SummaryPeanut nut and tree nut allergy are characterised by IgE mediated reactions to nut proteins. Nut allergy is a global disease. Limited epidemiological data suggest varying prevalence in different geographical areas. Primary nut allergy affects over 2% of children and 0.5% of adults in the UK. Infants with severe eczema and/or egg allergy have a higher risk of peanut allergy. Primary nut allergy presents most commonly in the first five years of life, often after the first known ingestion with typical rapid onset IgE-mediated symptoms. The clinical diagnosis of primary nut allergy can be made by the combination of a typical clinical presentation and evidence of nut specifc IgE shown by a positive skin prick test (SPT) or specific IgE (sIgE) test. Pollen food syndrome is a distinct disorder, usually mild, with oral/pharyngeal symptoms, in the context of hay fever or pollen sensitisation, which can be triggered by nuts. It can usually be distinguish clinically from primary nut allergy. The magnitude of a SPT or sIgE relates to the probability of clinical allergy, but does not relate to clinical severity. SPT of ≥ 8 mm or sIgE ≥ 15 KU/L to peanut is highly predictive of clinical allergy. Cut off values are not available for tree nuts. Test results must be interpreted in the context of the clinical history. Diagnostic food challenges are usually not necessary but may be used to confirm or refute a conflicting history and test result. As nut allergy is likely to be a long-lived disease, nut avoidance advice is the cornerstone of management. Patients should be provided with a comprehensive management plan including avoidance advice, patient specific emergency medication and an emergency treatment plan and training in administration of emergency medication. Regular re-training is required.

SummaryThis guideline advises on the management of patients with egg allergy. Most commonly, egg allergy presents in infancy, with a prevalence of approximately 2% in children and 0.1% in adults. A clear clinical history and the detection of egg white-specific IgE (by skin prick test or serum assay) will confirm the diagnosis in most cases. Egg avoidance advice is the cornerstone of management. Egg allergy often resolves and re-introduction can be achieved at home if reactions have been mild and there is no asthma. Patients with a history of severe reactions or asthma should have reintroduction guided by a specialist. All children with egg allergy should receive measles, mumps and rubella (MMR) vaccination. Influenza and yellow fever vaccines should only be considered in egg-allergic patients under the guidance of an allergy specialist. This guideline was prepared by the Standards of Care Committee (SOCC) of the British Society for Allergy and Clinical Immunology (BSACI) and is intended for allergists and others with a special interest in allergy. The recommendations are evidence-based but where evidence was lacking consensus was reached by the panel of specialists on the committee. The document encompasses epidemiology, risk factors, diagnosis, treatment, prognosis and co-morbid associations.

SummaryThis guidance for the prescription of an adrenaline auto-injector has been prepared by the Standards of Care Committee (SOCC) of the British Society for Allergy and Clinical Immunology (BSACI). There is insufficient quality evidence-based data in some areas, including the question of how often a second dose is required, and the optimal dose and absorption after subcutaneous vs. intramuscular injection. Thus, indications for adrenaline (which are partly opinion based) in guidelines from different countries vary slightly. The guideline is based on evidence as well as on expert opinion and is for use by both adult physicians and paediatricians practising allergy. During the development of these guidelines, all BSACI members were included in the consultation process using a web-based system. Their comments and suggestions were carefully considered by the SOCC. Evidence from randomized controlled trials is lacking in anaphylaxis for ethical reasons. Consensus was reached by the experts on the committee. Included in this guideline are aetiology, risk of recurrence and management of anaphylaxis (after treatment of the acute episode), including allergen avoidance and written treatment plans. There are sections on dose and absorption of adrenaline, and adrenaline auto-injectors, including indications for their prescription, risk assessment for the number required and training in their use. The guidelines are not intended to be prescriptive, and clinicians should use their clinical judgement. Finally, we have made recommendations for potential areas of future research. • Adrenaline is the first-line treatment for anaphylaxis.It should be used in patients with significant airway involvement or hypotension, occurring as part of an anaphylactic (IgE-or non-IgE-mediated) reaction.• An adrenaline auto-injector should be prescribed for those at risk of anaphylaxis.• An auto-injector allows early administration of adrenaline as this improves outcome. It should be seen as a first-aid measure combined with calling for help (ambulance/emergency medical services).• After acute anaphylaxis, an adrenaline auto-injector should be prescribed in the Emergency Department or primary care and an allergy referral immediately triggered (NICE guidance).• Specialist allergy experience is required to make a risk assessment to determine the continuing need for an adrenaline auto-injector. This requires accurate diagnosis of the aetiology, assessment of severity and future risk, including consideration of the amount of allergen involved in previous reactions and the ease of avoiding the trigger. Certain co-factors increase the risk of anaphylaxis, for example asthma in the case of food allergy, raised baseline serum tryptase and the age of the patient.• Patients at risk of anaphylaxis that should be con- • A recent MHRA drug safety update (2014) recommended that people who have been prescribed an AAI should carry two; however, normally only one autoinjector is required for self-administration during a reaction. For children, two should usua...

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