Twitter summary: Asthma is a key predictor of severe reactions in food allergic patients.
Dr Hourhaine: Don't allergy test for food allergies in patients with eczema. Many false positives. Address the skin barrier integrity to help prevent food allergies.
Eczema is typically NOT caused by food allergy! It can certainly co-exist but not causal for most. Slide credit to Dr Hourihane: https://twitter.com/maryjmchenry/status/1040646648068599808
Atopic dermatitis (AD) precedes food allergy. Skin barrier dysfunction increases risk of both. Evolution of skin barrier function occurs in the first 2 months of life. AD of increased severity and chronicity is particularly associated with food sensitization and allergy. AD develops before food sensitization, supporting a causal relationship.
Early staph colonization protects against eczema. Microbiome is critical in the evolution of not only gut health but also skin health.
“Dr. Hourihaine - Don't delay, introduce peanuts early. No screening approach is best as a public health measure. The opposite way of doing it wastes resources. - this is different from guidelines but very reasonable!!!”
Severe FA reaction is result of "Swiss cheese" model of multiple consecutive mistakes.
"Life can be successfully lived with Peanut allergy as it can be successfully lived without Peanut allergy."
The responsibility for disease should be carried by society not by individual patients. Can society start to share in this responsibility?
Dr. Hourihane: Epipens should be available for not just FA patients but also for people who don’t know they need them e.g. in schools. Move the onus away from patients to carry their own pens.
Peanut allergy - threshold dose
Dr. Jonathan Hourihane - Low dose and high dose reactivity to peanut - Different people, different outcomes, different treatment plans?
Hourihane: 1.25 mg of peanut protein is the dose that 5% of the peanut allergic population will react to; 50% of people with peanut allergy need to eat a whole peanut to have a reaction. Thus 50% of people with peanut allergy are not at risk for trace exposures.
5% of people with peanut allergy will react to 5 mg of peanut. 50% of reactors need to have eaten 1 full peanut to react to it. 50% of patients with peanut allergy may not react until they have 100 mg - Peanut Allergen Threshold Study (PATS). More than 50% of allergic patients only react until they eat 1 peanut. That’s huge !
Peanut allergen threshold study (PATS) - single dose oral challenge with peanut, 1.5 mg of peanut protein caused less than 5% of patients to react, in this study no Epi was used in reactors. Should our labeling standards change?
In Australia, there are some allergists who will do a ‘trace peanut challenge’ to prove they could eat it. It would be a similar dose to what’s listed above.
Peanut Allergen Threshold Study (PATS) showed that only 8 of 372 patients challenged with a low dose of peanut - doing this challenge helps to free up patients to eat food with precautionary labelling. The thought would be that parents would then not have to worry so much about reading precautionary labels when shopping which improves quality of life.
Associated benefits with increasing peanut threshold with peanut immunotherapy - from 1 mg to 300 mg of peanut protein allows patients to consume foods that are contaminated, without concern.
Dr Hourihane: We must not label all peanut allergics as being pre-fatal. Dr. Hourihane- If we can't predict severity of food allergy, we must appreciate the nuances of differences - different phenotypes in our patient populations.
Single dose challenge to cow’s milk can lead to accelerated tolerance in children.
We need to change the mindset: allergic people are tolerant to everything they’re not allergic to! Instead of "i can’t have peanuts", think I can have hazelnuts - Dr Hourihane.
Tweets by:
Dr. Mariam Hanna, MD @PedsAllergyDoc
Mary McHenry MD @maryjmchenry
Dr. Ellis @DrAnneEllis
Dr. A for Allergy MD @Health_Ontario_
Loubna Akhabir @lakhabir
David Fischer, MD @IgECPD
Emilie Manny @emanny_red
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