Article

Second Symposium on the Definition and Management of Anaphylaxis: Summary Report—Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network Symposium

Johns Hopkins University, Baltimore, Maryland, United States
Annals of emergency medicine (Impact Factor: 4.68). 05/2006; 47(4):373-80. DOI: 10.1016/j.annemergmed.2006.01.018
Source: PubMed
ABSTRACT
There is no universal agreement on the definition of anaphylaxis or the criteria for diagnosis. In July 2005, the National Institute of Allergy and Infectious Disease and Food Allergy and Anaphylaxis Network convened a second meeting on anaphylaxis, which included representatives from 16 different organizations or government bodies, including representatives from North America, Europe, and Australia, to continue working toward a universally accepted definition of anaphylaxis, establish clinical criteria that would accurately identify cases of anaphylaxis with high precision, further review the evidence on the most appropriate management of anaphylaxis, and outline the research needs in this area.

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Available from: Lawrence M Lewis, Jan 28, 2014
Second symposium on the definition and
management of anaphylaxis: Summary
report—Second National Institute of Allergy
and Infectious Disease/Food Allergy and
Anaphylaxis Network symposium
Hugh A. Sampson, MD,
a
Anne Mun
˜
oz-Furlong, BA,
b
Ronna L. Campbell, MD, PhD,
c
N. Franklin Adkinson, Jr, MD,
d
S. Allan Bock, MD,
e
Amy Branum, MSPH,
f
Simon G. A.
Brown, MBBS, PhD,
g
Carlos A. Camargo, Jr, MD,
h
Rita Cydulka, MD, MS,
i
Stephen J.
Galli, MD,
j
Jane Gidudu, MD, MPH,
k
Rebecca S. Gruchalla, MD,
l
Allen D. Harlor, Jr,
MD,
m
David L. Hepner, MD,
n
Lawrence M. Lewis, MD,
o
Phillip L. Lieberman, MD,
p
Dean
D. Metcalfe, MD,
q
Robert O’Connor, MD,
r
Antonella Muraro, MD, PhD,
s
Amanda
Rudman, BA,
q
Cara Schmitt, MS,
b
Debra Scherrer, BA,
b
F. Estelle R. Simons, MD,
t
Stephen Thomas, MD, MPH,
u
Joseph P. Wood, MD,
v
and Wyatt W. Decker, MD
c
New York, NY, Fairfax, Va, Rochester, Minn, Baltimore, Hyattsville, and Bethesda, Md, Boulder and
Denver, Colo, Fremantle, Australia, Boston, Mass, Cleveland, Ohio, Stanford, Calif, Lilbum, Ga,
Dallas, Tex, Eugene, Ore, St Louis, Mo, Cordova, Tenn, Padua, Italy, Winnipeg, Manitoba, Canada,
and Scottsdale, Ariz
There is no universal agreement on the definition of anaphylaxis
or the criteria for diagnosis. In July 2005, the National Institute
of Allergy and Infectious Disease and Food Allergy and
Anaphylaxis Network convened a second meeting on
anaphylaxis, which included representatives from 16 different
organizations or government bodies, including representatives
from North America, Europe, and Australia, to continue
working toward a universally accepted definition of
anaphylaxis, establish clinical criteria that would accurately
identify cases of anaphylaxis with high precision, further
review the evidence on the most appropriate management
of anaphylaxis, and outline the research needs in this area.
(J Allergy Clin Immunol 2006;117:391-7.)
Key words: Anaphylaxis, IgE-mediated hypersensitivity, anaphylac-
toid, epinephrine
Even though anaphylaxis was first described around
100 years ago and is one of the most alarming disorders
encountered in medicine, there is no universal agreement
on its definition or criteria for diagnosis. Furthermore, this
lack of specific criteria for diagnosing anaphylaxis has
greatly hampered research into the epidemiology, patho-
physiology, and management of this disorder; led to
confusion on the part of first responders, emergency
personnel, primary care physicians, and patients; and
resulted in a failure to diagnose and treat anaphylaxis in a
consistent manner.
1-3
In an attempt to resolve these problems, the National
Institute of Allergy and Infectious Disease (NIAID) and
the Food Allergy and Anaphylaxis Network (FAAN)
convened a meeting in April 2004 to address these
deficiencies.
