At the clinic you will be seen by a Consultant Immunologist or an Immunology Registrar (who will discuss your case with the consultant). The doctor will take a detailed history of your symptoms and ask about previous illnesses and what medications you are on. The history is the crucial part of the consultation. Part of good history-taking includes asking questions about what you do for a living, who you live with, what support you have, and mood and emotional factors. You will also be asked about smoking, alcohol etc. There will be other questions about your health designed to add helpful information to diagnose what is causing your symptoms. The doctor will then examine you. They will explain to you as they go the reasons for the examination and then what tests or treatments are coming. What allergy testing is there? If relevant, the doctor may ask for skin tests to be performed, either on the first clinic appointment or at a subsequent appointment. Certain skin tests may take some time to perform (up to 2 hours). You may be started on some medications or asked to undergo further testing (e.g. blood tests) before being seen again in the clinic or may be referred back to your GP for ongoing management. A letter will be sent to your GP (and commonly copied to you) with treatment recommendations as well as the results of any tests that are undertaken. Some patients will be referred to the Immunology Day Ward for further investigations or management. These would include patients who need drug, venom or inhalant allergen desensitisation and also patients who need challenge procedures (e.g. with drugs or foods). Our waiting time for Day Ward interventions varies but may be up to 3-4 months.

The specialty of Clinical Immunology and Allergy is concerned with managing disorders of the immune system: 1. ALLERGIES: where there is an excessive immune response to an external or environmental substance such as foods, drugs, pollens, mould spores, animal fur, house mites, latex etc. Some allergies are very common and some are very rare. Sometimes an illness may look like an allergy but actually be due to a non-allergic mechanism. These mechanisms may include chemical and drug effects and emotional factors. Many allergic disorders are the result of multiple factors. Disorders routinely seen include ANAPHYLAXIS, URTICARIA AND ANGIOEDEMA, ATOPIC ECZEMA, INSECT STING ALLERGY, ASTHMA, EYE AND NOSE ALLERGIES (RHINO-CONJUNCTIVITIS/HAYFEVER), FOOD ALLERGY AND PSEUDO-FOOD ALLERGY, DRUG ALLERGY AND HYPERSENSITIVITY (INCLUDING ASPIRIN AND PENICILLIN), EXCESSIVE REACTIONS TO PERFUMES AND ODOURS ETC. 2. IMMUNE DEFICIENCY: where the immune system fails to react as well as it should and the person becomes prone to infections of different kinds depending upon what aspect of the immune system is deficient. Immune deficiency may be present at birth or develop later in life. Disorders routinely seen include ANY PATIENT WITH A TENDENCY TO RECURRENT OR UNUSUAL INFECTIONS. 3. AUTO-IMMUNE DISEASES: where the immune system reacts against the tissues of the body rather than confining itself to foreign invaders and threats. Disorders routinely seen include VASCULITIS, VASCULITIC URTICARIA, SUSPECTED CONNECTIVE TISSUE DISORDERS, AUTOIMMUNE DISORDERS. 4. MISCELLANEOUS: the Department is frequently asked to help decide whether or not a patient's illness is due to an immune disturbance. Sometimes this is because the patient has symptoms involving many body systems or organs. The immune system is by its very nature involved with all bodily systems, and disturbances of the immune system commonly cause multisystem disorders. There are other disorders where questions about the immune system may emerge such as CHRONIC FATIGUE, POST-VIRAL SYNDROME, CHEMICAL SENSITIVITY, GLUTEN SENSITIVITY, MULTIPLE DRUG HYPERSENSITIVITY, PSEUDO-FOOD ALLERGY, PSYCHOSOMATIC OR 'MINDBODY' DISORDERS. The Immunology Laboratory does a wide range of specialised tests for all these immune disorder categories.

What is allergic rhinitis or rhinoconjunctivitis? Allergic rhinoconjunctivitis is the inflammation of the lining of the nose and eyes due to allergy. It causes a blocked, runny and itchy nose, sneezing and itchy running eyes. For some people bad rhinitis can be associated with worsening asthma so it is hard to breathe. What causes allergic rhinitis? - Inhalant allergens Allergic rhinoconjunctivitis (hay fever) is caused by a reaction to inhalant allergens. An allergen is a tiny particle that people are often allergic to. Inhalant allergens are particles that travel through the air to cause allergy. Given that they travel through the air, inhalant allergens tend to land on people's eyes or in the nose and mouth. When this happens inhalant allergens cause the following symptoms: allergic rhinitis - (running, itchy nose and sneezing) allergic conjunctivitis - (running, itchy eyes) itching in the mouth, ears and palate for some people asthma. Some typical inhalant allergens are house dust mite, grasses, plantain (a weed), tree pollen and cat and dog hair. Hay fever is allergic rhinitis due to grass allergy and is mostly during spring/summer. Allergic rhinitis due to dust mite lasts year round and can be worse overnight, in the mornings or around vacuuming or dusty environments. Cat/dog allergy can also cause year round symptoms. Testing for allergic rhinitis The specific allergen (the thing that you are allergic to) may be identified by skin prick tests. This involves placing a drop of the allergen on your skin and then scratching your skin through the drop. If you are allergic, your skin will become red and swollen at the site. Skin tests are only of value if interpreted with respect to a careful history of a patient's clinical symptoms. They are not a diagnosis by themselves. Treatment of allergic rhinitis Click here for information on the treatment of rhinitis.

