Come si dovrebbe fare e valutare il Test di Provocazione ... - RIAP

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TEST DI PROVOCAZIONE ORALE PER ALIMENTI 14 anche quelli di nuova generazione (cetirizina, loratadina, ecc). Se nel corso della reazione allergica si sono manifestati sintomi gastrointestinali sarà da preferirsi la via di somministrazione intramuscolare (ad esempio difenidramina alla dose di 1,5-2 mg/kg, dose massima da somministrare 50 mg), in caso contrario, gli antistaminici potranno essere somministrati per os. La stessa dose del farmaco può essere ripetuta per via intramuscolare nel caso in cui insorga vomito entro 30 minuti dall’assunzione orale. La loro somministrazione può essere consigliata anche per i tre giorni successivi all’episodio anafi lattico 114 . Quando invece insorgano sintomi di interessamento del laringe, come tosse secca e abbaiante o stridore, può essere somministrata della adrenalina per via aerosolica 62 . La sua somministrazione tuttavia non dovrebbe sostituire la somministrazione di adrenalina per via IM, laddove necessaria, come nel caso di interessamento delle basse vie respiratorie o di compromissione cardiovascolare (ipotensione, bradicardia, ecc.). In questi casi l’adrenalina va somministrata per via intramuscolare profonda, preferibilmente sulla superfi cie anterolaterale della coscia 115 . Le quantità sono in funzione del peso corporeo: 0,01 mg/kg, ossia 0,01 ml/kg di una soluzione 1:1000 (dose massima 0,5 ml). La dose iniziale può essere ripetuta dopo 5-10 minuti, fi no ad un massimo di tre dosi, in caso di persistenza o aggravamento della sintomatologia 62 116 . In caso di ipotensione è utile somministrare rapidamente per via endovenosa dei liquidi, in particolare la soluzione fi siologica (NaCl 0,9%), fi no alla dose di 20-30 ml/kg nella prima ora 117 . In presenza di diffi coltà respiratoria (stridore laringeo, wheezing, dispnea) occorre inoltre somministrare ossigeno in maschera e un farmaco broncodilatatore per via inalatoria 118 . Il Salbutamolo, per la sua rapidità di azione, è il farmaco di prima scelta e può essere somministrato alla dose di 2,5 mg (0,5 ml - 10 gtt) della soluzione allo 0,5% o per mezzo di aerosol predosati. In caso di persistenza di sintomi respiratori e/o gastrointestinali (refrattari alle terapie precedenti) si ricorre all’utilizzo di corticosteroidi: 1-2 mg/kg di prednisone orale. La dose di steroidi deve essere ripetuta se insorge il vomito entro 30 minuti dalla prima assunzione 119 . BIBLIOGRAFIA 1 Saarinen KM, Savilahti E. Infant feeding pattern and the subsequent immunological features in cow’s milk allergy. Clin Exp Allergy 2000;30:400-6. 2 Rona RJ, Keil T, Summers C, Gislason D, Zuidmeer L, Sodergren E, et al. The prevalence of food allergy: a meta-analysis. 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Pediatr Allergy Immunol 2008;19:276-8. 43 Berti I, Bergamini M, Calzone L, Dello Iacono I, Galli E, Martelli A, et al. Risultati clinici ed immunologici del test di provocazione orale. Studio multicentrico retrospettivo. Atti del XX Congresso Nazionale di Immunologia ed Allergologia Pediatrica, Roma 2009. 44 Venter C, Pereira B, Voigt K, Grundy J, Clayton CB, Gant C, et al. Comparison of open and double-blid placebo controlled food challenges in diagnosis of food hypersensitivity amongst children. J Hum Nutr Diet 2007;20:565-79. 45 Brouwer ML, Wolt-Plompen SAA, Dubois AEJ, van der Heide S, Jansen DF, Hoijer MA, et al. No effect of probiotics on atopic dermatitis in infancy: a randomized placebo-controlled trial. Clin Exp Allergy 2006;36:899-906. 46 Adverse Food Reactions Committee. Diagnostic methodology in food allergy. Allergol Immunol Clin 1999;14:50-62. 47 Roberts S. Challenging times for food allergy tests. Arch Dis Child 2005;90:564-6. 48 Sicherer SH. 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Curr Allergy Asthma Rep 2008;8:45-8. 64 Kemp SF, Lockey RF, Simons FER. Epinephrine: the drug of choice for anaphylaxis – A statement of the World Allergy Organization. WAO Journal 2008:s18-s26. 65 Sampson HA. The role of food allergy and mediator release in atopic dermatitis. J Allergy Clin Immunol 1988;81:635-45. 66 Novembre E, Cianferoni A, Bernardini R, Mugnaini L, Caffarelli C, Cavagni G, et al. Anaphylaxis in children: clinical and allergologic features. Pediatrics 1998;101:E8. 67 Fiocchi A, Bouygue GR, Sarratud T, Terracciano L, Martelli A, Restani P. Clinical tolerance of processed foods. Ann Allergy Asthma Immunol 2004;93(Suppl 5):38-46. 68 Urisu A, Ando H, Morita Y, Wada E, Yasaki T, Yamada K, et al. Allergenic activity of heated and ovomucoid-depleted egg white. J Allergy Clin Immunol 1997;100:171-6. 69 Des RA, Nguyen M, Paradis L, Primeau MN, Singer S. Tolerance to cooked egg in an egg allergic population. Allergy 2006;61:900-1. 70 Bock SA. The natural history of severe reactions to foods in young children. J Pediatr 1985;107: 676-80. 71 American Academy of Pediatrics Committee on Nutrition. Hypoallergenic infant formulas. Pediatrics 2000;106:346-9. 72 Untersmayr E, Jensen-Jarolim E. The effect of gastric digestion on food allergy. Curr Opin Allergy Clin Immunol 2006;6:214-9. 73 Niggeman B. When is an oral challenge positive? Allergy 2009;in press. 74 Bock SA, Sampson HA, Atkins F, Zeiger RS, Lehrer S, Sachs M, et al. Double-blind, placebo- controlled food challenge (DBPCFC) as an offi ce procedure: a manual. J Allergy Clin Immunol 1988;82:986-97. TEST DI PROVOCAZIONE ORALE PER ALIMENTI 15
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