Posts Tagged ‘stabilisers’

When it comes to making bread and cakes, wheat has some remarkable cooking properties that nothing else

can match. Its characteristic proteins, called gluten, form very strong elastic threads. These make a

stringy dough that can be stretched and stretched as the bread rises. As a result, the bubbles of gas

given off by the yeast or baking powder are all embraced by the dough, giving an open, airy consistency

to the finished product.
Have no illusions – without wheat flour you cannot make a crispy baguette or a well-risen cottage loaf.

If you are able to eat rye, then rye flour makes a pretty good substitute, because it also contains

gluten, though not as much as wheat flour. But a gluten-free diet excludes rye too (see p. 177), and

then baking definitely becomes a challenge.
Even on a gluten-free diet, however, you can still make several perfectly edible, even delicious, types

of bread and cake. The secret, especially with bread, is to accept that the texture is going to be

different from wheat-based bread, but to add enough interesting flavours to give the finished product

its own special character. The gluten-free bread you make at home will taste vastly better than the

pale and pappy commercial substitutes – and at a fraction of the price.
Wheat-free and gluten-free bread tends not to keep as well as ordinary bread, so make a batch of small

loaves and freeze some of them. You can slice them before freezing, then extract and defrost a few

slices at a time, as needed. Bread that is not frozen should be kept in a plastic bag in the

refrigerator. Even when kept in this way, the bread gets rather dry and tough after a few days, and

will benefit from being toasted. Try spreading it with butter, margarine or solidified olive oil (see

page 182) before putting it under the grill – this revives bread far better than ordinary toasting.
Pastry-making without wheat is also a challenge (see p. 180) but cakes, biscuits and other sweet items

are much less of a
problem. As long as you accept the limitations of non-wheat flours, cakes can be made perfectly well

using gluten-free flours. With the right culinary tricks, you can even make a light fluffy sponge (see

pp. 180-81).
To thicken sauces and gravy, you can use cornflour or any other non-wheat flour.
If you have an allergy or intolerance to other foods, besides wheat, the recipes here can be adapted

accordingly. For example, commercial egg replacers (see p. 186) can be used in place of eggs, and milk

substitutes (see p. 183) can replace cow’s milk.
Wheat-free diets
This section is for people with an allergy or intolerance reaction to wheat. Those with coeliac disease

should read the section on gluten-free diets.
In devising a successful diet for yourself, you need to take account of two factors:
1 How sensitive are you? If you have a true allergy (see p. 62) to wheat, you may be very sensitive and

need to avoid even the tiniest amount of wheat. But if you are just intolerant of wheat (see pp. 74-6),

you probably won’t react to such small amounts. so you don’t need to be so careful.
2 Are you sensitive only to wheat, or do you also react to related cereals, namely rye, barley and

oats? Some people have to avoid these as well, because of cross-reactions (see p. 14).
Those who are highly sensitive to wheat and have cross-reactions to related cereals, need to follow the

same kind of diet as the most sensitive coeliacs (see Gluten-free diets). Ready-made gluten-free foods

(such as bread and biscuits) can be useful, and they should be safe for you, unless you are

ultra-sensitive.
Those who don’t have any cross-reactions to related cereals can tolerate the following:
•    rye bread and rye crackers, as long as they are 100% rye
always double-check. If you buy rye bread from a local bakery, and it is unlabelled, make sure the

staff understand that you must always have 100% rye bread. Ask them to tell you if they ever change the

recipe – and jog their memories about this from time to time.
•    beer – as long as it is brewed using barley. Most is, but watch out for German Weissbier, which

is made from wheat.
•    oatcakes, as long as they don’t contain wheat flour or bran. Check the label carefully.
Gluten-free diets
A gluten-free diet is more restrictive than a wheat-free diet, since gluten is also found in rye,

barley, triticale and spelt. All these must be carefully avoided.
At one time, this list would have included oats as well, but new research suggests that the proteins

found in oats, called avenin, are sufficiently unlike gluten to be safe for many coeliacs. If you have

coeliac disease, you must have medical approval before eating oats. Only those who are healthy and

doing well on a gluten-free diet should try oats, and they should not eat more than one small serving

(less than 50g/13/4oz) per day. It is vital that the oats are grown, harvested, transported, milled and

packaged separately from all wheat to avoid contamination. See your doctor regularly for check-ups (and

if possible a biopsy) to check that the oats are not causing problems.
Various flours are used to make gluten-free breads, including
flours derived from rice, potatoes, soya beans and buckwheat (not
a true wheat). These are sold in health-food shops, and can also
be bought by mail order. For gram flour, try Indian groceries. There
are also special gluten-free bread mixes available in both health-
food shops and pharmacies, but these almost always contain
soya, and it is best to avoid eating too much soya (see page 71).
coeliacs who are extremely sensitive to gluten, and have to
avoid all trace of it, should be very careful about ready-made food.
These are just some of the unexpected sources of gluten:
•    Thickeners and stabilisers sometimes contain traces of gluten. These additives are very widely

used in ready-made foods.
•    A number of food additives (including caramel, citric acid, dextrin, mono- and di-glycerides,

gum base, malt, malt flavouring, maltodextrin, maltose, MSG and vegetable gum) are manufactured from

wheat, barley or oats. Although the amount of gluten/avenin they contain is extremely small, it can

affect a few coeliacs.
•    Barley enzymes, used to make rice milk, some brands of soya milk, soy sauce and miso, can leave

minute traces of gluten in the finished product. Blue cheese can also contain minute traces of gluten

(see p. 174).
•    Whisky and gin – both grain-based spirits – can contain gluten. So may distilled white vinegar.

