Paediatric Allergic disease a case based discussion

1. Paediatric Allergic diseasea case based discussion Penny Fletcher MSc MRPharmS Ipresc Senior lead pharmacist W&C St Mary’s Hospital, London

2. Objective • Allergy - “the myths and facts”

3. Prescription John 10¾ years 33.5kg (31st May 2011) Prednisolone 40mg od & reducing dose over 9 days Lansoprazole 30mg on Montelukast 5mg on Cetirizine 10mg bd Seretide 125mcg MDI via Volumatic Salbutamol 2-10 p prn to 4h via volumatic Cetraban moist qds Eumovate oint bd not face Hydrocortisone oint bd face Calcium sandoz liquid 15ml a day

4. Asked to dispense and counsel What further info would you like?

5. Drug history Epipen

6. Allergy history NKDA “not sure, may be fish, nuts, milk / soya”

7. Background GP Referral: 25 May 2010 (one year ago) 9 yr old, vomiting on & off for 5 years Doesn’t want to eat, if does complains of feeling sick Does suffer from hayfever PMH 2003 productive cough, 2001 Eczema Meds – hydrocortisone cream, aqueous cream, oilatum plus, loratidine

8. Background DNA 14 July 2010 22 Sept 2010

9. Referral background Second GP letter 14 March 2011 “Please see this young lad admitted to local hospital 12 March 2011 following collapse and chest pain” “Extensive tests done, requested allergy referral & repeat epipen – 2 used at school”

10. What do you do next?

11. Notes for further history Birth – term, SVD 3 kg - 9th centile Breast fed 3-6/12 & formula, no probs NKDA Vaccines up to date Has had ibuprofen Ok with latex (blows up balloons) Current weight 33.5Kg, 25th centile Height 138.5cm 9th centile

12. Family / Social history Father non-atopic Mother eczema & asthma, FH atopy 20yr old sister well 16yr old brother used to have eczema & allergic rhinitis No pets, mixed flooring, mild damp No smokers in house, dad occ outside

13. Allergic disease – whole system review Skin – eczema Chest – Asthma – start at nose, allergic rhinitis Gastrointestinal system Allergy including food Diet history

14. On examination Active eczema Wheezy & cough Significant allergic rhinoconjunctivitis Abdomen normal, mild epigastric tenderness on deep palpation

15. Eczema Developed eczema at 1 month Bad Hospital Potent topical steroids Now just aqueous cream & oilatum No steroids in past 12 months Scratches all the time, worse with high pollen counts

16. Eczema Cetraban moisturiser Topical steroids – ointments Eumovate Less potent on face Hydrocortisone Why different? Why ointments?

17. Allergic rhinitis (GP mentioned hay-fever) Significant symptoms May – Sept Piriton, partially helps Allergic rhinitis wakes him Frequent nose bleeds Concentration affected Doesn’t snore

18. How could we optimise? Avoid piriton Sedation GP had prescribed loratidine, but was taking piriton cheap to buy (?) Non sedating anti-histamine – cetirizine Dose (montelukast)

19. Respiratory history Asthma since age one Note, no mention of this in GP letter (!) Uses brown inhaler prn when symptoms Not in GPs medicine history (!) Salbutamol 3-4 x a week Both via Volumatic with mouth piece Coughs all the time, esp at night Wakes 3-4 x a week Coughs with sore throat (not itchy or swollen) Chest worse since pollen season started Cough on exertion & pet exposure Cough not related to chest pain

20. Spirometry

21. How can we optimise? – long term Use brown inhaler regularly Add in long acting B2 agonist ie change to Seretide Why? (Montelukast) Devices What guidance? School?

22. How can we improve now? Asthma – long standing poorly controlled Lung function poor (found hard with cough) Oral steroid course

23. Gastrointestinal system No problems in infancy Worse since starting school Last few months vomiting after most meals Occasional whitish phlegm like substance in vomit Bad taste in mouth, feels sick all the time Refused gaviscon – doesn’t like taste Not sure re food triggers Very fussy eater, doesn’t like lumps or dry food Sticking sensation when swallowing dry/lumpy food

24. Gastrointestinal system Cannot relate chest pain to meal times or certain foods Chest pain not related to vomiting Recent epigastric pain Stools once a day Lots of flatulence

