Examination of Witnesses (Questions 200-219)
PROFESSOR STEPHEN
DURHAM, PROFESSOR
PETER BARNES,
PROFESSOR ANDREW
WARDLAW AND
PROFESSOR ANTHONY
FREW
18 DECEMBER 2006
Q200 Lord Taverne: Is the risk because
people are not properly trained in administering it or is there
something inherently unsafe about it?
Professor Durham: No, it is two-fold. First
of all people do need to be trained in the administration of the
treatment and, secondly, the patient has to be in an environment
where, in the unlikely event of a severe reaction occurring, that
can be recognised and promptly treated. This is why it really
is confined to specialist centres. Having said that, I think it
is safe when prescribed in those circumstances and is highly effective
and may induce long term remission in the selected group of patients
that I have described for you in terms of venom, anaphylaxis and
severe unresponsive hay fever.
Q201 Lord Taverne: But in the case
of other desensitisation is it something that is only temporary
in its effects or is it something which often leads to long term
remission?
Professor Durham: The evidence for long term
remission is in the context of the subcutaneous route at the present
time, and there are now some six or seven studies that have shown
that if you give injection treatment for hay fever or pollen allergies
due to grass or trees for a period of three to four years you
can induce a long term remission for at least three to four years
after discontinuation. That is also true in the context of venom
anaphylaxis to wasps and bees. For the sublingual route the evidence
is in the phase of evolution at the present time. There are two
control trials at the moment that will deliver that information
within the next five years.
Q202 Lord Rea: What I wanted to ask
has been addressed by that question. My question was about the
durability of the immunotherapy. Is it ever completely lifelong
or has it always failed? I declare an interest here because I
was a patient of Professor Durham in his clinic and was successfully
desensitised from wasp venom.
Professor Frew: There are difficulties in the
natural history. If we take the wasp venom issue, if you look
at how likely people are to have anaphylaxis, the risk gets less
with time, so once you have gone 10 years after a sting your chances
of having anaphylactic reaction are really quite low; they are
about five per cent compared to nearly 75 per cent the month after
you have had that anaphylactic reaction, so there is a natural
improvement that goes on and you can bring the risk right down
at the beginning by treating with immunotherapy. It is very difficult
then to do 10 years' studies to follow up placebo controlled studies
to see what is going on at the end of it. In terms of hay fever,
we have many patients who come and tell us that they had immunotherapy
in the seventies and it cured their hay fever and they are now
20 or 30 years down the track and they do not have symptoms. We
simply do not know what would have happened to them if they had
not been treated because there are no controlled trials that go
that sort of length.
Lord Rea: I am prepared to submit myself
for further testing if required.
Q203 Baroness Platt of Writtle: How
do allergists communicate with appropriate organ specialists such
as chest physicians and dermatologists in improving the management
of patients with allergic diseases, and should chronic severe
asthma be managed by allergists or chest physicians?
Professor Durham: Certainly speaking on behalf
of our national society, it is a major priority for us to empower
secondary care specialists in individual specialities—dermatologists,
respiratory physicians, immunologists—in how to manage allergy
effectively. I think it is in the interests of allergy sufferers
that the wider the knowledge of allergy management within the
speciality the better, and if we just keep our eye on the ball
in terms of keeping our eye on the patient, I think it is important
that we continue that mission which is central to our society.
In terms of chronic asthma, I think chronic asthma should be managed
by chest physicians with input from allergists where appropriate.
As Professor Barnes has highlighted, there is a large proportion
of patients with chronic asthma who are adequately managed by
currently available therapists. I think the contribution that
the allergist has to make is that they identify and treat underlying
causes where possible. In terms of chronic asthma I think the
overall approach of an allergist to consult a patient with chronic
asthma can be very valuable. For example, I have strong links
with Professor Barnes at the Brompton, and he sends me occasional
patients to assess from the point of view of their allergies,
for example, food allergies, which is one very good example. The
presence of asthma is a major risk factor for sudden death in
patients with food allergy. I think it is the allergist that should
be treating here, and although it is uncommon in adults with asthma
it is a life-threatening combination which needs to be recognised
and appropriately treated. We have not talked much about paediatric
practice but the combination of food allergy and asthma in children
is a potentially lethal combination which in my view should be
managed by a paediatric allergist.
