The role of the GP in the care of people with allergic disorders
- The UK has one of the highest prevalence of asthma, rhinitis and eczema. Allergy-related conditions may present in a significant number of consultations. The GP has the lead role in identifying underlying allergic symptoms that can be difficult to distinguish from the range of normality or other illnesses.
- Anaphylaxis is a life-threatening emergency that can present in primary care. GPs have a role in not only managing emergencies, but supervising the ongoing management of risk factors and prescribing.
- Allergy is a multisystem disease where relationship-based care and continuity of care are important.
- GPs need to understand how to take an allergy-focused clinical history and understand the differentiation of different types by appropriate testing and referral. This includes recognising and recording food and drug sensitivities.
Emerging issues in allergy care
- Despite the increasing prevalence of allergic and immune disorders, there is limited access to expertise and resources. This requires community-based services to take a wider role and develop integrated multidisciplinary pathways
- Allergies are the commonest chronic disorders in childhood and the prevalence has increased dramatically in the last 25 years
- Climate change and environmental factors are increasingly recognised as determinants for the allergen landscape and the impact on allergic disease
- Interaction of Covid-19 and allergy on respiratory function
- Personalised care in allergy management plans is being developed in association with the patient and other specialties such as paediatrics. Awareness is increasing in schools, which may request plans for students
- Advances in food allergy testing
- The role of immunotherapy for chronic allergic disorders.
Knowledge and skills guide
For each problem or disease, consider the following areas within the general context of primary care:
- the natural history of the condition, including whether acute or chronic
- the incidence and prevalence, including in different demographic groups
- typical and atypical presentations
- recognition of normal variations throughout life
- risk factors, including lifestyle, socio-economic and cultural factors
- diagnostic features and differential diagnosis
- recognition of ‘alarm’ or ‘red flag’ features
- appropriate and relevant investigations
- interpretation of test results
- management, including initial and continuing care, chronic disease monitoring and emergency care
- patient and carer information and education, including self-care prognosis.
Symptoms and signs
- Anaphylaxis
- Angioedema
- Atopy – asthma, eczema and hay fever
- Drug reactions
- Gastrointestinal (GI) symptoms
- Urticaria and rashes
Common and important conditions
- Anaphylaxis, including doses of adrenaline and resuscitation
- Autoimmune conditions in primary care
- Drug allergies and their mechanisms
- Food allergies, including milk allergy (types such as IgE-mediated and non-IgE-mediated, presentation, primary care management and referral)
- Occupational allergies such as latex allergy and contact allergies such as hair dye, metals and plants
- Pollen food syndrome
- Types of allergic reaction: immediate, delayed, possible mechanisms
- Venom allergy: referral and emergency management; the role of immunotherapy
Examinations and procedures
- Administration of adrenaline
- Effective administration of topical nasal steroids and inhaler devices
Investigations
- Allergy: skin patch and prick testing, specific IgE testing (blood and skin prick), exclusion and reintroduction in suspected non-IgE disease
Service issues
- The impact of variability in local service provision for allergic disorders
- Extended hub and spoke models such as allergy and clinical immunology networks involving specialist nurses, health visitors and dietitians in integrated referral pathways
- Digital health and decision support software to enable remote consultation and more accurate diagnosis and management
- Patient safety measures, including appropriate prescribing (for example, systems to document allergies in the patient record, MedicAlert bracelet)
The role of the GP in the care of people with immune disorders
- Increasing numbers of people with secondary immune deficiencies from chemotherapy and use of biologics may present to their GP.
- GPs deliver preventative public health strategies through routine immunisation and should expand provision of vaccination as new disease patterns emerge.
Emerging issues in immune disorders
- Immune manipulation is increasingly being used in a range of therapies (such as monoclonal antibodies)
- Risk management in a pandemic, such as allergies to vaccinations (Covid-19)
Common and important conditions
- Immune deficiency states (inherited, primary and acquired such as human immunodeficiency virus (HIV), chemotherapy) as applicable to primary care, particularly the different requirements for antibiotics
- Immunisation:
- antibody test results used in guiding management of specific situations such as chickenpox in pregnancy, rubella immunisation, hepatitis B and C
- routine and catch-up primary childhood immunisation schedules, contraindications and adverse reactions
- Covid-19 vaccinations and understanding indications, regulations and up-to-date guidance on risk and benefits
- for occupational medicine such as healthcare workers and hepatitis B
- vaccine hesitancy and its wider implications
- Needlestick injuries and risk of hepatitis B and C, HIV
- Skin manifestations of immune disease such as Kaposi’s sarcoma
- Transplantation medicine as applicable to primary care, particularly in management of organ transplants
- Indications and complications of transplantation such as immunosuppression and immunosuppressant drugs
Symptoms and signs
- Recurrent infections – use of risk assessment checklists to assess susceptibility
Investigations
- Immune disorders: immunoglobulin levels and complement
Case discussion
Leo Mead, a 15-year-old boy, presents with a history of redness and soreness around his mouth and vomiting after eating a peanut. His mother tells you he had ‘lactose intolerance’ in childhood but has grown out of it. He is previously well and is unsure whether he has any other history of specific reactions.
