This week on the GI bulletin board there was a brief discussion about overcoming allergic/anaphylactic reactions to infliximab. A reference and a thoughtful response by Athos Bousvaros (in italics) follows:
Inflamm Bowel Dis. 2001 Feb;7(1):34-7. Successful desensitization and therapeutic use of infliximab in adult and pediatric Crohn’s disease patients with prior anaphylactic reaction. Puchner TC, Kugathasan S, Kelly KJ, Binion DG.
1. Premed with 4 days of steroids (1mg/kg up to 40mg), and hydrocortisone day of the infusion.
2. Give two test doses (0.1 mg, 1 mg), each over 10 minutes,
3. If no problems, run the infusion over 4 hours instead of two.
Getting antibodies to infliximab before the challenge may also be helpful. If high levels of antibodies are present, the patient may be more likely to fail the challenge. WE can “rescue” about half our patients using this protocol, and keep them on infliximab. IMPORTANT that a physician is around during the challenge.
Given the potential for adverse reactions and the importance of not depleting useful treatments, it is definitely worthwhile to read the entire cited reference rather than the aforementioned summary.
Related blog entry:
In subjects with known food reactions, avoiding food ingestions is quite difficult (Pediatrics 2012; 130: e26-e32).
This study enrolled 512 children at ages 3-15 months and followed them for a median of 35.5 months. Patients had to have positive skin prick test to milk or egg in addition to either a history consistent with an IgE-mediated food reaction to milk or egg or a history of moderate-to-severe atopic dermatitis.
- High rate of reactions: 1171 reactions reported in 367 (72%) of subjects.
- Most reactions were attributed to lack of vigilance, like not checking ingredients
- Parents most frequently were the providers at time of incident (36%); however, about half of all allergic reactions were attributed to other providers (eg. grandparents, teachers)
- Of severe reactions (n=134, 11%), only 30% were treated with epinephrine. Almost all severe reactions were due to ingestions (95%) rather than skin or inhalation exposures.
Bottom line: More work is needed to prevent these reactions and to improve the treatment when they occur.
Food allergy affects 4-8% of children and allergic reactions can be fatal. In fact, the main cause of poor outcome with accidental food allergy exposure is delay in the use of epinephrine. To improve parental knowledge and overall management of food allergies, a group of allergists, nurses and dieticians has developed and validated educational materials (J Pediatr 2012; 160: 651-6). In addition, they have made these materials available at no cost online:
- www.cofargroup.org (Consortium of Food Allergy Research Website)
To validate their materials, the authors enrolled 60 parents of newly referred children with a prior food allergy. The measured outcome was demonstration of an autoinjector for epinephrine. The correct number of steps in the use of the autoinjector increased from a 3.4 to 5.95 score (max score 6). In addition, at 1 year, the score remained high, 5.47. Knowledge tests improved as well: from 9.2 to 12.4 (out of 15); at one year, the score was 12.7. On a practical basis, the frequency of allergic reactions was reduced as well. The annualized allergic reaction rate dropped from 1.77 (historical data) to 0.42 after the instruction.
The article also relates that some of the material relied on previous educational material, in particular the food allergy emergency plan available from the Food Allergy & Anaphylaxis Network (www.foodallergy.org).
Materials available include information on specific allergic disorders, avoiding allergens, management in and outside home, and living a safe/healthy life. In addition, an educational video is available.
- -Bock SA et al. J Allergy Clin Immunol 2007; 119: 1016-8. Poor outcome with accidental food allergy exposure is delay in the use of epinephrine.
- -J Pediatr 2011; 158: 578. Oral food challenges allowed 84% to return foods to diet. n=125.
- -Clin Gastro & Hep 2010; 8: 755. Review of food allergy (vs intolerance) in adults. Gives list of hypoallergenic diet , pg 758.
- -Pediatrics 2009; 124: 1549-55. 3.9% of US kids w food allergy. Nat’l surveys.
- -NEJM 2008; 359: 1252 Review. Usual age of resolution: eggs @ 7yr (75%), milk @ 5yr (76%); wheat/soy -rarely cause IgE-mediated allergies 80% resolve by 5yrs> More persistent allergens: peanuts/tree nuts/sesame seeds = persistent in 80-90% at 5yrs, fish = persistent.
- -Pediatrics 2003; 111: 1591-1680. (supplement) Pediatric Good Allergy symposium
- -Pediatrics 2003; 111:829-835. Infants c food-induced enterocolitis often have multiple food allergies (cereal, veggie, poultry, meat) IgE based tests are negative (skin prick & IgE Abs
- -Gastroenterology 2001; 120: 1023-25; 1026-40. AGA position paper; technical review.
- -J Allergy Clin Immmunol 1999; 103: 717-728 &981-9. Pathogenesis & Dx/ mgt.