Select Committee on Science and Technology Sixth Report

CHAPTER 8: Different Patterns of Management

Introduction

8.1.A variety of interventions are potentially available to patients with allergic disease. Adrenaline autoinjectors can be supplied on prescription in case an anaphylactic emergency occurs, immunotherapy can offer a long-term modification of the immune response, and novel treatments such as anti-IgE therapy may be used for patients who fail to respond to more conventional treatments. However, people who think they have an allergy consult widely. They often seek help and information from pharmacists, complementary practitioners, over the telephone from NHS Direct or via the internet. In this Chapter we explore some proven and unproven therapies directed at allergy, and the ways in which these are provided.

Immunotherapy

8.2.Treatment with drugs such as antihistamines or steroids can be used to manage the symptoms of allergic disease but do not modify the underlying disease process. In contrast, immunotherapy (sometimes called specific immunotherapy, desensitisation or "allergy vaccine") involves the administration of increasing doses of allergen, which over time desensitises the allergic patient by altering their immune system. As Professor Stephen Durham, President of the British Society for Allergy and Clinical Immunology (BSACI) told us, this could provide a useful long-term solution to the management of allergy for both "patients with severe hayfever which does not respond to conventional treatment," and "patients with venom anaphylaxis from stinging insects, wasps and bees" where the treatment could be life-saving (Q 193). Immunotherapy can be administered either via injection (subcutaneous immunotherapy) or via oral tablets (sublingual immunotherapy). At ALK-Abelló in Denmark we heard that immunotherapy, although not a cure for allergy irrespective of the allergen load, rendered the patient tolerant enough of an allergen in order to safely undertake or resume everyday tasks in normal life.[121]

8.3.In both Denmark and Germany we learnt that immunotherapy was a standard and effective way of managing allergies in many countries, and patients told us how it had allowed them to lead much more normal lives. But witnesses forcefully told us that immunotherapy was not used to its full potential in the United Kingdom. The reason for this was partly historical; when early types of immunotherapy were administered by general practitioners, a number of patients had suffered anaphylactic shock. Professor Anthony Frew, President of the EAACI, told us that "between 1952 and 1986 there were about 27" associated fatalities (Q 195) and the EAACI felt that the limited use of immunotherapy in the United Kingdom "reflects concerns about safety" (p 68). However, there was general consensus that this treatment was safe to use if administered by specialists in the tertiary care environment where, in Professor Durham's words, "in the unlikely event of a severe reaction occurring, that can be recognised and promptly treated" (Q 200). The EAACI added that "elsewhere in Europe and North America, desensitisation is commonly used in patients presenting with rhinitis and asthma" (p 68).

8.4.Professor Frew commented, amongst others, that the Medicines and Healthcare products Regulatory Agency (MHRA) had "been much more strict in terms of the regulation than other parts of Europe" and this was inappropriately stringent (Q 195). Representatives from ALK-Abelló told us that although their subcutaneous immunotherapy products had received product licences within several European countries, the company had virtually given up seeking these product licenses in the United Kingdom because the MHRA was seen as intransigent over the approval of this treatment.[122]

8.5.Mr Richard Gutowski, Head of Compliance and European Business for Medical Devices at the MHRA, explained that in 1994 the Committee on Safety of Medicines (CSM) had "recommended that these treatments should be restricted to those patients who have not responded to anti-allergy drugs" (Q 764). The MHRA added that there was no fixed view on any product class as "scientific evidence is the most important determinant of the regulatory decision(s)" (p 284). Although some subcutaneous immunotherapy products are unlicensed in the United Kingdom, they may be legally prescribed on a named-patient only basis within the NHS.[123]

8.6.Currently, two subcutaneous products hold MHRA product licences: "Pollinex" (for the treatment of grass or tree pollen allergies), and "Pharmalgen" (for the treatment of bee or wasp venom allergies). "Grazax," an immunotherapy product for the treatment of grass pollen, has also been granted a product licence (p 283). It is a prophylactic treatment for hayfever sufferers which is easily administered as sublingual tablets, and avoids the side-effects of sedative antihistamines which only modify the symptoms and can seriously impair children's school and exam performance.

8.7.Immunotherapy treatment is expensive, but by reducing the need for other types of medication, might prove cost-effective in the long-term.[124] Furthermore, the Royal National Throat Nose and Ear Hospital highlighted the fact that sublingual immunotherapy treatment in rhinitis patients might prevent the development of asthma, and reported that "there is an urgent need for large well-controlled studies to validate this, to examine the doses of allergen needed and to look at pharmaco-economic implications since this form of immunotherapy is safer and more convenient" to use than desensitisation injections (p 285).