He is known to be atopic with chronic eczema, which he is embarrassed about and is stopping him from swimming. His hay fever is usually sufficiently controlled with occasional antihistamines, but he is getting worsening asthma in the hay fever season and during exercise. His mother wonders whether you could refer him to a clinic for ‘allergy testing’.
How would you respond?
Questions
These questions are provided to prompt you to consider the key points of the case. They can form the basis for a case-based discussion with your educational supervisor and will assist you in writing reflective entries in your ePortfolio. The questions are examples to trigger reflection and are not intended to be comprehensive.
This is about professionalism and the actions expected to protect people from harm. This includes the awareness of when an individual’s performance, conduct or health, or that of others, might put patients, themselves or their colleagues at risk.
How do my personal beliefs about the impact of allergies on wellbeing influence the care that I provide?
Do I listen without preconceived ideas to patients’ thoughts on allergies or intolerance even if unlikely to have any medical basis?
This is about professionalism and the actions expected to protect people from harm. This includes the awareness of when an individual’s performance, conduct or health, or that of others, might put patients, themselves or their colleagues at risk.
| Core capabilities | Questions |
|---|---|
Fitness to practise This is about professionalism and the actions expected to protect people from harm. This includes the awareness of when an individual’s performance, conduct or health, or that of others, might put patients, themselves or their colleagues at risk. | How do my personal beliefs about the impact of allergies on wellbeing influence the care that I provide? Do I listen without preconceived ideas to patients’ thoughts on allergies or intolerance even if unlikely to have any medical basis? |
An ethical approach This is about practicing ethically with integrity and a respect for equality and diversity. | What are my attitudes towards people with allergies? If the patient had been three years old, or 30 years old, instead of 15, might that have changed my management? Do I empower patients to self-manage and to have confidence in accessing information on their condition and using treatments appropriately? |
Communicating and consulting This is about communication with patients, the use of recognised consultation techniques, establishing and maintaining patient partnerships, managing challenging consultations, third-party consulting, the use of interpreters and consulting modalities across the range of in-person and remote methods. | How do I ensure that I accurately assess the needs and health beliefs of a 15-year-old boy in the presence of his mother? How do I respond to the inherent uncertainties in diagnosis and management? How do I seek to understand how the patient and family might feel about the risk of further events, the medications required and the fear of death from anaphylaxis? |
Data gathering and interpretation This is about the gathering, interpretation and use of data for clinical judgement, including information gathered from the history, clinical records, examination and investigations. | What other questions should I ask to help me with my diagnosis? Do I know how to take an allergy history and understand the important key points to enable me to adequately assess risk and document symptoms in a way that accurately describes allergy? What investigations, if any, could I do in primary care? What is ‘allergy testing’? How can it be performed? Do I understand different indications for skin prick testing, blood tests or patch tests? |
Clinical examination and procedural skills This is about clinical examination and procedural skills. By the end of training, the GP registrar must have demonstrated competence in general and systemic examinations of all the clinical curriculum areas, including the five mandatory examinations and a range of skills relevant to general practice. | How would I clinically assess and manage a patient presenting with acute angioedema? |
Decision-making and diagnosis This is about having a conscious, organised approach to making diagnosis and decisions that are tailored to the particular circumstances in which they are required. | How do I explore other factors that might influence Leo and his mother’s health beliefs about his management? How can I incorporate shared decision-making in my management? What options are available to me if I am unsure what to do? |
Clinical management This is about the recognition and a generalist’s management of patients’ problems. | What management options might be considered? Do I know the right dose of adrenaline for the patient’s age, and can I discuss types of devices, needle length etc.? How do I assess the need for or urgency of referral? How can I empower patients and their carers to recognise symptoms of anaphylaxis if unintended allergen exposure occurs, and train them to use adrenaline devices if needed? How do I provide the patient and family with information on next steps in the management process and also with emergency management plans they can share with his school or college, for example? |
Medical complexity This is about aspects of care beyond the acute problem, including the management of comorbidity, uncertainty, risk and health promotion. | In what ways might I know or find out whether a patient has an allergy (such as asking in consultation, noting MedicAlert bracelet)? How far am I aware of the nature of multisystemic allergy, including rhinitis and its associations with asthma, and food allergy with GI, respiratory and skin symptoms? |