4
This 2-day symposium brought together
experts and representatives from 13 professional, govern-
mental, and lay organizations to address the issue of
defining and managing anaphylaxis. Organizations repre-
sented included the American Academy of Allergy,
Asthma and Immunology; the American Academy of
Emergency Physicians; the American Academy of Family
Physicians; the American Academy of Pediatrics; the
American College of Allergy, Asthma and Immunology;
the American College of Emergency Physicians; the
From
a
the Mount Sinai School of Medicine, New York;
b
the Food Allergy &
Anaphylaxis Network, Fairfax;
c
the Mayo Clinic, Rochester;
d
the Johns
Hopkins University School of Medicine, Baltimore;
e
representing the
Food Allergy & Anaphylaxis Network, Boulder;
f
the National Center for
Health Statistics, Hyattsville;
g
Fremantle Hospital, Fremantle, WA,
Australia;
h
Massachusetts General Hospital, Boston;
i
the Case Western
Reserve University School of Medicine, Cleveland;
j
the Stanford
University School of Medicine, Stanford;
k
representing the Centers for
Disease Control and Prevention, Lilburn;
l
the University of Texas
Southwestern Medical Ce nter, Dallas;
m
representing the American
Academy of Pediatrics, Eugene;
n
representing the American Society of
Anesthesiologists, Boston;
o
representing the Society for Academic
Emergency Medicine, St. Louis;
p
representing the American College of
Allergy, Asthma and Immunology, Cordova;
q
the National Institute of
Allergy and Infectious Diseases, the National Institutes of Health,
Bethesda;
r
representing the National Association of EMS Physicians,
Baltimore;
s
the University of Padua, Padua, Italy;
t
representing the
American Academy of Allergy, Asthma and Immunology, Winnepeg,
MB, Canada;
u
representing the American College of Emergency
Physicians, Boston; and
v
representing the American Academy of
Emergency Medicine, Scottsdale.
Received for publication December 7, 2005; accepted for publication
December 8, 2005.
Reprint requests: Hugh A. Sampson, MD, Division of Pediatric Allergy and
Immunology, Mount Sinai Hospital, One Gustave L. Levy Pl, Box 1198,
New York, NY 10029-6574. E-mail: hugh.sampson@mssm.edu.
0091-6749/$32.00
Ó 2006 American Academy of Allergy, Asthma and Immunology
doi:10.1016/j.jaci.2005.12.1303
391
Food allergy, dermatologic
diseases, and anaphylaxis
Page 1
Abbreviations used
FAAN: Food Allergy and Anaphylaxis Network
NIAID: National Institute of Allergy and Infectious Disease
American Society of Anesthesiologists; the Centers for
Disease Control and Prevention; the Food Allergy
Initiative; the International Life Sciences Institute; the
National Association of EMS Physicians; the Society for
Academic Emergency Medicine; and the US Food and
Drug Administration. Clinical criteria were proposed that
emphasized the need for heightened suspicion of anaphy-
laxis in patients with a previous history of allergic reac-
tions to a specific allergen and a known exposure, as well
as in patients in whom there is no known history of allergic
reactions.
Recently, the Joint Task Force of the American
Academy of Allergy, Asthma and Immunology and the
American College of Allergy, Asthma and Immunology
published an updated practice parameter on the diagnosis
and management of anaphylaxis.
5
In this report the Task
Force defined anaphylaxis as ‘as a condition caused by
an IgE-mediated reaction’ and noted that such reactions
‘are often life-threatening and almost always unantici-
pated.’ The purpose of the practice parameter was to
provide ‘the practicing physician with an evidence-based
approach to the diagnosis and management of anaphy-
lactic reactions.’ In July 2005, the NIAID and FAAN
convened a second meeting, which included representa-
tives from the previous organizations and the European
Academy of Allergy and Clinical Immunology, the Aus-
tralasian Society of Clinical Immunology and Allergy,
and the Australasian College for Emergency Medicine,
to begin the process of facilitating an international agree-
ment. The purpose of this second NIAID/FAAN Sympo-
sium was to continue working toward a universally
accepted definition of anaphylaxis, establish clinical crit-
eria that would accurately identify cases of anaphylaxis
with high precision, further review the evidence on the
most appropriate management of anaphylaxis, and outline
the research needs in this area.
DEFINITION OF ANAPHYLAXIS AND
CRITERIA FOR DIAGNOSIS
Anaphylaxis is a severe, potentially fatal, systemic
allergic reaction that occurs suddenly after contact with
an allergy-causing substance. Participants at the sympo-
sium agreed that a brief, broad definition of anaphylaxis
that reflected its course and potential severity would be
most useful to both the medical and lay community and
recommended the following: ‘Anaphylaxis is a serious
allergic reaction that is rapid in onset and may cause death.’