8.8.We were therefore disappointed to hear that the National Institute for Health and Clinical Excellence (NICE) had no plans to appraise immunotherapy products. Mr Andrew Dillon, Chief Executive of NICE, explained that with the "limited capacity" of NICE, this was a low priority and Grazax had been deemed "not suitable for appraisal" (QQ 766, 776). After hearing our concerns about immunotherapy appraisal, Mr Lewis reported that his Department had "passed the Sub-Committee's views to the NICE topic selection team" for consideration in the topic selection process (p 323).

KEY RECOMMENDATION

8.9.Immunotherapy is a valuable resource in the prophylactic treatment of patients with life-threatening allergies, or whose allergic disease does not respond to other medication. Although initially expensive, immunotherapy can prevent a symptomatic allergic response for many years, and may prevent the development of additional allergic conditions, so its wider use could potentially result in significant long-term savings for the NHS. We recommend that NICE should conduct a full cost-benefit analysis of the potential health, social and economic value of immunotherapy treatment.

Adrenaline autoinjectors

8.10.Adrenaline autoinjectors, such as Epipens and Anapens, provide a quick dose of adrenaline that can be life-saving for people suffering an anaphylactic shock to food or insect stings, but there is wide variation in when these injectors are prescribed. Dr Pumphrey reported that over half of those who die from an allergic reaction "did not have any previous serious reaction" (p 180). Dr Rosenthal said there is "very little laid down" in terms of guidelines for the prescription of autoinjectors and Dr Hyer told us simply that "we do not know yet exactly who should carry them" so "there is no fixed protocol a GP can follow" (Q 674).

8.11.Mr Lewis told us that "in the year to 30 September 2006, almost 165,000 prescriptions were dispensed in the community in England for Epipens, at a cost of about £8.2 million" (Q 869). But several witnesses expressed concern that these autoinjectors were not being used effectively. Dr Pumphrey reported that "of the last 48 fatal reactions to foods," 19 of these patients had adrenaline pens yet the rate of food allergy deaths was rising. Failure of pens was sometimes because "the patient was too fat for the pen to give the necessary intramuscular injection" or poor training of patients, including pens having past their expiry date, pens being used too late in the reaction, or pens not being carried at the time of the reaction (p 180).

8.12.However Dr Pumphrey also told us that "others used the pen correctly, were thin, had the correct dose and still died. One 16-year-old girl took the risk of eating a chocolate labelled 'may contain nuts' because she had her pen with her. She used the pen immediately she saw nuts in the chocolate but nevertheless died from her reaction. Clearly pens cannot be relied upon to save someone with a food allergy reaction and patients must continue to take great care to avoid their trigger food even when they have a pen" (p 180).

8.13.The prescription of adrenaline autoinjectors requires specialist allergy knowledge which is currently lacking amongst many general practitioners, and needs to be coupled with patient training. The establishment of allergy centres and the general upskilling of practitioners in allergy should improve the quality of training provided to patients regarding the administration of their treatments.

Anti-IgE therapy

8.14.Novel therapies for the treatment of allergy are constantly being researched and recently an anti-IgE therapy has been developed to treat severe allergic asthma. Anti-IgE therapy omalizumab (Xolair), is an antibody which binds to and removes IgE from the circulation, thus inhibiting the allergic reaction. Mr Dillon reported that NICE were assessing this "for treating severe, persistent, allergic asthma" (Q 773).

8.15.The DH reported that anti-IgE therapy was "presently licensed in the UK only for severe asthma, but could potentially be used in the management of other severe IgE (immunoglobulin E) mediated allergic problems" (p 5). However, academics felt that the cost would limit its use and Professor Peter Barnes, from the National Heart and Lung Institute at Imperial College London, commented that "it costs something like £10,000 a year to treat some patients with higher levels of IgE, so it could only really be considered for very severe asthma patients." But he emphasised that it was an extremely valuable treatment for patients whose symptoms "have not been controlled by conventional therapy" (Q 182). The costs are unlikely to fall in the near future as Professor Frew noted that "it is the combination of the frequency of administration, the production costs and associated hospital costs that make the treatment an expensive option" (Q 185).