25. Food allergy Milk – has on cornflakes – doesn’t like milk Tolerates occ yogurts, doesn’t eat cheese Soya – doesn’t like Egg – itchy – eczema Nuts – avoided as mother is worried, has had nutella & snickers, once made him a bit itchy Wheat – does eat wheat and pasta Sesame – tolerated & used in cooking Veg – not keen, has had beans, not peas or lentils

26. Food allergy Fish – angioedema & urticaria & breathlessness Eczema flares if fish cooked in house Prawns ok at home Recently at a party, prawns cooked “differently”  profuse vomiting & breathless Fruit – tolerates grapes, banana, mango Kiwi – itchy mouth, apples itchy tongue Meat – tolerated, chicken can flare eczema

27. Diet Rice based foods, sausage, carrots, cornflakes Doesn’t like new foods / textures / tastes On OTC multi-vitamins Note, weight is 25th centile

28. Food allergy plan Fish - avoid Need to Ix nuts – was prawn reaction cross contamination with fish or nuts? Blood taken for specific IgEs Avoid nuts for time being

29. What management for food allergy? • Calcium sandoz liquid • Needs Epipen at all times • Allergy management plan

30. GI Symptoms Significant gastro-intestinal problems Allergic gut disease ? Eosinophilic oesophagitis Trial of milk and soya free diet for 6 weeks Montelukast, cetirizine, lansoprazole May need gastro referral & endoscopy

31. Collapse – presenting / referring problem Two episodes Assembly, sitting, severe chest pain, drowsy, passed out No exertion, hadn’t just eaten anything Running in playground, bumped into another pupil, found himself on ground Other times dizzy if gets up quickly All cardiac Ix at local hospital (including ECG) normal, but no details available

32. Impression & management Difficult to know, esp without cardiac Ix Sounds like fainting episodes Nothing to suggest due to anaphylaxis Manage multi-system allergic disease and see what happens…

33. Adherence? Lots of new medicines Adolescent (almost) Secondary school

34. Management plans & counselling Eczema Asthma & Rhinitis Device refresher Allergic reaction plan Epipen training refresher

38. Follow up Plan for 3 weeks time on day unit

39. Follow up - 22 June 2011 Well, generally happier No chest pain / collapse Occasional epigastric pain, overall better Sticking to diet – rice-milk on cereal Good appetite No sensation of food sticking Much less vomiting, once in last week Was after most meals Reduced flatulence

40. Food allergy Avoided milk, soya, egg, fish Avoiding nuts as mum “worried” Total IgE 361units/mL - high Coeliac & immunoglobulins normal Vitamin D 37 (insufficient) Remember we have excluded fish, egg, milk

41. What would you do? Vitamin D or multivitamins? Excipients in multivitamins Problems re vitamin D supplies

42. Signs and Symptoms Eczema Much improved still some scratching on legs Allergic rhinitis Much improved Respiratory Much improved, coughing 2-3x/week, usually at night Better inhaler technique Spirometry much improved Salbutamol once in last 3 weeks (using “routinely” after school)

43. Spirometry

44. What would you do? More potent topical steroid for legs Consider pocket sized inhaler for school

45. Impression & management Much improved on anti-reflux treatment Perhaps fainted with severe reflux pain Uncontrolled asthma may have contributed Skin tests after pollen season Add multivitamins (Vit D 400 units) Add Elocon (mometasone) to body (potent steroid)

46. Next appt 10th August 2011 Stop cetirizine 4 days before For skin prick tests

47. Follow up 10th August • Allergic rhinitis worse since stopping cetirizine for skin prick tests • All symptoms much improved • Ran out of lansoprazole & Montelukast two weeks ago, not clear if affected symptoms

48. Skin prick tests 10th August • Positive for: • Grass, Tree pollens • Cat • Milk, Soya • Fish • Peanut, brazil nut, hazelnut, almond • Not walnut, cashew, pecan

49. What could you rationalise? • Stop lansoprazole • Continue (restart) montelukast • If sticking sensation doesn’t improve may need gastro opinion & endoscopy, & swallowed budesonide • Avoid Milk, Soya, Fish, Nuts, Eggs

50. Summary • Allergy - “the myths and facts” • Multi system allergy • Poorly managed previously • Not really got to bottom of 2 collapses • Patient is much improved with the variety of medicines • Adherence