Iribarren C, Tolstykh IV, Miller MK, Eisner MD. Asthma and the prospective risk of anaphylactic shock and other allergy diagnoses in a large integrated healthcare delivery system

Division of Research, Kaiser Permanente, Oakland, California 94612, USA.
Annals of allergy, asthma & immunology: official publication of the American College of Allergy, Asthma, & Immunology (Impact Factor: 2.6). 05/2010; 104(5):371-7. DOI: 10.1016/j.anai.2010.03.004
Source: PubMed


The association between asthma and anaphylaxis remains poorly understood.
To ascertain, in a managed care organization in northern California, the association of asthma and asthma severity with future risk of anaphylactic shock and other selected allergy diagnoses.
Using electronic data and validated algorithms, we assembled a cohort of 526,406 patients who met the criteria for asthma between 1996 and 2006 and a referent cohort (with no utilization for asthma) individually matched on age, sex, and race/ethnicity. In each cohort, 54% of patients were female and 55% were white; their mean (SD) age was 24 (20) years. The main outcome measures were anaphylactic shock (caused by an adverse food reaction, caused by serum, or other/idiopathic), allergic urticaria, anaphylaxis after sting(s), and angioedema.
The incidence of anaphylactic shock was 109.0 per 100,000 person-years in the asthma cohort and 19.9 per 100,000 person-years in the referent cohort. After adjustment for age, sex, race/ethnicity, comorbidities, and immunotherapy, asthma was associated with a 5.2-fold (95% confidence interval, 4.7- to 5.6-fold) increased hazard of anaphylactic shock. Asthma was also significantly associated with an increased risk of the 3 selected allergy diagnoses, with hazard ratios of 1.4 to 1.9. A significant trend by severity of asthma was apparent for food-related and other/idiopathic anaphylactic shock and for anaphylaxis after sting(s).
In this insured population, asthma was prospectively associated with increased risk of anaphylactic shock and other allergy diagnoses. However, the effect of asthma severity was not consistent across outcome measures.