These will only affect the most sensitive coeliacs, whereas beer must be avoided by all coeliacs, since

it is made from barley.
•    Composite ingredients in ready-made food are covered by the 25% rule (see p. 174), and

frequently contain wheat.
•    Wheat flour may be used as an aid to food preparation, leaving tiny residues in the food (see

p. 174).
•    Non-wheat flour may be delivered to the factories, or transferred from one area to another,

through hoppers or vacuum tubes that have previously been used for wheat flour. Very low levels of

contamination can occur in this way, sufficient to affect those coeliacs who are extremely sensitive.

This is one problem with gluten-free foods (see below), unless they are made in dedicated gluten-free

factories.
•    Products labelled ‘gluten-free’ may not be suitable for the most sensitive coeliacs. Testing

for very small amounts of gluten is difficult, and the international standard set by the FAO/WHO (not

more than 200 parts per million) is dictated by what can be accurately measured, and therefore policed.

Many countries (e.g. Sweden and the United States) feel that the permitted level of gluten should be

lower, and have set their own standards. These higher standards can be achieved by careful control of

the production methods.
There is a great deal of useful information about gluten on the
Internet, but there is also some very misleading information on one
particular website. It is advisable to consult several different sites.
Wheat-free baking powder
Some brands of baking powder contain a little wheat flour. You can make a wheat-free version by mixing

60g (2oz) sodium bicarbonate with 125g (41/2oz) cream of tartar and 60g (2oz) of a non-wheat flour.

Sieve together very thoroughly.
Brown bread
This mixture of buckwheat and potato flour makes a light-textured loaf that also toasts well.
PREPARATION TIME: 15 minutes, plus about 1 hour rising time
COOKING TIME: about 35 minutes
MAKES: 1 large loaf
250g (9oz) buckwheat flour
250g (9oz) potato flour 1 tsp salt
1 sachet easy-blend yeast
25g (1oz) butter
1 tbsp black treacle 1 large egg, beaten
Mix the flours, salt and yeast in a large bowl and rub in the butter. Dissolve the treacle in 225ml

(8fl oz) hand-hot water. Add this and the egg to the flour, and mix to a soft dough. Transfer to a

buttered 900g (21b) loaf tin, wrap in a polythene bag and leave in a warm place for about 1 hour – or

until the mixture has risen to the top of the tin.
Bake in a preheated oven at 220°C/ 425°F/gas mark 7 for about 35 minutes until risen and firm to the

touch. Remove from the tin and tap the base – it should sound hollow. If not, return to the oven for a

further 5 minutes. Cool in the tin for 10-15 minutes.
Variations: many different kinds of flavourings can be added to this bread. Try seeds such as poppy

seeds, mustard seeds, caraway seeds and onion seeds (Indian stores usually stock these with their

spices). Sunflower seeds and sesame seeds – either plain or lightly toasted – are also good. A

combination of black olives, sun-dried tomatoes and a pinch of mixed herbs makes a Mediterranean -style

bread.
Seeded rice bread
This makes a delicious, ‘nutty’, textured loaf that is yeast-free as well as wheat-free. It toasts

quite well.
PREPARATION TIME: 30 minutes COOKING TIME: 40 minutes MAKES: 1 small loaf
150g (5′12oz) brown rice, well rinsed
100g (31,2oz) rice flour 100g (3V2oz) fine oatmeal
1 tsp wheat-free baking powder
1 tsp salt
50g (13/4oz) sunflower seeds
25g (1oz) linseed
1 large, slightly under-ripe pear. peeled, cored and coarsely grated
2 large eggs, beaten
2 tbsp vegetable oil
4 tbsp buttermilk, live natural yogurt, milk or milk substitute
Cook the rice in plenty of boiling water for 15-20 minutes until tender. Drain thoroughly and cool

slightly.
Preheat the oven to 200°C/400°F/gas mark 6.
Combine all the ingredients in a large bowl, then transfer to a well-oiled 450g (1 lb) loaf tin and

bake for about 40 minutes, until slightly risen and golden, and firm to the touch. Cool slightly, then

turn out onto a wire rack and leave until completely cold. Serve cut into thick slices.
Banana loaf
This semi-sweet bread is yeast-free as well as gluten-free. It is good for packed lunches – and it