Q204 Baroness Platt of Writtle: In
the oral evidence we have heard that GPs are not sufficiently
trained, and you have emphasised that today, in allergic diseases.
What do you think needs to be done to ensure that GPs can deal
with allergic disorders in an appropriate way and then refer patients
to be more suitably treated by specialists?
Professor Frew: I think medicine is changing
at the moment and we no longer exist as people who have a large
body of information in our heads that we keep private and people
come to see us. Part of our job is to put our information in the
public domain, so we go out to meet people and in our various
societies in Europe and in Britain we go out to the GPs and specialist
societies. We are thin on the ground so we cannot go to every
single meeting that happens and we know that the primary care
level is very local. You have to go around small areas to do this;
you cannot expect all the GPs to come together in one place, and
so part of our job is to provide information via the internet
with appropriate guidance on how to manage people prior to referral.
There are NHS systems that do this as well, and again we try to
have input from the specialists to make sure that the advice they
give to general practitioners when they are not sure what to do
is appropriate and helps them to manage allergies in the community.
We are not in the business of just going out and touting for business.
We want people to be managed in the community where possible and
we want people who go to their GP asking for a referral to be
able to get a hearing for that and, if it is appropriate, to get
referred to somebody who can help them with the problem and has
the time and expertise to do that.
Q205 Chairman: Professor Barnes,
I think you wanted to come back on the previous question.
Professor Barnes: Yes. I would just like to
address the issue of specialist management because I think this
is really a critical issue in this discussion about the need for
allergists. At the moment the way things work, which I think is
very satisfactory, is that people with severe asthma get managed
by chest physicians because it is important to have people who
understand other lung diseases that can present with symptoms
like asthma. Some patients will need critical care and, therefore,
specialists would have an input into that. The allergist has a
very important role as a specialist adviser because there are
situations with severe asthma where you need the advice of allergists,
so it is very important for allergists to be in tertiary centres
but not looking after severe asthma routinely, which I think is
better done by pulmonary specialists. I would say the same would
apply to people with severe eczema which has to be distinguished
from other skin diseases. In some patients it may be very helpful
to have specialist allergy input.
Q206 Lord Taverne: Is it correct
that something like 30 per cent of asthma sufferers have not been
offered allergy testing?
Professor Frew: We have no idea because we do
not see them. The majority of people with asthma will not get
to a specialist clinic and they certainly will not get to a difficult
asthma clinic, so it is difficult to get to the denominator. That
information would have to come from the community, from rather
more dispersed things than our patient base.
Professor Barnes: I would say that skin testing
for allergies is not very helpful in the management of asthma
because we treat patients with the same management whether they
have allergic or non-allergic asthma, so it is not so critical
for the management of asthma in general practice.
Professor Wardlaw: I was going to say that I
agree with Peter, but I think that is where Peter and I would
profoundly disagree. Severe and difficult asthma in particular
should be managed primarily by chest physicians but the allergist
has a huge role to play because it is amazing—with colleagues
I probably run one of the biggest severe or difficult asthma clinics
in the UK—how these very excellent physicians sometimes
forget about the allergy perspective, which I think is hugely
important. You cannot make any judgment about an allergic perspective
unless you do some tests and one of the major problems for primary
care is that they cannot diagnose allergy because they do not
have access to this relatively simple but hugely important test.
In difficult and severe asthma, and other forms of asthma actually
but it is more important in asthma, a large proportion of patients
do have an allergy mainly to their pets, their cats, dogs and
rabbits, which plays a very big part in their disease but the
problem is they will not get rid of their pets, and that is a
separate thing. Peter and I would profoundly disagree on the role
of allergy in that context.