To identify individuals experiencing such a reaction,
criteria proposed at the first symposium were revised,
4
as
outlined in Table I. Participants at the second symposium
agreed that the diagnostic criteria must provide the
emergency responder or treating physician with a rela-
tively simple and rapid means to make the diagnosis of
anaphylaxis. It was acknowledged that no criteria will
provide 100% sensitivity and specificity, but it was be-
lieved that the criteria proposed are likely to capture
more than 95% of cases of anaphylaxis. Because the ma-
jority of anaphylactic reactions include skin symptoms,
5-10
which are noted in more than 80% of cases when care-
fully assessed, it was judged that at least 80% of anaphy-
lactic reactions should be identified by criterion 1, even
when the allergic status of the patient and potential cause
of the reaction might be unknown. However, cutaneous
symptoms might be absent in up to 20% of anaphylactic
reactions in children with food allergy or insect sting al-
lergy.
11-13
Consequently, in patients with a known allergic
history and possible exposure, criterion 2 would provide
ample evidence that an anaphylactic reaction was occur-
ring. Gastrointestinal symptoms were included as a perti-
nent target response because they have been associated
with severe outcomes in various anaphylactic reactions.
9
Finally, criterion 3 should identify the rare patients who
experience an acute hypotensive episode after exposure
to a known allergen, as described by Pumphrey and
Stanworth.
14
Although participants believed that these cri-
teria should accurately identify anaphylactic reactions in
more than 95% of cases, it was agreed that these criteria
need to be subjected to a prospective multicenter clinical
survey to establish their utility and determine whether
there is need for further refinement.
MANAGEMENT OF ANAPHYLAXIS
As with the treatment of any critically ill patient, the
treatment of anaphylaxis begins with a rapid assessment
and maintenance of airway, breathing, and circulation.
When a patient fulfills any of the 3 criteria of anaphylaxis
outlined above, the patient should receive epinephrine
immediately because epinephrine is the treatment
of choice in anaphylaxis. There undoubtedly will be
patients who present with symptoms not yet fulfilling
the criteria of anaphylaxis yet in whom it would be
appropriate to initiate therapy with epinephrine, such as a
patient with a history of near-fatal anaphylaxis to peanut
who ingested peanut and within minutes is experiencing
urticaria and generalized flushing. Subsequent interven-
tions are determined on the basis of the clinical course and
response to epinephrine. In general, participants at the
Second NIAID/FAAN Anaphylaxis Symposium support
the therapeutic approach outlined in recently published
guidelines.
5
A summary of these guidelines is provided
below, along with a more detailed discussion of the recom-
mended route of parenteral epinephrine, positioning
during treatment of anaphylaxis, and suggested observa-
tion periods after treatment of an anaphylactic episode.
Epinephrine
Epinephrine is the treatment of choice for anaphylaxis.
5
Aqueous epinephrine, 0.01 mg/kg (maximum dose,
J ALLERGY CLIN IMMUNOL
FEBRUARY 2006
392 Sampson et al
Food allergy, dermatologic
diseases, and anaphylaxis
Page 2
0.5 mg) administered intramuscularly every 5 to 15 minutes
as necessary, is the recommended dosage for controlling
symptoms and maintaining blood pressure.
15,16
The
5-minute interval between injections can be liberalized
to permit more frequent injections if deemed necessary
by the clinician.
Intramuscular versus subcutaneous epinephrine. Astudy
in children not experiencing anaphylaxis demonstrated
more rapid absorption and higher plasma epinephrine levels
when epinephrine was administered intramuscularly in the
anterior-lateral thigh with an autoinjector when compared
with values after subcutaneous administration.
17
Similarly,
in adults not experiencing anaphylaxis, peak plasma epi-
nephrine concentrations were attained more quickly and
were higher after intramuscular epinephrine was injected
into the thigh than after epinephrine was injected intramus-
cularly or subcutaneously into the upper arm (deltoid).
18
Similar results were obtained with both an ampule of epi-
nephrine or a spring-loaded (eg, EpiPen [Dey, Napa,
Calif]) automatic epinephrine device.