toasts well.
PREPARATION TIME: 10 minutes COOKING TIME: about 1 hour MAKES: 1 large loaf
4 medium ripe or under-ripe bananas 300g (10′,12oz) brown rice flour, sieved 100g (3112oz) butter,

softened
2 tbsp wheat-free baking powder 2 large eggs
225ml (Bfl oz) milk or soya milk
Butter and line the base of a 900g (21b) loaf tin. Peel and cut up the bananas and place in a food

processor with the remaining ingredients. Blend thoroughly, then transfer the mixture to the prepared

tin Bake in a preheated oven at 180  350°F/gas mark 4 for about 1 hour until risen and firm to the

touch. Cool in the tin then turn out onto a wire rack and leave to cool completely.
Rich herb bread
This is useful for those who have to avolo yeast as well as wheat/gluten.
PREPARATION TIME: 20 minutes COOKING TIME: 30-40 minutes MAKES: 1 small loaf
1108 (4oz) gram or chickpea flour
1 tsp syrup or honey
2 tbsp olive oil
1 tsp salt
1 unripe pear, peeled and grated
200m1 (7fl oz) boiling water
2 eggs
V2  onion, finely chopped
fresh herbs (thyme, tarragon or marjoram)
Mix the first five ingredients, then pour on the boiling water. Separate the eggs, beat the yolks

thoroughly and add to the flour mixture when It has cooled, along with the onion and herbs. This

mixture should now be the consistency of double cream. If too thick, add a little more water.
Whisk the egg whites until they will stand in soft peaks. Carefully fold them into the flour mixture.

Pour into a well-greased loaf tin and cook at 180 - C/ 350°F/gas mark 4 for 30-40 minutes.
Seeded rice bread    Pressed prune and walnut bread
Crispy millet baps
Tasty and filling, these are popular with children. They make no pretence to be bread but are an

excellent substitute for breakfast toast or a lunchtime sandwich. They are free from yeast, milk and

eggs, as well as wheat.
PREPARATION TIME: 30 minutes COOKING TIME: about 20 minutes MAKES: about 20 small baps
225g (Boz) millet seeds
1 tsp salt
150g (5′,12oz) peanut butter (or cashew, pecan or another nut butter)
1 tsp sesame seeds, toasted until golden
oil for frying
Wash the millet and soak overnight. Wash again to remove the starch, drain and add 600ml (1 pint) water

plus the salt. Boil over a low heat for 20 minutes, or until the water is absorbed.
While still hot add the nut butter and sesame seeds. Mix together well using a potato masher to break

up the millet. Take egg-sized lumps of the mixture, roll into a ball between the palms of your hands,

then squash into a flattish shape. It is vital to do this while the mixture is still warm.
Fry the baps in oil over a low heat, for about 20 minutes, or until the outside is golden and crunchy.

(They can also be frozen, and then fried from frozen, for a quick meal.) Serve with fruit or a salad.
Savoury spiced pancakes
This variation on a traditional drop scone makes a good substitute for bread. The pancakes are

delicious served warm from the pan. When cold, they may be reheated in a moderate oven.
1008 (3112oz) gram flour
1008 (3 72oz) rice flour
1 tsp wheat-free baking powder
1 tbsp ground cumin
large pinch of salt
1 large egg
300mi (112 pt) coconut milk
vegetable oil for frying
To serve:
Skinned and chopped fresh tomato mixed with a little freshly chopped coriander, or fried mushrooms with

chopped spring onion and parsley moistened with a little crbme fraiche.
Mix the dry ingredients together in a bowl then beat in the egg and coconut milk to give a thick

batter. Set a large non-stick frying pan or griddle over medium heat. Generously oil the surface of the

pan then drop well-spaced tablespoons of the mixture into the pan.
Cook until the edges of the drop scones start to form bubbles and the base of each is golden, then

carefully turn and cook on the second side until golden. Keep warm, covered with a clean tea towel,

while you make the rest.
Serve warm, spread with butter or topped with one of the savoury mixtures.
Variations: for sweet drop scones omit the cumin and add 25g (I oz) caster sugar and either a sweet

spice such as cinnamon, or the finely grated zest of 1 lemon or orange.
Pressed prune and walnut bread
Based on a traditional Spanish recipe, this is delicious served with cheese, or as a snack on its own.
PREPARATION TIME: 10 minutes, plus overnight COOKING TIME: 45 minutes MAKES: 1 x 18cm (7in) loaf
500g (1 lb 2oz) ready-to-eat pitted prunes 100g (3%2oz) walnut or pecan halves 50g (13/4oz) brown rice

flour
1 large egg, beaten
Place all the ingredients in a bowl and mix together. Press into an oiled 18cm (7in) sandwich tin,

cover with oiled foil and cook in a preheated oven at 170°C/ 325°F/gas mark 3 for 45 minutes. Place a

