Food Allergies and the Pharmacy


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The Food Allergy Guide to the Zombie Apocalypse (or your everyday power outage)

I bet you’ve discussed, at one time or another, what to do in case of the Zombie Apocalypse. If not, I suggest you find someone and do so immediately! I’ll wait.

[I’m assuming you are returning 30 minutes later if, in fact, you had never done this. If not, I assume you are skipping very quickly to the next part.]

When you thought about your Zombie Apocalypse/Mayan Calendar End of Times prepping, did you think of all the things you might need to do for the food allergic individual in your life? It’s one aspect most zombie movies/end of the the modern era films, books, and television shows don’t address.   But we, the food allergy community, need to  “Doomsday” prep for the everyday mishaps. And, hey, you’re already doing some of it! What do I mean? Let’s go back to elementary school and the 5 Ws: Who, What, When, Where, Why, and that sneaky, pesky, essential H–How.

WHO?

Every member of the food allergy community “preps” on a regular basis. We “prep” safe foods for school lunches, special trips, and just everyday eating. We also “prep” by always carrying epinephrine and diphenhydramine (Benadryl) in addition to various creams, lotions, asthma medications, etc. Preventative measures are a part of who we are and what we do in regards to food allergy.

As we are more vigilant than many in our day-to-day lives so we need to be more prepared in emergency situations.

WHY?

http://www.wsaz.com/news/headlines/79728272.html

Stuck on the WV Turnpike via WSAZ

We are fundamentally a community of preparedness but what happens in the event of an emergency when essentials such as water and power are unavailable for extended periods of time? Could you prepare safe foods for your family in the event of a massive power outage (West Coast 2011) or a water crisis (Charleston, WV)?  What if you were stranded in your car on an impassable highway? You may think it’s not likely, but I bet that’s what people in Atlanta (aka Hotlanta), GA thought in January of this year when a snow and ice storm brought the city to a standstill.

In the last year in my in my home state of West Virginia, there have been massive statewide power outages, weeks to months of water safety concerns, and winter travelers stranded for up to  20 hours on the WV Turnpike. I know these local events have changed the way I think about preparedness for my family but particularly for my food allergic child.

The power outage in July 2012 was an eye opener  as gas stations didn’t even have the power to pump the gas needed for vehicles or generators, pharmacies were closed, and the local hospitals struggled to stay powered.  The water crisis in Charleston was horrifying on so many levels, but it made many of us keenly aware of how much we truly take clean, potable, readily available water for granted. After the Turnpike incident, I began carrying an emergency bag (based on season) in the car.

Water and power are key components in how we care for our food allergic loved ones. The health and, ultimately, lives of food allergic individuals rely on proper cleanliness to reduce risks of cross contamination.

The federal government in conjunction with various state institutions use this month as an opportunity to encourage citizens to prepare for a multitude of scenarios. Assorted government entities have even addressed, sometimes tongue and cheek, a few worst case events.  HealthyChildren.org has posted information on family disaster supply lists as well.

Now, don’t get me wrong, I am not advocating Doomsday Prepping.  What I am advocating is having a family plan and  an emergency car travel bag.

What and How?

1. What are the most likely scenarios in your neck of the woods? Tornado, flooding, earthquake, hurricane, snow, wild fire, etc.? Make your plan fit your location.

2. Find out the specifics of each child’s daycare or school disaster plan in the event of separation.

3. Create the family disaster plan which will include (but is not limited to): meeting places, routes of evacuation, and communication strategy.

4. Obtain two copies of important documents (and don’t keep them in the same location)

5. Stock the emergency car travel bag. Items may need rotated based on season but may include:  blankets, battery powered flash lights/radio, extra batteries, first aid kit, change of clothes/shoes, important numbers, extra phone charger, cash,  garbage bag, etc. This list is not all inclusive; please use the resources below for more ideas.

6. Food Allergy specific needs:

  • Safe for your family canned, ready to eat fruit, veggies, meat, soup, safe drinks (in addition to water), cereal, crackers, trail mix, cookies, etc.
  • Manual can opener
  • Wipes (since we know hand sanitizer will not remove food proteins)
  • Prescription and OTC medications  (this is not just food allergy specific but it is a MUST)
  • Knowing the effects of anaphylaxis and how to quickly and effectively treat our loved ones is just as important as actually having the medication.

More on the meds. (I wouldn’t be a good Food Allergy Pharmacist if I didn’t discuss the meds.)

  • As always, carrying your epinephrine auto-injector (EAI)  is key as well as any other “as needed, ” or, PRN, medications such as albuterol inhalers, nitroglycerine, etc.   Never keep medications stored in the car; extreme heat or cold can cause the medication to breakdown and become less effective.
  • Having an extra EAI, inhaler, etc. on hand could be life saving in the event of an emergency situation. However, as a pharmacist, I see “refill too soon” rejections several times per day while at work. So how can a patient get around the “refill too soon” dilemma?