17,18
Epinephrine in-
jected intramuscularly into the deltoid or subcutaneously
over the deltoid did not result in a significant increase of
plasma epinephrine levels over endogenous epinephrine
levels. It should be noted that studies of the route of injection
have not been performed in patients experiencing anaphy-
laxis. On the basis of this evidence, the participants of the
NIAID/FAAN Symposium concluded that intramuscular
administration of injectable epinephrine in the anterior lat-
eral thigh is preferred over subcutaneous injection. How-
ever, as noted below, intravenous epinephrine might be
preferred in some cases if an intravenous line is in place
(eg, during surgery).
Intravenous epinephrine. Intravenous epinephrine is an
option for patients with severe hypotension or cardiac
arrest unresponsive to intramuscular doses of epinephrine
and fluid resuscitation. Although there is no precisely
established dosage or regimen for intravenous epinephrine
in anaphylaxis, 5- to 10-mg intravenous bolus (0.2 mg/kg)
doses for hypotension and 0.1 to 0.5 mg administered
intravenously in the presence of cardiovascular collapse
have been suggested.
19
A recent single-center trial de-
scribed successful initial management with intravenous
epinephrine infusions for anaphylaxis with hypotension,
suggesting that this might be a viable strategy.
10,20
Detailed procedures for the preparation and administra-
tion of epinephrine infusions have been published.
5
It is
important to recognize the potential for lethal arrhythmias
when administering intravenous epinephrine, and there-
fore continuous cardiac monitoring is recommended.
Continuous low-dose epinephrine infusions might repre-
sent the safest and most effective form of intravenous de-
livery because the dose can be titrated to the desired effect
and can avoid the potential for accidental administration of
large boluses of epinephrine.
Oxygen and adrenergic agonists
High-flow oxygen (through a nonrebreather mask or
endotracheal tube) should be administered to patients ex-
periencing respiratory symptoms or hypoxemia. Those who
are hemodynamically unstable might benefit from oxygen
as well. Inhaled b
2
-agonists, such as albuterol, might be
useful for bronchospasm refractory to epinephrine.
5
Positioning of the patient
Patients in anaphylactic shock (ie, those with anaphy-
laxis and signs of critical organ hypoperfusion) should be
placed in a recumbent position with the lower extremities
elevated unless precluded by shortness of breath or
vomiting. These recommendations are based on evidence
that passive leg raise can increase stroke volume and
cardiac output by shifting fluid centrally in patients in
shock.
21
Furthermore, observations of victims of fatal
anaphylactic shock suggest that postural changes, such as
moving to a more upright position or being prevented
from taking a supine posture, might have contributed to
the fatal outcome.
22
Fluid resuscitation
Patients who remain hypotensive despite epinephrine
should have aggressive fluid resuscitation. Large volumes
TABLE I. Clinical criteria for diagnosing anaphylaxis
Anaphylaxis is highly likely when any one of the following 3 criteria are fulfilled:
1. Acute onset of an illness (minutes to several hours) with involvement of the skin, mucosal tissue, or both (eg, generalized hives, pruritus or
flushing, swollen lips-tongue-uvula)
AND AT LEAST ONE OF THE FOLLOWING
a. Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced PEF, hypoxemia)
b. Reduced BP or associated symptoms of end-organ dysfunction (eg, hypotonia [collapse], syncope, incontinence)
2. Two or more of the following that occur rapidly after exposure to a
likely allergen for that patient (minutes to several hours):
a. Involvement of the skin-mucosal tissue (eg, generalized hives, itch-flush, swollen lips-tongue-uvula)
b. Respiratory compromise (eg, dyspnea, wheeze-bronchospasm, stridor, reduced PEF, hypoxemia)
c. Reduced BP or associated symptoms (eg, hypotonia [collapse], syncope, incontinence)
d. Persistent gastrointestinal symptoms (eg, crampy abdominal pain, vomiting)
3. Reduced BP after exposure to
known allergen for that patient (minutes to several hours):
a. Infants and children: low systolic BP (age specific) or greater than 30% decrease in systolic BP*
b. Adults: systolic BP of less than 90 mm Hg or greater than 30% decrease from that person’s baseline
PEF, Peak expiratory flow; BP, blood pressure.
*Low systolic blood pressure for children is defined as less than 70 mm Hg from 1 month to 1 year, less than (70 mm Hg 1 [2 3 age]) from 1 to 10 years,
and less than 90 mm Hg from 11 to 17 years.