heavy weight on top and leave until completely cold before unmoulding. Serve cut into thick slices

using a serrated knife.
PREPARATION TIME: 25 minutes MAKES: about 27
Walnut macaroons    Lemon surprise pudding
Millet tabbouleh
Tabbouleh is a salad from the Middle East that is traditionally made with cracked wheat. Millet makes a

very tasty wheat-free alternative. This dish can be useful for packed lunches.
PREPARATION TIME: about 40 minutes MAKES: 4-6 servings
175g (6oz) millet 7 tbsp olive oil
3 tbsp lemon juice
3 tbsp each freshly chopped mint and
flat-leaf parsley
2 spring onions, finely chopped
salt and pepper
Place the millet in a saucepan with 1 tbsp oil and cook over medium heat, stirring, for 2-3 minutes

until lightly toasted. Stir in 350ml (12fl oz) boiling water and simmer uncovered for about 20 minutes

until the water is absorbed and the millet seeds are just cooked. Transfer to a bowl, stir in the rest

of the oil and season generously. Stir in the lemon juice and fork it through the mixture. Leave to

cool, then add the herbs and spring onion and stir well.
Variations: add other finely chopped ingredients such as tomato, red pepper or dried apricots.
Wheat-free flan pastry
Make a flan as suggested below, or chill the pastry then grate it roughly over a savoury or sweet pie

filling. For a savoury pie, the grated pastry can be mixed with grated cheese.
PREPARATION TIME: 15 minutes, plus 30 minutes freezing
COOKING TIME: about 20 minutes MAKES: 1 x 20cm (8in) flan case
125g (412oz) fine cornmeal (maize flour) 50g (13/4oz) gram flour
25g (1 oz) arrowroot powder
25g (I oz) ground almonds
75g (23/4oz) butter or baking margarine 1 egg white
Mix the dry ingredients together in a bowl then rub in the butter. Mix to a soft dough with the egg

white. Press the pastry evenly into a 20cm (8in) fluted flan tin and set in the freezer for a minimum

of 30 minutes.
Preheat the oven to 200′C/400′F/gas mark 6 and cook the flan case towards the top of the oven for about

20 minutes, until lightly golden.
Variation: for sweet pastry, add 25g (I oz) caster sugar
Rich cheese biscuits
These crisp biscuits are good to serve with drinks. Store them in an airtight tin.
PREPARATION TIME: 20 minutes COOKING TIME: about 25 minutes MAKES: 20 biscuits
55g (2oz) soya flour
40g (1 V2oz) potato flour
40g (I Y2oz) rice flour
115g (4oz) butter, softened
1158 (4oz) Cheddar cheese, grated
1 large egg, separated
2 tbsp seeds such as celery or poppy
Mix the flours together in a bowl, then work in the butter, cheese and egg yolk to give a firm dough.

Roll into 20 balls. Lightly whisk the egg white and turn the balls in it until lightly coated, then dip

in the seeds to coat lightly.
Space the balls well apart on baking trays and press down firmly to flatten. Bake in a preheated oven

at 200°C/400 T/ gas mark 6 for about 25 minutes until golden. Cool slightly then transfer to a wire

rack. Leave until cold and crisp.
Whisked sponge cake
This cake’s lightness lies in the whisking. A trail of the mixture, falling from the whisks, should

remain visible for at least 30 seconds. Then it’s time to add the flour.
PREPARATION TIME: 25 minutes COOKING TIME: 25-30 minutes MAKES: 1 x 23cm (91n) cake
75g (2314oz) gram flour
50g (13/4oz) cornflour
4 large eggs
125g (4 V2oz) caster sugar
50g (13/4oz) butter, melted
To serve:
jam or lemon curd
whipped cream (optional)
caster sugar
Sift the flours together. Butter a 23cm (9in) spring-release tin and line the base with greaseproof

paper. Using a handheld electric whisk, whisk the eggs and sugar in a heatproof glass bowl over a

saucepan of simmering water for about 10 minutes until thick and mousse-like.
Fold the flour into the egg mixture in 2-3 batches until completely incorporated, then fold in the

butter.
Transfer to the prepared tin and cook in a preheated oven at 190′C/375′F/gas mark 5 for about 25

minutes until risen and golden. Cool slightly then remove from the tin and cool on a wire rack. When

cold, split and fill with jam or lemon curd, and whipped cream if wished. Dust with caster sugar.
Walnut macaroons
These biscuits are good with coffee. Store in an airtight container. If you want, only decorate half of

them with walnut halves, then sandwich together with the other halves using coffee-, chocolate- or

orange-butter cream, or whipped cream. Do this just before serving.
PREPARATION TIME: 15 minutes COOKING TIME: about 45 minutes MAKES: 24
rice paper
2 egg whites
100g (3112oz) golden icing sugar
1008 (3 Y2 oz) walnut pieces, finely
chopped
grated zest and juice of 112 small unwaxed
lemon (if waxed, wash thoroughly in
hot water)
24 walnut halves
Line a large baking tray with rice paper. Whisk the egg whites in a heatproof glass bowl until stiff.