Q207 Viscount Simon: Professor Frew,
in your submission to us you mentioned intolerance reactions which
from my reading means all kinds of things that can cause certain
reactions and it would be difficult to establish what they are.
In these circumstances would the patient be referred to a chest
physician or an allergist immediately?
Professor Frew: Again, I should make the point
that these things are not mutually exclusive. I am trained as
a chest physician, I see lung cancer, critical care, and acute
medical emergencies as well as dealing with allergies, so there
are people in the community who bridge that gap and it is not
necessarily two different people who would be seeing it, although
you might be wearing a slightly different hat. If we are talking
about intolerance reactions, the first issue really is to take
a proper history. Sometimes people get into the trap of saying
"I am intolerant of milk" or whatever, without defining
in what way they are intolerant, so quite a lot of our time is
spent sitting down trying to get the patient to tell us what is
wrong with them, not in terms of what is causing it but in terms
of what symptoms and problems they have. It is quite interesting
that a lot of people have constructed great scaffolding around
symptoms such that if they go to eat a pizza in such and such
a place they will get a problem but not in other places without
someone sitting down and saying "What is the problem and
how consistent is this?" It is general medical skills but
it is specialist practice in the sense of having enough time to
sit down, to force the patient to tell you what they actually
have in the way of symptoms and then try to map back and say,
"When do you get these? What are the circumstances? What
do you think is causing them? What is the evidence for that?"
That is the approach allergists are trained to do because quite
a lot of patients believe, rightly or wrongly, that allergy, particularly
food allergy and intolerance, is responsible for a variety of
non-specific symptoms. The term "food intolerance" was
brought in because the term "allergy" was being slightly
abused. We would use "food allergy" to mean when there
is an immune reaction against the food which is causing the symptoms.
If you eat something and it disagrees with you but there is no
immune reaction, what are you going to call that? "Food intolerance"
is a useful portmanteau term that says, "When you eat this
food in a certain quantity you get predictable symptoms and the
food disagrees with you" and it is without prejudice to the
mechanism, it allows us to have a term that we can use to talk
to the patients without implying that it is caused by an immune
reaction to it.
Professor Durham: If I may make a point that
I think is extremely important. If you open any journal or magazine
it will tell you that allergy is the cause of the problem and
a huge role of the specialist allergist is that he is equipped
to exclude allergy as the cause of problems. If you can do that
at an early stage at a one-stop shop and nip the problem in the
bud you will avoid the patient going off on a crusade into the
high street or seeking alternative opportunities to treat what
they conceive as allergies. An important role of the allergist
is to exclude allergy as a cause of non-specific symptoms, including
food intolerance and all the other things that come up under the
guise of allergy. It is exclusion of allergy. The problem is that
the general practitioner is not equipped to do that. If the patient
comes in and says, "I have got an allergy", it is very
difficult for the GP to say, "No, you do not" if he
is not familiar with the diagnosis and treatment of allergy. I
believe the same is true at the secondary care level within specialties.
Many of my referrals are, "Is allergy related to this problem?"
and I can write back and say, "No, it is not" and everybody
breathes a sigh of relief and the patient is happy. You need somebody
who recognises the beast in order to exclude it and that is an
important role of allergists.
Q208 Lord Colwyn: When my two younger
daughters, who are in their mid-twenties now, were in their twos
and threes they used to have the usual problem at this time of
year with respiratory breathing problems and, of course, the GP
suggested corticosteroids. At the time I resisted that and found
it easier to stay up night and day. I must not say that, my wife
used to stay up night and day. We resisted the corticosteroids
and just watched them because I felt they only tackled the symptoms
of the disease rather than treating the cause and the progression.
Would you agree with that? Would corticosteroids make a disease
worse because they are affecting the immune system and depressing
that?