Team working This is about working effectively with others to ensure good patient care and includes sharing information with colleagues and using the skills of a multiprofessional team. | Am I aware of the boundaries of primary care and the role of specialist services? What do I know about allergy services in my area? To whom would I make a referral? How can I coordinate ongoing care with the specialist multidisciplinary teams? What are the best ways of communicating with regionalised teams such as allergy services? |
Performance, learning and teaching This is about maintaining the performance and effective CPD of oneself and others. The evidence for these activities should be shared in a timely manner within the portfolio. | What do I know about the evidence-based management of allergy, and do I understand and implement key national guidelines? What are my personal educational needs that this scenario identifies and how will I address them? Who might be able to help me? In what ways can I assess and improve the care of patients with allergies through quality improvement or audit? |
Organisation, management and leadership This is about understanding how primary care is organised within the NHS, how teams are managed and the development of clinical leadership skills. | What systems does my practice have in place for recording patient allergies? What shared care arrangements would I expect to be in place for patients with severe allergies? What further support does the practice need to provide? |
Holistic practice, health promotion and safeguarding This is about the ability of the doctor to operate in physical, psychological, socio-economic and cultural dimensions. The doctor is able to take into account the patient’s feelings and opinions. The doctor encourages health improvement, self-management, preventative medicine and shared care planning with patients and their carers. The doctor has the skills and knowledge to consider and take appropriate safeguarding actions. | How do I assess the psychological and social impact of diagnosis on quality of life (QOL), including school or nursery settings, social occasions, travel and fear of reactions? How do I balance health anxiety with actual health risk? What other aspects of health promotion need to be addressed? |
Community health and environmental sustainability This is about the management of the health and social care of the practice population and local community. It incorporates an understanding of the interconnectedness of health of populations and the planet. | How common are clinically significant allergies in my practice population? What are the cultural differences in my patient population and how does this impact on management of allergy? What support can be identified in my locality? What voluntary organisation might be able to offer support and resources? |
How to learn this area of practice
Work-based learning
General practice is a good place for you to learn how to manage immune and allergic disorders because of the wealth of clinical material. Patients will present with various symptoms at varying stages in the natural history of their illness. Discussion with a trainer will aid GP registrars in developing strategies to help in problem-solving. Supervised practice will also give GP registrars confidence.
In particular, the GP registrar should be able to gain experience in the management of immune and allergic disorders as they present in the community (incidental, acute and chronic), including life-threatening emergencies. Primary care is also the best place to learn about holistic long-term disease management (for example, immunosuppressed patients, atopy, food allergies, occupational allergies).
The acute setting is the place for you to learn about the immediate management of life-threatening presentations. You will also learn about the interpretation of clinical findings and the use of appropriate specialist investigations such as serology and allergy testing. Outpatient or clinic settings are ideal places for seeing concentrated groups of patients with immune problems.
GP specialty training programmes should offer you the opportunity to attend these clinics when working in other hospital posts and during your general practice-based placements.
Self-directed learning
There is a growing body of eLearning to help you consolidate and build on the knowledge you have gained in the workplace. You can find an eLearning module(s) relevant to this topic guide at elearning for healthcare.
Learning with other healthcare professionals
Chronic disease management in primary care is a multidisciplinary activity. As a GP registrar it is important for you to gain an understanding of the diagnosis, management and follow-up of patients with immune and allergic disorders, even when the clinical lead is taken by secondary care or a community clinical nurse specialist. It is also important to understand the role of specialist allergy services and when it is appropriate to access their expertise.
Examples of how to area of practice may be tested in the MRCGP
Applied Knowledge Test (AKT)
- Management of urticaria
- Recognition of common food allergies in children and adults
- Interpretation of antibody results
Simulated Consultation Assessment (SCA)
- A young woman is concerned that her lifestyle may have put her at risk of HIV and requests testing
- A parent requests allergy testing for their child with eczema
- A woman who works as a beautician has suspected contact dermatitis from cosmetic products
Workplace-based Assessment (WPBA)
- Consultation Observation Tool (COT) about having to explain anti-D immunoglobin immunisation to a pregnant patient who has not understood the hospital specialist’s explanation
- Audit of the practice data on the appropriateness of prescribing adrenaline devices for patients at risk of anaphylaxis
- Reflective learning log entry about safety advice for a parent of a child with severe peanut allergy
- Clinical examination and procedural skills (CEPS) for administration of seasonal flu immunisation