Age, epinephrine use, anaphylaxis impact quality of life in patients with food allergy
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SAN ANTONIO — Older food allergy patients who have had anaphylaxis or needed epinephrine had lower quality of life than other patients, according to data presented at the American Academy of Allergy, Asthma & Immunology Annual Meeting.
“We wanted to figure out which factors influence quality of life the most,” Stephanie A. Kubala, MD, a fourth-year allergy and immunology fellow with the NIH, told Healio.
“While food allergy may be fatal, this outcome is very rare, and most people can get by without having severe reactions, but they are always worried about it, or they live with hypervigilance,” Kubala said. “We’re trying to figure out how we hit that sweet spot of living a good life but also not getting into situations that may cause serious harm.”
Study design, results
The researchers used age-validated questionnaires that assessed food allergy quality of life in 125 individuals aged 2 to 28 years (median age, 9.42 years; 79% male; 65% white) with IgE-mediated food allergy.
Comorbidities included atopic dermatitis (83.2%), allergic rhinitis (75.2%), asthma (52%) and eosinophil-associated gastrointestinal disorders (EGID; 7.2%). Respondents avoided a median of four of the top nine allergenic groups of foods as well.
The parent form, administered to caregivers of children aged 0 to 12 years, assessed social and dietary limitations, food anxiety and emotional impact. The child form, completed by children aged 8 to 12 years, assessed allergen avoidance, dietary restrictions, risk for accidental exposure and emotional impact.
Adolescents aged 13 to 17 years completed the teen form, which assessed allergen avoidance and dietary restrictions, risk for accidental exposure and emotional impact. The adult form, for those aged 18 years and older, assessed the same factors in addition to food allergy-related health.
“We designed a way to compare food allergy-related quality of life with these age-validated questionnaires across patients' ages because each form is slightly different,” Kubala said.
The researchers focused on allergen avoidance and dietary restrictions, risk for accidental exposure and emotional impact in their calculations.
“We have three different subscores, and those added up equal total quality of life,” Kubala said.
Overall, as age increased, food allergy quality of life got worse (r = 0.33; P = 2e–04). The sub-scores for allergen avoidance and dietary restrictions (r = 0.23; P = .0089), emotional impact (r = 0.42; P = 8.6e–07) and risk for accidental exposure (r = 0.3; P = .00057) each got worse with age as well.
“As patients develop emotionally and physically, they worry, and it affects their quality of life more as they get older, especially within that emotional impact area,” Kubala said.
The nature of these worries varied between the age groups as well, Kubala continued.
“Younger ages worry internally about themselves, like, when will my food allergy go away?” Kubala said. “Older people worry about outside things, like food labeling — is it comprehensive enough?”
Women reported worse scores for risk for accidental exposure than men (3.1 vs. 2.1; P = .046), as did Black (3.1) and Asian (3.3) patients compared with white (2.4), multiracial (1.3) and Native American (0.3; overall P = .001) patients. Similarly, risk for accidental exposure scores were worse for patients with EGID than those without (3.7 vs. 2.4; P = .017).
The researchers found associations between greater allergic reaction severity and worse food allergy quality of life. For example, patients with a Sampson score of 1 had a food allergy quality of life score of 2.5, whereas those with a Sampson score of 4 had a food allergy quality of life score of 4.4 (Spearman P = .04386).
Patients reporting epinephrine autoinjector use had a score of 3.2, whereas those with no use had a score of 2.5 (P = .04). Also, patients who had experienced anaphylaxis had a score of 3.1, whereas those who had not had a score of 2.2, although this did not reach statistical significance. Patients with a respiratory reaction had a score of 3.1 compared with 2.5 for those who had not (P = .028).
However, food allergy quality of life scores improved with time since a previous event. Patients who required epinephrine in the previous year had a score of 3.3, whereas those who had not needed epinephrine in more than 4 years had a score of 2.9 (Spearman P = .01968).
Additionally, patients who had experienced anaphylaxis in the previous year had a score of 3.3, and those whose previous episode was more than 4 years earlier had a score of 2.8 (Spearman P = .03544). Patients who had an allergic reaction in the previous year had a score of 2.8, and those who had not had a reaction in more than 4 years had a score of 2.9.
Other scores included 2.5 for patients who never had to use epinephrine, 2.2 for those who had never experienced anaphylaxis and 1.6 for those who had never had an allergic reaction.
“Four years is really when quality of life has improved, but it does not reach that level for patients who have never had epinephrine use or anaphylaxis,” Kubala said. “But if they've had a regular allergic reaction, you don’t see that difference. They’re pretty flat. Quality of life score doesn’t really change as time goes by.”
Further, the researchers found associations between the number of foods that patients avoid and how strictly they avoided foods with poorer quality of life, with impacts particularly among patients who avoided milk, egg, soy and sesame.
“Sesame was something new that I hadn’t seen in the literature, which is good timing because sesame is now part of labeling,” Kubala said.
Further, patients who experienced reactions to nonconcentrated foods had scores of 3.3, compared with 2.4 among patients who had not (P = .0068).
“Food allergic patients can be scared and worried about reactions due to allergy inhalation and skin touching,” Kubala said. “If people have ever had a reaction like that in their past, they seem to exhibit worse quality of life, which is intuitive to me, but it is interesting to see it is very significant.”
Next steps
The researchers said that allergists should use these factors to help guide quality of life strategies.
“Who are the patients we should really intervene on, especially with clinics that may not have psychologists on staff or are extremely busy?” Kubala asked. “Older patients that have used epinephrine or who have had anaphylaxis in the last 4 years are going to be your patients with the worst quality of life.”