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Anaphylaxis in general practice

GPs play a key role in the treatment and education of patients who present with anaphylaxis and other allergy-related issues. 

Given the very broad spectrum of modern general practice, it is inevitable that there will be some areas in which GPs receive less exposure, whether in their practice or in terms of education. 

‘General practice is holistic and all-encompassing, so we have to know something about everything, but you can’t possibly know everything about everything,’ Dr Charlotte Hespe, Head of General Practice and Primary Care Research at the University of Notre Dame Australia, told Good Practice

Anaphylaxis could be considered one of these less-experienced aspects of healthcare, albeit an increasingly prevalent one. 

Anaphylaxis is caused by a number of different factors, most notably medicines, insect venom and foods. While food is a relatively minor cause of anaphylaxis in Australia, food allergies are on the rise. Recent studies have found that food allergies are estimated to affect approximately 10% of infants younger than 12 months and 4–8% of children under the age of five,1 and food-related anaphylaxis increased in all age groups between 2004–05 and 2011–12.2 

According to Dr Richard Loh, paediatric immunologist and Chair of the National Allergy Strategy, the relatively swift increase in the number of people who can be affected by anaphylaxis may have played a role in some GPs’ relatively limited experience in the area. 

‘Because this has changed very rapidly in the past 15–20 years, there are GPs who have had very limited exposure to allergy training for general practice,’ he told Good Practice

‘It is an area in which they now, as practising GPs, can benefit from upskilling and increasing their knowledge and experience.’ 

Education

The fact so many people in Australia regularly visit general practice, combined with the increasing numbers of those who can be affected by anaphylaxis, means GPs are vital in its treatment. 

‘When you talk about such a rise in allergic diseases in Australia, it’s no longer the domain of tertiary sub-specialists,’ Dr Loh said. ‘With many of the allergic conditions, GPs have such a critical role: to refer patients appropriately, to be aware of intolerances versus allergies, to be aware of who is at greater risk.’ 

Dr Loh believes patient education is one of the most important aspects of GPs’ role in treating anaphylaxis.

‘If patients are prescribed an EpiPen, for example, as a specialist I don’t really want to see many of them every year, but I do want them to go and see their GP,’ he said. ‘Because a lot of parents or older patients forget how to use the EpiPen. 

‘[A GP visit] is a very opportunistic time if you’re giving someone a vaccine, for example, to bring out a trainer [EpiPen] device and say, “I note in my records that you have an EpiPen, can you show me how you use it?”. You will likely find that a lot of people don’t know how to use it. 

‘GPs have a critical role in educating the patient or the parents of a child, or both.’ 

GPs can also work with patients who have experienced anaphylaxis and/or who are at risk of allergic reactions to develop an action plan that details the emergency management of such a reaction. 

These personalised emergency action plans should include:

  • contact details for the patient and appropriate emergency services
  • a list of specific allergens for the individual patient
  • the doctor’s contact details and signature
  • the date on which the plan was prepared (updated annually)
  • information on features of anaphylaxis
  • and appropriate emergency management.3

 In practice

Dr Hespe agrees that education and planning are vital aspects of a GP’s role in the area, but also believes that primary healthcare professionals need to be equipped for the treatment of anaphylaxis within their practice. 

‘We have to be prepared for anaphylaxis happening in our surgeries when we deliver treatment, particularly around immunisations,’ she said. ‘As part of being an accredited practice, you also need to show that you can respond to an acute anaphylaxis.’

 While acute anaphylaxis may be somewhat less probable in general practice, GPs are likely to have patients affected by allergies or who present with some signs of anaphylaxis. 

‘In terms of anaphylaxis in general practice, it may be a slower-developing one or it may be that the patient was just down the road from the practice when it started,’ Dr Hespe said. 

‘For instance, if someone is trying a certain food for the first time and it causes that [anaphylaxis], then sometimes it takes a few hours to come on and, as it’s coming on, they might realise that something really scary is happening and the general practice is just there.