NHS Direct

8.16.Ms Helen Young, Executive Clinical Director and Chief Nurse at NHS Direct, estimated that its telephone helpline received over 600,000 calls per month in total, and its website received over 1 million hits per month. Ms Young told us that all their calls were recorded and a selection were "peer reviewed by a supervisor and usually another clinician." There were four different algorithms that could be launched in relation to allergy queries, but the true number of allergy-related calls could not be deduced because people might also report symptoms such as "wheezes, rashes [or] nasal congestion" which may or may not be allergy-related. She estimated that around one per cent of allergy calls would be dealt with as an urgent 999 call, 50 per cent would be referred to "a GP practice or some form of out of hours care," and the rest would be advised to "self care." NHS Direct staff might advise "that a particular group of drugs might be helpful in alleviating symptoms" but Ms Young acknowledged that many symptoms should be seen by a clinician face to face, so added that staff would advise callers to "go to the pharmacy, speak to the pharmacist and be advised on what is the best product" (Q 755-756, 771).

The role of pharmacists

8.17.The Royal Pharmaceutical Society of Great Britain (RPSGB) reported that there is a "vast and potentially bewildering" choice of treatments available for allergy sufferers, so pharmacists often help them to "recognise symptoms, identify allergy triggers and select appropriate products" (p 374). As Ms Covey pointed out, pharmacists provide a useful service for patients with lifelong conditions who "do not want to go back to a GP every five minutes" (Q 793).

8.18.Although agreeing that pharmacists provided a valuable resource for allergy sufferers, Dr Scadding warned that pharmacies "should not be used to diagnose allergy" (Q 795). But Allergy UK felt "the majority of allergy could be successfully diagnosed and managed in primary care" providing the professionals, including pharmacists, were "given the correct training" (p 303).

8.19.Pharmacists are not licensed to prescribe treatments such as adrenaline autoinjectors but they offer advice on a range of other drugs. The RPSGB reported that at undergraduate level, pharmacists received training in "the pathological and immunological basis of allergy" and education regarding treatment. At postgraduate level, the Centre for Pharmacy Postgraduate Education in England did not run specific courses on allergy, but was building one with Allergy UK. Furthermore, the RPSGB commented that the Pharmacists and Pharmacy Technicians Order 2007[125] would "update, strengthen and clarify the RPSGB's powers to protect, promote and maintain the health and safety of the public" (p 375).

8.20.Pharmacists are often consulted by the general public about allergic conditions, and thus lift a significant burden from general practitioners. It is therefore essential that the advice offered regarding allergy is accurate, and should be given by trained pharmacists rather than unqualified assistants. We recommend that as part of the implementation of the Pharmacists and Pharmacy Technicians Order 2007, adequate allergy education should be provided for all pharmacists, to ensure that they provide high quality advice to allergy sufferers.

Complementary medicine

8.21.Many patients turn to complementary medicine to diagnose and treat their allergy which may reflect their dissatisfaction when unable to access adequate treatment from the NHS. Allergy UK reported that "the inability to obtain proper diagnosis is driving an increasing number of people into undertaking alternative testing" (p 293), and Professor Chris Corrigan, Professor of Asthma, Allergy and Respiratory Science at King's College London, added that "one will seek help from anywhere if one is desperate enough" (Q 534).

8.22.But Professor Edzard Ernst, Director of Complementary Medicine at the Peninsula Medical School, Exeter, felt that complementary therapies were "used in addition, as a complement" to conventional medicine. Furthermore, Ms Kate Chatfield from the Research Ethics Committee at the Society of Homeopaths, added that parents most often turned to homeopathy to treat their child because "they do not want to use conventional treatment or, if they have used conventional treatment, they are worried about the side effects" (Q 534).

8.23.The ways in which complementary therapists diagnose allergic conditions are considerably different from those used by conventional practitioners. We were therefore disappointed at the lack of response from complementary practitioners to our Call for Evidence. Ms Chatfield explained that "in homeopathy we have a very different definition of diagnosis. It is not diagnosing a specific allergy according to a specific allergen. A homeopathic diagnosis for us literally means finding the right remedy for the person, so it is not a conventional diagnosis in that sense" (Q 506).

8.24.Other complementary practitioners may offer various diagnostic techniques for allergies which have faced much scepticism from practitioners of conventional medicine. Vega testing is the observation of electrical measurements over acupuncture points when a substance relevant to the patient is placed in series in the circuit. Applied kinesiology assesses changes in patients' stress resistance upon hand contact with suspected allergens. The Royal College of Paediatrics and Child Health was concerned that "kinesiology, vega testing and hair analysis as forms of allergy testing have no scientific rationale and are not valid diagnostic procedures" (p 120), and in Professor Corrigan's opinion, "there is no scientific evidence or mechanistic base to suggest that these tests could be remotely effective" (Q 511).