Professor Barnes: Corticosteroids are highly
effective treatments for allergic diseases but people have been
concerned about the side-effects of steroids and the reason we
use inhaled steroids for asthma is to avoid the side-effects seen
with steroid tablets. For most patients these treatments are extremely
safe because only low doses are needed. However, they do not deal
with the underlying cause of the disease because although they
can completely control the disease, when the steroids are stopped
usually the symptoms come back. They are the most effective treatment
we have now but clearly there is a need to find treatments in
the future that will switch off the disease long-term. Professor
Durham has already talked about immunotherapy in that context
but there may be other drugs that can be developed that are curative,
or at least have long-term effects. I think inhaled steroids have
had rather a bad press in the general public and in the media
because of the side-effects that people know about steroids in
general.
Q209 Lord Colwyn: Are you saying
that, in fact, there are no side-effects from long-term use of
inhaled steroids?
Professor Barnes: No important side-effects
at the doses most patients need to control the disease. Only patients
who need high doses may have some side-effects but usually these
are not serious. They do not deal with the underlying disease
problem, so for the future we need to find more curative treatments.
Professor Durham: And also identify and avoid
provoking causes which requires a careful history and knowledge
of the problem without any medication in that context. Steroids
are very effective by the inhaled route and they are the right
treatment in that circumstance but it is also important to identify
provoking causes and avoid them. I think that is a particular
role the allergist can contribute.
Q210 Lord Colwyn: Do some patients
not respond to corticosteroids and how do you deal with that?
Professor Barnes: There is a condition called
"steroid-resistant asthma" but it is extremely rare,
we think it happens in about one in 10,000 asthmatics. There are
other people with more severe asthma who are relatively resistant,
which means they need high doses of steroids, and again they are
relatively uncommon. We are talking about one per cent of asthma
patients.
Q211 Lord Colwyn: Would they be treated
systemically?
Professor Barnes: They may require systemic
steroids or some other treatment like anti-IgE that we talked
about earlier.
Q212 Baroness Perry of Southwark: You
mentioned the difficulty that GPs do not have any facility for
good diagnosis, what do you think about these over-the-counter
allergy tests that are currently being offered? Are they of any
value for patients at all?
Professor Frew: I would say largely no. The
reason for that is any test you do in this area needs to be interpreted
in the light of a history. I am not trying to make work for doctors
but if you have not got the history and do a test it will be misleading.
Very often the patients have gone to get the test because they
have self-diagnosed the problem. There is some usefulness in tests.
Those tests are mainly useful when they are negative. For example,
if you were contemplating spending your money on allergen avoidance
covers for your bed and you went and got a test which showed that
you were not allergic to house dust mite you would have saved
yourself and the health service quite a lot of money. If you came
up positive there would be no guarantee that the bedding covers
you were about to buy would be effective because for about half
the people who have a positive test it is not important in driving
their symptoms, and to work that out you need a little bit more
insight and knowledge. My general advice to patients who come
armed with this information, and usually they have been and had
the tests before they see us, is "Can we just talk about
your symptoms first before we talk about whether or not the test
result is important".
Q213 Lord Rea: What do you think
of the idea that all general practitioners should have a kit rather
like those because they would be able to interpret them with a
bit more knowledge?
Professor Frew: We are going back to this issue
of who it is in the practice who will be dealing with allergy.
The majority of regular straightforward asthma is now managed
by practice nurses, not by general practitioners. There is an
interest in whether practice nurses could also take on the role
of doing allergy diagnosis and advice. There is quite good evidence
that they can do the tests perfectly well, there is not a technical
problem with doing the test, but sometimes there is some over-interpretation
of the results. With any test that is done you need to know its
strengths and weaknesses and my view is if there is a difference
between what doctors and nurses do it is that doctors are more
concerned with the diagnostic aspects and we use our specialist
nurses predominantly for managing the condition rather than for
making the diagnosis. I do not see skin testing by nurses as a
panacea. I do think, however, it would be useful to have it available
and we are trialling this at the moment, in the community to see
whether you can improve people's care by doing skin tests and
providing standard protocol advice for straightforward allergies.