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VOLUME 117, NUMBER 2
Sampson et al 393
Food allergy, dermatologic
diseases, and anaphylaxis
Page 3
of crystalloid might be needed in the first 5 to 10 minutes;
in severe reactions with hypotension, up to 35% of the
blood volume might extravasate in the first 10 minutes,
and vasodilatation can cause pooling, with even more
reduction in the effective blood volume and thus distrib-
utive shock.
23
The volume given must be tailored to the
clinical situation; persistent hypotension requires a more
aggressive approach with multiple fluid boluses (10-20
mL/kg under pressure), including colloid, as well as crys-
talloid, whereas a largely respiratory reaction or one that
responds promptly to initial treatment requires less aggres-
sive fluid management.
Vasopressors
Potent vasopressors, such as noradrenaline, vasopres-
sin, or metaraminol, might be required to overcome
vasodilatation if epinephrine and fluid resuscitation have
failed to maintain a systolic blood pressure of greater than
90 mm Hg.
20
Recent case reports and animal studies have
demonstrated that vasopressin is useful when treating
hemorrhagic and septic shock. The effect of vasopressin
on systemic anaphylaxis has not been investigated, except
in clinical case reports. Vasopressin increases blood pres-
sure because of vasoconstriction through the V1 receptor.
24
H
1
- and H
2
-antihistamines
Antihistamines (H
1
- and H
2
-antagonists) are slower in
onset of action than epinephrine, have little effect on blood
pressure, and should be considered a second-line treat-
ment for anaphylaxis. Antihistamines are useful for the
symptomatic treatment of urticaria-angioedema and pru-
ritus. Diphenhydramine, administered intravenously or
intramuscularly (or orally for mild symptoms), can be
given at 25 to 50 mg for adults and 1 mg/kg (up to 50
mg) for children. Treatment with a combination of H
1
-
and H
2
-antagonists has been reported to be more effective
in attenuating the cutaneous manifestations of anaphylaxis
than treatment with H
1
-antagonists alone.
25,26
Ranitidine
and cimetidine have been most studied, but no controlled
studies have demonstrated superiority of one H
2
-antagonist
over another.
Corticosteroids
The effectiveness of corticosteroids in anaphylaxis has
never been determined in placebo-controlled trials.
However, their usefulness in other allergic diseases has
led to their incorporation into anaphylaxis management.
Because the onset of action is slow, steroids are not useful
in the acute management stage. It has been suggested that
their use might prevent a protracted or biphasic reaction,
although there is no evidence to prove this.
11,27
If given,
the dosing of intravenous corticosteroids should be equiv-
alent to 1.0 to 2.0 mg/kg per dose of methylprednisolone
every 6 hours. Oral administration of prednisone, 1.0
mg/kg, up to 50 mg might be sufficient for milder attacks.
Glucagon for persistent hypotension in
patients taking b-blockers
Although there are no epidemiologic studies that dem-
onstrate increased frequency of anaphylaxis in patients
receiving b-blockers, there are multiple reported cases of
increased severity or treatment-refractory anaphylaxis in
these patients.
28
Theoretically, there are multiple mecha-
nisms by which b-blockade could blunt the response to
epinephrine. If administration of epinephrine in these
patients is ineffective, administration of glucagon can be
attempted. Glucagon is thought to reverse refractory hypo-
tension and bronchospasm by activating adenylate cyclase
independent of the b-receptor; however, the occurrence
and importance of this mechanism of action in anaphy-
laxis is unproved. The recommended dosage for glucagon
is 1 to 5 mg (20-30 mg/kg [maximum dose, 1 mg] in
children) administered intravenously over 5 minutes and
followed by an infusion (5-15 mg/min) titrated to clinical
response. Airway protection must be ensured because
glucagon frequently causes emesis.
Observation
After the treatment of an anaphylactic reaction, an
observation period should be considered for all patients
because the reaction might recur as the effect of epineph-
rine wears off (intramuscular epinephrine results in in-
creased serum levels for an hour or more) and because of
the risk of a biphasic reaction. The occurrence of biphasic
reactions has been established in the literature and appears
to occur in 1% to 20% of anaphylactic reactions (as
depicted in Table II).
8,11,27,29-34
In a study evaluating
patients with fatal or near-fatal food reactions, approxi-
mately 20% of patients experienced a biphasic reaction,
indicating that biphasic reactions might be more likely
in patients who present initially with severe symptoms.