Stir in the icing sugar, chopped walnuts, lemon zest and juice, and stir over a saucepan of simmering
water for about 10 minutes until the mixture is slightly stiffened. Drop well-spaced spoonfuls of the

mixture onto the rice paper and top each with a walnut half.
Bake in a preheated oven at I 50′C/300′F/gas mark 2 for about 45 minutes. They should be risen but

still slightly chewy. Cool on the tray, then trim away the excess rice paper.
Lemon surprise pudding
The surprise is in the two layers. You end up with a creamy lemon sauce topped with a delicate sponge.
PREPARATION TIME: 20 minutes COOKING TIME: about 45 minutes MAKES: 4-6 servings
50g (1314oz) butter
125g (4 Y2oz) caster sugar
2 large eggs, separated
25g (1 oz) cornflour, sieved
25g (1oz) fine cornmeal (maize flour), sieved
finely grated zest and juice of 2 unwaxed lemons (if waxed, wash thoroughly in hot water)
250m1 (9fl oz) milk To serve:
icing sugar
Cream the butter and sugar with 1 tbsp hot water until pale and fluffy. Beat in the egg yolks followed

by the flours. Slowly stir in the lemon zest and juice, and then the milk. The mixture may appear to

have curdled but this is normal.
Whisk the egg whites to form soft peaks, then fold into the lemon mixture. Transfer to a 1 litre (13/4

pint) ovenproof dish and set in a roasting tin. Pour hot water from a kettle around the dish and cook

in a preheated oven at 180°C/350°F/gas mark 4 for about 45 minutes, until risen and just firm to the

touch. Dust with icing sugar and serve immediately.
Apricot and apple Eve’s pudding
This wheat-free Eve’s pudding can be varied by changing the fruit. Try peaches, strawberries or

blackberries instead of the apricots.
PREPARATION TIME: 30 minutes COOKING TIME: about 1 hour MAKES: 4-6 servings
400g can of apricot halves in juice
2 medium cooking apples, peeled and thickly sliced
50g (1314oz) caster sugar
Topping:
125g (472oz) butter, softened
125g (4 Y2oz) caster sugar
2 large eggs
125g (4V2oz) ground almonds mixed with
1 tsp wheat-free baking powder
50g (1 31ioz) flaked almonds
To serve:
pouring cream or whipped cream
Pour the juice from the can of apricots into a saucepan, add the apple and sugar and cook gently for

about 5 minutes, until the apple is softened. Remove from the heat and stir in the apricots. Transfer

to a 1 Iltre (13/4 pint) ovenproof dish.
In a separate bowl, cream the butter and sugar together until pale and fluffy then beat in the eggs one

at a time. Fold in the ground almonds and baking powder. Spread the almond mixture over the fruit and

sprinkle with flaked almonds. Cook in a preheated oven at 180°C/ 350°F/gas mark 4 for about 1 hour

until risen and golden and just firm to the touch. Serve with pouring cream or whipped cream.