Inhalant allergens Allergic rhinoconjunctivitis is caused by a reaction to inhaled allergens (i.e. travelling through the air and landing on nose/eyes/lungs). An allergen is a tiny particle that people are often allergic to. An inhalant allergen is a particle that travels through the air to cause allergy. Because it travels through the air it tends to land on people's eyes or in the nose and mouth. When this happens inhalant allergens cause the following symptoms: allergic rhinitis - (running, itchy nose and sneezing) allergic conjunctivitis - (running, itchy eyes) itching in the mouth, ears and palate for some people asthma. Some typical inhalant allergens are house dust mite, grasses (hay fever), plantain (a weed), tree pollen and cat and dog hair. Medical treatment Treatment with medicine involves nasal sprays and antihistamines. While antihistamines work quite fast, they mainly control the symptoms but do not decrease the underlying inflammation. Nasal corticosteroid sprays such as Flixonase or Butacort work more slowly but have a more long lasting effect. They need to be used regularly. Not much difference may be noticed in the first few days, but they have a cumulative effect if used daily over at least a few weeks. They are therefore a much better preventative treatment. To encourage regular use it is good to have several nasal spray puffers positioned in strategic places where you know you will see them each day e.g. by your toothbrush or your desk at work. That makes it easier to ensure regular treatment. Also, if you use these nasal spray puffers and your symptoms improve, it is good to continue them regularly as a preventative even once the symptoms have improved rather than waiting for symptoms to return, then trying to rescue the situation from there. Nasal sprays must be used continuously for one month before it is possible to judge their effect. Desensitisation This is the most effective long term treatment. This treatment exposes a patient to small amounts of the allergen in gradually increasing amounts. Your immune system adjusts to this and as it does patients become gradually less allergic. 85% of people improve with desensitisation (provided the diagnosis is correct). The average improvement in symptoms is by 50%, with decreased medication use by 80%. Desensitisation involves either injections in the skin under the arm (subcutaneous desensitisation), or drops under the tongue (sublingual desensitisation). Injections are weekly for 14 weeks, then move to monthly for the remainder of 3 years. It is important to continue the treatment for all of 3 years to get the maximum long lasting benefit. When the course of injections finishes, the effect usually continues for years afterwards and is permanent for many. At present the evidence suggests that subcutaneous desensitisation is on average significantly more effective than the sublingual drops. Cost of desensitisation and where to get this done For patients with allergic rhinitis only, this can be done in community practice (i.e. a GP) if they are familiar with the practice. For patients who have asthma as well, it is generally done here at our ADHB Immunology day ward, or by a private immunology specialist. The product is not funded by Pharmac, and needs to be purchased by the patient.

What is urticaria? Urticaria (also known as hives) is an itchy rash that can appear like welts, which comes and goes in a seemingly unpredictable fashion. Sometimes, if you scratch the skin, you may notice it comes up in a raised red line. This is called dermatographism. Urticaria is actually quite common with one out of three people getting it at some stage in their life. The skin swelling seen in urticaria is due to the release of chemicals such as histamine from mast cells and basophils in the skin, which causes small blood vessels to leak. The welts can be a few millimetres or several centimetres in diameter, coloured white or red, often surrounded by a red flare, and frequently itchy. Each wheal (or weal) may last a few minutes or several hours, and may change shape. Wheals may be round or form rings, a map-like pattern or giant patches. The surface wheals may be accompanied by deeper swelling of eyelids, lips, hands and elsewhere. The deeper swelling is called angioedema and may occur with or without urticarial wheals (10%). Did you know? 80% of cases of hives occurring in adults are not due to allergy This is particularly true for hives that are recurrent or chronic (occurring on a daily basis). Hives due to allergy more often comes on in sudden discreet attacks after food only. Non-allergic hives can come and go any time of the day, and often occurs overnight or first thing in the morning too. Causes of chronic or recurrent hives Recurrent or chronic hives can be caused by different factors. Sometimes one of these factors can cause urticaria by itself, but sometimes a combination of multiple factors is needed. Also, these factors can be intermittent, causing hives only sometimes. This can make it confusing when trying to identify the cause. Here is a list of some common causes: Autoimmune causes - this is where the body's immune system tends to activate itself and cause the hives. This is quite a common cause of hives. It is important to note that it is very rare that this signifies any significant other autoimmune disease though. A thyroid test should be done however. Medications - commonly codeine or non-steroidal anti-inflammatory drugs NSAIDS like ibuprofen, diclofenac, Voltaren, Nurofen and aspirin. Many cough and cold remedies can contain NSAIDs. One in three adults with recurrent hives will intermittently and unpredictably react to NSAIDs and aspirin. If this happens all NSAIDs and aspirin must be avoided. Patients may need an alternative for analgesia, and an Arcoxia challenge can be considered. Stress and any extraordinary or emotional recent events in a person’s life may trigger or maintain hives. Infections including viruses and bacteria. This often causes hives during or after the infection for a few days. Time of menstrual cycle. Physical triggers may include pressure, cold, heat, sunlight, exercise and, rarely, water. Dermatographism or "skin writing" is marked by the appearance of weals or welts on the skin as a result of scratching or firm stroking of the skin. Seen in 4–5% of the population, it is one of the most common types of urticaria, in which the skin becomes raised and inflamed when stroked, scratched, rubbed, and sometimes even slapped. Treatment of chronic or recurrent urticaria (hives) The first step is diagnosis of the cause, which involves accurate, detailed discussion between doctor and patient, with particular emphasis on the multiple factors listed above. Sometimes, just understanding the role of these multiple factors with intermittent effects, helps a patient understand the nature of hives and can provide a feeling of control over the situation. Antihistamines For patients with recurrent or even daily hives it is best to take regular antihistamines. This can be once daily, but often twice daily is needed. They should be non-sedating such as loratadine or cetirizine. If hives occur mainly at night or early morning, they should be taken before bed. Sometimes higher doses of regular antihistamines are required for urticaria than the doses used in other conditions. In general, these higher doses are well tolerated and side-effects are rare. Avoid the causes Looking at the factors in the list above to see if any of these can be modified. Does chronic urticaria go away? For people who have chronic urticaria (hives every day for more than six weeks), this problem always goes away eventually. It does tend to take months to completely resolve. 50% of long term cases resolve by one year and 30% resolve the year after. Milder cases will often go away sooner.

