Susan Leech

BSACI guidelines for the management of allergic and non-allergic rhinitis.

This guidance for the management of patients with allergic and non‐allergic rhinitis has been prepared by the Standards of Care Committee (SOCC) of the British Society for Allergy and Clinical Immunology (BSACI). The guideline is based on evidence as well as on expert opinion and is for use by both adult physicians and paediatricians practicing in allergy. The recommendations are evidence graded. During the development of these guidelines, all BSACI members were included in the consultation process using a web‐based system. Their comments and suggestions were carefully considered by the SOCC. Where evidence was lacking, consensus was reached by the experts on the committee. Included in this guideline are clinical classification of rhinitis, aetiology, diagnosis, investigations and management including subcutaneous and sublingual immunotherapy. There are also special sections for children, co‐morbid associations and pregnancy. Finally, we have made recommendations for potential areas of future research.

BSACI guidelines for the management of chronic urticaria and angio-oedema

This guidance for the management of patients with chronic urticaria and angioedema has been prepared by the Standards of Care Committee of the British Society for Allergy and Clinical Immunology (BSACI). The guideline is based on evidence as well as on expert opinion and is aimed at both adult physicians and paediatricians practising in allergy. The recommendations are evidence graded. During the development of these guidelines, all BSACI members were included in the consultation process using a Web‐based system. Their comments and suggestions were carefully considered by the Standards of Care Committee. Where evidence was lacking, a consensus was reached by the experts on the committee. Included in this management guideline are clinical classification, aetiology, diagnosis, investigations, treatment guidance with special sections on children with urticaria and the use of antihistamines in women who are pregnant or breastfeeding. Finally, we have made recommendations for potential areas of future research.

Diagnosis and management of hymenoptera venom allergy: British Society for Allergy and Clinical Immunology (BSACI) guidelines

This guidance for the management of patients with hymenoptera venom allergy has been prepared by the Standards of Care Committee (SOCC) of the British Society for Allergy and Clinical Immunology (BSACI). The guideline is based on evidence as well as on expert opinion and is for use by both adult physicians and pediatricians practising allergy. During the development of these guidelines, all BSACI members were included in the consultation process using a web‐based system. Their comments and suggestions were carefully considered by the SOCC. Where evidence was lacking, consensus was reached by the experts on the committee. Included in this guideline are epidemiology, risk factors, clinical features, diagnostic tests, natural history of hymenoptera venom allergy and guidance on undertaking venom immunotherapy (VIT). There are also separate sections on children, elevated baseline tryptase and mastocytosis and mechanisms underlying VIT. Finally, we have made recommendations for potential areas of future research.

Immunotherapy for allergic rhinitis.

Allergic rhinitis (AR) affects more than 20% of the population in the United Kingdom and western Europe and represents a major cause of morbidity that includes interference with usual daily activities and impairment of sleep quality. This guidance prepared by the Standards of Care Committee (SOCC) of the British Society for Allergy and Clinical Immunology (BSACI) is for the management of AR in patients that have failed to achieve adequate relief of symptoms despite treatment with intranasal corticosteroids and/or antihistamines. The guideline is based on evidence and is for use by both adult physicians and paediatricians practising allergy. During the development of these guidelines, all BSACI members were included in the consultation process using a web‐based system. Their comments and suggestions were carefully considered by the SOCC. Where evidence was lacking, consensus was reached by the experts on the committee. Included in this guideline are indications and contraindications for immunotherapy, criteria for patient selection, the evidence for short‐ and long‐term efficacy of subcutaneous and sublingual immunotherapy, and discussion on safety and the different modes of immunotherapy including, pre‐seasonal and co‐seasonal treatments. There are sections on children, allergen standardization, vaccines used in the United Kingdom, oral allergy syndrome, cost effectiveness of immunotherapy and practical considerations of undertaking immunotherapy including recommendations on who should undertake immunotherapy and dosing schedules. Finally, there is discussion on potential biomarkers of response to immunotherapy, the use of component‐resolved diagnostics, novel approaches, alternative routes and potential areas for future research.