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    • "The incidence of anaphylaxis in the United Kingdom has been reported to be 8.4 per 100,000 in 1994 to 1999 [14] and 7.9 per 100,000 in 2005 [15]. This compares with the US incidence in an HMO population of 19.1 per 100,000 (1996–2006) [16•]. The strength of these reports is the large population studied. "
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    ABSTRACT: Anaphylaxis incidence rates and time trends in the United States have been reported using different data sources and selection methods. Larger studies using diagnostic coding have inherent limitations in sensitivity and specificity. In contrast, smaller studies using chart reviews, including reports from single institutions, have better case characterization but suffer from reduced external validity due to their restricted nature. Increasing anaphylaxis hospitalization rates since the 1990s have been reported abroad. However, we report no significant overall increase in the United States. There have been several reports of increasing anaphylaxis rates in northern populations in the United States, especially in younger people, lending support to the suggestion that higher anaphylaxis rates occur at higher latitudes. We analyzed anaphylaxis hospitalization rates in comparably sized northern (New York) and southern (Florida) states and found significant time trend differences based on age. This suggests that the relationship of latitude to anaphylaxis incidence is complex.
    Current Allergy and Asthma Reports 11/2010; 11(1):37-44. DOI:10.1007/s11882-010-0154-7 · 2.77 Impact Factor
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    ABSTRACT: The illustrated World Allergy Organization (WAO) Anaphylaxis Guidelines were created in response to absence of global guidelines for anaphylaxis. Uniquely, before they were developed, lack of worldwide availability of essentials for the diagnosis and treatment of anaphylaxis was documented. They incorporate contributions from more than 100 allergy/immunology specialists on 6 continents. Recommendations are based on the best evidence available, supported by references published to the end of December 2010. The Guidelines review patient risk factors for severe or fatal anaphylaxis, co-factors that amplify anaphylaxis, and anaphylaxis in vulnerable patients, including pregnant women, infants, the elderly, and those with cardiovascular disease. They focus on the supreme importance of making a prompt clinical diagnosis and on the basic initial treatment that is urgently needed and should be possible even in a low resource environment. This involves having a written emergency protocol and rehearsing it regularly; then, as soon as anaphylaxis is diagnosed, promptly and simultaneously calling for help, injecting epinephrine (adrenaline) intramuscularly, and placing the patient on the back or in a position of comfort with the lower extremities elevated. When indicated, additional critically important steps include administering supplemental oxygen and maintaining the airway, establishing intravenous access and giving fluid resuscitation, and initiating cardiopulmonary resuscitation with continuous chest compressions. Vital signs and cardiorespiratory status should be monitored frequently and regularly (preferably, continuously). The Guidelines briefly review management of anaphylaxis refractory to basic initial treatment. They also emphasize preparation of the patient for self-treatment of anaphylaxis recurrences in the community, confirmation of anaphylaxis triggers, and prevention of recurrences through trigger avoidance and immunomodulation. Novel strategies for dissemination and implementation are summarized. A global agenda for anaphylaxis research is proposed.
    World Allergy Organization Journal 01/2011; 4(2):13-37. DOI:10.1097/WOX.0b013e318211496c
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    ABSTRACT: The WAO Guidelines focus on recommendations for the basic initial treatment of anaphylaxis, as summarized below. Prepare for anaphylaxis assessment and management of anaphylaxis in healthcare settings. Have a posted, written emergency protocol and rehearse it regularly. As soon as the clinical diagnosis of anaphylaxis is made, discontinue exposure to the trigger, if possible; for example, discontinue an intravenously administered diagnostic or therapeutic agent. Assess the patient rapidly (circulation, airway, breathing, mental status, and skin). Simultaneously and promptly: call for help; inject epinephrine (adrenaline) by the intramuscular route in the mid-anterolateral aspect of the thigh; and place the patient on the back or in a position of comfort with the lower extremities elevated. When indicated at any time during the anaphylactic episode, administer supplemental oxygen, give intravenous fluid resuscitation, and initiate cardiopulmonary resuscitation with continuous chest compressions. At frequent and regular intervals, monitor the patient's blood pressure, cardiac rate and function, respiratory status and oxygenation and obtain electrocardiograms; start continuous noninvasive monitoring, if possible. Patients with anaphylaxis refractory to the above measures, for example, those requiring intubation and mechanical ventilation and those requiring intravenous epinephrine or another vasopressor should, if possible, be transferred to a healthcare facility where additional support is available. Ideally, this includes specialists in emergency medicine, critical care medicine and/or anesthesiology, trained and experienced nurses and technicians, and appropriate medications, supplies, and equipment. Where such skilled support is not available, physicians should, if possible, obtain additional training and experience in the management of refractory anaphylaxis and additional training in lifesupport measures. At the time of their discharge from the healthcare setting, equip patients with epinephrine for self-administration, an anaphylaxis emergency action plan, and medical identification to facilitate prompt recognition and treatment of anaphylaxis recurrences in the community. Advise patients that they need follow-up visits with a physician, preferably an allergy/immunology specialist, to confirm their specific anaphylaxis trigger(s), prevent recurrences by avoiding specific trigger(s), and receive immunomodulation, if relevant. The authors thank Professor G. Walter Canonica, WAO President, 2008- 2009, for initiating this project and appointing the WAO Anaphylaxis Special Committee, and Professor Richard F. Lockey,WAO President, 2010-2011, for his support.We express our sincere appreciation to all representatives of the 84 WAO member societies and members of the WAO Board of Directors who reviewed the Guidelines and provided important input. We are grateful to Jacqueline Schaffer, MAMS, for illustrating the principles of anaphylaxis assessment and management promulgated in the Guidelines. We acknowledge the assistance provided by the WAO Secretariat, Milwaukee, WI, and by Lori McNiven, Health Sciences Centre, Winnipeg, MB, Canada.
    The Journal of allergy and clinical immunology 03/2011; 127(3):587-93.e1-22. DOI:10.1016/j.jaci.2011.01.038 · 11.48 Impact Factor
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