Allergy basics 2014
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The document outlines the basics of allergies, types of allergic reactions, and various testing methodologies. It discusses the management of allergy cases, including workups, dietary changes based on test results, and hyposensitization treatment options. Diagnostic criteria for testing are included, along with statistics on food allergies and the effectiveness of different treatment protocols.
Allergy basics 2014
- 2. WHAT IS AN ALLERGY? Body’s Misidentification: − Pollens − Molds − Food Proteins
- 3. TThhrreesshhoolldd Itchy!! Not itchy… WHAT IS THRESHOLD?
- 4. TYPES OF ALLERGIC REACTIONS 5 different types of Allergic Reactions, 1 – 4.
- 6. Serum/Blood TYPES OF DIAGNOSTIC TESTING Intradermal/Skin
- 8. SERUM BASED TESTING Benefits: – No steroid/antihistamine withdrawal for testing – Simple blood draw – Non-invasive – Numeric values rather than visual confirmation
- 9. MANAGEMENT OF ALLERGY CASES Workup to Rule out Other Issues Allergy Testing Methodology & Preparation Change Diet based on Allergy Results Hyposensitization Reasons for Poor Response
- 10. WORK UP TO RULE OUT OTHER ISSUES Complete dermatological work-up such as: – Scabies / Parasite Infections. – Malassezia / Yeast Infections. – Bacterial Infections. – Endocrinology disease (Cortisol test). – Thyroid disease (T4/T5 test).
- 11. DIAGNOSTIC CRITERIA FOR TESTING by T. Willemse Primary Features: − Pruritus − Facial and/or digital involvement − Hardening/crusting of sores − Chronically-relapsing dermatitis − Individual or family history − Breed predisposition
- 12. DIAGNOSTIC CRITERIA FOR TESTING by T. Willemse Secondary Features: − Onset of signs before 3 years of age. − Generalized dry skin. − Superficial staphylococcal infection. − Cutaneous Malassezia infection. − Bilateral external otitis. − Facial erythema.
- 13. MANAGEMENT OF ALLERGY CASES Workup to Rule out Other Issues Allergy Testing Methodology & Prep Change Diet based on Allergy Results Hyposensitization Reasons for Poor Response
- 15. REGION SPECIFIC PANELS − Alaska − California − Great Plains − Hawaii − Mid Atlantic − Midwest − North East − North West − Rocky Mountain − South East − South Florida − South West
- 17. SUBMITTING A SAMPLE 3 – 5 ml of serum Absolute minimum - 1.5 ml. Order & History Form Pre-paid FedEx mailers provided Within 48 hours of the samples receipt, the results are e-mailed/ faxed to the ordering Veterinarian
- 19. INTERPRETING RESULTS SSEERRUUMM -- mmeeaassuurreess tthhee ssttrreennggtthh ooff tthhee rreeaaccttiioonn bbeettwweeeenn tthhee ssppeecciiffiicc IIggEE aannttiibbooddyy aanndd tthhee aalllleerrggeenn.. SSKKIINN -- mmeeaassuurreess tthhee iimmmmeeddiiaattee rreeaaccttiioonn ccaauusseedd bbyy tthhee ddeeggrraannuullaattiioonn ooff tthhee MMaasstt CCeellllss..
- 20. SERUM VS SKIN TESTING Update on Atopic Dermatitis & Secondary Infections - 2006 Stephen D. White, DVM Professor, University of California at Davis: “There is a great deal of controversy over which is more accurate, intradermal skin testing or serological tests. In 3 studies, at University of California at Davis, Colorado State University and Gifu University (Japan), involving a combination of over 250 dogs, the number of positive responses to hyposensitization were similar regardless of whether the hyposensitization solutions were based on Intradermal Skin Testing results or ELISA tests”.
- 21. TYPES OF ALLERGY TREATMENT AAVVOOIIDDAANNCCEE –– iiddeeaall bbuutt nnoott aallwwaayyss ppoossssiibbllee.. HHYYPPOOSSEENNSSIITTIIZZAATTIIOONN –– iinnccrreeaasseess ttoolleerraannccee ttoo aannttiiggeennss,,
- 22. MANAGEMENT OF ALLERGY CASES Workup to Rule out Other Issues Allergy Testing Methodology & Preparation Change Diet based on Allergy Results Hyposensitization Reasons for Poor Response
- 23. WHY FOOD ALLERGY TESTING?