British Society for Allergy and Clinical Immunology guidelines for the management of egg allergy

This guideline advises on the management of patients with egg allergy. Most commonly, egg allergy presents in infancy, with a prevalence of approximately 2% in children and 0.1% in adults. A clear clinical history and the detection of egg white‐specific IgE (by skin prick test or serum assay) will confirm the diagnosis in most cases. Egg avoidance advice is the cornerstone of management. Egg allergy often resolves and re‐introduction can be achieved at home if reactions have been mild and there is no asthma. Patients with a history of severe reactions or asthma should have reintroduction guided by a specialist. All children with egg allergy should receive measles, mumps and rubella (MMR) vaccination. Influenza and yellow fever vaccines should only be considered in egg‐allergic patients under the guidance of an allergy specialist. This guideline was prepared by the Standards of Care Committee (SOCC) of the British Society for Allergy and Clinical Immunology (BSACI) and is intended for allergists and others with a special interest in allergy. The recommendations are evidence‐based but where evidence was lacking consensus was reached by the panel of specialists on the committee. The document encompasses epidemiology, risk factors, diagnosis, treatment, prognosis and co‐morbid associations.

Management of allergy to penicillins and other beta‐lactams

The Standards of Care Committee of the British Society for Allergy and Clinical Immunology (BSACI) and an expert panel have prepared this guidance for the management of immediate and non‐immediate allergic reactions to penicillins and other beta‐lactams. The guideline is intended for UK specialists in both adult and paediatric allergy and for other clinicians practising allergy in secondary and tertiary care. The recommendations are evidence based, but where evidence is lacking, the panel reached consensus. During the development of the guideline, all BSACI members were consulted using a Web‐based process and all comments carefully considered. Included in the guideline are epidemiology of allergic reactions to beta‐lactams, molecular structure, formulations available in the UK and a description of known beta‐lactam antigenic determinants. Sections on the value and limitations of clinical history, skin testing and laboratory investigations for both penicillins and cephalosporins are included. Cross‐reactivity between penicillins and cephalosporins is discussed in detail. Recommendations on oral provocation and desensitization procedures have been made. Guidance for beta‐lactam allergy in children is given in a separate section. An algorithm to help the clinician in the diagnosis of patients with a history of penicillin allergy has also been included.

Molecular mimicry in autoimmune disease

The origins of autoimmune disease are multifactorial. Environmental factors and a genetic predisposition result in tissue injury caused by autoreactive T cells or antibodies. Usually a single organ or individual cell type is affected in the absence of gross abnormalities of the immune system. Autoimmune diseases tend to have long, asymptomatic prodromal periods and the initiating events leading to loss of self tolerance occur long before the disease becomes clinically manifest. This makes the initiating factors harder to identify and they remain largely unknown in humans.#### Key messages Several different pathological processes have the potential to break tolerance and cause autoimmune disease. Antigenic similarity between pathogenic organisms or foreign proteins and self proteins (molecular mimicry) is one of them. The major histocompatibility complex (MHC) is a collection of genes on chromosome 6 that codes for the human leucocyte antigens (HLA). These are glycoproteins expressed on the surface of cells that bind short peptides, degraded or generated by the cell, and present them to T lymphocytes (figs 1 and 2). The term “molecular mimicry” was used in the 1970s to explain persistent viral infections. It was suggested that the MHC and viruses encoded similar peptide sequences, which allowed the host to regard an infecting virus as “self” and forego an immune response. More recently, it has been used as a hypothesis to explain autoimmune disease.1 Several pathogens share antigenic …

BSACI guideline for the diagnosis and management of allergic and non-allergic rhinitis (Revised Edition 2017; First edition 2007)