8.25.Concern has also been raised regarding the causes of allergy which may be diagnosed and treated. The EAACI reported that some complementary therapists "are offering to look for allergy as an explanation for symptoms that we do not think are allergic. So for example, someone might offer to test for an allergic basis for fatigue, headache, weight gain etc" (p 70).

8.26.Specific criticism has been meted out against the diagnosis of "multiple chemical sensitivity" (MCS) issued by some "environmental allergists." Dr Damien Downing, President of the British Society for Ecological Medicine, described MCS as "another form of allergy that is getting worse and more common." He added that although the causes of this condition were complex, he believed that in the future it would be proven that MCS was caused by "environmental pollution and chemicals having a disrupting effect on the immune system and making all allergies worse." Mr Don Harrison, Principal of the British Institute for Allergy and Environmental Therapy, added that other factors which contributed to MCS development included "factories; traffic; flight paths; laboratory work; farming in particular, with the spraying of pesticides and … dipping of sheep; excessive inoculations in time of war … and perhaps surgical anaesthetics" (Q 545).

8.27.To diagnose and treat MCS, Dr Jean Monro, Medical Director of Breakspear Hospital, used the provocation/neutralisation test, which she described as "a form of low-dose immunotherapy" (Q 561). However, Professor Simon Wessely, a psychiatrist from King's College London, reported that "the phenomenon of multiple chemical sensitivity cannot be explained by allergy and/or immunological mechanisms … there is convincing experimental evidence that this can be explained by psychological conditioning." He continued to explain that some of these people might be suffering from depression or anxiety, but an inaccurate diagnosis meant they may "receive treatments that do little good and in some cases considerable harm" (p 227).

8.28.Following diagnosis, complementary practitioners may offer a range of therapies to treat allergic conditions. Although herbalism and homeopathy had been embraced by some conventional practitioners, there was widespread scepticism regarding the use of other complementary therapies. One example was enzyme-potentiated desensitisation, which the Faculty of Homeopathy described as "a therapeutic technique in which low dose allergens … are injected intradermally to desensitise patients with atopic diseases" (p 347). Professor Jonathan Brostoff, Professor Emeritus of Allergy and Environmental Health at King's College London, claimed that the side effects were minimal and that "anecdotally many patients respond well to it" (Q 529). But Professor Ernst told us that "there are virtually dozens of complementary therapies that have been submitted to clinical trials … for no treatment modality is there good evidence that it is clinically effective in asthma, atopic eczema or hayfever" (Q 507).

8.29.Nevertheless it is clear that anecdotally, patients often report a benefit after seeking treatment from complementary practitioners. Because anxiety plays a role in the symptoms of asthma, Professor Corrigan suggested that many of these techniques may improve the wellbeing of allergy patients, not by treating the underlying cause of disease, but by teaching patients breathing techniques which presumably "help them to calm down and breathe more naturally" (Q 508).

8.30.There were concerns expressed to us about the indirect consequences from complementary practices used in isolation from more conventional medicine. Professor Corrigan was worried that, in his view, homeopathic consultations may be dangerous because "they may delay accurate, valid and pressing diagnosis" (Q 523) and the National Allergy Strategy Group forcefully made the point that "many patients get the wrong diagnosis. This sometimes leads to medical harm; or financial problems for the patient" (p 131).

8.31.It is unknown whether the positive effects reported by patients following complementary therapy are due to the actual techniques or a placebo effect. Professor Ernst claimed that "research funding is the most difficult thing in my life to obtain … it has become even more impossible over the last few years because regulation of clinical trials is now such that it is very expensive … Public funds are by and large not available … Industry funds are non-existent so we are reliant on charitable funds which are very scarce indeed" (Q 526). This argument was rejected by Professor Wessely though, who argued that "I do not think it is that difficult to get money for research, if you have well-designed studies with good hypotheses and good outcome measures," and felt that there had been more than enough research on some areas, such as provocation tests and electrical hypersensitivity (QQ 550, 552).

