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A MANAGEMENT PLAN FOR PATIENTS WITH NUT ALLERGIES (pp 87, 111)

January 11, 2001

In this week’s issue of THE LANCET, researchers from Cambridge, UK, report the success of a newly designed management strategy for people with potentially fatal allergies to peanuts and other nuts.

Despite the high level of media attention given to nut allergies, little is known about the clinical features of such disorders, and strategies for the management of patients with known allergies are commonly poor. P W Ewan and A T Clark, from Addenbrooke’s Hospital, Cambridge, UK, set out to design and assess individualised management plans for patients with nut allergies on the basis of the severity of their past reactions.

567 patients with a confirmed peanut or tree-nut allergy were asked about the severity of their most serious reaction before referral (index reaction) and the amount of nut that had caused the reaction. The reaction was then graded on a scale of 1 (localised skin reaction only) to 5 (difficulty breathing or loss of consciousness). All patients were thoroughly briefed on the importance of nut avoidance, and advice on situations such as eating out and going abroad was given. Patients were also given different types of medication to take in case of accidental nut ingestion (antihistamine tablets alone for mild reactions; antihistamines plus an epinephrine [adrenaline] inhaler for moderate reactions; and antihistamines, epinephrine inhaler, and an epinephrine injector for severe reactions), and were instructed on how to use them.

After a median of 2 years, 88 (15%) of the 567 patients had had further reactions, most of which were mild. All patients except one successfully treated themselves. The remaining patient had a reaction that was more severe than the index reaction and which therefore required medication more powerful than he had available. This patient was successfully treated with an injection of epinephrine. In an accompanying Commentary (p 87), David J Hill and colleagues (Royal Children’s Hospital, Parkville, Victoria, Australia) question the wisdom of restricting the availability of epinephrine injectors, given that some studies - albeit those that did not include the avoidance education of Ewan and colleagues’ study - suggest that up to 44% of patients with mild index reactions can subsequently have life-threatening reactions.

Contact: Dr P W Ewan, Department of Allergy and Clinical Immunology, Addenbrooke’s Hospital, Hill’s Road, Cambridge CB2 2QQ, UK T: +44 (0)1223 217777 F: +44 (0)1223 21695;
E: pamela.ewan@msexc.addenbrookes.anglox.nhs.uk

Dr David J Hill, Department of Allergy, Royal Children’s Hospital, Parkville, Victoria 3052, Australia
T: +61 3 9345 5701 F: + 61 3 9326 6418 E: allergy@cryptic.rch.unimelb.edu.au

Lancet