Guidance for Referral to the Allergy Clinic

 

NOTE Please be advised that the Allergy Service at Medway NHS Foundation Trust (MFT) is no longer available

Patients who require allergy services must now be referred to Guy’s and St Thomas’ Hospital (GSST)

Please read the allergy referral guidelines below before considering referral. The GSST allergy service also includes Advice and Guidance which should be accessed via the e-referral system (ERS)

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Referral guidance (by condition):

Anaphylaxis

Any patient with a history of anaphylaxis should be referred to the allergy clinic

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Asthma

Testing of asthmatics for allergy can be a useful guide to advice on allergen avoidance but desensitisation therapy is not currently recommended as a treatment for asthma per se

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Bee or wasp venom allergy

Any patient with a history of respiratory or a systemic allergic reaction (generalised urticaria, angioedema, bronchospasm or anaphylaxis) following a bee or wasp sting should be referred for assessment. Prescription of an Epipen is appropriate and some patients may benefit from desensitisation

Do not refer for screening due to other allergies, local reactions to stings or due to another family member being allergic to bee or wasp venom

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C1-Inhibitor deficiency

A diagnosis of C1-inhibitor deficiency should be considered in patients with:

  • unexplained episodic angioedema (without urticaria) and/or episodic severe abdominal pain presenting as an acute abdomen
  • a family history of these symptoms (or of known hereditary angioedema)

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Investigation:

  • a complement C4 is an efficient screening test, as this is markedly reduced in the vast majority of untreated patients
  • if a high index of suspicion remains, send both a clotted and a citrate-anticoagulated blood sample for C4, C1-inhibitor and functional C1-inhibitor level (if possible, while symptoms are present)

All confirmed cases of C1-inhibitor deficiency should be referred to a clinical immunologist

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Eczema

In the absence of symptoms of actual food allergy, there is little likely benefit of referring patients beyond the dermatology clinic. If the history suggests contact eczema, patch testing can be organised via dermatology

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Rhinitis

Rhinitis can be allergic or non-allergic, although both forms can co-exist

Allergic rhinitis is likely if symptoms obviously coincide with exposure to known aero-allergens, such as pollens and animal danders.  Allergic rhinitis due to a house dust mite allergen is less easy to distinguish clinically from non-allergic rhinitis

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Referral of patients with rhinitis to the allergy clinic is justified if it is:

  • to confirm the agent(s) responsible for allergic rhinitis, so that advice on avoidance can be given
    • (If the allergen is already clinically obvious, (e.g. pollen or cats) referral for purely diagnostic reasons may not be necessary)
  • to advise on treatment
  • to offer allergen desensitisation therapy

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Urticaria and angioedema

Urticaria (hives, weals or "nettle rash") and angioedema (soft tissue swelling) can occur independently or together.  Although these symptoms can be allergic or non-allergic, in the majority of cases no underlying trigger factor or associated disease is found and the condition is self-limiting

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The presence of any of the following features suggest symptoms are not due to food allergy:

  • there is no consistent relationship to a particular food trigger. In genuine food allergy, symptoms usually occur within 30 minutes of exposure and a delay of more than 2 hours is extremely rare
  • symptoms are spontaneous without any apparent triggering factor or come on overnight or first thing in the morning
  • symptoms have physical triggers, minor trauma, temperature change, sweating or exposure to water
  • symptoms persist for several days at a time
  • development of angioedema while on treatment with an ACE inhibitor. This can occur of the first time even after prolonged treatment

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Urticaria may follow non specific infections: hepatitis, streptococcal infections, campylobacter and parasitic infestation

In rare cases, urticaria may be a symptom of underlying systemic disease such as thyroid disease or connective tissue disease

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Management:

  • Provide advice regarding the benign and usually self limiting nature of the condition
  • Minimise overheating , stress, alcohol, caffeine
  • Prick tests and RAST tests are not useful for screening of potential allergens in chronic ordinary urticaria
  • Contact urticaria can be confirmed by contact urticaria tests but these are not the same as patch testing
  • Food allergy can normally be identified from a careful history
  • If angioedema is the only symptom exclude C1 esterase deficiency
  • Drug history
    • Many drugs including NSAIDs, penicillins and statins can cause urticaria
    • Opiates and NSAIDs may exacerbate existing urticarial

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Treatment:

  • Antihistamines
    • Individuals may vary in their response to different agents
    • Use fast acting antihistamines for sporadic attacks
    • Use continuous medication if attacks occur regularly
    • If there is no response to one antihistamine after 6 weeks switch to another
  • Steroids
    • In some cases of severe acute urticaria, such as a penicillin reaction, a short reducing course of prednisolone 30-40mg daily may be beneficial
    • Systemic steroids should not be used in chronic urticarial

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Advice and Guidance is being made available for all specialties, and is being provided by consultant specialists at East Kent Hospitals.  To make a request or to check to if a query has been answered, you will need to log in via the electronic Referral System (eRS)

Click here for the "how to access" e-Referral Advice and Guidance Manual for instructions on how to make a request and check responses

Have a question or query?

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