Allergy testing – what do skin tests mean? Skin testing and blood tests for IgE (RAST tests) are the only proven tests for allergy. We use both skin testing (skin prick testing) for allergy and specific IgE blood tests. Skin tests are a safe and easy way to investigate allergy. Skin testing should be interpreted by a doctor who has experience with allergy and allergy testing, in combination with a careful history of symptoms from the patient. Are skin tests and blood tests for allergy accurate? Skin tests can prove a diagnosis of allergy, but not always. Skin tests for some allergies are more accurate than others. Furthermore, the size of the skin test reaction also increases the chance that the test is a true positive result for allergy. The most important thing however, is whether the skin test result matches the symptoms of allergy from the patient. If it does, then the diagnosis may be clear. If it does not, then the skin tests can be a "false positive". A positive skin test result in a patient with no symptoms to suggest allergy may in fact be a false positive. Alternatively, if a patient has a very clear history to suggest allergy to a particular substance and the testing is negative, it may be a false negative test. As such, the interpretation of skin prick tests (and IgE blood or RAST allergy tests), can only be done in combination with a history of a patient's symptoms to see if these are consistent with allergy as well. This is one of the most important aspects of allergy testing and allergy diagnosis. Oral food challenge For food allergy testing or medication allergy testing a "challenge test", also known as an oral food challenge, can be considered. This should only be considered by an experienced Immunologist/Allergist. The advantage of an oral food challenge is it can definitively disprove allergy. For patients this can be very helpful, to free up this worry from their life. An understanding of skin test and allergy blood tests, as well as a good clinical knowledge of probabilities and good communication and discussion with a patient about their preferences, helps guide any decision whether to progress to an oral challenge. Which allergy test is best, skin test, blood test, or food challenge? This actually depends on the clinical situation and the allergy in question. Sometimes a blood test is preferable, sometimes a skin test gives more information, sometimes both are necessary, and in some clinical situations actually neither should be done. Any broad statements about one type of testing being better than another will be incorrect over simplifications. Food challenge does give the definitive answer, however should only be done if clinical history and skin tests/blood tests suggest it is safe. Did you know? Hair testing has no scientific basis and no evidence to support it. Hair testing is not an accepted part of medical practice and is not supported by major international allergy organisations. This is also true for sending IgG blood tests to foreign countries. Use of alternative sham allergy testing like Hair tests and IgG testing is unfortunately common in New Zealand, spreading false information which actually can be very harmful. Please see this link to a commerce commission ruling regarding these false allergy practices. Also, large screens of numerous allergy tests should not be ordered either because they greatly increase the chances of false positive test results. Harms of unproven allergy tests Unproven allergy tests can be very harmful. Below is a list of some potential harms of hair testing and IgG testing. Missed non-allergic diagnosis. For example, if symptoms were due to another disease, not allergy, and the disease was serious (for example cancer). If missed this could be very harmful. Giving a false allergy diagnosis might stop a patient pursuing investigation for the real cause. Allergic reaction. Hair testing for allergy and IgG blood tests for allergy have no reliable evidence to support their use. A risk is these tests stating a patient is not allergic to a substance when in fact they are. In the case of serious allergic reactions, such as urticaria, anaphylaxis or angioedema, this could be very dangerous or even fatal. This is why accepted testing methods which have extensive evidence to support their efficacy should be used i.e. skin prick tests, specific IgE or RAST blood tests, followed by oral challenge if considered safe and appropriate by an experienced Allergist / Immunologist. Harms of unnecessary avoidance diets. For people with food allergies it can be very stressful avoiding foods. Did you know that rates of depression in carers for children with allergy are high? Also, patients can become significantly malnourished due to food avoidance. Food anxiety and food aversion can develop. For young children the stigma of not being able to join in at birthday party meals and being an "allergy kid" can be very significant. For these reasons unnecessary avoidance diets are very harmful. Causing these problems unnecessarily with unproven and unscientific allergy tests is unfortunately commonplace in Auckland. Placebo then nocebo. Many people embark on an unnecessary avoidance diet and feel better. This is due to a placebo effect. Unfortunately, this tends to wear off by a few months, leaving a patient feeling confused. The avoidance diet seemed to help, but now symptoms have returned. It is natural to think "It must be something else I need to avoid as well". As a result, a whole cycle of ongoing food avoidance continues, yet symptoms intermittently continue as well. This is the "Nocebo" effect (effectively like a placebo effect but actually negative and harmful). This is another risk of "sham" unproven allergy tests such as hair testing or IgG testing. Dr Andrew Baker Immunologist Allergy Specialist Auckland 03/08/13.

Auckland Hospital Immunology Clinic Food Allergy Testing and Diagnosis What are the usual symptoms of food allergy? Most food allergy causes marked symptoms to come on within 90 minutes of eating the food. The type of symptoms that occur include: urticaria or hives with food angioedema (swelling of lips, eyes or tongue) with food wheezing, coughing, difficulty breathing with food anaphylaxis (a severe reaction which can cause collapse) mouth itching after food marked sudden nausea and vomiting diarrhoea abdominal pain with specific food. It is important to note that all these symptoms can be caused by things other than food. In fact 80% of cases of hives (urticaria) in adults are not due to an allergy, but rather due to other causes (which we can also investigate and treat.) Other non-specific symptoms - Is it food allergy? In general symptoms such as headache, tiredness, bloating, trembling, fatigue, constipation are very unlikely to be a food allergy. Unfortunately often these nonspecific symptoms are diagnosed as a food allergy. Tests such as "hair analysis" or "IgG blood testing" make claims without proof with regard to such symptoms. What is a food challenge? One of the best tests to investigate this is a double blinded placebo controlled food challenge (DBPCFC). With this test the patient is given either the food in question (disguised in a capsule, or something like yoghurt) or a placebo. Neither the patient nor the doctor knows if the patient is given a placebo or the food. That way both the patient's and the doctor's preconceptions of what might happen are removed. This is in fact the "gold standard" test of food allergy. It should only be done in a monitored environment and in patients in whom the history of allergy and skin testing/blood tests do not suggest any significant risk. In NZ self-reported rates of food allergy are up to 15%. In studies of food allergy done by double blind test, these are usually positive in only 2 - 5%. This means that about 10% of our population may believe they have a food allergy when, in fact, they don't. This is quite problematic for them for two reasons: They have to avoid food and all the social issues with food avoidance can be significant The 'real' cause of their symptoms does not get diagnosed because it is put down to food allergy. Unfortunately real food allergies also exist, and can cause alot of anxiety. A recent well conducted study of infants in Melbourne found rates of food allergy as high as 10%, and admissions for anaphylaxis (severe allergic reaction) have doubled in the last ten years. So how do I find out if I have an allergy or not? The only way to work out which of these situations applies to you, is to see a doctor: with a good knowledge of allergy who has experience in the use of the scientifically validated ways of testing for allergy who takes a detailed clinical history (essential) then uses only the appropriate skin tests and/or IgE blood tests. After this a discussion must take place between doctor and patient about: has allergy been completely ruled out now? is allergy definitely confirmed now? is allergy still possible but not definite. In this case should a challenge test be considered? What to do with this information is a decision made together, taking into account the information the immunologist provides, with the patient weighing up their options and deciding what to do. This can be an individual decision for each patient, according to what is important to them.