‘So they will pop in and say what’s happening to them and it evolves before your eyes. I have had a couple of those in my time as a GP.’ 

Access to education

As Chair of the National Allergy Strategy, an initiative of the Australasian Society of Clinical Immunology and Allergy Limited (ASCIA) and Allergy and Anaphylaxis Australia, Dr Loh is very keen to increase access to – and awareness of – high-quality information and training options for all people in the community, including healthcare professionals. 

‘Part of the National Allergy Strategy is to try and give patients one or two sites where they get the latest, most up-to-date information that is accurate and consistent,’ he said. ‘One is ASCIA website and the other one is Allergy and Anaphylaxis Australia. One is medical and the other is very practical.’ 

One of the most important aspects of the information available on these sites is ASCIA’s free anaphylaxis e-training. 

‘Over 300,000 teachers and childcare providers have done the ASCIA e-training in anaphylaxis,’ Dr Loh said. ‘And the same e-training information, though more detailed, is provided to health professionals – GPs, nurses, pharmacists. Over 7000 health professionals have done the e-training. 

‘It’s very important that you give really consistent, up-to-date information to everyone. For example, do not stand or walk when experiencing anaphylaxis. We tell that to teachers, we tell that to ambulance workers, we tell that to GPs and pharmacists.’ 

Another of the more prominent messages in the anaphylaxis e-training training is, when in doubt, use an EpiPen to administer an intramuscular injection of adrenaline, which works within minutes to reduce throat-swelling, open airways and maintain blood pressure.4 Withholding or delaying adrenaline can result in deterioration and potentially death of a patient experiencing anaphylaxis.

According to Dr Loh, there remains confusion among some people about the use of EpiPens and of adrenaline, which can also be administered via a subcutaneous injection, for the most efficient and effective treatment of anaphylaxis. 

‘We know that health professionals sometimes give a shot of adrenaline with a 25–27 gauge needle. If you use that and you’re actually giving subcutaneous adrenaline it takes 30 minutes to be absorbed, whereas intramuscular adrenaline takes 3–5 minutes,’ he said. 

‘And there are still some of my colleagues giving intramuscular phenergan and intramuscular hydrocortisone, which have no role in the management of anaphylaxis. 

‘That’s something we need to upskill and educate our colleagues on … and things like that are in the e-training.’ 

ASCIA’s e-training, as well as other anaphylaxis and allergy information, has been designed for easy access to provide busy healthcare professionals with a simple and efficient education process.

‘If you’ve got 6–8 minutes when you see a patient you don’t really want to be on a website that’s got 60 clicks to get to the information that you want,’ Dr Loh said. ‘So we have revamped the site to try and make sure you can get to the e-training within three clicks. 

‘With the National Allergy Strategy, the patient and their family are at the centre of everything we do, so it will be great to have the involvement of GPs in everything that we do in the management of allergic conditions.’ 

References

  1. Australian Allergy Centre. Kids’ food allergies for dummies – A must-read for parents of children with food allergies. Edgecliff, NSW: Australian Allergy Centre, 2016. Available at www.australianallergycentre.com.au/kids-food-allergies-for-dummies-a-must-read-for-parents-of-children-with-food-allergies [Accessed 26 October 2016].
  2. Mullins RJ, Dear KB, Tang ML. Time trends in Australian hospital anaphylaxis admissions in 1998–1999 to 2011–2012. J Allergy Clin Immunol 2015;136(2):367–75.
  3. Laemmle-Ruff I, O'Hehir R, Ackland M, Tang ML. Anaphylaxis: Identification, management and prevention. Aust Fam Physician 2013;42(1–2):38–42.
  4. Australasian Society of Clinical Immunology and Allergy. Anaphylaxis emergency medication (adrenaline [epinephrine] autoinjectors) Frequently Asked Questions (FAQ). Balgowlah, NSW: ASCIA, 2016. Available at www.allergy.org.au/health-professionals/anaphylaxis-resources/adrenaline-autoinjectors-faqs [Accessed 28 October 2016].