Posted tagged ‘allergy’

What’s the best peanut policy to prevent severe allergic reactions in schools?

April 12, 2017

The Pediatric Insider

© 2017 Roy Benaroch, MD

Peanut-free schools, peanut-free rooms, peanut-free tables – they’re all an effort to protect children who have severe peanut allergies from accidental exposures. We’d all like to make sure our school are as safe as possible for everyone. So what’s the best policy on peanuts and tree nuts?

A study in press at the Journal of Allergy and Clinical Immunology adds some science to the debate.  Researchers looked back at peanut allergy experiences at Massachusetts public schools from 2006-2011. They polled every public school from K through 12 to determine their “peanut policy”. Though the response rate was only about 55%, the policies varied a lot – from completely no-serve, no-bring peanut schools (about 2-3%), to no peanuts allowed from home (about 10%), no peanuts served by the school (60%), to keeping some classrooms peanut free (70%), to having designated “peanut free tables” in the cafeteria (this was the most common policy in place, accounting for about 90% of the schools). (Some schools had multiple policies, so the numbers are > 100%). The peanut policies remained about the same for the 5 years of the study, and didn’t vary too much from elementary to high schools.

Data was also collected on every episode at school where epinephrine was administered. Epinephrine is the drug given to treat a serious allergic reaction (that’s the medicine in those weirdly expensive Epi-pens.) It turns out that Massachusetts schools must file a form when epi is given, so those were easy to track. Over the 5 years, epinephrine was given to children having an allergic reaction to peanuts in Massachusetts public schools about 20-40 times per year, with a modest increase from year-to-year during the study. We’re not talking huge numbers, here. Epinephrine administration was used as a “proxy”, or substitute number, for the actual number of peanut reactions in the schools – though it’s possible that epi was sometimes given when it wasn’t indicated, or sometimes was withheld when it should have been given.

The results are interesting. Of the peanut policies in place, the only one associated with a significantly decreased number of epinephrine uses was the presence of peanut-free tables in eating areas. Other policies, including having an entirely peanut-free school, did not result in fewer instances of epinephrine use. In other words, a school with a policy to be completely free of peanuts didn’t seem safer for peanut-allergic kids than a school that allowed peanuts to be brought from home.

These results aren’t super-strong. The number of serious reactions was small, and the number of absolutely peanut-free schools was small, too. There were only two nut reactions in the peanut-free schools (and one of them was in a boy that brought his own walnut cookie from home, despite being known to be walnut allergic.) When you crunch the numbers, the per capita chance of reactions in nut-free schools was actually higher than in schools with less-restrictive numbers, but with numbers so small I don’t think you can hang your hat on that conclusion.

A few lessons can be learned from this study. Even among schools that claimed to be “peanut free”, many allowed peanuts to be brought from home. Schools should have clear policies that make sense to parents. It’s also clear that even truly peanut-free schools aren’t a guarantee that no peanut exposures will occur—schools shouldn’t just declare no nuts, and leave it at that.

I wonder if the relative superiority of peanut-free tables is because that policy is easier to enforce. When an entire school is meant to be “peanut free”, you might be more likely to have some families break the rules. Also, “peanut free” policies might lead to a false sense of security among children who are nut allergic. They still have to watch what they eat. This study didn’t look into these factors, or how well peanut policies were enforced, or exactly how children were exposed in every instance.

Allergic reactions to peanuts are not common in schools, but when they do occur they can rapidly become life-threatening. Avoidance of exposures is the main way to treat peanut allergies; and when a serious reaction does occur, epinephrine should be given immediately. Beyond that, we just don’t know what the most-effective school policy should be. This study gives us some insight, but we’ve still got more to learn.

 

edit: Here’s a tangentially-related, sickening story about the apparent hazing of a peanut-allergic college student. What the hell is wrong with people? Accidents happen, but this is just…. just… I have no words.

 

 

 

Epipen alternatives – there are cheaper options

August 30, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

Epipens have gotten crazy expensive, yes — $600 for a two-pack. Here are some alternatives that might help you save a few bucks.