11
The reported time intervals between the initial reaction
TABLE II. Biphasic reactions
Study
Frequency of biphasic
reactions
No. of biphasic
reactions/total no. of
patients in study
Time from
initial to biphasic
reaction (h)
Brazil and MacNamara
33
18% 6/34 4.5-29.5
Douglas et al
31
6% 6/103 1-72
Lee and Greenes
34
6% 6/105 5.6-47.6
Starks and Sullivan
29
20% 5/25 1-8
Brady et al
32
3% 2/67 24-28
Smit et al
8
5% 15/282 1-23
Adapted from Smit et al.
8
J ALLERGY CLIN IMMUNOL
FEBRUARY 2006
394 Sampson et al
Food allergy, dermatologic
diseases, and anaphylaxis
Page 4
and the onset of the second phase ranged from 1 to 72
hours.
11,27,30-34
Unfortunately, no reliable clinical predic-
tors have been identified to enable the identification of
patients at increased risk of a biphasic reaction, although
some studies have suggested that patients requiring higher
doses of epinephrine to control initial symptoms or de-
layed administration of epinephrine might be associated
with increased risk of a biphasic reaction.
11,15,33,34
Generally, the same organ systems are involved in the
initial and secondary reaction. However, in the study
by Smit et al,
8
3 patients with initially stable vital signs
returned with abnormal vital signs (2 with hypotension
and 1 with dyspnea and decreased oxygen saturation).
On the basis of the evidence to date, the participants
attending the NIAID/FAAN Symposium recommended
that observation periods be individualized on the basis
of the severity of the initial reaction, reliability of the
patient, and access to care. A reasonable length of time
to consider observing the postanaphylactic patient is 4 to
6 hours in most patients, with prolonged observation times
or hospital admission for patients with severe or refractory
symptoms. More caution should be used in patients with
reactive airway disease because most fatalities associated
with anaphylaxis occur in these patients.
Outpatient follow-up and management
Patients who have experienced anaphylaxis from ex-
posures that might be encountered in nonmedical settings
should carry self-injectable epinephrine for use if anaphy-
laxis develops.
5,11
As noted above, there has been no uni-
versally accepted definition of anaphylaxis. Therefore the
clinical criteria suggested above might be helpful in deter-
mining who should be prescribed self-injectable epineph-
rine. Until there are universally accepted criteria for the
diagnosis of anaphylaxis, the indications for the pres-
cription of self-injectable epinephrine will continue to be
problematic. Currently, there is a consensus that patients
experiencing respiratory or cardiovascular symptoms after
exposure to a known allergen in the community should
receive self-injectable epinephrine. Beyond this consen-
sus, it is unclear who should be given a prescription for
self-injectable epinephrine. However, limiting prescrip-
tions of self-injectable epinephrine to this criteria in
patients with peanut and other nut allergy, for example,
would fail to cover up to 80% of patients experiencing a
fatal anaphylactic reaction.
35
Patients who are prescribed
self-injectable epinephrine should also have an emergency
action plan detailing its use and the follow-up manage-
ment. The complexities of prescribing self-injectable
epinephrine and providing an accompanying emergency
action plan have been described recently by Sicherer and
Simons,
36
and the ethical dilemmas have been discussed
by Hu et al.
37
Before discharge from an emergency facility, all
patients experiencing an anaphylactic reaction should
receive information about how to avoid the precipitating
allergen (if known). Other issues to consider include
alerting patients about national organizations providing
important information and educational materials (eg, the
Food Allergy and Anaphylaxis Network, www.foodallergy.
org), as well as being advised to obtain prompt follow-up
with an allergist and notify their primary care physician.
At present, these 3 steps (ie, self-injectable epinephrine
prescription, patient education, and follow-up evaluation)
are infrequently performed in North American emergency
departments.
38,39
Because emergency departments are the
treatment setting for most anaphylaxis visits,
1
this repre-
sents an important and as yet untapped opportunity to
improve patient care.
RESEARCH NEEDS
The investigation of anaphylaxis has been impeded
by the lack of universally accepted diagnostic criteria and
the absence of reliable laboratory biomarkers to confirm
the clinical impression. This in turn has thwarted efforts
to ascertain the incidence and outcome of anaphylaxis in
various populations, to determine the most effective forms
of therapy, to identify patients at risk for life-threatening
anaphylaxis, and to elucidate the basic immunologic and
pathogenic mechanisms responsible for the variable
course of anaphylaxis in different individuals. A multi-
center prospective study of the diagnostic criteria pro-
posed herein is needed to determine whether they allow
the clinician and investigator to identify accurately pa-
tients with anaphylaxis regardless of cause. Assuming that
these criteria prove to be adequately sensitive and specific
for diagnosing anaphylaxis, studies determining the inci-
dence, cause, clinical features, natural course, and out-
come of anaphylaxis are needed to provide the clinician
with evidence-based features of this disorder that will
enable more effective prevention and therapeutic inter-
ventions. Clinical trials can be facilitated by the formation
of an anaphylaxis consortium.