Testing for food allergy The diagnosis of food allergy has become much more common in the last 20 years. It was rare before the 1980s, now about 15% of the population report that they have a food allergy. Is this increase in perceived food allergy due to: an increase in real food allergy for some reason? an increase in testing for food allergy so we just pick it up more? or more widespread use of inaccurate food allergy testing and diagnosis? There is some evidence to support all three of these factors. This is very unfortunate, because there are significant social and psychological effects of having a label of food allergy. Did you know? In studies where the population is asked in surveys whether they have a food allergy, 15% report that they do. In some studies where allergy is accurately diagnosed with a "blinded" food challenge, it turns out only 2% are allergic. This means that many people are labouring under a false diagnosis and experiencing the social and psychological burden of an incorrect and unnecessary food allergy diagnosis. Alternatively, genuine food allergy can cause anaphylaxis (a serious allergy reaction) and be dangerous (although actual fatalities are extremely rare). Furthermore, admissions for anaphylaxis have doubled in the last ten years and a study from Melbourne using food challenges found a positive rate of 10% of the population. These are 2 reasons why accurate diagnosis of food allergy is essential. It's important to know if you do have it, it's important to know if you don't have it...so how do we find out? Diagnosing food allergy - symptoms of food allergy, skin tests, and blood tests Investigating food allergy requires careful discussion of a patient's symptoms. Simply ordering skin tests or blood tests alone is not sufficient. These are useful diagnostic tests, but only when analysed together with a patient's symptoms. Typical symptoms for food allergy should occur within about 90 minutes of eating, and include: hives (urticaria) after eating sudden itch of body or mouth with eating swelling of lips, tongue or eyes (angioedema) after eating lightheadedness with eating or collapse wheezing, coughing or difficulty breathing with eating sudden marked nausea, vomiting or diarrhoea after eating. If any of these symptoms occur within about 90 minutes of eating a specific food, a food allergy is possible. For people who do not have symptoms of food allergy, allergy testing with skin tests or allergy blood tests can be unreliable and give incorrect diagnoses. For this reason, accurate assessment by a doctor with good experience in allergy diagnosis is critical before allergy tests are ordered. Common food allergies Over 90% of food allergies are caused by: Milk allergy Egg Allergy Peanut allergy Tree nut allergy (Cashew, Pistachio, Almond, Walnut, Hazelnut, Brazil Nut, Pecan) Soy allergy Wheat allergy Fish allergy Shellfish allergy. Which food allergies affect children? All of these allergies can occur in children. Milk and egg allergies in infants often resolve (but not always). Which food allergies affect adults? New onset allergies in adults are most often shellfish, fish, peanut, or tree nuts. It is exceptionally rare to have new onset milk or egg allergy as an adult. Sometimes wheat can be associated with exercise induced urticaria/hives or anaphylaxis in adults. Treatment for food allergy The first step is accurate diagnosis. Next, information must be provided about which foods need to be avoided. Click this link for information on peanut, tree nut and seed allergy An action plan for allergy should be provided with a supply of antihistamines. A discussion with your doctor should involve whether an adrenalin auto-injector such as an Epipen or Anapen is necessary. Do I need an Epipen® ? For those with food allergy, an Epipen® is necessary if: There has been anaphylaxis (a severe allergic reaction which compromises breathing or blood pressure causing lightheadedness, weakness or fainting) There is asthma as well (this increases the chance of severe reaction) Click this link for more information on Epipen® (Adrenalin Auto-injector) Will I die from food allergy like peanut allergy? Dying from food allergy is very rare. If you have a peanut allergy, one study estimated the yearly risk of dying from peanut allergy as 1 in 50000. Alternatively, US statistics say the lifetime risk of dying in a car is 1 in 80 (more than ten times higher). Therefore if you have a peanut allergy, you should be more afraid of the car ride to the restaurant, than the chance of dying from peanuts hidden in the meal. This does not mean we should be complacent about taking appropriate precautions, and eating out is one of the main times anaphylaxis from hidden peanut ingredients can occur, but it is reassuring for patients with peanut allergy who can be constantly fearful for their lives.