Various anti-allergy drugs
An allergic reaction is a lengthy, complex process, and the various anti-allergy drugs all work on different stages of that process. That is why it often makes sense to use several different drugs for the same allergic condition: they each tackle the problem in their own way.
Steroids (see p. 140) intervene at a very late stage, quelling the inflammation that follows on from an allergic reaction. Using a steroid is rather like calling the fire brigade to put out a fire, whereas using an antihistamine (see p. 138) is like having fire-proof doors, to prevent the fire spreading at an early stage. Cromoglycate-type drugs (see below) intervene at an even earlier stage. They are like basic fire prevention - teaching children not to play with matches, or fitting smoke detectors.
Anti - leukotnene drugs (see p. 149) work at roughly the same stage of the process as anti-histamines but tackle an entirely different aspect of the allergic reaction.
Cromoglycate-type drugs
These drugs are also referred to as mast-cell stabilisers or mast-cell Mockers.
There are three drugs in this group, sodium cromoglycate (also spelled cromoglicate), nedocromil sodium, and lodoxamide. All operate at an early stage of the allergic reaction, stopping it before it actually starts. They stabilise the outer membrane of the mast cells (see box on p. 12), which prevents the allergic response from occurring.
Some common brand names
Common brand names of cromoglycate-type drugs include:
inhalers - Cromogen Easi-Breathe, Intal, Tilade
eye drops - Hay-Crom, Opticrom, Rapitil, Vividrin, Viz-on nose sprays - Rynacrom, Vividrin
capsules - Nalcrom
This is a far more satisfactory way of dealing with an allergic reaction than trying to tackle it after the reaction has occurred. But from a purely practical point of view, it has a drawback. I order to work at all, these drugs must reach the mast cells in advance of the allergen. They are of very little use if taken after the allergic reaction has begun.
For those who are taking cromoglycate-type drugs on a regular schedule, several times a day, it is very important to be conscientious about taking them on time. This maintains the protective effect of the drug, without any gaps.
If you are using these drugs on an ‘as-needed’ basis, you should take them 30 minutes before an allergen is encountered. or 30 minutes before a bout of exercise, if they are being prescribed for exercise-induced asthma. (Note that children sometimes respond differently, getting protection from these drugs immediately.)
The effect of these drugs takes time to build up. You should take them regularly for at least four weeks before deciding whether they are helping you or not.
One point in favour of cromoglycate-type drugs is that they are extremely safe, with few or no side effects in most people. Sadly, they do not work for everyone. A fairly high percentage of children respond well to them, but the response rate is much lower for adults. Nevertheless, adult allergy sufferers, especially those who need steroids to control their symptoms, should always be given the opportunity to try out these drugs. When cromoglycate-type drugs do work, they are very effective and almost always trouble-free, so they are a good alternative to steroids.
Both sodium cromoglycate and nedocromil sodium are available in inhaler form for asthma (see p. 157). Sodium cromoglycate is also available as nose drops for hayfever and other nasal allergies.
All three drugs are available as eye drops. Recent evidence suggests that sodium cromoglycate drops are less effective than the other two, particularly for the treatment of severe allergic conjunctivitis (inflammation of the eye).
Sodium cromoglycate is available in capsule form for food allergy. Note that these capsules are of very limited value in food allergy, and are certainly not a substitute for food avoidance. They do reduce sensitivity a little and can sometimes be helpful for those with multiple food allergies (see p. 67).
Side effects
There are no serious side effects at all for nedocromil sodium. cromoglycate can, very rarely, cause joint pain and swelling. An allergic reaction to the drug itself is even more uncommon. Stop taking the drug and see your doctor promptly if either of these occurs.
The only other side effects that have occasionally been reported are headache, nausea and vomiting. None of these indicates any damaging effect by the drugs – they are all minor side effects.
Eye drops containing these drugs may cause stinging and burning when inserted, but this is a minor side effect and usually wears off. Flushing and dizziness have sometimes been reported with lodoxamide eye drops.
Nose drops may also cause local irritation. This could be due to the drug itself, in which case it is a minor side effect. Alternatively, the irritation may be due to the preservative used or some other non-drug ingredient (see box on p. 33).
Occasionally cromoglycate nose drops cause bronchospasm – contraction of the airway muscles – but this tends to wear off quite quickly. Bronchospasm can also occur when cromoglycate-type drugs are inhaled (see p. 157).
Anti - leu kotriene drugs
These drugs, which have a set of very specific effects (see p. 159), were originally designed to treat asthma. Their potential for treating other allergic diseases is currently being explored:
•    Several studies show that they work well for perennial allergic rhinitis brought on by allergens such as house-dust mite. They also have some effect on hayfever, but standard treatment (such as antihistamines plus a steroid spray for the nose) is more effective.
•    They are especially useful for both rhinitis and asthma in patients suffering from triad (see box on p. 28). Research shows that they also reduce asthmatic reactions to very small test doses of aspirin, but they don’t give protection against anaphylaxis brought on by normal doses.
•    They have also been used successfully in cases of chronic urticaria and for some patients with delayed pressure urticaria. It seems plausible that they would also be helpful for chronic urticarla linked to aspirin sensitivity.
•    Preliminary trials suggest that these drugs might be useful in atopic eczema. Some studies show a very good response that allows a reduction in steroid creams.
•    Montelukast works very well for eosinophilic gastroenteritis and eosinophilic oesophagitis (see p. 72), according to some new studies.
For side effects of these drugs see pp. 159-60.