#1: Wait a few weeks, and see what Mylan does. Mylan, the company that makes the “Epipen” brand of epinehphrine auto-injector, has been under a lot of pressure lately to back off their unseemly price gouging. They’ve introduced a savings card that claims to lower your out-of-pocket expense to no more than $300 dollars, and say they’ve expanded eligibility for their patient assistance program for their less-wealthy-yet-still-allergic patients. Just yesterday, they accounced a new generic version of their own Epipen, claiming it will be identical to the genuine Epipen, but at half the price. Weird, yes, selling two things that are identical (other than the price), but I suppose stranger things have happened. Give Mylan a few more weeks, and they’ll probably start giving away Epipens in cereal boxes.

#2: Find out if you really need to have an Epipen available for your child. Epipens, until recently, weren’t prescribed for many children. A robust marketing program from Mylan (including appearances by Sarah Jessica Parker on daytime talk shows) along with an expanded FDA indication for people at any risk for allergic reactions turned a niche product into a billion-dollar moneymaker – and that was before they raised the prices through the roof. A reasonable question: are all of those Epipens really necessary? Certainly, those who’ve had a life-threatening allergic reaction to a food or bee sting in the past need one available. And high risk patients (for example, those allergic to peanuts who also have a history of asthma) clearly need them, too. But what about people allergic to other foods, who’ve had multiple reactions in the past, but never anaphylaxis? What about the many people who’ve tested positive for allergic sensitization, but have never actually had any reaction at all? Doctors are loathe to withdraw an Epipen recommendation (better safe than sorry!), but there are times when all of this money could be better spent in another way. If you’re not sure if or why your child needs an Epipen prescription, ask your doctor to review this with you before you refill it.

#3: Hold on to expired Epipens, at least for a little while. Epipens keep at least some potency beyond their expiration dates, especially if they’ve been stored in a cool place. Don’t discard your old Epipens until you’ve purchased new ones – it’s better to use an expired Epipen than to have no epinephrine available when needed.

#4: Consider the Other Brand, “Adrenaclick”. Epipens have pretty much flooded and dominated the market, but there is another epinephrine auto-injector out there, the “Adenaclick.” Instructions for using it are a little different, so if you get one make sure you’re familiar with it. A two-pack lists for $140 less than Epipen, and you can get that price even lower by using a coupon from GoodRx.com. Even better: there is a generic Adrenaclick out there, and it’s even cheaper if you can find it (supplies, I’m told, are limited.) To get an Adrenaclick or the generic version, you need a specific prescription from your doctor listing this by name. In most states, pharmacists cannot substitute Adrenaclick for an Epipen. You’ll want to check your insurance formulary, too – the list prices may not matter as much as what “tier” these products fall under for your plan.

Epinephrine (or adrenaline, if you prefer)

Expired Epipens – Safe to use?

August 29, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

The sticker shock for Epipen purchases has some people wondering: Do I really have to buy a new one every year or so? Does it really matter if the drug has aged past its expiration date?

An Epipen is a device that automatically injects epinephrine. It is The Drug for potentially catastrophic allergic reactions to things like foods or bee stings. If someone’s having a bad reaction, epinephrine can save a life. In a medical situation, we’d typically draw up epinephrine from a little vial (which is way cheap, less than 5 bucks) and inject it into an available big muscle. Presto, you’re in the clear (it really can work super-quickly. Quite satisfying.) Since it’s awkward and perilous to draw up epinephrine into a syringe while you or your child is dying of an allergic reaction, for home use an automatically-injecting device is prescribed. Handy! Just remove a cap, press against the skin, and a little spring loaded mechanism fires off, poking out the needle and injecting the medicine in one E-Z step.

Those autoinjectors were first developed by the US military for treating nerve gas attacks. By the mid-1970’s a home version for allergies came out, and though the company that developed it has changed hands, merged, and moved on, the thing that’s currently sold uses pretty much the same technology. The medicine in there, epinephrine, is (and has been) dirt cheap for decades. What makes an Epipen expensive is the device used to inject it, which is currently protected by both patent law and an FDA that seems keen on making sure it’s the only widely available brand. Free from any competition, and with sales buoyed by aggressive marketing, by the manufacturer has been jacking the price through the roof.

