Family Food Allergy Foundation Memorializes Elijah-Alavi
The parents of three-year-old Elijah-Alavi were devasted by the loss of their son. While at preschool, Elijah, who had food allergies including dairy, was mistakenly given a grilled cheese sandwich. He suffered a fatal attack of anaphylaxis. From that tragedy Elijah’s parents embarked on a path of advocacy and education, so that other parents wouldn’t have to experience the same heartbreak. They founded the Elijah-Alavi Foundation, which includes “Elijah's Echo,” an initiative raising awareness of food allergies and anaphylaxis. Read the article here.
As the spring allergy season gets underway, a new pill to treat grass pollen allergies was just approved by the US Food and Drug Administration.
As the spring allergy season gets underway, a new pill to treat grass pollen allergies was approved this week by the US Food and Drug Administration. Oralair—a once-daily tablet that rapidly dissolves after it is placed under the tongue—treats sneezing, congestion, running nose, and itchy, watery eyes caused by hay fever.
It’s the first treatment made with an allergen extract that’s not a shot approved for use in the United States for allergy sufferers ages 10 through 65.
The first dose needs to be given in a doctor’s office to determine if there are any allergic reactions, according to the FDA. People can take subsequent doses at home.
“While there is no cure for grass pollen allergies, they can be managed through treatment and avoiding exposure to the pollen,” Dr. Karen Midthun, director of the FDA’s Center for Biologics Evaluation and Research said in a statement. “The approval of Oralair provides an alternative to allergy shots that must be given in a health care provider’s office.”
Like allergy shots, Oralair should be started four months before the start of the grass pollen season—which usually hits during the late spring—and continued throughout the allergy season.
The FDA reviewed clinical trials involving about 2,500 people found that those who were treated with Oralair had a 16 to 30 percent reduction in their allergy symptoms compared to those given a placebo. The manufacturer didn’t compare, though, whether Oralair was as effective as allergy shots.
The drug contains warning about severe allergic reactions — such as life-threatening anaphylaxis — that can occur from the product. The most common side effects in adults were itching in the ears and mouth and on the tongue, as well as swelling of the mouth and throat irritation, according to the FDA. Children were most likely to experience itching and swelling in the mouth and throat irritation.
Imagine a severely allergic child unknowingly taking a bite of a cookie containing unknown peanut protein. Today the result could be an anaphylactic reaction requiring use of an epinephrine auto-injector and a trip to the emergency room. But tomorrow, who knows?
For parents of a child with life-threatening allergies, the idea that allergies could be lessened in severity sounds like a dream come true. Researchers agree and are working to make that dream happen.
Immunotherapy is a method used to make an individual less sensitive to a substance be it an air allergen like ragweed, a medication such as an antibiotic or even a food like peanuts. Three methods have been studied in foods
oral where the food is eaten,
sublingual where the area under the tongue is exposed to the food, and
epicutaneous where a piece of the food is placed on the skin
In all cases, patients start with a very tiny quantity and increase the dose over a period of days to weeks. Next they stay on a fixed maintenance amount for weeks to months.
“There are a lot of studies mostly in peanuts, cow’s milk, and eggs that have shown immunotherapy does in fact have the ability to make someone less sensitive to whatever food they’re studying,” says S. Shahzad Mustafa, MD, a specialist in Allergy and Clinical Immunology at the Rochester General Medical Group and Clinical Assistant Professor of Medicine at the University of Rochester School of Medicine & Dentistry. That’s the good news.
What is less sure is what happens after individuals stop the maintenance dose. Studies have shown a significant percentage of people experience a return of their allergic reaction or sensitivity leading doctors to believe that immunotherapy can be successful at suppressing the reaction while on the maintenance dose but that it is not actually curing the allergy.
“Protection requires continued therapy,” says R. John Looney, MD, Stephen I. and Elise A. Rosenfeld Distinguished Professor of Allergy and Clinical Immunology at the University of Rochester. “The immunotherapy itself can also cause reactions.”