Anti-IgE drugs
Since the antibody IgE (see box on p. 12) is such a crucial player in allergic reactions, developing drugs that disable this antibody should help allergy sufferers. The first such drug is omalizumab (brand name Xolair) which was licensed for use in the United States in 2003. It is expected to become available in Britain some time in the next few years.
Omalizumab binds to IgE antibodies and stops them from interacting with mast cells, so blocking any allergic reaction. The drug is given as a ‘depot injection’, just under the skin, every 2-4 weeks. It is gradually released from the injection site and moves around the body in the blood, mopping up IgE molecules.
At present, omalizumab is used for severe hayfever and for people with asthma who are not responding well to the usual treatments. It is only worth using if there is clear evidence that allergies play a part in the asthma. Patients who use omalizumab are often able to reduce their dose of inhaled steroids – and they suffer fewer serious asthma attacks and have better lung function. Some patients can even stop using steroids completely.
Other anti-IgE drugs are in the pipeline. Pilot studies show that one works very well for peanut allergy: after just four injections, sensitivity to the allergen falls sharply, reducing the risk of anaphylaxis from traces of peanut eaten accidentally.
More powerful anti-allergy drugs
Occasionally people with severe allergies, who are on constant high doses of steroid tablets, or who fail to respond to steroids, need treatment with powerful anti-inflammatory drugs, such as methotrexate or cyclosporin. These suppress the immune system, and extremely careful monitoring for side effects is needed.
Adrenaline (epinephrine)
Anyone who has suffered anaphylactic shock (see p. 58) should be carrying a special syringe, called an auto-injector, loaded with adrenaline. The injector is very simple to operate and is designed for emergencies. Most allergy sufferers, even children, can give themselves the injection – or a parent or other adult can give it.
Some asthmatics, and those with food allergy who suffer swelling of the throat, may be given adrenaline in inhaler form as well (see pp. 155-6). This can be useful as an additional treatment but it’s definitely not a substitute for an injector.
See pp. 98-9 for instructions on using adrenaline in a crisis.
Wherever you go, take your injector with you. Always keep it close at hand: you need to be able to use it within minutes of the allergic reaction starting. You may be unable to speak (and therefore unable to ask someone else to fetch it) quite soon after the attack begins. The injector must never be refrigerated. It can also be damaged by sunlight and excess heat.
If you live in the countryside or in an area with a poor ambulance sevice, or if you are going camping or hiking somewhere remote, ask your doctor for a second injector, or one that can deliver multiple injections. Also ask about the maximum number of injections that can be given, and never exceed this total. Some doctors believe everyone should have two injectors, just in case the first dose doesn’t do the trick and help is slow in coming.
It is vital that you are shown exactly how to use the auto-injector. Canadian researchers discovered that only one in four
Some common brand names
Common brand names of adrenaline preparations include: auto-injectors – Anapen, EpiPen
inhalers – AsthmaHaler Mist, Bronkaid, Epiphrine
health professionals got the technique correct when demonstrating how to use an auto-injector In this study, pharmacists were much the best as regards accurate instructions. Dummy injectors are useful for training purposes and most pharmacies have them.
When the adrenaline auto-injectors expire, they can be very useful for practising with, or for showing a new baby-sitter or teacher – practise on an orange or grapefruit.
If you are taking beta-blockers (e.g. for a heart condition or anxiety), adrenaline may not have much effect.
Heavy daily use of beta-2 relievers for asthma (see p. 152) will also make adrenaline less effective when you need it.
Side effects
The important side effects of adrenaline involve the heart. Anyone with a heart condition should be given special advice in advance by their doctor about using adrenaline. The same goes for people with diabetes, hyperthyroidism or high blood pressure, and anyone taking tricyclic anti-depressants. There are quite a few minor side effects from adrenaline, such as anxiety, trembling, nausea. sweating, dizziness and cold extremities. These soon wear off.
Drugs that can make you worse
Aspirin and its relatives have a very bad effect on some people with rhinitis and/or asthma (see box on p. 151). Unfortunately, recent research shows that paracetamol is not safe either. It makes asthma more likely to develop in those who do not yet have the disease, and increases the severity of asthma symptoms for those who do. Unlike aspirin, paracetamol affects everyone, because it lowers the levels of a natural antioxidant, called glutathione, which the body makes to protect the lungs from oxidants. The greatest effects are seen in people who take paracetamol regularly (once a week or more), but even an occasional dose makes some difference.
All the other drugs that can make you worse are prescription drugs, and your doctor should be alert to the dangers. But doctors are overworked and sometimes forget, so it is sensible to know about the risks for yourself. If you have any doubt about the drugs you are taking, ask a pharmacist.
Beta-blockers are a major hazard for people with allergies. They can make the airways contract, and can bring on a serious asthma attack. They also make anaphylaxis more likely in someone who already has allergic reactions (see p. 59) and they increase the risk of a severe reaction to
immunotherapy (see p. 166) or skin-prick tests (see p. 91). Beta-blockers are prescribed for high blood pressure, angina and other heart problems, migraine and thyroid disease. There are alternative drugs in all cases. Sometimes asthma develops in people who have been taking beta-blockers for years. The beta-blockers are not responsible for this, but once asthma has begun, they will make symptoms worse. Eye drops for the treatment of glaucoma may also contain beta-blockers and can have a bad effect on asthmatics.
ACE inhibitors, used for heart conditions, may cause a cough and airway narrowing. They may also increase the risk of a severe reaction to immunotherapy.
