VOL: 101, ISSUE: 31, PAGE NO: 26
Sue Cross, BSc, RN, NPDip, FAANP, is national project manager, WIPPs General Practice Nursing Project
Allergic diseases are a major cause of illness in developed countries. They affect as many as one in three people in the UK, and this prevalence is increasing (Royal College of Physicians, 2003).
Allergy management is an important specialty, providing high-quality diagnosis and treatment. Allergic diseases now cause increasingly complex problems that can involve multifaceted investigation of several organ systems.
Unfortunately, the UK does not yet have a comprehensive service. Patients are often subjected to a succession of referrals to different specialists such as chest physicians, dermatologists, immunologists, paediatricians and dietitians - a time-consuming, costly and often counter-productive experience. In recent years primary care practitioners have become increasingly accountable for the treatment and management of allergy patients.
Following a report by the Royal College of Physicians (2003) the government was urged to introduce appropriately staffed regional allergy centres, evenly distributed across the country. These centres would give equality of access to appropriate allergy services for both adults and children, irrespective of their locality. They would also provide expertise and lead the development of other local services by liaising with organ-based specialists and primary carers.
Nurse-led allergy care
Another RCP recommendation was that frontline allergy provision should be driven by trained primary care practitioners. It recognised that more nurses and GPs should receive allergy training and advised that this should form part of a top-down scheme driven by specialist trainers from tertiary allergy centres (Table 1) (RCP, 2003). These primary care experts would be known as practitioners with a special interest in allergy (Allergy PwSIs).
The introduction of Allergy PwSIs was supported by a House of Commons Health Committee (2004), while the Department of Health (2005) agreed that PwSI provision would help to ensure that more serious and complex allergies could be treated locally. It recommended that PCTs assess local needs and determine whether they would be best served by commissioning PwSI services, and/or training practitioners wishing to specialise.
Allergic disorders commonly coexist, so a sensible and seamless approach to management is to link allergy care with existing nurse-led primary care services such as asthma clinics. Approximately 76 per cent of asthmatic patients also report symptoms of rhinitis (Walker and Sheikh, 2005), and its comorbid impact is known to be profound.
For example, compared with those with asthma alone, patients with concomitant allergic rhinitis require significantly more asthma-related hospitalisations and GP visits, and incur higher asthma-related drug costs (Price et al, 2005). Studies have shown that patients with both diseases also have substantially greater quality-of-life impairment when compared with those with neither disease or with allergic rhinitis alone (Leynaert et al, 2000).
The pathogenesis of asthma and allergy is extremely complex. Studies show that both conditions induce type 1 hypersensitivity responses (IgE attaches to a mast cell surface, causing immediate eosinophilia and chronic inflammation and later T-cell secretion of cytokines). Indeed, recent findings have demonstrated that allergic rhinitis and asthma are two clinical manifestations of a single airway disorder (Passalacqua and Canonica, 2001).
Several nurses already run integrated practice-based asthma/allergy services, most of which are popular and successful. Their dedicated nature enables nurses in these clinics to gain experience in patient monitoring and managing concomitant asthma and allergic disorders. They can also monitor other chronic allergic conditions such as eczema and urticaria. The aims of the clinics are to:
- Reduce the number of secondary care referrals;
- Prompt accurate and timely patient diagnoses;
- Facilitate better patient self-management;
- Help to prevent deterioration of existing allergic conditions by giving patients a point of contact;
- Effectively manage comorbid allergy and asthma via a single surgery visit.
Patients with the following conditions usually benefit most from practice-based allergy services and should be targeted as a priority:
- Occupational rhinitis, asthma or dermatitis;
- Allergic conjunctivitis.
Once an allergic diagnosis is suspected, the following parameters should be investigated:
- Family history (including first-degree relatives);
- Eyes, ears, nose, chest and skin;
- Height, weight and general appearance;
- Frequency of symptoms;
- Home environment;
- Quality of life;
- Smoking status (active or passive);
- Recent infections.
Diagnostic testing for common allergens such as cat, dog, house dust mite and pollen may include skin-prick, blood and lung function testing.
Referral to secondary care may be needed in the following situations:
- Where there is poor response to treatment;
- To confirm sensitisation to foods;
- For children who have suspected peanut allergy and asthma;
- For specialised diagnostic tests;
- When allergy is severe or life-threatening;
- When history suggests allergy but a trigger cannot be identified;
- When occupational asthma is suspected (refer to occupational chest physician).
Nurses could also work with local pharmacy-based allergy services. Some local pharmacists offer general allergy advice and patient-focused allergy materials, and a working knowledge of the extent of these local services will help to ensure continuity of care.
- This article has been double-blind peer-reviewed.
For related articles on this subject and links to relevant websites see www.nursingtimes.net