Food Allergy Management and Response with Epinephrine

Susan Waserman MD FRCPCProfessor of Medicine

Division of Allergy/Clinical Immunology

McMaster University

September 23, 2016

Disclosures

I have the following financial relationships to disclose:

Consultant for: GSK, Merck, Takeda, Paladin, CSL Behring, Pfizer Canada, Shire Canada, Sanofi Canada, Health Canada, Novartis, Meda

Honoraria from: All of the above

Employee of: McMaster University

AND -

I will not discuss off label use and/or investigational use in my presentation.

What is food allergy?

• A person with a food allergy has an immune system that mistakenly treats the protein in a particular food as if it is dangerous.

The body reacts to the food by having an allergic reaction.

How common is food allergy?

• Current estimates

– Up to 7.5% of Canadians are affected by food allergy

– Approximately 2.5 million people

• Growing public health issue

– Appears to be increasing, especially in children

– No cure exists today

Priority food allergens

• Peanut

• Tree nuts (almonds, Brazil nuts, cashews, hazelnuts, macadamia nuts, pecans, pine nuts, pistachios, walnuts)

• Seafood

– Fish (e.g. trout, salmon)

– Shellfish

º Crustaceans (e.g. lobster, shrimp, crab)

º Molluscs (e.g. scallops, clams, oysters, mussels)

• Milk

• Egg

• Sesame

• Soy

• Wheat

• Mustard

The common name of the priority allergens listed above as well as gluten sources (wheat, triticale, barley, rye, oats) and added sulphites must be included on a food label.

Food odours

• The protein in a food causes an allergic reaction

• Food odours do not contain protein (e.g. smell of peanut butter)

• If someone smells the food they are allergic to, they may feel anxious or uncomfortable

Airborne proteins

• If someone inhales food proteins that they are allergic to, they may have a reaction

Example: a person with a fish allergy who inhales protein in the steam of cooking fish (cooking may release the protein)

• Reactions are typically mild

• In rare cases, someone may experience a severe reaction

Other allergens

• Insect stings

• Medications

• Latex

• Exercise (for some, this involves exercising after eating a specific food which usually is not a problem)

What is anaphylaxis?

• Most serious type of allergic reaction

– Can affect different parts of the body

– Can happen quickly

– Can be life-threatening

• Immediate treatment is necessary

• Symptoms can vary

• Any of these can appear

• Most dangerous symptoms

– Difficulty breathing

– Drop in blood pressure

• Immediate treatment is necessary

Staying safe

• Until a cure is found, the keys to remaining safe are:

– Avoiding allergen(s)

– Wearing medical identification, e.g. Medicalert® bracelet

– Carrying epinephrine, the first line treatment for anaphylaxis

People with stinging insect allergy can talk to an allergist to determine if they can benefit from venom immunotherapy (allergy shots).

Fatalities from anaphylaxis

• Risk factors for fatality

– Not using epinephrine immediately

– Past allergic reactions

– Asthma not under control

– Age (teens/young adults taking more risks)

…but deaths are rare and preventable. Anaphylaxis can be managed.

EpiPen® epinephrine auto-injector

www.epipen.ca

The 0.3 mg dosage is for adults and children weighing 30 kg (66 lbs) or greater.

The 0.15 mg dosage is for children weighing between 15 and 30 kg (33 and 66 lbs).

In Canada, epinephrine auto-injectors are available as behind-the-counter medication and can be obtained without a prescription.

5 emergency steps

1. Give epinephrine at first sign of a reaction.

2. Call 9-1-1 or local emergency medical services.

3. Give a 2nd dose of epinephrine as early as 5

minutes after the first dose if there is no

improvement in symptoms.

4. Go to the nearest hospital right away (ideally by

ambulance) and stay for observation.

5. Call emergency contact person.

Stock epinephrine

• Undesignated or “stock” epinephrine auto-injectors– Devices that are not prescribed for a particular person and

can be used in anaphylactic emergencies

– Settings may include public places, schools, child care centres, camps, restaurants, food courts

Challenges with “stock epi”

• Access to medication

– Cost and maintenance of stock (adult/junior doses, expiry dates, replacing used devices)

• Training

– Who provides and who receives

• Liability concerns

– General public

– Educators

– Restaurant staff

Where is stock epi in place?• Public places

– St. Hubert chain of restaurants (ON, QC)

– Bell Centre (Montreal, QC)

– La Ronde Amusement Park (Montreal, QC)

– Jackson Square Mall (Hamilton, ON)

– 72 city recreation facilities (Hamilton, ON) in Fall 2016

• Schools– Some school boards/schools purchase auto-injectors for emergencies

involving identified students

– For 5+ years, PEI school boards have provided additional auto-injectors to schools (number of devices/school is based on a formula)

– EpiPen4Schools® is a program offered to US schools

• Airlines– Qantas, British Airways, JetBlue, Virgin, Jetstar

Success story• Kelly Dunfield, a Canadian nurse practitioner, led the initiative to

secure stock epi in 30 public locations in her town of Sussex, NB and surrounding regions

• An allergy emergency occurred at a wilderness lodge near Sussex– Wellington McLean, 53, was riding an all-terrain vehicle (ATV) with his

family– During the ride, he was stung in the face by wasps and had an

anaphylactic reaction– Muriel McCallum, a first-aid responder, administered the stock epi

available at the lodge under the new program– She used the adult device first and then administered the children’s

dose because McLean needed a 2nd injection

“If the units hadn’t been there, I would have watched him die,” McCallum says.

Impact of stock epi

• Stock epi can be used:

– For first time reactions

– When a 2nd dose is required

• Leads to better outcomes:

– Reduces the severity of reactions

– Results in fewer fatalities

Stock epinephrine can help save lives.

Thank You