Trial of elimination of cow's milk only for mild non-IgE mediated

Latent onset, no urticaria, maybe atopic eczema, constipation

Two options

1) Pure breastfeeding - MOTHER needs to eliminate cow's milk

2) Mixed breastfeeding or formula fed - BABY needs to eliminate cow's milk, use Extensively Hydrolysed Formula (EHF)

Two week trial

If improves, keep on EHF for 6 months, then plan for reintroduction according to iMAP ladder with dietician

https://gpifn.files.wordpress.com/2019/10/imap-presentation-algorithm-1.pdf

https://gpifn.files.wordpress.com/2019/10/imap-treatment-algorithm.pdf

Tolerance develops 20% every 4 years

• 20% by age 4
• 42% by age 8
• 60% by age 12
• 80% by age 16

Food allergy may be

• IgE-mediated (resp, skin, face, GI symptoms)
• Non IgE-mediated

Cross-reactivity

• Latex - banana, kiwi, avocado, potato
• Oral allergy syndrome - pollen, transient localized urticaria and associated tingling, itching, and swelling of the lips, tongue, and throat, often with co-morbid allergic rhinitis symptoms

If there is oral allergy syndrome, need to also treat allergic rhinitis

Egg, soybean, wheat = retest every 12-18m until 5y, then every 2 y

Nut/seafood = retest every 2-4 years as likely to persist

1) Acute urticaria (<6 weeks)

2) Chronic urticaria

• CSU - chronic spontaneous urticaria
• AU - autoimmune urticaria
• CINDU - chronic inducible urticaria (water, heat)

Treatment of HAE and AAE - do not respond to antihistamines

• plasma-derived C1 esterase inhibitor (C1-INH) concentrates
• ecallantide (a kallikrein inhibitor [kallikrein is involved in the production of bradykinin]),
• icatibant (a bradykinin receptor antagonist)
• prophylactic doses of C1-INH
• long-term prophylaxis with danazol (an androgen)

Referral to immunologist/dermatologist

• Hereditary angio-oedema
• Acquired angio-oedema
• At risk of anaphylaxis
• Asthma
• COPD
• Heart disease

Treatment of angio-oedema

• Stop ACEI
• Non-sedating antihistamine 6 weeks (can give up to 4x standard max dose)
• Short-course of oral corticosteroid if severe
• Specialist opinion on continuing beta blockers

angio-oedema = deep tissue swelling face, genitalia, hands, feet, bowel.

Can be acute or chronic (> 6 weeks)

Can be:

• Allergic
• Idiopathic
• Hereditary (HAE - eg C1 esterase inhibitor deficiency)
• Acquired (AAE - C1 esterase inhibitor deficiency - SLE or other CTD)

Anaphyalxis is life-threatening systemic hypersensitivity. affecting airway, breathing and circulation

T1DM children

• annual flu vaccine
• pneumoccocal vaccine

the DAFNE (dose-adjustment for normal eating) programme

immediate (same-day) referral to a specialist for

• adults diagnosed with T1DM
• children and young people with suspected type 1 diabetes

Serious hypoglycaemia = endocrinology referral

• Active foot problem = podiatry ferral within 1 day

1) lie flat

2) pilocarpine drops

• 2% in blue eyes
• 4% in brown eyes

3) acetazolamide 500 mg orally

aqueous humour is produced the posterior chamber (behind the iris, in front of the lens) by the ciliary body using carbonic anhydrase and flows into the anterior chamber through the pupil

Routine pneumococcal vaccine for:

Infants - PCV13 - 2m,4m,12m

Over 65 - PPV23 - one-off

People at increased risk of pneumococcal disease or complications include those with:

• Asplenia or splenic dysfunction.
• Chronic respiratory, heart, kidney, or liver disease.
• Diabetes requiring insulin or oral hypoglycaemic drugs.
• Immunosuppression due to a medical condition or treatment.
• Cochlear implants.
• Cerebrospinal fluid leaks (including leakage following trauma or major skull surgery).
• Occupational risks (including welders). For more details, see the section on Risk factors.

Contraindications

• Egg allergy
• Anaphylaxis
• Acutely unwell
• Children who are severely immunocompromised
• Children with respiratory symptoms

Influenza vaccine for >65s and specific risk groups

• Asplenia or splenic dysfunction.
• Chronic respiratory, heart, kidney, or liver disease.
• Diabetes requiring insulin or oral hypoglycaemic drugs.
• Immunosuppression due to a medical condition or treatment.
• Chornic neurological disease
• Pregnant women
• Children aged 2 to 10 years (but not aged 11 years or older) on 31 August 2019.
• People living in long-stay residential and nursing homes or other long-stay care facilities (not including prisons, young offender's institutions, or university halls of residence).
• Close contacts of immunocompromised people, including carers (people who expect to share living accommodation on most days over the winter).
• All healthcare and social care workers directly involved in patient care, including students, trainees, and volunteers working with patients.

Aminosalicylates — mesalazine and sulfasalazine may be considered for a mild-to-moderate first presentation

They are often prescribed topically (suppository or enema) initially, and orally if remission is not achieved within four weeks. For extensive disease, topical and high-dose oral treatment may be offered first-line.

Corticosteroids — monotherapy with a time-limited course of corticosteroids may be used for induction of remission

Calcineurin inhibitors — tacrolimus or ciclosporin may be added to oral corticosteroids to induce remission in people with mild to moderate disease if there is an inadequate response to oral corticosteroids after 2–4 weeks.

Immunosuppressive drugs — the thiopurines (azathioprine, mercaptopurine) or methotrexate (second-line) may be considered to maintain remission if there are two or more inflammatory exacerbations in a 12-month period that require treatment with oral corticosteroids, or if remission cannot be maintained by aminosalicylates.

Biologic therapy — the anti-tumour necrosis factor (TNF)-alpha monoclonal antibody agents intravenous infliximab and subcutaneous adalimumab and golimumab are effective at inducing remission in people with severe active disease which has not responded to conventional therapy, or where conventional therapy is not tolerated. These drugs are also effective at maintaining remission.

• Appendicectomy and smoking protect from UC.
• NSAIDs worsen UC.
• UC 2.4x greater risk of bowel cancer - needs screening colonoscopy 10 years after diagnosis
• In a flare-up, use Tuelove and Witt criteria to exclude acute severe colitis (6-8 episodes of bloody diarrhoea + SIRS + raised ESR)
• Severe flare-ups need emergency hospital admission, non-severe flare-ups need specialist review within 5 days

PSC increases risk of bowel cancer

Prednisolone 40 mg od for 7 days, reducing by 5 mg every 7 days.

252 tablets of 5 mg prednisolone in total.

Need to let IBD nurse know.

If has >2 episodes of steroid use, needs to change or increase maintenance therapy