Referral Criteria for Adult Allergy Outpatient Appointments
Referrals are considered to be appropriate in the following clinical circumstances:
Allergic Rhinitis /Rhinosinusitis/Nasal polyposis
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Symptoms uncontrolled on conventional pharmacotherapy 1, 2
Or if question of causation by avoidable allergen e.g. Pets
Or consideration of immunotherapy (desensitisation)3
Most patients with allergic rhinitis can be managed effectively in a primary care setting.
Asthma
Most asthma is successfully managed primary care4. Indications for referral to allergy clinic:
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Suspicion of avoidable allergic trigger for asthma (e.g. pets, latex, occupational causes)
Consideration of immunotherapy (desensitisation)
Severe uncontrolled allergic asthma for consideration of Omalizumab therapy5
Food Allergy6
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Significant food allergy reactions especially with potentially life-threatening features
Or where the cause of a food allergy is unclear from history
Or where there is uncertainty about use of adrenaline autoinjector
Or where anxiety about food allergy is affecting mental or physical health
In patients with food intolerance (IBS type symptoms) testing for IgE mediated allergy is usually
unhelpful and referral is not recommended
Anaphylaxis
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All patients with anaphylaxis should be referred to an Allergy clinic for appropriate testing,
advice on avoidance of triggers and use of adrenaline, as per recent NICE Guidelines.7
Venom Allergy
All patients with a history of systemic allergic reaction after bee or wasp sting should be referred for
investigation and consideration of immunotherapy (desensitisation).8
Drug Allergy
Detailed testing protocols are available for many, but not all, drugs which cause allergic or
immunological reactions. Not all patients with drug allergy require referral, but using the example of
Penicillin allergy the following criteria apply9:
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Where reaction occurred when taking more than one drug e.g. during general anaesthesia10
Where drug allergy compromises care of a chronic condition (such as COPD, bronchiectasis,
recurrent UTIs ) by limiting therapeutic options
Where drug allergy (e.g. local anaesthetics) delays medical or dental procedures
Urticaria/Angioedema
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Acute episodes where the cause is unclear from history
Recurrent urticaria and/or angioedema uncontrolled with regular oral antihistamines11
Eczema
Referral of patients with eczema may be appropriate where there is suspicion of an IgE mediated
trigger such as food or PETS. Most patients with troublesome eczema however should be referred to
Dermatology.
Contact Dermatitis
In this situation patch testing (not skin prick testing) is the investigation of choice, and patients should
be referred directly to Dermatology where the history suggests contact dermatitis
Pruritus/Non-specific rashes
Allergy testing is unlikely to be helpful in this context and patients should be referred to Dermatology if
needed
Non-specific presentations
Testing for allergy is not recommended in patients with non-specific presentations for instance ME and
fibromyalgia
Comments
Crucial to the field of Allergy is the ability to take and accurate history, which should always be the basis
for any proposed testing. Blanket testing for a wide panel of allergens is not recommended.
In primary care, occasionally patients may present who are convinced that allergy explains their
symptoms. In this situation, a detailed history should be taken and efforts made to reassure patients
and provide alternative explanations for symptoms. Occasionally this may not be successful, in which
case referral to an Allergy specialist may be helpful in order to help move a patient on to a more
appropriate treatment pathway. This circumstance should be exceptional.
References
1) BSACI (British Society for Allergy and Clinical Immunology) guidelines for the management of
Allergic and non-allergic rhinitis. Clin Exp Allergy 2008; 38: 19-42
http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2222.2007.02888.x/pdf
2) BSACI guidelines for the management of rhinosinusitis and nasal polyposis. Clin Exp Allergy 2008;
38: 260-275
http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2222.2007.02889.x/pdf
3) BSACI guidelines : Immunotherapy for Allergic rhinitis. Clin Exp Allergy 2011; 41: 1177-1200
http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2222.2011.03794.x/pdf
4) British Thoracic Society/SIGN Asthma Guidelines 2011
http://www.brit-thoracic.org.uk/guidelines/asthma-guidelines.aspx
5) NICE Technology Appraisal : Omalizumab for severe persistent Allergic Asthma (TA 133)
http://publications.nice.org.uk/omalizumab-for-severe-persistent-allergic-asthma-ta133
6) NICE Guidance on Food Allergy in Children and Young people (CG 116)
http://publications.nice.org.uk/food-allergy-in-children-and-young-people-cg116
7) NICE Guidance on Initial Assessment and referral following a suspected anaphylactic episode (CG
134)
http://guidance.nice.org.uk/CG134
8) Diagnosis and management of hymenoptera venom allergy : BSACI Guidelines. Clin Exp Allergy
2011; 41: 1201-1220.
http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2222.2011.03788.x/pdf
9) BSACI guidelines for the management of drug allergy. Clin Exp Alergy 2009;39: 43-61
http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2222.2008.03155.x/pdf
10) BSACI guidelines for the investigation of suspected anaphylaxis during general anaesthesia. Clin
Exp Allergy 2009; 40 : 15-31
http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2222.2009.03404.x/pdf
11) BSACI guidelines for the management of chronic urticaria and angioedema. Clin Exp Allergy 2007;
37: 631-650.
http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2222.2007.02678.x/pdf
Adult Allergy Team
Dr Steve Jenkins, Consultant Lead for Allergy and Respiratory Physician
Kathryn Powrie, Allergy Nurse Specialist
Amanda Lyle, Allergy Nurse
Contact details:
Department of Respiratory Medicine
Old Fracture Clinic Offices
Broomfield Hospital
Mid Essex Hospital Services NHS Trust
Court Road
Chelmsford CM1 7ET
Secretary
01245 514416
Allergy nurses answerphone
01245 516740
Fax
01245 514044
This document can also be downloaded from the EQUIP Website.www.essexequip.nhs.uk
Click on the tab ‘powerpoint presentations’, then select ‘Primary Care Allergy Day 3 rd April’