What causes eczema? Eczema is probably multifactorial, but it may be predominantly a deficiency in the bonding between cells in the skin. This leaves small breaks in the skin which can become inflamed, hence the red, itchy rash. Should I stop certain foods for eczema? There is a lot of mis-information about this. Advice to avoid large numbers of foods can be very harmful nutritionally, psychologically and socially, both for adults and children. Almost all eczema in adults is not food related. In only a small proportion of eczema cases in children should foods be avoided just because of eczema. In most cases it is better managed by other means. Steroid creams can be safe with excellent relief Certain creams, such as 1% hydrocortisone, are so mild they can be put on the skin every day for 25 years without causing any skin damage. The skin will be less damaged if steroid creams are used, and eczema kept away. Heard of bleach baths? In one study, some patients were randomised to normal baths and the others to a bath with half a cup of Janola in it. This makes the bath basically about the same chlorine concentration as a swimming pool. Those having the bleach baths twice weekly for 15 minutes each time had a 30 - 40% improvement in their eczema. Bleach baths work by killing a bacteria on your skin called Staph Aureus, which drives eczema. What about dust mite desensitisation? In those patients with a positive dust mite skin test, or IgE RAST blood test to dust mite, a study has shown that eczema improves on average by about a third if they have dust mite desensitisation. For people with only mild eczema this may not be worth it, but for those with more severe eczema, this may be valuable.

Auckland Hospital Immunology Department Allergy Information Do I need an Epipen® ? For those with food allergy an Epipen® is necessary if: there has been anaphylaxis (a severe allergic reaction which compromises breathing or blood pressure causing lightheadedness, weakness or fainting) there is asthma as well (this increases the chance of severe reaction). Click this link for more information on Epipen (Adrenalin Auto-injector) Epipen® Patient Information EpiPen® Auto-injector is for emergency use in anaphylaxis (severe allergic reaction) for people with a history of anaphylaxis. About EpiPen® This is a single use, disposable, spring loaded injection that contain 0.3mg adrenaline which counteracts the effects of a severe allergic reaction and can be life saving. They are designed as emergency supportive therapy only and are not a replacement or substitute for emergency medical or hospital care. We will show you how to use the Epipen® and give you a practice. They have pictures on them which show: the needle end is orange the blue safety cap it can be injected into the thigh muscle through clothes if necessary, even jeans, but its best to avoid seams and pockets. When should I use my or EpiPen®? What is an Action Plan? An action plan tells you what to do if you think you might be having an allergic reaction. The Australasian Society of Clinical Immunology and Allergy (ASCIA) action plan can be downloaded from http://www.allergy.org.au/health-professionals/anaphylaxis-resources/ascia-action-plan-for-anaphylaxis This tells you what treatment to give yourself and advice on calling for help. How to use an EpiPen® Take the EpiPen® out of the plastic holder. Grip the EpiPen® in a tight fist. Do not put your thumb on the end (this is in case it’s the wrong way round and the adrenaline injection goes into the thumb which can cause damage to your thumb or fingers). Hold the middle of the pen in a tight grip. Remove the grey cap. You may have been shown one of two ways to do this; you can either position the pen on the outer middle of the thigh, and push hard into the thigh until the unit functions and a click is heard, or you can take off the grey cap and then aim the pen and hit the outer thigh from a short distance away. Hold the pen on the leg and COUNT TO TEN to allow the adrenaline to be injected by the auto-injector pen. If your EpiPen® has not clicked push harder into the thigh. Massage the area for several seconds to allow the adrenaline to spread out. What should I do then? If you have just given yourself the injection you should: phone or ask someone to phone an ambulance on 111 (in New Zealand) and tell the operator you are having anaphylaxis and have given yourself adrenaline don’t sit upright if you feel light headed or dizzy as it can be dangerous lie down and wait for the ambulance record the time the injection was given and take it with you to the emergency room. Disposal Dispose of the EpiPen® by putting it back the plastic holder. How do I get an Epipen®? You don’t need a prescription to get an EpiPen®. An EpiPen® costs about $140 and you usually have to pay for the first one, but if you are receiving support from WINZ they may help. Prices vary and some pharmacies charge up to $180. When I researched this recently I found the cheapest option to order it online at http://www.allergypharmacy.co.nz/. If you have to use your EpiPen® it is usually because of an accident (e.g. you accidentally ate peanut when you were peanut allergic, or you got stung by a bee). In this case the cost of a replacement Epipen® and any ambulance costs may be ACC refunded, so please keep your receipts and approach ACC about this. Unfortunately pens that go past their use by date are not refunded. Also pens used for reactions of unknown causes are also not funded. An EpiPen® should last 18 months but some pharmacies will sell you one which lasts less time because it has been waiting on the shelf already so check the expiry date. Shop around and get the cheapest one and make sure you get one that lasts over 12 months. Epipen® maintenance and travelling Regularly check the EpiPen® expiry date. Renew the EpiPen® before the expiry date and record the expiry date on your calendar. Always have your EpiPen® with you at all times even if travelling abroad. DON’T put it in sunlight, in the glove compartment of your car or anywhere it may get too hot or in the fridge which is too cold. Room temperature is best. Pouches are available for men, women tend to use their handbags. You can buy Epipen® trainers off the Internet to practise with. It is better to use an out of date EpiPen® / EpiPen® junior than nothing at all in the event of a severe allergic reaction. Some people have 2 Epipens® – e.g. if they are going to be significantly long way away from any medical help (on a boat/ship or tramping/mountaineering).

Bee Wasp Allergy Desensitisation Auckland Hospital Immunology Clinic For those with bee or wasp allergy, reactions can range from mild through to life threatening. We provide bee and or wasp sting desensitisation, which is an effective treatment to prevent reactions to future stings. Bee or wasp allergy can cause anaphylaxis. There is a fatality approximately once every 2 - 3 years in New Zealand from bee or wasp anaphylaxis. Desensitisation can help prevent this. For those who are allergic, the chance of a severe reaction with each bee sting is 75%. After desensitisation the chance of a reaction is only 5% and these are mild reactions. Desensitisation involves injections under the skin of small amounts of either bee or wasp venom. This starts from very small doses and gradually increases as the body builds up a tolerance. The injections are initially once weekly, then persist for 5 years. It is this length of treatment (5 years) that provides the longlasting benefits which continue after the treatment is stopped. Auckland Hospital Immunology has also desensitised a number of patients from other areas of New Zealand. This can be done by using newer faster protocols which can get up to the maximum dose over several days, so the patient does not need to stay in Auckland for long. Thereafter, ongoing maintenance injections can be done by a local GP. Auckland Hospital Immunology has contacts with DHBs from both the North and South Island. This treatment should, therefore, be available to anyone, if necessary.