8.32.It was also felt that research studies might ask the wrong questions when analysing complementary therapies. Professor Ernst noted that "we have, if anything, too many quality of life measurements rather than too few these days … in complementary medicine, it has largely been adopted so I do not know of any reasonably good trial that totally neglects the patient's view in that sense." But this was countered by Ms Chatfield who commented that although quality of life assessments had improved over the last few years, "with the kind of holistic treatment that we are measuring in homeopathy, we still do not have an outcome measure that successfully can measure the effect on every level. By their very nature, randomised control trials are trying to measure very specifically. Homeopathy is going to affect the whole person. It is very difficult to measure an outcome for a whole person" (Q 541).

8.33.We recommend that robust research into the use of complementary diagnostic tests and treatments for allergy should examine the holistic needs of the patient, assessing not only the clinical improvement of allergy symptoms, but also analysing the impact of these methods upon patient wellbeing. Such trials should have clear hypotheses, validated outcome measures, risk-benefit and cost-effectiveness comparisons made with conventional treatments. Allergy centres (para 9.40) will allow the collection of information about any indirect consequences of misdiagnoses or delayed treatment.

Self-diagnosis

8.34.During the course of our inquiry witnesses have also voiced concern regarding allergy self-testing kits available over the counter in pharmacies or via the internet. Most of these kits test for food allergies or intolerances, and require the individual to send a blood sample to the manufacturers for analysis. The results of the test are then returned to the patient along with advice about the types of food they should avoid.

8.35.In particular, criticism has arisen of tests which analyse the level of IgG antibodies to foods in the blood. Antibodies of the IgG class have a general protective role in the immune response to infectious agents, and healthy individuals make a harmless IgG response to virtually all external agents, including foods.[126] Also, a subclass of IgG antibodies (termed IgG4) plays a protective role in atopic allergy. Dr Gill Hart, Technical Director of Yorktest Laboratories, a company which manufactures such tests, told us that the presence of either IgE or IgG antibodies does not necessarily prove whether a food allergy exists, but claimed that IgG could be used "as a marker that a reaction has occurred" (Q 742). However, there is limited evidence to support this claim.

8.36.Furthermore, the EAACI even discredited the use of well validated tests based on IgE antibodies if they are used on a self-testing basis. This was because the tests "cannot be interpreted without a detailed clinical history taken by an allergy-trained individual, thus over the counter and postal testing is open to misinterpretation unless expert opinion is available" (p 70). There was therefore concern that incorrect diagnoses could lead to unnecessary food avoidance in individuals who used these tests.

8.37.Aware of the responsibility that therefore lies with the providers of such tests, Dr Hart told us that Yorktest always gave individuals the option of sending results to their general practitioner, but noted that "in most cases they choose not to have their results sent back to their GP" (Q 734). Dr Hart admitted that the mechanisms used in the tests were "unclear and as a company we have tried to support and collaborate with groups to find out more about these mechanisms" but "we have struggled working with others to get grants to do this sort of work" (Q 742).

8.38.Given the lack of evidence for these services we were concerned to learn that Allergy UK recommended the Yorktest service for food intolerance. The charity acknowledged that a patient's best option would be to consult a dietician, but noted that "being able to obtain a referral to a dietician who understands food intolerance is extremely difficult on the NHS" (p 303). Allergy UK had commissioned a survey of Yorktest consumers, independently audited by the University of York, which in Dr Hart's words showed that of the "people who rigorously adhere to our diet, three out of four of those people are showing some benefit to their chronic conditions" (Q 744).

8.39.The charity added that in addition to clinical trials and anecdotal studies, "we also assured ourselves of the service level to their clients by Yorktest," and stressed that this was the only test which it endorsed. Allergy UK continued: "in addition to the test, Yorktest clients have the opportunity (usually taken up) for two consultations with a nutritionist/dietician. They receive an excellent guide to their condition and the advice is very clear that they should not continue on an exclusion diet beyond the stated period of time" (p 303). However, Dr Scadding argued that "I do not think there is any point in spending money on IgG antibody tests … the IgG antibody tests are liable to leave patients on diets that are inadequate and patients often like to think they are improving and they carry on in the teeth of very little improvement and may end up malnourished" (Q 802).

8.40.We are concerned both that the results of allergy self testing kits available to the public are being interpreted without the advice of appropriately trained healthcare personnel, and that the IgG food antibody test is being used to diagnose food intolerance in the absence of stringent scientific evidence. We recommend further research into the relevance of IgG antibodies in food intolerance, and with the establishment of more allergy centres, the necessary controlled clinical trials should be conducted. We urge general practitioners, pharmacists and charities not to endorse the use of these products until conclusive proof of their efficacy has been established.