Making this even more expensive: a newly purchased Epipen has a manufacturer’s expiration date, typically less than 2 years after purchase. So what happens after that date? Does the medicine really “go bad”?

There aren’t a lot of studies about this. I found two (thanks very much to the Simons, both F. Estelle and Keith, from Winnipeg, Canada – they’re authors on both papers!) In May, 2000, the Simons examined 34 donated Epipen injectors, administering them to 6 New Zealand White rabbits (not at the same time.) The out-of-date injectors delivered less epinephrine, and the drop was proportional to the age past expiration. The older the device, the more it lost its punch. Still, eyeballing their data in Figure 2, devices that were less than 24 months past expiration had between 60-90% of their drug intact, which isn’t terrible. They concluded that as long as the epinephrine wasn’t visibly discolored or damaged, it was better to use an expired Epipen than nothing at all.

Those same authors (with a few extra friends, minus the rabbits) looked at expired Epipens again in 2015, measuring potencies of 80-100% in devices up to three years past their expiration. Again, not too shabby.

Epinephrine is especially vulnerable to breaking down in heat. Epipens stored in car glove boxes aren’t going to last. And the auto-injecting mechanism, while robust, isn’t made for kickboxing practice or roller coaster festivals.

Still, for ordinary households who try to keep their Epipens in a cool, the devices  probably keep at least some potency somewhat past their printed expiration dates. It’s best if families replace them after they expire, to make sure they’re getting a full and reliable dose. But if someone needs a dose of epinephrine, and the only Epipen you’ve got is expired – use it.

And when you do buy a new one, make sure to ask the pharmacist to give you the new stuff, even if she has to reach way in the back. Since they’re so expensive, it might even be worth it to call around a few places, to see whose stock is the freshest.

More about drug expiration dates

I'm Gerald Ford, and you're not.

The myth of iodine allergy

September 28, 2015

The Pediatric Insider

© 2013 Roy Benaroch, MD

 

Since every second of my life, and then some, seems preoccupied with the transition to the New and Improved ICD-10 code set — I can’t imagine how I lived so long without being able to code for macaw attacks – I’ve had no time to write anything new. So today you get a refurbished, classic post. And by classic, I mean old. I put a new photo somewhere in the text to freshen it up, so I promise it’s worth a read. Enjoy!

 

One of the goals of this site—along with soliciting donations and letting me write and publish goofy stuff—is to promote good, solid science-based medical information. If you’ve been around, you know I don’t go for made-up-stuff. And I especially don’t like it when it’s other doctors spreading the misinformation.

Have you had a reaction to intravenous contrast dye during a CT scan or other exam? Have you been told you’re allergic to iodine, and that you should avoid seafood?

Wrong wrong wrong. You’re not allergic to iodine. And you can almost certainly have seafood—you’re no more likely than anyone else with any allergy to be allergic to seafood, or salt, or dairy products, or anything else that contains natural or added iodine. The only thing you may need to avoid is that same kind of IV contrast dye in the future—though even then, it can probably be safely used with simple premedication.

Iodine is a natural element. It is essential for life—if you didn’t have any, your thyroid gland couldn’t work, and you’d get sick and die. Iodine is found especially in seafood, but also in some vegetables and dairy products (especially if the cows were grazing on land where the soil was rich in iodine.) In many countries, including the USA, salt is routinely fortified with iodine to prevent thyroid disease.

Allergies are almost always triggered by proteins—big, honking, complex molecules made of chains of amino acids—or other big molecules. Someone who’s had a reaction to IV contrast dye has not reacted to the iodine, but to the other constituents of the dye. People who’ve had these reactions may need to be premedicated or use a different, low-reaction type of dye is used in the future if they need further studies.

These are dangerous macawsIt may be that people who’ve had reactions to IV contrast might also have a food allergy, and that food allergy might even be to seafood. But there is no increased risk of seafood allergy than to allergy to any other foods. You might be allergic to seafood or milk or eggs or peanut or… nothing. But you’re not allergic to iodine.