Anaphylaxis is a severe reaction which can involve itchy skin rash, shortness of breath, dizziness or even loss of consciousness. Some patients can feel nauseated, get abdominal cramping, vomiting or diarrhoea. Sometimes anaphylaxis can cause immediate loss of consciousness without other symptoms (this is usually with insect stings or reactions due to drugs). Anaphylaxis is often due to allergy (but not always). This includes foods, medications and insect stings. Exercise can cause anaphylaxis, as can cold temperatures or water immersion. Infection can be a co-factor/partial cause. While just about any medication can cause anaphylaxis, common causes are antibiotics, aspirin and NSAIDs (Non Steroidal Anti-inflammatories), and anaesthetics. All patients with anaphylaxis should be seen by an Immunologist. Treatment involves identifying the cause and avoiding it. An action plan that advises what should be done in the event of any further attacks is necessary. This should be organised in consultation with your doctor, and should include the use of an adrenaline autoinjector such as an Epipen. Education must be given to show how the adrenalin autoinjector work (with a trainer pen). Finally, good education needs to be given on how to avoid the cause. Occasionally, regular daily antihistamines are used to prevent recurrent anaphylaxis, but most people do not need this.

Samter's triad - Aspirin Exacerbated Respiratory Disease (AERD) Some people develop a running, blocked nose in early adult life that may progress to asthma and sinusitis. Some of these people turn out to have nasal polyps. This is known as Samter's triad. The complete combination is: rhinitis (constant or frequent running nose) asthma nasal polyps (and sinusitis) aspirin or anti-inflammatory (NSAID) sensitivity. Click here for an article on Samter's triad written for Allergy New Zealand by Andrew Baker ADHB Immunologist. Treatment of Samter's triad can be started with nasal sprays and sinus rinses however many people require surgery such as polypectomy. Furthermore, some people with these symptoms can have adverse reactions when they take aspirin or anti-inflammatories. Aspirin desensitisation is an important treatment in this scenario. Aspirin desensitisation has the following proven benefits: improved asthma symptoms fewer episodes of sinusitis slower polyp regrowth after operation (from average 3 years to 10 years) less steroid medication required fewer hospitalisations.

Non-steroidal anti-inflammatories (NSAIDs) and aspirin are a large group of medications which are freely available over the counter in both pharmacies and stores such as supermarkets. They are used for pain most often, but also for fever and sometimes other reasons. There are several ways in which people can have adverse reactions to NSAIDs and aspirin. Worsening asthma, coughing or rhinitis/nose running. Urticaria (hives). Angioedema (swelling lips tongue or around the eyes). Anaphylaxis (severe reaction). Other serious rashes. In general, because these medications all work the same way, if you have reacted to one of them, the risk is now there for all of them so all must be avoided. Also, the risk is often intermittent, so tolerating an NSAID or aspirin one day, does not guarantee tolerating an NSAID or aspirin another day. Furthermore, it is not uncommon to have a mild reaction or no reaction sometimes, then on another day to have a severe reaction. This is unpredictable, and therefore they all should be avoided at all times. Finally NSAIDs work for several hours, so although reactions may occur in just a few minutes, they can also occur several hours after taking the tablet. NSAIDs are very common medications and there are a large number of different names for them, so check the ingredients/back of packets to make sure your medication is not an NSAID. This includes even cold and flu remedies, some throat lozenges. We can provide a list of the aspirin and NSAID containing medication in New Zealand for you. This list is very long and hard to remember, so the safest way is to check the back of any tablet packet and look for the warning NSAID or non-steroidal anti-inflammatory or aspirin. The main risk is a severe asthma attack or anaphylaxis. Most people will need treatment for pain at some stage in their life. Arcoxia® is an anti-inflammatory which is likely be safe for you, but this needs to be discussed and a challenge test is necessary first to prove this is safe. This may be useful to provide an effective pain relief option in the future for you which could be invaluable. Otherwise paracetamol is generally safe, and there are other pain relief options such as codeine which can be taken with the usual precautions. LIST OF MEDICATIONS AVAILABLE IN NEW ZEALAND THAT CONTAIN ASPIRIN AND ASPIRIN-LIKE DRUGS, JUNE 2007 This sheet lists most aspirin or non-steroidal anti-inflammatory (NSAID) containing preparations available in New Zealand, however, there are new preparations coming onto the market all the time. As well as this, there are many other aspirin-containing preparations that originate from overseas. It is therefore important to check any preparations that you use carefully, particularly those used for pain relief and for treating colds. If you are unsure whether a particular preparation contains aspirin or other NSAID, please check with your doctor and/or pharmacist. List of oral or injectable medications that contain aspirin or other NSAIDs TRADE NAME ASPIRIN / NSAID Acetyl Salicylic Acid Aspirin ACT-3® Ibuprofen Alka-Seltzer® Aspirin Apo-Diclo EC® Diclofenac Apo-Ibuprofen® Ibuprofen Arthrexin® Indomethacin Aspec 300 or 75® Aspirin Aspro/Aspro Clear® Aspirin Brufen® Ibuprofen Calm-U® Salicylamide Cardiprin® Aspirin Cartia® Aspirin Cataflam® Diclofenac Clinoril® Sulindac Daclin® Sulindac Diclax® Diclofenac Disprin and Disprin Max® Aspirin Ecotrin® Aspirin Ethics Aspirin® Aspirin Ethics Ibuprofen® Ibuprofen Fenpaed® liquid Ibuprofen Flameril ® Diclofenac Heartcare Aspirin® Aspirin Ibucare® Ibuprofen Ibuprofen-lysine injection Ibuprofen I-Profen® Ibuprofen Mobic® Meloxicam Naprogesic® Naproxen Naprosyn® Naproxen Naxen® Naproxen Noflam® Naproxen Nurofen®(including, Nurofen®cold & flu) Ibuprofen Oruvail® Ketoprofen Panafen® Ibuprofen Piram-D® Piroxicam Pirophen® Aspirin Ponstan® Mefenamic acid Rheumacin® Indomethacin Solprin® Aspirin Sonaflam® Naproxen Surgam® Tiaprofenic acid Synflex® Naproxen Tilcotil® Tenoxicam Voltaren® Diclofenac Ibuprofen and aspirin are both available from supermarkets and may have different brand names. Preparations of these products are made by Pam’s®, Signature Range® and other brands – look out for the medicine that they contain. List of topical medications that contain aspirin or other NSAIDs TRADE NAME ASPIRIN / NSAID Crampeze® Wintergreen oil* Coco-scalp® Salicylic acid Deep Heat® Methyl salicylate Duofilm® wart gel/paint Salicylic acid Egozite® Salicylic acid Ionil-T® Salicylic acid Metsal® Methyl salicylate Nurofen® Ibuprofen Posalfilin® Salicylic acid Oruvail® Ketoprofen Rheumon® Etofenamate Sebitar® Salicylic acid Sloan’s® Methyl salicylate or glycol monosalicylate Tiger Balm muscle rub® Methyl salicylate Voltaren emulgel® Diclofenac Whitfields® Salicylic acid Willow Bark *Wintergreen and wintergreen oil is another name for methyl salicylate – this ingredient may be found in other muscle or pain creams, balms or rubs. Willow Bark is a herbal compound that has aspirin-like properties, it may be present in oral or topical products. Salicylic acid may be found in corn and wart removal products, dandruff and psoriasis treatments as well as some face washes for acne. List of mouth/throat preparations that contain aspirin or other NSAIDs TRADE NAME ASPIRIN / NSAID Difflam® (oral and throat products) Benzydamine Strepfen® (oral and throat products) Flurbiprofen List of ocular (eye) preparations that contain aspirin or other NSAIDs TRADE NAME ASPIRIN / NSAID Acular® Ketorolac Ocufen® Flurbiprofen Voltaren® Ibuprofen List of medications that contain COX-2 inhibitors* TRADE NAME COX-2 INHIBITOR Arcoxia® Etoricoxib Celebrex® Celecoxib Dynastat® injection Parecoxib Prexige® Lumiracoxib *COX-2 (cyclo-oxygenase-2) inhibitors work in a similar way to aspirin but are more selective in their action. Because of this, there is likely to be a slightly increased risk of reactions in those sensitive to NSAIDs. They can still be used in most people who are sensitive to NSAIDs but medical advice should be sought prior to use. Vioxx® (Rofecoxib) and Bextra® (Valdecoxib) were withdrawn from sale in 2004 and 2005 respectively. Both of these products are COX-2 inhibitors.