Regulation of complementary medicine and self-testing kits

8.41.Many witnesses were outraged at the lack of regulation for some complementary practitioners and allergy diagnostic self-testing services. According to Allergy UK, "currently there is nothing to guide the consumer on whether the test, clinic or service has been clinically proven in any way" (p 293). The Royal College of Pathologists emphasised that "regulation of non-NHS clinics and over-the-counter treatments for allergy is not adequate—extensive evidence that it leads to direct harm to individuals is lacking, but there is clearly a legitimate concern that ineffective or misleading advice may be harmful, costly and may divert patients from effective evidence-based interventions" (p 126).

8.42.The DH reported that "private and voluntary healthcare providers are subject to regulation by the Healthcare Commission if they provide services set out in current legislation. Those services do not include over the counter allergy tests. However, providers registered with the Commission might offer allergy tests as part of a wider range of services" (p 7). Mr Lewis told us that the DH was developing legislation to regulate practitioners of acupuncture, herbal medicine and traditional Chinese medicine. It had also "funded the Prince of Wales' Foundation for Integrated Health to set up a voluntary register of unregulated professions" and was establishing "a UK working party to consider the criteria to be used to decide whether a profession should or should not be statutorily regulated." But the Department had no immediate plans to extend statutory regulation of complementary practitioners further (Q 892).

8.43.Various steps had already been taken by some societies of complementary practitioners towards voluntary self-regulation. The Society of Homeopaths noted that its members were "subject to a rigorous Code of Ethics" and that it was also "a key player in the Council of Organisations Registering Homeopaths … working to establish a single register for the profession" which would allow patients and healthcare workers "to be sure of the professional standards, competency and accountability of the homeopaths they employ" (pp 202, 204). The British Institute for Allergy and Environmental Therapy also reported that the "300 holistic allergy therapists" that it represented were "obliged to accept the strictest standards of practice and Code of Conduct." Admission to the Institute was via its own Diploma course, and the Institute believed that "all complementary therapists should be members of a well-regulated professional association for their own therapy" (pp 224, 226).

8.44.However, Professor Ernst was concerned that regulation was "seen as a substitute for evidence," and that regulation of complementary therapies would cause further research into their efficacy to cease. This was agreed with by Professor Corrigan, who added that "regulation does not mean the treatment is effective. At best, it may protect some patients from being poisoned and it may protect some patients from charlatans. Once you do license them, they are under less obligation then to show that what they do is of any benefit, which is counterproductive" (Q 531).

8.45.With regard to allergy self-testing kits available for public use, the in vitro diagnostic devices (IVDs) are regulated by the Medical Devices Regulations 2002. Manufacturers of IVDs in the United Kingdom must register with the MHRA, and the self-test element of the IVD must be assessed by a third party certification organisation, or "notified body," designated by an EU member state (p 7). Mr Gutowski emphasised that the legislation does "not regulate in any way the service provider or the treatment regime" (Q 751). However, Dr Hart noted that "there is confusion within different competent authorities within Europe, my understanding is, of how the regulations are interpreted and even within the notified bodies within the UK," and added that it was very important for these services to be regulated in the future (QQ 741, 752).

8.46.Despite the concerns raised, as yet there is no conclusive evidence to show that the tests and treatments offered by complementary practitioners, or the self-testing kits sold to the general public, cause any direct harm. These consultations, tests and therapies may indeed reduce patient anxiety and improve their general sense of wellbeing, even though their underlying allergy may not necessarily be diagnosed or treated. However, we are concerned that individuals who use such tests or seek such treatments without consulting a more conventional practitioner may suffer indirect consequences to their health and may spend large sums of money unnecessarily.

8.47.In 1999-2000 this Committee conducted a detailed inquiry into complementary and alternative medicine,[127] and some of the recommendations regarding the regulation of certain techniques are still being implemented. We therefore do not make further recommendations at this point but support ongoing scientific evaluation.

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121  Note of the visit to Denmark, Appendix 8.  Back

122  Note of the visit to Denmark, Appendix 8. Back

123  Note of the visit to Denmark, Appendix 8.  Back

124  Note of the visit to Allergy Therapeutics, Appendix 7. Back

125  Statutory Instrument 2007 No. 289.  Back

126  Barnes et al., International Archives of Allergy and Immunology 87, 1988, "Human serum antibodies reactive with dietary proteins. IgG subclass distribution," pp 184-188. Back

127  Science and Technology Committee, 6th Report (1999-2000): Complementary and Alternative Medicine (HL 123). Back