Side effects are a risk too. Some patients undergoing immunotherapy have reported abdominal discomfort with anywhere from five to twenty percent possibly experiencing an inflammation of the lower part of the esophagus known as eosinophilic esophagitis. There may be other side effects as well that researchers have yet to determine.
More studies need to be done in a variety of areas related to immunotherapy before it can be considered a practical option for everyday use. “These include optimal criteria for patient selection regarding timing and duration of treatment and the optimal protocol to maximize safety and effectiveness,” says Theresa Bingemann, MD, an allergist at Rochester General Allergy, Immunology and Rheumatology and Clinical Assistant Professor of Pediatrics and Medicine at the University of Rochester School of Medicine & Dentistry.
In other words, more data is required in a variety of areas before it’s ready for prime time. For one, experts need to determine which individuals will likely be the most successful in terms of having the fewest adverse reactions or side effects. Patients’ psychological profiles could also be helpful in identifying everything from who might be the most compliant with the regimen to who might find the process too anxiety-inducing to continue.
Additional studies also need to be completed to create a standardization of treatment. At the moment some doctors are building up dosing faster while others are proceeding more slowly. The length of time individuals are kept on the therapy treatment also varies. The hope is after more data is collected experts will be able to determine the proper dosing amounts, the right schedule to increase it and the correct length of time for people to undergo treatment—and then make that information readily available to all doctors as a general standard of care.
Research may also lead to even more new treatment options such as a “peanut patch” where an allergic individual is able to wear an adhesive patch that delivers the allergen through the skin. “It has some advantages,” says Dr. Looney “but we need more data.”
Because there are still so many unknowns, none of the large governing bodies in the allergy arena support immunotherapy outside a research setting and it is certainly not something individuals should try at home.
“As of today the management of food allergies is still avoidance, carrying an epinephrine auto-injector and having an emergency action plan,” stresses Dr. Mustafa. For those newly diagnosed with food allergies, finding a collection of safe “go to” snacks and meals can help make life easier. Reaching out to others whether in person or online to share information, fears and camaraderie can be a lifesaver as well.
As for the future, who knows? All three doctors are excited by the possibility of what immunotherapy could mean for their patients. They have the dream…now they just need the data and specifics to make it a safe, effective reality.
BARABOO | An estimated 15 million Americans suffer from food allergies. To help clear up the facts about food allergy, Dean Clinic allergist Dr. Christine Virnig shares four top myths and the truth about these common misconceptions.
Myth 1: All food related adverse reactions are due to an “allergy.”
Fact: “Food intolerances and food allergies are often confused,” Virnig said. “A food allergy is a specific immune response in which a person’s immune system produces IgE (the allergy antibody) against a food. Food allergies lead to rapid onset, reproducible, and potentially life-threatening reactions.”
Typical symptoms of a food allergy include hives, throat swelling, a hoarse voice, coughing, wheezing, abdominal cramping, nausea, and vomiting. In contrast, food intolerances are adverse food reactions that are not mediated by IgE, the allergy antibody. Typical symptoms of food intolerance include stomach upset, bloating, cramps, nausea, and vomiting.
“Eating a food you are intolerant to can leave you feeling miserable, but eating a food you are allergic to can be life-threatening,” Virnig said.
The prevalence of food allergy is perhaps 3 to 8 percent of children and less than 2 percent of adults. This is far less than reported food intolerance, which can occur in up to 30 percent of the population. There seems to be an increasing prevalence of food allergy, particularly to peanuts and tree nuts, in children over the past decade. Unfortunately the factors responsible for this are unknown.
The most common food allergens in the U.S. are peanuts, tree nuts, milk, egg, wheat, soy, fish and shellfish. Allergies to these foods are usually caused by specific proteins found in the food products.
Myth 2: If a person is allergic to shellfish they are allergic to iodine.
Fact: There is no relationship between the shellfish allergen, which is a muscle protein, and iodine. A person allergic to shellfish has no increased risk of reacting to x-ray contrast involving iodine compounds.