PATIENT INFORMATION ON ASPIRIN DESENSITISATION What are the reasons for aspirin desensitisation? There are two main clinical situations where aspirin desensitisation is needed: The first is when a patient has had a previous reaction to aspirin, but now requires a daily aspirin tablet for the blood thinning effect to prevent stroke or heart disease. The second situation is when a patient has aspirin exacerbated respiratory disease (also known as AERD or Samter’s triad). In this condition patients suffer from aspirin sensitivity, nasal polyps, rhinitis (running nose), recurrent sinusitis and asthma. Aspirin desensitisation allows these patients to take a daily aspirin tablet which helps in a number of ways as follows: Reasons for undertaking aspirin desensitisation in AERD/Samter’s triad In patients with Samter’s triad (nasal polyps, asthma and proven aspirin sensitivity) aspirin desensitisation has a large number of benefits, well proven in multiple studies, as follows: improved asthma control. Studies have shown patients have improved asthma symptoms and fewer exacerbations less medication required for asthma in the future – most importantly less oral prednisone less hospitalisation in the future a reduction the severity of sinusitis/nasal polyposis and patients need less nasal steroid spray in the future fewer infective episodes of sinusitis and fewer courses of antibiotics required a significant reduction in the rate at which polyps regrow after operation. After a polypectomy/sinus operation, the average time until further operation is required is just 3 years without aspirin desensitisation, but it is 10 years with aspirin. Aspirin desensitisation also decreases the chance of polyp regrowth in the first year by 45% improved sense of smell. How is it done? The process of desensitisation is performed in our clinic (called Immunology Daystay) and takes separate visits usually over a number of weeks. This can vary depending on the dose required and whether any allergic symptoms develop. A very low dose of aspirin is started. Patients take this same dose each day until seen a week later to try a slight increase in dose at our clinic. The increased dose is then taken over the next week until you see us again for another increase in dose. It is very important that aspirin is taken every day following this but never at a dose larger than that given in the day ward unless instructed otherwise. Possible side effects of aspirin desensitisation Because we increase the doses gradually starting at very low doses, many patients experience no side effects from aspirin desensitisation. Nevertheless a number of side effects can occur. If side effects do happen it is usually when you are at clinic with us giving the increase in dose and we can give you some treatment. Running nose/cough - the most common side effect in the short term is some nose running or a cough which can happen at the time we increase your dose in our clinic, and usually only lasts for a few minutes. Wheezing, particularly if being treated for Samter’s triad. This potentially can be severe and is the most significant risk. It is important to monitor your peak flow closely during the desensitisation process. Any drop in the peak flow should be treated effectively with your asthma medications and the doctors looking after you should be notified before continuing with the desensitisation. All regular asthma preventer inhalers must be taken regularly throughout the process. Singulair must be taken throughout on a daily basis. This helps with your symptoms and decreases the risk of desensitisation. Runny, congested eyes and nose, particularly in Samter’s triad. It is important to continue the nasal spray prescribed. Stomach irritation causing indigestion can occur. Rarely ulceration and bleeding can occur at high doses over a long period of time e.g. months/years. We aim for low (but effective) aspirin doses to minimise this risk, and to treat/avoid these symptoms a drug called Losec® will often be prescribed. Easy bruising on high doses is common but rare at the lower doses we use. Tinnitus (ringing in the ears) is rare, usually occurs at high doses and is very rare at the lower doses we use. Skin reactions e.g. urticara (also known as hives). Swelling of lips / tongue – also known as angioedema. Anaphylaxis – this can cause urticaria (hives), angioedema (swelling) and can cause low blood pressure and stomach cramps and can be severe. Are there any risks in undertaking aspirin desensitisation as an outpatient? In most cases, low dose aspirin desensitisation is effective and safe. However there is always the potential for a significant reaction. For this reason desensitisation is only undertaken in a clinic supervised by an immunologist, and patients are asked to stay for up to two hours (one hour if not Samter’s triad) after the last dose before you can go home. We recommend that you organise someone to take you home afterwards in case you have required additional treatment. Ongoing management after aspirin desensitisation It is very important that you continue to take aspirin at the prescribed dose on a daily basis unless advised otherwise by an immunologist. If aspirin is discontinued patients will become sensitive to it again. If one dose of aspirin is missed, it should be taken as soon as remembered, however if more than two (2) days without aspirin have elapsed then aspirin should not be restarted, and the on-call immunologist at Auckland Hospital should be contacted for a plan. If you miss more than 2 days you may need to begin the aspirin desensitisation process again supervised in clinic from the starting dose. For this reason it is important to plan ahead and not miss your aspirin doses. You should never take more than the dose received at clinic as you are at risk of reacting to a higher dose unless there is a gradual build up and this should only ever be done under our specialist advice. Issues with pain relief/analgesia in the future It is very important to avoid all bigger doses of aspirin (e.g. Disprin 600mg) and all non-steroidal anti-inflammatory medications (NSAIDs) in the future. These include Nurofen, Brufen, ibuprofen, Voltaren, diclofenac, naproxen, tranexamic acid, indomethacin and many others. Despite successful aspirin desensitisation, all non-steroidal anti-inflammatories (NSAIDs) should still be avoided because they are effectively similar to a very high dose of aspirin (much higher than you have been desensitised to). These are very common medications and there are a large number of different names for them, so check the ingredients/back of packets to make sure your medication is not an NSAID. This includes even some cold and flu remedies and even some throat lozenges, and many NSAIDs are available over the counter in supermarkets and other stores. We can provide a list of the aspirin and NSAID containing medication in New Zealand for you. This list is very long and hard to remember, so the safest way is to check the back of any tablet packet and look for the warning NSAID or non-steroidal anti-inflammatory. The main risk would be a severe asthma attack or anaphylaxis. Arcoxia® Challenge Most people will need treatment for pain at some stage in their life though. Arcoxia® is an anti-inflammatory which is likely be safe for most people who have aspirin sensitivity, but this needs to be discussed with an immunologist, and a challenge test is necessary first to prove this is safe. An Arcoxia® challenge is therefore useful to provide an effective alternative pain relief option, which could be invaluable when pain eventually does occur. Paracetamol is generally safe after aspirin desensitisation, and opiate pain relief options such as codeine can be taken with the usual precautions, such as monitoring for nausea or sedation. Please follow this link for further information regarding aspirin desensitisation for Samter's triad written by Dr Andrew Baker for Allergy NZ website.