- 24. IDENTIFYING ADVERSE FOOD REACTIONS EELLIIMMIINNAATTIIOONN DDIIEETTSS –– 66--88 wweeeekkss,, rreessuullttss vvaarryy,, ddiiffffiiccuulltt ttoo ccoorrrreellaattee cclliinniiccaall ssyymmppttoommss && ddiieett.. BBLLOOOODD TTEESSTTIINNGG –– iiddeennttiiffiieess pprreesseennccee ooff pprrootteeiinn ssppeecciiffiicc IIggEE,, uussee aass aa bbaassiiss ttoo ssttaarrtt ddiieett mmooddiiffiiccaattiioonn.. OOvveerr 220000 ddiiffffeerreenntt ffoooodd aanndd ttrreeaatt mmaannuuffaaccttuurreerrss iinncclluuddeedd..
- 25. HOW PREVALENT ARE FOOD ALLERGIES? Up to 10% of allergic disease is food protein based (Scott, 1978). Up to 23% in non-seasonal allergic skin disease is food protein based (Reedy and Miller, 1989). True prevalence is not known (Hall, 1994) but it is much greater than dermatological signs. Clinical signs of an allergic response may only become apparent when some arbitrary threshold of immunological activity is exceed (Brostoff and Hall, 1996).
- 26. PROBLEMATIC FOODS Most protein based foods are potentially allergenic Base molecule must be: – 18,000 – 30,000 Daltons – Heat resistant – Stable to hydrolysis
- 28. MANAGEMENT OF ALLERGY CASES Workup to Rule out Other Issues Allergy Testing Methodology & Preparation Change Diet based on Allergy Results Hyposensitization Reasons for Poor Response
- 29. HYPOSENSITIZATION TREATMENT Time/Dosage Concentration IgG IgE Threshold
- 30. TREATMENT SETS Patient Specific – No Stock Formulas Treat all Positive reactions – Except foods/Staph 3 vials – increasing concentration Green – Vial A Blue – Vial B Red – Vial C Up to 20 allergens in a single set*
- 32. EFFECTIVENESS OF TREATMENT What is Success? Volume of Testing to Date Results - 2,463 patients Diet change alone: 48% improvement. Hyposensitization only: 67% improvement. Diet change & Hyposensitization: 85% improvement
- 33. WHY A 91 ANTIGEN PANEL? 30 Allergens 45% 50 Allergens 55% 70 Allergens 70% 91 Allergens 85%
- 34. TECHNICAL SUPPORT DURING TREATMENT Worsening of symptoms returns. Why? Hyposensitization too aggressive for the particular animal’s immune system. Successfully handled by an adjustment to the hyposensitization schedule.
- 35. MANAGEMENT OF ALLERGY CASES Workup to Rule out Other Issues Allergy Testing Methodology & Preparation Change Diet based on Allergy Results Hyposensitization Reasons for Poor Response
- 36. REASONS FOR POOR RESPONSE 1. Poor owner compliance 2. Age of animal 3. Failure to treat other illnesses prior to testing 4. Suppressed immune system
- 37. HOW TO ORDER TREATMENTS/REFILLS • Contact Spectrum – Order online – Fax back reminder card – Call toll-free number • Delivery within 7-10 days • Statement at E.O.M.
- 38. THE SPECTRUM ADVANTAGE 1. Increased services/care to existing client base. 2. Test for more-including foods; lower price. 3. No need to wean of steroids. 4. No need to sedate/shave animal. 5. Blood draw isn’t painful. 6. List of approved foods provided. 7. More comforting to the pet and owner. 8. Same technology used by Veterinary Dermatologist. 9. Competitor Retest provided at no charge.
- 39. Questions?
- 40. THANK YOU!! Lyndee Kelver lkelver@vetallergy.com 800.553.1391, ext. 116 www.VetAllergy.com www.VacciCheck.com
Editor's Notes
- #2: Welcome/Intro Spectrum –22 years; all 50 states / 40 + countries Anyone testing currently? With whom? One and done approach.