“Years ago doctors believed that shellfish allergies stemmed from the increased amounts of iodine present in shellfish, so patients with a shellfish allergy were told to avoid iodine and iodine-based contrast dyes,” Virnig said. “Now we know that people who are allergic to shellfish are actually allergic to the proteins found in shellfish, not the iodine. There is about a three percent chance that a person who is allergic to shellfish will have a reaction to contrast dyes, but this percentage is about the same in people with no known shellfish allergy.”
Myth 3: With each exposure to a food allergen, the reaction is likely to get worse.
Fact: Although a reaction is likely to occur in a patient who is exposed to a food that they are allergic to, the severity can be highly variable and unpredictable. It may depend on whether the allergen was ingested, inhaled or contacted a skin area. Risk factors for more severe reactions may include a history of asthma, alcohol use and/or concomitant exercise.
Food allergies most commonly present in childhood during the first few years of life, but allergies to shellfish or fish may develop in adulthood. Allergies to milk, egg, wheat and soy are often outgrown, while allergies to peanuts, tree nuts, and seafood usually persist. Children allergic to eggs and milk may be able to tolerate these foods if they are heated, such as in baked goods.
Like most everything else in the medical field, the diagnosis of food allergy starts with a careful history. This should include a list of the possible foods suspected, the route of exposure, (oral, ingested, or topical), the timing of the onset of symptoms after exposure and details of the specific symptoms and their severity. It is also important to note if this has happened more than once with contact with the suspected food.
“To diagnose a food allergy we need both a history suggestive of a food allergy and a positive allergy test to the food in question,” Virnig said. “Many people believe that if you have a positive allergy test to a food you are definitely allergic, but unfortunately things are not that straightforward. False positive allergy tests are very common, and frequently a person with positive allergy tests can actually eat the food without having symptoms. This is why having a history suggestive of a food allergy is an important part of the equation. If there is no such history, or if the history is uncertain, we often challenge a person to the food in question to see if they tolerate the food or not.”
Skin prick testing is one of the more common methods used to aid the diagnosis of a specific food allergy. This is done by placing a small drop of the food extract or material on the skin and making a tiny puncture. Results can be determined within 15 minutes and are dependent on the size of the wheal and flare response. Caution is necessary since very sensitive patients may experience a systemic allergic reaction to testing.
Food allergy testing can also be done by obtaining a sample of blood, but these tests may be more expensive and it usually takes several days for the results to become available. After a diagnosis of a specific food allergy is made, the primary therapy is strict avoidance of that food or foods.
Patients, their families, and other caregivers need to be educated on how to read food labels and how to ask whether prepared foods might contain the allergen. Younger children should be taught to never share food, unless it is from a trusted source. All patients should have self-injectable epinephrine (an EpiPen or Auvi-Q) always available and should have a medical alert bracelet or tag they can wear.
Myth 4: Allergic reactions to food can safely be treated with antihistamines such as Benadryl.
Fact: Epinephrine is always the drug of choice to treat an allergic emergency. Epinephrine works quickly and can stop an allergic response more completely than antihistamines such as Benadryl. Fatalities due to severe food allergy are more common when there is a delay in the administration of epinephrine or a false reliance on antihistamines.
When it comes to treating someone who suffering from a life-threatening allergic reaction, Virnig said immediate administration of epinephrine is key.
“If epinephrine is available, administer the epinephrine and call 911,” Virnig said. “If epinephrine is not available, call 911 so that epinephrine can be brought to the patient as quickly as possible. It is OK to administer antihistamines while waiting for the paramedics to arrive.”
There is currently no other approved treatment for food allergy other than careful avoidance, although there is promise of better therapy in the future. It remains unclear whether restricting the mother’s diet during pregnancy or breast feeding affects the development of food allergy in their children. Breast feeding for at least four to six months after birth is commonly recommended.
Although food allergy can be serious, understanding and careful planning can greatly minimize any risks and allow patients to live a normal and nutritionally sound life.