There is no good quality evidence to support the use of low salicylate diets for the treatment of: urticaria angioedema Samter's triad (asthma, nasal polyps, sinusitis rhinitis aspirin sensitivity) anaphylaxis. Salicylates in aspirin are very different to salicylates in food. While a number of patients with urticaria, angioedema, asthma, rhinitis/sinusitus do react adversely to aspirin, (acetyl salicylic acid) studies have shown that these same patients do not react to dietary salicylates. Furthermore, concerns regarding the harms of low salicylate diets have been raised. Please click this link for a scientific article reviewing what the published medical evidence says about low salicylate diets. The majority of Immunologists in Australasia do not support the use of salicylate exclusion diets.

Please see the link below for information on subcutaneous immunoglobulin infusions. Subcutaneous Immunoglobulin Infusions - NZCIAG Administration Information (DOC, 771 KB) Administration guidelines for subcutaneous immunoglobulin infusions

Please click for nursing information on how to administer subcutaneous immunoglobulin Nursing guidelines for administration of subcutaneous immunoglobulin (DOCM, 514.6 KB)

NZCIAG Nursing guidelines for administration of IVIg (DOCM, 286.1 KB)

A food challenge is a definitive way of testing for the presence of a food allergy. Usually an allergist begins the process of diagnosing a food allergy with a detailed history about previous exposure to the food(s) in question and symptoms that arose following intake of the food. Often allergy testing with blood and/or skin testing will follow. However sometimes, even with this information, it still isn’t clear whether there is an allergy to a particular food or not. In these circumstances, a food challenge can offer valuable information about the way in which the body will respond to intake of the food in question. It can therefore be a very accurate diagnostic test. A food challenge involves being given carefully measured amounts of a food to eat under monitoring. Usually this is done in a specialised environment with highly trained medical professionals. Schedules have been developed for the optimal amounts to use, and time intervals between doses in order to optimise safety. The initial amounts of food are very small and unlikely to cause a significant allergic response, even in an individual with allergy. If signs of an allergic reaction are displayed during a food challenge, this is treated accordingly. Often food challenges are conducted ‘blinded’. This means that either the patient alone, or both the patient and health professional are unaware of whether any given dose contains the food being tested or not. This increases the objectivity of the test. This is because biases or preconceived notions about allergy (of either patient or doctor) are removed. At the end of a food challenge, it is often known whether a) there isn’t an allergy to the tested food (therefore it is safe to eat it) b) there is a food allergy (therefore the food should be avoided). However, like any diagnostic test, sometimes there isn’t a clear result, and the challenge may need to be repeated or another step taken.

Please see the attached article below. Article Explaining the Rationale of Immunotherapy Desensitisation Injection Technique by Nurse Specialist Simone Stephens of ADHB (DOC, 79 KB)