk infants for the primary prevention of peanut allergy. There is a need for educational initiatives to assist in dissemination and implementation of updated clinical guidelines on peanut allergy prevention.

APPROACH

The aim for this project was to create an innovative curriculum for paediatricians on peanut allergy prevention. The Intervention to Reduce Early Allergy (Peanut) in Childhood (iREACH) study was leveraged to recruit paediatricians for a needs assessment. Materials from the iREACH study, including an educational YouTube video and knowledge survey, were evaluated. Applying findings from the needs assessment, an innovative curriculum was developed, and updated knowledge survey questions were developed.

EVALUATION

The iREACH YouTube video had suboptimal viewing behaviours, and iREACH participants had high baseline knowledge scores that did improve after viewing the video. The majority of respondents to the needs assessment felt that all paediatricians needed access to an effective educational module on peanut allergy prevention, and they wanted a broadly accessible curriculum that incorporated quality media and content segmentation. An online, interactive curriculum was developed that includes clinical cases and games, and updated knowledge questions were created with associated internal structure and reliability evidence, as well as relation to other variables evidence.

IMPLICATION

The next steps of this project will focus on curriculum implementation and evaluation through a randomised, prospective study with the aim to serve as an educational model for how to integrate specialty-specific guidelines into broader clinical practice through education.

Variation in the Guidelines for the Acute Management of Anaphylaxis in Pediatric Patients: An International Narrative Review

OBJECTIVES

Evidence-based guidelines have been created and disseminated by multiple organizations to standardize the care of pediatric patients with anaphylaxis. Differences across these guidelines can cause confusion and potentially errors in clinical practice leading to patient harm. The aim of this study was to describe and identify patterns of variation in the current guidelines.

METHODS

A narrative review with 3 major components was designed. First, a narrative review of current, peer-reviewed, guidelines published by national and international allergy and immunology, pediatric, and emergency medicine organizations was performed. That was followed by a gray literature review of guidelines by resuscitation councils and national health organizations. The third component focused on the translation of these guidelines at local and institutional levels by reviewing clinical pathways published by academic institutions.

RESULTS

With regard to the fixed epinephrine autoinjector dosing, 50% (6 of 12) of the reviewed guidelines offered weight-based and 41.7% (5 of 12) age-based dosing recommendations. Furthermore, different weight cutoffs for the 0.15- and 0.3-mg autoinjectors were identified among guidelines. Variation was identified in the description of intramuscular epinephrine concentration ("1:1000," "1 mg/mL," or both), the recommended concentration for intravenous administration ("1:10,000" or "1:1000"), or the rate of infusion or titration. Eight of the 12 guidelines (66.7%) recommend a dose in milligrams, and 33.3% (4 of 12) in micrograms. Five of 12 (41.7%) used both milliliters and milligrams or micrograms.

CONCLUSIONS

Notable variation in the current guidelines for the acute management of anaphylaxis in the pediatric population was identified. Flagging this variability could help inform a consensus-based approach toward harmonization of guidelines, which in turn could streamline the management of anaphylaxis in pediatric patients across the United States, Canada, Ireland, the United Kingdom, Europe, Australia, and New Zealand, and hopefully prevent errors and mitigate patient harm.

Food Allergy Management Practices Utilizing Individual Patient Thresholds: A Work Group Report of the AAAAI Adverse Reactions to Foods Committee

The paradigm for food allergy management has been strict avoidance of the food allergen. There is literature supporting a "high-threshold" phenotype, those who tolerate a small-to-modest amount of allergen but react to larger amounts. There is no consensus for best practice for these "high-threshold" individuals. We sought to understand management practices of "high-threshold" reactors using a survey that was distributed to a random sample of fellows and members of the American Academy of Allergy, Asthma, and Immunology. There were 89 respondents from the United States and Canada (11% response rate), with 64 (72%) answering all questions. Participants worked in private (52%) and academic practice (38%) and saw a median of 30 food allergic patients monthly. Eighty-one percent of respondents reported management strategies other than strict avoidance. When threshold was known, strategies ranged from allowing ingestion up to a specified amount (57%), proactively advising ingestion to a certain amount (56%), or oral immunotherapy (47%). Participants were more likely to choose a permissive approach for a mild reaction in a high-threshold milk-allergic patient compared with a peanut-allergic patient (83% vs 71%, p=.01). Important factors that influenced the approach included severity of reaction (52%), comfort with family/patient using emergency medications (42%), and family/patient preferences (41%). These survey results suggest that food allergy management recommendations are no longer binary in nature, with clinicians solely recommending avoidance for those who are allergic and ingestion for those who may not be.

Validated anxiety assessments among pediatric patients with peanut allergy on oral immunotherapy

BACKGROUND

Although efficacy, safety, and quality of life measures associated with peanut oral immunotherapy (OIT) have been studied, the relationship between peanut OIT and clinical anxiety has not yet been evaluated. The latter is important to help providers and families have an improved shared medical decision discussion around the benefits of initiating OIT.

OBJECTIVE

To investigate the relationship between undergoing OIT and anxiety in patients with peanut allergy.

METHODS

In this prospective cross-sectional cohort study, using validated and age-appropriate anxiety scales administered with electronic survey questionnaires, we used generalized linear regressions to compare anxiety between patients undergoing OIT and similar patients with peanut allergy but not on OIT (controls).

RESULTS

In the younger cohort (<7 years, n = 80), there was generally a low prevalence of diagnosable anxiety across patients on OIT and controls. In the older cohort (>7 years, n = 125), there was a higher prevalence of anxiety but no clinically meaningful difference between anxiety scores of patients on OIT and controls. In the older cohort, patients with asthma were more likely to have higher mean anxiety scores (P = .04), as were female patients compared with male patients (P = .004). A subanalysis of separation anxiety scores in the older cohort revealed that younger age (7-12 years vs >12 years, P < .001), non-White race (P = .04), and eczema (P = .02) were found to be meaningful predictors of higher scores. A subanalysis of social anxiety on the older cohort pointed toward non-White race as a meaningful predictor of higher scores (P < .02).

CONCLUSION

The clinical implications of these findings suggest that allergists should particularly consider screening children with food allergy for anxiety and anxiety subtypes among patients who are non-White, female, or have asthma.

Recent Update in Food Protein-Induced Enterocolitis Syndrome: Pathophysiology, Diagnosis, and Management

Food protein-induced enterocolitis syndrome (FPIES), though first reported in the 1970s, remains poorly understood and likely underdiagnosed. It is a non-immunoglobulin E (IgE)-mediated food allergy syndrome, most commonly identified in infancy and childhood. It can manifest as a constellation of symptoms following food ingestion, including repetitive and projectile emesis (1-4 hours), accompanied by pallor, lethargy, muscular hypotonia, and diarrhea (5-10 hours). In more severe reactions, significant leukocytosis with neutrophilia, thrombocytosis, metabolic derangements, methemoglobinemia, anemia, low albumin, and total protein may be present. Hypotension and ultimately hypovolemic distributive shock may occur in up to 15%-20% of cases. The diagnosis of FPIES is challenging and providers continue to face difficulties in management. This review article aims to highlight the most recent updates in epidemiology, natural history, pathophysiology, potential diagnostic markers, and guidelines for the management of FPIES.