Refs:

http://www.ncbi.nlm.nih.gov/pubmed/20045605

http://www.ncbi.nlm.nih.gov/pubmed/16541971

Get ready for spring! Allergy therapy update, 2015

March 9, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

In last year’s Pulitzer Prize winning* post, I reviewed the medications available for treating the symptoms of spring allergies—antihistamines, nasal sprays, prescription and non-prescription goodness. There’s some new information and changes this year, so it’s time for an update!

First, a study just published provides more reassurance about the use of topical nasal spray steroids and growth. About 220 kids aged 3-9 were randomized to receive placebo nasal spray or intranasal triamcinolone (sold OTC as “Nasacort”), and their growth was followed before, during, and after treatment. Growth when the medication started was very slightly slower (by about an eighth of an inch a year), but that difference was quickly erased by catch-up growth after the medication was stopped. In typical practice, these medicines aren’t used year-round anyway. Bottom line: if there is any effect on growth, it’s insignificant, and it’s temporary.

We’ve also got the first FDA-approved sublingual allergy immunotherapy tablet to come to market. Sold as “Grastek”, taken regularly this can help children and adults overcome allergy to one specific plant, Timothy Grass. Downside: it takes a long time to “kick in”, and it only protects against this one specific pollen—when usually, people with polen allergies are allergic to multiple things. So I’m not sure just how useful this is. Still, it’s an interesting foot-in-the-door for home immunotherapy without the shots. I’m sure we’ll be seeing more of this kind of thing.

Here’s the rundown on all of the other medications, updated for 2015:

Antihistamines are still very effective for sneezing, drippy noses, and itchy noses and eyes. The old standard is Benadryl (diphenhydramine), which works well—but it’s sedating and only lasts six hours. Most people use a more-modern, less-sedating antihistamine like Zyrtec (cetirizine), Claritin (loratidine), or Allergra (fexofenidine.) All of these are OTC and have cheapo generics. They work taken as-needed or daily. There are still a few prescription antihistamines, but they have no advantage over these OTC products. Antihistamines don’t work at all to relieve congested or stuffy noses—for those symptoms, a nasal steroid spray is far superior.

Decongestants work, too, but only for a few days—they will lose their punch quickly if taken regularly. Still, for use here and there on the worst days, they can help. The best of the bunch is old-fashioned pseudoephedrine (often sold as generics or brand-name Sudafed), available OTC but hidden behind the counter. Don’t buy the OTC stuff on the shelf (phenylephrine), which isn’t absorbed well. Ask the pharmacist to give you the good stuff he’s got in back.

Nasal cromolyn sodium (OTC Nasalcrom) works some, though not as strongly as prescription nasal sprays. Still, it’s safe and worth a try if you’d rather avoid a prescription.

Nasal oxymetazolone (brands like Afrin) are best avoided. Sure, they work—they actually work great—but after just a few days your nose will become addicted, and you’ll need more frequent squirts to get through the day. Just say no. The prescription nasal sprays, ironically, are much safer than OTC Afrin.

Nasal Steroid Sprays include OTCs Nasacort and now OTC Flonase. There are also many prescription products, like generic fluticasone, Rhinocort, Nasonex, Nasarel, Veramyst, and others. All of these are essentially the same (though some are scented, some are not; some use larger volumes of spray.) All of them work really well, especially for congestion or stuffiness (which antihistamines do not treat.) They can be used as needed, but work even better if used regularly every single day for allergy season.

Antihistamine nose sprays are topical versions of long-acting antihisamines, best for sniffling and sneezing and itching. They’re all prescription-only (though they’re super-safe). They’re marketed as either the Astelin/Astepro twins (Astepro came out later, when Astelin became available as a generic; it lasts longer) or Patanase.

Bonus! Eye allergy medications include the oral antihistamines, above; and the topical steroids can help with eye symptoms, too. But if you really want to help allergic eyes, go with an eye drop. The best of the OTCs is Zaditor, which works about as well as rx Patanol, which they’re trying to replace with rx Pataday.

 

* That post didn’t win a Pulitzer. Does anyone read these footnotes?