The one thing we already have is evidence that patients are very
pleased about this because it is delivered close to them at home
and they find the information useful.
Q214 Lord Soulsby of Swaffham Prior:
Coming back to over-the-counter tests, how many of these have
been looked at from the point of view of efficacy and safety in
the way that you would look at non-complementary or alternative
medicines?
Professor Frew: If you do an internet search—we
did this earlier this year—looking for home allergy tests
in the US and Europe there is a huge range, anything from a small
questionnaire which is about trying to identify allergic triggers
through to about £1,000 worth of blood tests. There is very
little back-up advice on this, so people are encouraged to pick
their own level of tests, gold, platinum or silver, and the test
is done without much input from the patient. Some of these tests
are standard laboratory tests that will be done in every NHS hospital;
others are tests that we do not think have any value at all. It
is very much like the internet, it is a wide open market. They
really ought to get some advice but tests are available and out
there and if people want to pay for them then they can.
Q215 Lord Soulsby of Swaffham Prior:
There is no system of kite mark or anything like that with
some of these tests?
Professor Frew: Not that I am aware of.
Q216 Lord Soulsby of Swaffham Prior:
I can see the problem is that some patients feel that they
are relying on these things absolutely, but if they are not efficient—
Professor Frew: I think there are two separate
issues there. One is the quality of the test. If the test measures
what it says it measures then generally speaking that would be
dealt with by quality control in the lab. There is a separate
issue about whether the test tells you anything about your condition,
which in turn depends on what your condition is and on the possible
connection between the problem you have got and whether the test
is informative. That is not kite markable because it depends on
what your condition is. It is up to the buyer to either get advice
from their practitioner or to know enough about it to know that
this test is appropriate for that.
Q217 Viscount Simon: At the moment
there are five NHS hospitals which currently offer homeopathic
and other alternative medicine, two of which have special allergy
clinics. Should the NHS provide alternative therapies for allergies
alongside these more conventional treatments?
Professor Barnes: I think the answer is no.
Q218 Viscount Simon: The fact you
say "no" does not surprise me.
Professor Frew: There are three different parts
to this. The first is homeopathic and other unconventional treatment
for conventionally diagnosable disease, e.g. homeopathic treatment
for hay fever, if you want to you can go out and get that and
it may or may not work; the evidence is it probably does not do
much good. There is also quite a lot of unconventional diagnosis
for conventional disease, so you have got people using very odd
techniques to diagnose causes of asthma, causes of eczema etc.
The third issue is unconventional tests for diseases that we do
not think have anything to do with allergies at all, things like
migraine or hyperactivity disorder in children. If you go along,
people will do tests for you and tell you that such and such a
thing is causing your disease. I think you have to separate those
things off because the first one is legitimate as an option that
people may choose to follow but the other two are straying into
areas where we think the science is not there at all.
Professor Durham: What one has to do is evaluate
the evidence. As Professor Barnes has pointed out, when any homeopathic
treatment, for example for bronchial asthma, has been put under
scrutiny it has not been shown to be effective. My personal view
is those resources would be better invested in conventional NHS
allergy centres rather than homeopathy. On the other hand, of
course one has to acknowledge the fact that patients and the general
population are very supportive of the concept of homeopathy. For
me that is not a reason to continue this and I would support what
Professor Barnes has said.
Chairman: I do just wonder whether the
diagnostic step and the time taken to take a good history may
be helpful and that may need to be separated out from the administration
of different medicines.
Q219 Lord Colwyn: Can I just remind
you that the perfect solution is the use of high dilution sublingually,
which we have heard before this morning.
Professor Durham: As opposed to very high doses
sublingually which are effective.
Chairman: Thank you. If there are additional
points that you would like the Committee to consider please do
feel free to write in. Could I particularly thank you all for
the written evidence you have already submitted to us. Thank you.
| 