- #3: Genetic predisposition to develop an immunological hypersensitivity to common environmental substances. Pollen, molds, food proteins, etc. Only minute amounts of allergens required. Each animal has an internal Threshold to tolerate allergy symptoms. Below Threshold the animal can tolerate the symptoms of allergies. Above it, they can not. GOAL: To help the veterinarian identify the allergens causing the symptoms, and, through 2 different methods of treatment, help them bring the animal below its Threshold.
- #4: Itching appears when the specific IgE antibody levels, caused by the allergens, surpasses its threshold. Think of glass overflowing.
- #5: 5 different types of Allergic Reactions, classified: 1 – 4. allergy diagnosis, however, is mostly only concerned with: Classification - Type 1 - acute, internal Anaphylactic reaction: IgE mediated (caused). Degranulation of Mast Cells. Mediators released. Atopy, Dermatitis, Asthma, etc, result.
- #7: Intradermal testing takes place just under the skin, reaction is measured with a special ruler Serum: testing takes place in a microtiter plate
- #8: Subcutaneous injection of allergen. Dermatologist measures the reaction between the allergen and the degranulation of the Mast Cell. Sedation Discontinued suppression therapies Up to 4 to 6 weeks The test can range from uncomfortable to painful if the animal is highly allergic. Cannot test for as many allergens as serum -based testing. Cannot test for food allergens. Serum (simple blood draw; no withdrawl, no sedation, food allergy included in U.S)
- #9: Several types of serum testing: ELISA (simple to run, highly sensitive, provides quick and accurate results; cons: associated with false positives, false negatives ) RAST (excellent reproducibility, but can be costly-radioactive isotopes usage & disposal) Western Blot (runs patient’s sample thru a gel by using an electrical current; cons: can be difficult to perform& requires high level of skill) General benefits of serum vs intradermal testing: Now before we go through basics of testing we need to do some pre-work up to rule out and possibly address other issues
- #10: General vets expected to do more Great service to add to practice - Keeps u in control Clinic more comprehensive Provides real solutions
- #11: Rule these out as causes Allergy testing is diagnostic in nature; used to quantify what seeing clinically Scabies / Parasite Infections. Malassezia / Yeast Infections. Bacterial Infections. Endocrinology disease (Cortisol test). Thyroid disease (T4/T5 test). --CAN RUN IN CONJUNCTION WITH ALLERGY TEST THROUGH SPECTRUM
- #12: Based on: diagnostic criteria for all testing Dog should fulfill at least 3 of primary and 3 of secondary features Pruritus (scratching and itching). Facial and/or digital involvement (feet) Lichenification (hardening / crusting of sores). A chronic or chronically-relapsing dermatitis (skin-related issues dry, irritated, red, etc.). An individual or family history of atopy (allergy). A breed predisposition. Golden Retriever, West Highland White Terrier, and Bichon Frise.
- #13: Secondary Features Onset of signs before 3 years of age. Generalized dry skin. Superficial staphylococcal (bacterial) infection. Cutaneous (skin’s surface) Malassezia (yeast) infection. Bilateral external otitis (ears). Facial erythema (redness)
- #15: Spectrum has taken best of both RAST and ELISA and combined into 1 patented technology: simple to run, provides consistent and reliable results. Testing panels available for dog, cat, horse and even employees of the clinic with our human panel. We can and have also repurposed these for primates UC Davis and several zoos. IMPROVEMENTS TO TESTING May 2013: -increased ability for allergen to adhere to testing plate & optimize binding (red. False +) Standardized allergens to provide (more consistent results) All synthetic (non-protein) based reagents (red. False +) Buffer blocking competing antibodies (IgG, IgM and IgA—red False +)
- #16: US broken down into 10 regions: AK, CA, GP, HI, MA, MW, RM, SE, SF and SW Standard panels are 91 antigens for small animal (dogs, cat) and 87 antigens for large animal (equine) Other panels available for testing but most comprehensive is best as it give us the BEST overall picture Pollens can travel hundreds of miles (just BC in in back yard doesn’t mean no contact w/ it) Also have allergen database of over 200 allergens that they can add to test/treat for outside their traditional panel Let’s look at antigens included in the California Panel…
- #17: Some things don’t see in immediate environment- These cases: WTG are the same on each panel but the fungi, insects and indoor allergen are different for horses than small animal and they all have unique foods (specific to species) . For equine: timothy grass vs timothy hay or corn as food and corn pollens. Explain. Looking at antigens from 2 different perspectives: 1 as inhaled allergen 1 as a protein or food. FOODS: 24 most common ingredients in commercial pet food; can add additional allergens (250 database) for additional $15 each.