Food allergy testing: Do those big panels work?

December 1, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Theresa asked about eczema (see last post), and also asked about food allergy panels. Does all of that testing help?

Well, usually, no.

It turns out that allergy testing (whether done by skin scratches or blood tests) doesn’t even test for allergy. We sort of smudge through that distinction, because it’s complicated. But it’s time for someone to spill the beans about this kind of testing, and here at The Pediatric Insider, we’re all about telling you guys “the real deal”—the inside info that docs typically keep to ourselves. Here’s something you may not want to hear: “allergy” testing is, well, just not very good.

Let’s start basic. An “allergy” is an adverse reaction (a bad thing, some kind of symptom) triggered by an exposure to something, and caused by a reaction of the immune system. It requires symptoms of some kind, and requires the symptoms to be caused by an immune reaction of some sort.

A broader term, “adverse reaction,” includes allergies but also non-immunologic reactions to things. For instance, many people get bloaty and gassey after ingesting milk. That’s typically caused by lactose intolerance, an inability to digest milk sugar that has nothing to do with any allergy. Still, lactose intolerance and gluten sensitivity and many other reactions are sometimes lumped in with allergies. They’re not allergic, and no “allergy testing” of any kind could possibly identify non-allergic reactions.

Also, allergy – an allergic reaction – requires some kind of symptom, and the symptom ought to be reproducible after exposures. Allergy “testing” often reveals “positives” to foods or other things that upon exposure doesn’t actually trigger a reaction. If eating a food you’ve tested positive for doesn’t cause a reaction, you are not allergic to the food. Period. Allergy requires symptoms.

And that’s the biggest issue with allergy testing—because these tests don’t test for allergy. They test for “sensitization”. They show that your immune system has the capacity to react to the substance, but that doesn’t necessarily mean that you will react to the substance.

I can’t tell you how many times I’ve heard from families who tested positive for food XX, though they’ve never had a reaction to XX—and in fact, they used to eat XX all the time. If your child eats peanuts routinely and doesn’t have a reaction, it doesn’t matter what the allergy testing shows. He is not allergic. The test shouldn’t have been done in the first place.

There are other problems with allergy testing. Though individual tests can fairly accurately say who is sensitized, each test does have a chance of a false result. If the rate of an incorrect test is, let’s say, 5%, that might sound pretty good. But what if you do a panel of 40 foods, each of which has a 5% chance of a false result? There’s a 88%* chance you’ll get at least one false positive. If the panel is large, you’re going to get false results. The larger the panel, the more wrong answers you’ll get. What then?

Another problem: there are a lot of ways to do allergy testing, and they’re not all the same, and I most families have no idea what they’re getting into. The current, most reliable blood testing for sensitivity is called a Cap-RAST or ImmunoCap, and it tests for specific IgE molecules. Older tests are far less accurate, and some still in wide use are as worthless as flipping a coin. If you are going to do allergy testing, you should at least do the best one. Skin testing, too, has different reagents and methods, and it can be difficult to know if what’s being done is the most-reliable testing.

About skin tests: they’ll be unreliable if the patient has been taking antihistamines, and they’ll be less reliable if the patient has a skin condition like eczema, which causes high overall IgE levels and a sort of overall hypersensitivity that leads to many false positives on both skin and blood testing. Testing children with eczema is fraught with peril, which is one reason many dermatologists aren’t keen on addressing the possible allergy-eczema connection.

Still, allergy testing can sometimes help, if you keep these points in mind:

  • Consult with a board-certified, genuine allergist. Many companies market allergy kits and tests and things for general practitioners and ENTs and who knows who else. They’re a big money maker, but we really don’t know what we’re doing with them or how well they work. Please stay away from alt-med practitioners who claim to be able to diagnose allergies by holding your hands or waving vials about or using some kind of elecromagnetic hyperscience quantumconfusionating walletemptier.
  • Test only for foods or other allergens that might be causing a reaction. Foods that are eaten routinely without problems are NOT allergies (and testing will lead only to confusion); foods that always do cause a reactions ARE allergies, and don’t have to be tested. Only test the grey-zone, “maybe” foods, or you’re asking for trouble.
  • Test a limited number of foods. Almost all food allergies are to a small number of candidates: milk, egg, wheat, soy, shellfish, fish-fish, peanuts, and treenuts. Tests for mustard and plantain and okra and lamb are unlikely to yield useful results, and might upset the lambs.
  • Think of allergy testing as a starting point, for clues to what might be a real allergy (positive tests), and clues for what are probably not causes of allergy (negative tests.) Under most circumstances, unless there’s been a life-threatening reaction, you have to confirm ‘allergy testing’ with deliberate exposures. And if there has been a life-threatening reaction, you probably already know what the trigger was—so why do the test?

* It has been a long time since I did statistics. What I did was figured the 5% chance of a false result on one test means that 19/20 times the test will be correct. So if you’re doing that 40 times I figure the chance of 40 correct tests in a row is 19/20 raised to the 40th power = ~ .12, and the chance of that not happening is 1-.12 = 88%. Am I even close? At The Pediatric Insider we welcome comments that point out boneheaded mistakes. Be gentle.

Allergies and eczema: Are they related?

November 24, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Theresa wrote in, “I’d be interested in seeing an article about the connection (or lack thereof) between food allergies and eczema. Also interested in the helpfulness (or lack thereof) of large blood panels for food allergy testing.”

Two good topics—and I’ll get to food allergy panels in the next post. First: What’s the connection between allergies and eczema?

Eczema is by far the most common chronic skin condition pediatricians see. It’s present in about 1 in 3 young children, or maybe more if you count the milder cases. In fact, if you look closely enough, just about every child has at least some eczema. It’s usually mild, and improves nicely with good skin care and the occasional use of low-strength topical steroids.

What causes the itchy, scaly, red rash? Many things seem to contribute: dry skin, rough fabrics, and scratching all make eczema worse. It often runs in families, and often occurs in the same children who later go on to have allergic rhinitis (hay fever), asthma, and food allergies (those conditions, as a group, are called “atopic.”) Eczema is also called “atopic dermatitis”—atopic referring to inflammation and sensitivity, typically caused by an allergic trigger. These conditions are all interrelated, and often co-exist. So is eczema, the rash, caused by a specific, identifiable, and avoidable allergic trigger?

There’s the controversy.  If you ask allergists, they’ll say “probably yes.” They stress identifying and avoiding specific triggers, typically one or more foods. Sometimes their advice is guided by allergy testing, or sometimes just by history, and sometimes by trial and error. Just avoid food X, and if that doesn’t work, avoid food Y. If there is an allergic food trigger, it’s probably one of the common food allergies, like egg, milk, wheat, soy, fish, or peanut. Maybe try avoiding those.

But it’s hard to avoid all of those foods—and “testing” will often lead to false positive or negative results. If food allergy does trigger eczema, it does it slowly, so it may take several days or weeks of restrictions and reintroductions of multiple, overlapping foods to figure this out. Meanwhile, Junior is still itchy. So the dermatologists take a different approach.

If you ask dermatologists if eczema is caused by food allergy, they’ll say “probably no.” They stress taking care of the skin (using good bathing techniques, moisturizers, sometimes topical antiinflammatory medications, and sometimes agents to reduce bacterial colonization.) Just treat the skin, that’s the dermatologists’ motto. We can make this better, and quickly, without anyone going hungry.

Now, if you ask pediatricians if food allergy causes eczema, we’ll say “sometimes.” Though some of us are probably more allergy-focused than others, most of us probably favor practical advice: for mild-to-moderate eczema, it’s usually best to focus on good skin care, and treat the eczema, and get Junior feeling better. IF initial, safe therapy doesn’t work, or if the eczema is severe, then we’ll also try to identify food triggers—though we’ll keep up the good skin care at the same time. One approach doesn’t mean you can’t also follow the other. And, in fact, the best dermatologists and allergists will also recommend this kind of middle-of-the-road, practical advice.

What about those food allergy panels Theresa asked about? Short answer: They don’t work, at least not if your goal is to figure out what your child is allergic to. More in the next post.