Drug Treatment in the Management of Food Allergy

At present, drug treatment has little part to play in the management of food allergies. There are two exceptions. First, there are a very small number of cases in which the reaction to a food is exclusively gastrointestinal, and in whom the reaction can be blocked by taking the drug sodium cromoglycate by mouth 20min before the trigger food is swallowed. Second, there are a small number of individuals who develop the life-threatening reaction, of anaphylactic shock when exposed to a trigger food. There are three ways in which anaphylactic shock may prove fatal. First, rapid swelling of the soft tissues in the pharynx may completely obstruct the airway; the treatment is to bypass the obstruction, either by passing an endotracheal tube, or by performing a tracheostomy. Another mechanism is severe shock, with a profound drop in blood pressure; the life-

saving treatment is to restore the circulating volume with intravenous fluids and to give oxygen. The third mechanism is severe bronchoconstriction (asthma); here, the life-saving treatment is with bronchodilator drugs and artificial ventilation. If patients with life-threatening anaphylactic shock are to be saved, they must be given urgent (within minutes) medical attention. For individuals who have already experienced a life-threatening allergic reaction to a food, it is common practice to provide them with a syringe preloaded with adrenaline (epinephrine), with the aim that this should be administered while waiting for medical help. Unfortunately, self-administered adrenaline is not without its hazards (e.g., inadvertent intravenous administration causing fatal cardiac arrest), and there is no proof that it is life saving; indeed, there are many cases in which the subject died despite the use of epinephrine. Nevertheless, it is the best one can do when faced with someone who is experiencing a life-threatening allergic reaction to a food. The need for urgent medical help cannot be overemphasized.

There is little evidence that antihistamine drugs are of any value. It would be reasonable to take a nonsedating fast-acting antihistamine such as terfe-nadine if experiencing an allergic reaction to a food, but it is questionable whether it will have much effect.

A number of new approaches to the treatment of IgE-mediated food allergy are being examined. In a double-blind placebo-controlled study of monthly injections of a preparation of anti-IgE antibodies, treated patients with peanut allergy required significantly greater amounts of peanut protein to elicit allergic symptoms compared with control subjects. Another anti-IgE preparation has been used in the treatment of asthma but has not been evaluated in peanut allergy. Theoretically, anti-IgE antibody treatment should be protective against multiple food allergens, although it would have to be administered indefinitely. Other experimental approaches include a concoction of traditional Chinese herbs, injection of heat-killed Escherichia coli containing mutated recombinant peanut proteins Ara h 1 to Ara h 3, the use of immunostimulatory sequences, and the use of chimeric protein that could form complexes with allergen-specific IgE bound to mast cells and basophils.

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