This is an updated guideline for the diagnosis and management of allergic and non‐allergic rhinitis, first published in 2007. It was produced by the Standards of Care Committee of the British Society of Allergy and Clinical Immunology, using accredited methods. Allergic rhinitis is common and affects 10–15% of children and 26% of adults in the UK, it affects quality of life, school and work attendance, and is a risk factor for development of asthma. Allergic rhinitis is diagnosed by history and examination, supported by specific allergy tests. Topical nasal corticosteroids are the treatment of choice for moderate to severe disease. Combination therapy with intranasal corticosteroid plus intranasal antihistamine is more effective than either alone and provides second line treatment for those with rhinitis poorly controlled on monotherapy. Immunotherapy is highly effective when the specific allergen is the responsible driver for the symptoms. Treatment of rhinitis is associated with benefits for asthma. Non‐allergic rhinitis also is a risk factor for the development of asthma and may be eosinophilic and steroid‐responsive or neurogenic and non‐ inflammatory. Non‐allergic rhinitis may be a presenting complaint for systemic disorders such as granulomatous or eosinophilic polyangiitis, and sarcoidoisis. Infective rhinitis can be caused by viruses, and less commonly by bacteria, fungi and protozoa.

The investigation of chronic urticaria in childhood: which investigations are being performed and which are recommended?

Chronic urticaria (CU) is diagnosed on the basis of experiencing frequent weals, with or without angioedema, for 46 weeks. The most commonly identified avoidable precipitants are physical triggers such as exposure to pressure or cold. The prevalence of CU in the UK remains uncertain [1‐3]. CU has been shown to significantly impair the quality of life of suffers [4]. The precise pathophysiology of CU remains unknown; however, functional circulating antibodies (of the IgG1 and IgG3 subclass) directed against the FCeRIa or IgE have been demonstrated in a significant portion of both adults and children with CU [5, 6]. The British Society for Allergy and Clinical Immunology (BSACI) has recently joined the European Academy of Allergy and Clinical Immunology (EAACI/GA 2 LEN/EDF) in publishing recommendations for the investigation of CU [7, 8]. The BSACI makes specific recommendations for the investigation of CU in children. The BSACI recommendations state ‘if the clinical history and examination are typical of chronic idiopathic urticaria, then further laboratory investigations are rarely useful’. The recommended investigations are in two tiers; firstly, ‘if the clinical history suggests a candidate allergen, then allergy tests (skin testing or specific IgE tests) are warranted.’ A second tier of ‘additional investigations’ are also suggested‐if clinically indicated; these include, urine analysis, full blood count (FBC), erythrocyte sedimentation rate (ESR), liver function tests (and viral hepatitis screen if elevated) (LFTs), coeliac disease screen, thyroid function and anti-thyroid antibodies (TFTs), cold, dermographism and pressure provocation tests, elimination re-challenge diets, antinuclear antibodies (ANA), skin biopsy, complement/C1 inhibitor assays (C3/C4/C1 esterase), serum cryoproteins and an infectious disease screen (past/current viral, bacterial or parasitic).

The RCPCH care pathway for children at risk of anaphylaxis: an evidence and consensus based national approach to caring for children with life-threatening allergies

Aims Numerous studies have identified shortcomings in the management of children at risk of severe acute allergic reactions (anaphylaxis). The Science and Research Department at the Royal College of Paediatrics and Child Health (RCPCH) was commissioned by the Department of Health to develop competence based national care pathways for children with allergies. Anaphylaxis is the first completed pathway. Methods The anaphylaxis pathway was developed by a multidisciplinary working group, reviewed by a broad group of stakeholders and approved by the Allergy Care Pathways Project Board and the RCPCH Clinical Standards Committee. Results Pathway development is described under five headings: evidence review, mapping, external review, core knowledge documents and key recommendations. The full pathway can be downloaded from www.rcpch.ac.uk/allergy/anaphylaxis. This document describes the entry points and the ideal pathway of care from self-care through to follow-up. The five key recommendations focus on: (1) prompt administration of adrenaline by intramuscular injection; (2) referral to specialists with competence in paediatric allergies; (3) risk analysis; (4) provision of a self-management plan; and (5) suggested creation of a national anaphylaxis death register. Conclusions We present the first national care pathway for anaphylaxis, which is based on a critique of published evidence, expert consensus and multi-stakeholder input including patient representation via the Anaphylaxis Campaign. The Project Board urges health professionals to work together across networks to improve care for children at risk of anaphylaxis, in particular during the period after an acute reaction. Additionally, the Project Board strongly recommends the funding of a national anaphylaxis register.