            Here are a few options:

  1. Get the medication refilled as soon as the insurance will allow it.

Some plans allow for early fills up to a week or 10 days early for medications that are not controlled substances.  This is a time to be very familiar with your insurance plan; I have seen a “cumulative refill too soon” rejection which means that the insurance has kept track of how soon the fills have been and at some point, even if the fill is actually due and not early at this specific time, the insurance company will flag it. Very few insurance companies employ the “cumulative refill too soon”; it should be laid out in the policy paperwork. Cumulative refill too soon rejections shouldn’t be a huge issue since I am not suggesting stock piling medication. I am only suggesting having an extra month or so on hand.

        2. Use a coupon and don’t use your insurance.

       3. Pay the “cash price”.

“Cash price” is what pharmacy people call the price without insurance. Depending on the medication, this could be expensive or super cheap.  I will discuss how to get the best bang for your buck without compromising safety or efficacy in an upcoming post.

  • Finally, remember to always rotate your stock of medication if you have several bottles. First in means first out. In the pharmacy we mark each open/used box with an X and newly delivered medications go on the back of the shelf.

7. Practice. Just as we practice fire drills, we should practice our family emergency plan. This would also be a good time to evaluate the appropriateness of the emergency travel bag contents (i.e. different seasons means different needs).

When?

Now. (Just because you think the Zombie Apocalypse isn’t about to—I mean, power outage/natural disaster/chemical spill, isn’t going to affect you, the reality is anything could happen at any time.)

We don’t wait to make allergist appointments. We don’t wait to administer an epinephrine shot. We shouldn’t wait on this either. Basic preparedness is something we food allergy moms and dads do everyday; take this opportunity to take another step in ensuring the safety of our food allergic loved one.  For more information on how to discuss disasters with your children (but probably not zombies) and also how to cope with behaviors after your family has experienced an emergency situation, please visit the sites below.

 

Resources:

http://www.ready.gov/

http://www.bt.cdc.gov/

http://www.healthychildren.org/English/safety-prevention/at-home/Pages/Getting-Your-Family-Prepared-for-a-Disaster.aspx

http://www.healthychildren.org/English/safety-prevention/at-home/Pages/Family-Disaster-Supplies-List.aspx

http://pediatrics.aappublications.org/content/121/5/e1441.abstract

http://www2.aap.org/advocacy/emergprep.htm

http://store.samhsa.gov/shin/content/SMA11-DISASTER/SMA11-DISASTER-09.pdf

http://www.pbs.org/parents/talkingwithkids/news/help-kids-feel-safe.html

http://www.redcross.org/prepare/location/home-family/children

http://www.health.state.mn.us/oep/prepare/


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Head Lice, Star Wars, and Food Allergies?

School has started again. That means homework, packing lunches, after school sports, and the crud. In the retail pharmacy world, we see a flood of prescriptions about 3-5 weeks after school starts; children come down with everything from ear infections, strep throat, and bronchitis, to head lice.  That may be why September is “Head Lice Prevention Month”.

The scenario starts by receiving the dreaded letter from the school nurse. A kid in your child’s class has lice. Duh, duh, duuuh. I remember that note coming home when I was in elementary school. My mom sat my little second grade, Food Allergy Pharmacist self on a dining room chair and began to explore hair and scalp. Maybe I have been slightly traumatized (thanks Mom), but I clearly remember my mother, who had never seen a louse before, totally FREAK OUT. I had lice (insert the “Imperial March” music aka Darth Vader’s theme song).  My head is itching just typing this post.

Don’t panic and don’t death march up to the pharmacy. Its okay. Not the end of the world.

keep calm and strike back

Yes, you will spend hours examining every single hair on your child’s head with the precision of a surgeon and the intensity of…well…Darth Vader.  (Confession: E has been on a Star Wars kick for a while now, he and my husband will be happy to see that I have been fully integrated. At this moment, my brain can only conjure Dark Side metaphors.)

Numerous methods have been employed to do away with lice including heat (not a light saber), combing, smothering or suffocating, pediculicides (aka bug killer), and more. I want to be clear that I am not going to promote one type of lice treatment over another in this post. I simply want to discuss OTC lice treatment options as they relate to food allergies. I will provide links to a number of resources; I encourage everyone to read the good, the bad, and the ugly of each option and decide for themselves. Please use caution with anything (including food items and oils) placed on the head especially for those with atopic dermatitis, eczema, and any other skin conditions. Some of the forums I reviewed listed combinations of products, long treatment durations, large quantities, and use of plastic bags and sleeping caps especially in children that I felt were potentially dangerous. I did not include those links based on my opinion of safety issues.

I feel that two paths to reaction may be possible while treating and dealing with head lice. These paths are tentative, hypothetical connections. The medical community has not found definitive data directly correlating food allergy to the lice treatments I will discuss. What I am trying to highlight is a potential for allergic reaction. I am making a logical leap based on the clinical knowledge we do have.