- #18: Weigh bills will not be accepted but can call the 866 # or order form if out and ready to submit a sample (can take up to 2 hours) Call FedEx and schedule a pick up CRT-include previous results or any other pertinent information to order/history form (discuss later) ***A completed and accurate history form is VERY important to understanding a patient’s results as they come up from the lab.***
- #19: 24 page cust allergy profile – under pet parent tools on vetallergy.com Color code all reactions Red-positive List of foods –no offending allergens Manufacturer’s info General allergy overview Questionniare about environment List of sm things do to better manage what allergens you can
- #20: related but different reactions Correlation range from quite similar to minimal Our concern - not correlation between results, but will the animal get better with testing and by following the 2 different types of treatment.
- #21: “UPDATE on ATOPIC DERMATITIS and SECONDARY INFECTIONS”presented at the Ontario (Canada) Veterinary Medical Association, Jan 26 2006 Presented by Steven D White, DVM Professor at UC Davis Says essentially number of + responses Were similar regardless of testing method –skin vs serum
- #22: 2 Types of allergy treatment: Avoidance is best Not realisitic for all this reactive to Food- only avoidance Inhalent allergens can treat via hyposensitization or (controlled injection of offend allergens) in increasing vol & concentration Increase IgG production Makes immune more tollerant of allergens over time Relieves or reduces significately symptoms
- #24: Reiterated in 1st yr in Japan… (see details) Advise of internal study done 6 yrs ago when 1st serum for food allergy “studies” came out…
- #25: There are 2 main ways to identify food allergens: Food Elimination diets, or, 6 to 8 weeks. Connection between the clinical signs and the diet difficult to establish. Especially true when attempting to eliminate several food proteins at once. Poor owner compliance, especially if the benefits are not rapidly apparent. Poor owner compliance during the test meal challenge. A serum blood test that identifies the presence of the IgE “For optimal patient management, the correct identification of allergenic food proteins may be via an in vitro diagnostic test.” “Repeat ingestion of the allergen will result in clinical signs: Gastrointestinal with frequent diarrhea, and, Dermatological signs with non-seasonal Pruritus.” (Richard Halliwell, 1992). Elimination diets - greatly restrict foods consumed. Minimum number of protein sources. Test meal challenge (omitted proteins re-introduced). To have an immune system reaction, the elimination diet must have a relapse upon this challenge. “Studies indicate that elevated food allergen specific-IgE levels indicated that a patient is more than 95% likely to have an allergic reaction following the ingestion of that same food allergen (Sampson, 2001
- #27: FROM 2013 RESULTS, all domestic pets treated: Top feline food reactions were (most to least): Brewers Yeast, White Potato, Soybean, Corn, Egg, Tomato, Oat, Flax, Green Pea, Milk Top canine food reactions were (most to least): White Potato, Corn, Soybean, Barley, Sweet Potato, Green Peas, Peanut, Milk, Flax, Wheat
- #28: We test for 24 foods in our canine & feline panels. Included with the Results Report - a Food Recommendation Letter . Advises what major food groups a particular animal exhibits a positive or borderline sensitivity. THE BEST TREATMENT FOR FOOD SENSITIVITY IS COMPLETE AVOIDANCE. compare the animal’s results against our database containing the major food products and ingredients, as published by over 200 different food/treat manufacturers.
- #29: If dietary not enough – hyposensitization (controlled amts of offending allergens; increase in vol & concentration over time) Up to 20 in single set; good for 283 (approx 9 mo) Results – slowly & over time (not like steroid injection) When see results? Typically middle of Vial C (4-6 months; steroid dependant can be over 1 year)
- #30: All in one packaging: Treatment diary w/ DVD 25 prepacked sterile syringes Extract in sep container (to refrigerate upon arrival) Keeps everything organized, neat. in hand (clinic) w/in 7-10 days of ordering Clinical Objective: Stimulate production of specific-IgG, blocking antibodies by: Injecting back into the animal its offending allergens in a: Controlled amount. Controlled concentration. Strict schedule. IgG production is stimulated to where it blocks the allergic response by preventing the binding of the allergen with the IgE antibody. This can take as little as 1 month but usually takes 4 – 6 months in most animals. Although some can take 9 months in some animals. As concentration and volume of injections increase, IgG produced increases. Level of IgG eventually produced will allow animal to live in its environment. Animal is then hyposensitized - the allergy symptoms are controlled. The animal is now below its Threshold.