Female hormones affect asthmatics, so taking the contraceptive pill or hormone replacement therapy (HRT) may make asthma worse. Progesterone-only contraceptive pills tend to cause fewer problems.
The drug isoniazid (INH), prescribed for tuberculosis, makes the body far more susceptible to histamine in foods (see p. 200).
An allergic reaction to a specific drug (e.g. penicillin) can also occur in some people, resulting in urticaria, or even anaphylactic shock.
Aspirin sensitivity
Aspirin sensitivity is not an allergic reaction, because neither IgE nor mast cells are involved. What causes this problem is a metabolic abnormality — a malfunction in one aspect of the body’s chemistry. The details of this are very complicated: you may want to skip the next three paragraphs and
simply read about how to cope with the problem.
The exact nature of aspirin sensitivity is still far from clear, but it seems to involve a relatively poor production of prostaglandins, combined with a plentiful production of leukotrienes. Both these substances are messenger chemicals which, broadly speaking, promote inflammation. But the details of their pro-inflammatory activities differ. It seems that, ideally, the body should have a harmonious balance between the two, and an imbalance produces problems.
Both prostaglandins and leukotrienes are manufactured from certain fats that are found in the diet. These fats, the raw materials, are worked on initially by two different enzymes — one that leads to the production of prostaglandins and another that leads to the production of leukotrienes.
If one of these enzymes is defective, it may mean that the other is oversupplied with raw materials, resulting in a serious imbalance between prostaglandins and leukotrienes. In those with aspirin sensitivity, or at risk of developing aspirin sensitivity, the enzyme that produces prostaglandins seems to be defective.
Even in the absence of aspirin, this imbalance in the production of prostaglandins and leukotrienes causes problems. It leads to symptoms such as chronic urticaria (see p. 51) or rhinitis, nasal polyps and asthma (a cluster of symptoms that is commonly called triad — see box on p. 28).
Taking aspirin can make the imbalance between prostaglandins and leukotrienes even worse in a person with this underlying abnormality. Aspirin exerts its painkilling effects by disabling the main prostaglandin-making enzyme — the enzyme that is already defective.
When someone with aspirin sensitivity takes aspirin, they may suffer worsening asthma, a severe asthma attack or — the worst-case scenario —collapse. This is a potentially fatal reaction, similar to anaphylaxis, requiring emergency medical treatment (see p. 101).
The greatest puzzle about aspirin sensitivity is why it often takes so long to develop in someone who already has the symptoms of triad —indicating the basic metabolic abnormality. It may be as much as 20 years from when someone has their first triad symptoms to when they begin reacting badly to aspirin.
If you have triad symptoms already, but no aspirin sensitivity yet, what should you do? Unfortunately, there are no safe tests for aspirin sensitivity at present — taking a small dose of aspirin and seeing what happens is very hazardous. It is probably best to assume that you are going to become sensitive to aspirin at some stage, and avoid all aspirin and aspirin-like drugs. Caution is the best plan here because aspirin sensitivity can come on very suddenly, and be life-threatening the very first time it occurs. Note
that some triad sufferers have polyps and rhinitis but no asthma until they actually develop aspirin sensitivity — a dose of aspirin suddenly brings on their first asthma attack plus other symptoms of aspirin sensitivity.
Avoiding aspirin itself is not difficult, but aspirin-like drugs pose more of a problem. Every year there are a number of deaths from these drugs. Some cases occur because a busy doctor momentarily forgets that a patient should not take these drugs. The drugs that need to be avoided are all known as non-steroidal anti-inflammatory drugs (NSAIDs), COX-1 inhibitors or COX-2 inhibitors. However you will not see any of these names on the packet. These drugs are very widely used for pain relief (e.g. in headache and backache remedies such as Nurofen), for the treatment of arthritis, and for several other inflammatory diseases.
There are dozens of non-steroidal anti-inflammatory drugs available, and many are sold under several different brand names. The list grows every year, as new drugs or new brands are launched. The only way to avoid these drugs is to be very cautious:
•    When buying any cold- or flu-remedies, painkillers, medicines for sprains or sports injuries (including those you apply directly to the skin), headache tablets or migraine tablets, always buy them at a chemist’s shop rather than a supermarket, and check with the pharmacist that they do not contain aspirin or aspirin-like drugs.
•    Be cautious also about remedies for an upset stomach. A few (e.g. Alka-Seltzer) contain aspirin.
•    Don’t take any drugs unless you are 100% sure of what they contain. Remember that the ingredients of a familiar brand name can sometimes change — read the label every time.
•    When a doctor prescribes any new drug, always mention that you are sensitive to aspirin, or that you have triad symptoms. Alternatively, check with the pharmacist when the prescription is filled.
•    Aspirin-free painkillers almost always contain paracetamol, a drug which can cause a severe reaction (similar to the collapse induced by aspirin itself) in about 5% of those with aspirin sensitivity. If you are taking paracetamol for the first time, start with half a tablet. Be sure that, for the next 2-3 hours, you have a way of getting to hospital quickly should you start to feel ill. (Note that paracetamol has another entirely separate effect, increasing the severity of asthma, and it is best not to take it too often — see box on p. 150.)
Avoiding all aspirin-like drugs will prevent you having anaphylaxis or severe attacks of asthma. Unfortunately, triad symptoms will not go away however careful you are about avoiding aspirin.
It is well worth trying the new anti-leukotriene drugs (see p. 149), especially if you have aspirin-induced asthma. They seem to help with triad symptoms by curtailing the activities of leukotrienes and so redressing the balance between leukotrienes and prostaglandins.