1. food sensitization via damaged skin

A recent article in the Journal of Allergy and Clinical Immunology  detailed a sensitization route where a food allergen applied topically to eczematous skin lead to subsequent anaphylaxis upon ingestion of the food. The researchers suggest that skin care be bland, avoiding use of sensitizing agents especially food. This is hypothesized pathway one.

“Natural” treatments have historically included food products such as olive oil, almond oil, mayonnaise, coconut oil and essential oils such as tea tree (melalueca), lavendar, eucalyptus, clove, cinnamon, and peppermint. I have also seen lotions and creams listed as alternatives to mayonnaise; keep in mind that lotions and creams may also contain food allergens e.g. Cetaphil contains nut oils. Several of the sites/forums I reviewed suggested using these “natural” treatments frequently, in some cases every other day. It was also suggested that various essential oils be used on a daily basis (spritzed onto hair or several drops placed in shampoo) as a preventative measure. Lice can be surprisingly resilient.

Never underestimate power of dark side

The article findings coupled with the suggested preventative measures of spritzing or shampooing hair daily with various food items has made me wonder whether similar sensitizations will or have taken place.

2. cross-reactivity due to similar structural features of the allergens

The second pathway (cross-reactivity) might be achieved through use of over-the-counter, OTC, lice treatments.  Some OTC products contain Pyrethrins (Brand names include: RID, PRONTO, Triple-X) which are naturally occurring extracts from the chrysanthemum flower. Permethrin (Brand name: NIX) is a synthetic pyrethroid; a product similar to pyrethrins. Use of either pyrethrins or permethrin in ragweed allergic individuals may cause breathing difficulties and “asthmatic episodes” according to package warnings of both pyrethrins and permethrin.  Allergic reactions have been seen in a few people who have used pyrethrins according to the ASTDR and the potential for contact dermatitis exists as well. Ragweed and chrysanthemums are members of the Asteraceae/Compositae plant family. Other plants in this family include: sunflower, safflower, artichoke, marigolds, and dandelions.

I have been reviewing numerous resources but have yet to find a concrete yes or no answer to my question: Will pyrethrins and permethrin cross-react to food items that are known to cause oral allergy syndrome (or Type 2 hypersensitivity reactions) with ragweed?

the force is strong with this one

Oral allergy syndrome has become common knowledge in the allergy community. It has been noted by the Asthma and Allergy Foundation of America that “ragweed cross-reacts with bananas and melons, so people with ragweed allergies may also react to honeydew, cantaloupe, and watermelons, or tomatoes. Zucchini, sunflower seeds, dandelions, chamomile tea, and Echinacea may also affect some people.”

In other words, if a person has a severe allergy to cantaloupe or tomato (as an example), will that person also react to a topical lice treatment containing permethrin or pyrethrin?

I don’t know the answer to this question but, seemingly, neither does anyone else (yet). Given the data known to be true at this time, I would use caution when selecting permethrin or pyrethrin  for lice eradication if you or your child have a severe allergy to any of the ragweed cross-reactive foods (even more so with concurrent asthma diagnoses).

For more information on diagnosing and treating head lice at home visit headlice.org and the American Academy of Dermatology. It should also be noted that permethrin can be found in prescription scabies treatments, insect repellent directed to be used on gear and equipment, livestock insect repellent in the form of dust and spray, canine flea collars (permethrin is toxic to cats), and is listed on the World Health Organization’s Model List of Essential Medications Oct. 2013.

And remember , with lice “Do or do not.  There is no try.”

 

Images used are pieces of art for sale:

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http://ludovitnastisin.deviantart.com/art/Darth-Vader-Quote-360922238

https://www.etsy.com/listing/179051508/the-force-is-strong-with-this?

 

Sources:

CDC: http://www.cdc.gov/parasites/lice/head/treatment.html

Asthma and Allergy Foundation of America: http://www.aafa.org/display.cfm?id=9&sub=20&cont=728

http://www.atsdr.cdc.gov/phs/phs.asp?id=785&tid=153

http://www.aafa.org/display.cfm?id=9&sub=20&cont=728

http://www.healthline.com/health-slideshow/home-remedies-for-head-lice#1

http://healthfinder.gov/FindServices/Organizations/Organization.aspx?code=HR2088

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3362728/

http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=3cdec6f3-4da6-467f-96c3-c8941ff46b56

http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=9b44bf94-62c9-49d8-97ec-cf475824eb35

http://www.epa.gov/oppsrrd1/REDs/factsheets/permethrin_fs.htm

http://www.epa.gov/oppsrrd1/reevaluation/pyrethrins-pyrethroids-asthma-allergy-9-18-09.pdf

http://www.rxlist.com/pyrethrum-page2/supplements.htm

http://www.britannica.com/EBchecked/topic/39698/Asteraceae

http://www.skintherapyletter.com/treat/lice/permethrin_pyrethrin_piperonyl_butoxide.html