- #31: Made at time of order—in clinics hand within 7-10 business days All in 1 packaging – includes syringes, links to videos showing how to give injection, what to do if leave extract out, top 10 scenarios can occur while on treatment More allergens injected, more specific, IgG- antibodies produced = greater the opportunity to treat the symptoms, and bring below Threshold. Single set vs single split (same amount of time but single split separates out mites, molds and insects into set 2 to preserve integrity of weeds, trees and grasses in set 1. Cost is just less than a double treatment set but more than a traditional single set and is refilled as a double maintenance. Sublingual coming soon
- #32: Administered subcutaneously. Dosage and concentration increase over time. The initial 3 vial set lasts for 9 months (283 days). Once treatment completed continue with Maintenance vials. If stop; run risk start all over from scratch – allergies for life; no cure. This management. *Sublingual coming soon: please note: A great solution for pet parents who are needle averse or for patients that have had issues tolerating the injections in the past. Proper and consistent administration are the key to achieving success with allergy drops. Pros of Allergy Drops: Simple administration between cheek and gums Cons of Allery Drops: Requires daily administration No food/drink 10 minutes before/after drops Can be confusing to determine if pet got correct dosage Each Maintenance vial lasts approx. 6-8 months
- #33: Successful when: Dependence on steroids and / or anti-inflammatory drugs are greatly reduced / eliminated. Looking at their pet, both the veterinarian and the owner know that it is better. (say not better than stop; 9/10 realize were better; get back on track) To date, Spectrum has tested 380,000 animals. 70% have undergone the recommended diet change and hyposensitization treatment. In our last survey, Spectrum contacted 2,463 of our U.S. veterinarians whose animals have undergone treatment. Diet change alone: 48% improvement. Hyposensitization only: 67% improvement. Diet change & Hyposensitization: 85% improvement. Only diet change and hyposensitization will offer a near guarantee of lowering the animal’s Threshold to where it can live comfortably in its environment.
- #34: Allergies cumulative Limited panel – limited look Marry comprehensive test with comprehensive treatment for ind highest success rates: up to 90% Competitor Retest Program
- #35: Animal may be progressing well when it has a relapse. Worsening of symptoms returns. Why? Hyposensitization too aggressive for the particular animal’s immune system. Successfully handled by an adjustment to the hyposensitization schedule. The vet will call Spectrum with the case history. The hyposensitization schedule will be backed up to the point prior to the reaction. Summarize before call ends – advise pet parent right away of next steps
- #37: Poor owner compliance (hyposensitization regimen / recommended dietary change.) Older animals generally give a poor immune response. (young animals; maternal antibodies) Failure to treat other illnesses prior to testing. Suppressed immune system An immuno-stimulant may be required to “jump start” those animals with a suppressed immune system. Risks: Negative side effects of hyposensitization - extremely rare. Much less common than in human medicine. -17 recorded cases in 22 years of treatment. In all cases, the animal was easily treated by Epinephrine to counter the Anaphylaxis. No deaths or potentially life threatening reactions have ever been reported. This is why a veterinarian should administer hyposensitization.
- #38: Contact Spectrum order online fax back reminder card Call toll-free number then order will be placed. Delivery within 7-10 days after the order has been placed. Invoice sent with every order –advise of charge Statement at end of mo (pay from)
- #39: General Practitioner All testing and treatment are in their office. No need to send the animal to a specialist. Test for more allergens (incl food) Provide lower cost option to derm referral to client base Provide you list of approved foods (highlight ones in stock) More comforting to the pet and owner. - already trust you No need for sedation. No need to shave the animal. Blood draw not painful No Steroid withdrawl period The animal can be weaned slowly off of its medication with no harmful effects. Veterinary dermatologists use serum-based testing when: The animal cannot be taken off of steroids. There is not enough healthy skin left for intradermal testing. we retest on competitor results regardless of when last tested….