It was believed that the measurement of certain mast
cell–derived mediators, such as histamine and tryptase,
would provide confirmatory evidence of an anaphylactic
reaction. However, in a series of 97 patients presenting to
an emergency department and given diagnoses of ana-
phylaxis, only 42% were found to have increased plasma
histamine levels, and 21% were determined to have
increased plasma tryptase levels.
26
One small study dem-
onstrated that serial estimations of plasma tryptase levels
might improve sensitivity (36% to 73%).
40
Sensitive and
specific biomarkers of anaphylaxis and evolving anaphy-
laxis are needed that will establish the presence of the
disorder when sufficient historical information is not
available or symptoms are atypical. New proteomic ap-
proaches, metabolomic approaches, or both might prove
useful in identifying relevant biomarkers. Biomarker
assays could be useful to confirm the diagnosis when in
doubt, which can have important follow-up implications.
If available at the bedside, they could even assist in the
identification of patients at risk of persistent or delayed-
phase reactions. However, given the emergency and ful-
minant nature of this disease, such approaches are unlikely
to be useful for guiding immediate resuscitative
J ALLERGY CLIN IMMUNOL
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Sampson et al 395
Food allergy, dermatologic
diseases, and anaphylaxis
Page 5
interventions. Laboratory trials can be facilitated by the
formation of an anaphylaxis registry with close collabora-
tion between different centers and across specialties.
As outlined in the previous symposium,
4
most anaphy-
lactic reactions are due to IgE-mediated hypersensitivity
reactions resulting from cross-linking of allergen-specific
IgE molecules on the surface of tissue mast cells and pos-
sibly basophils. However, this mechanism alone does not
explain the severity of the allergic manifestations, the var-
iability in target organ responses among individuals or
within the same individual, the differences in threshold
doses of allergen necessary to provoke anaphylactic re-
sponses, the variable responses to therapy, the induction
of biphasic or protracted anaphylactic reactions, or the
eventual outcome of the reaction. A recent study sug-
gested that the diversity of IgE allergenic epitope recog-
nition might play a role in the severity of allergic
responses,
41
but this represents a fraction of the potential
variables occurring between the time an allergen enters
the body and the end result of an anaphylactic reaction.
For example, it might be informative to perform genomic
and functional studies of polymorphisms or gain-of-func-
tion mutations in various mediator, cytokine, and chemo-
kine receptors; the Kit receptor; elements of intracellular
signaling pathways; or other factors that might influence
either the activation or function of the effector cells of
anaphylaxis or the responses of the structural cells in the
target organs affected in this disorder.
In addition, investigation is required into the patho-
physiologic mechanisms and appropriate treatment of
reactions fulfilling the diagnostic criteria listed for
anaphylaxis but that do not involve an IgE-mediated
mechanism, commonly referred to as anaphylactoid or
pseudoallergic reactions . Furthermore, studies have sug-
gested a role for the nervous system in eliciting the full
symptom complex of anaphylaxis,
42
and this is an area
that warrants further investigation. Well-characterized an-
imal models would clearly facilitate efforts to understand
the basic pathophysiology occurring during anaphylaxis;
to determine the interactions between various cell types;
to elucidate effects of mediators, cytokines, and chemo-
kines released during an anaphylactic response; and to
delineate better therapeutic strategies. Recently, animal
models that appear reflective of anaphylaxis in human
subjects have been established in mice,
43
dogs,
44
and
pigs,
45
but better models are needed.
During the NIAID/FAAN Symposium and in the
recently published practice parameter on anaphylaxis,
5
therapeutic strategies for the management of anaphylaxis
were suggested largely on the basis of ‘clinical experi-
ence.’ In fact, there is a major need to evaluate the most
appropriate therapeutic measures and medications for
the treatment of anaphylaxis. Although virtually all au-
thorities agree that epinephrine is the drug of choice for
the treatment of acute anaphylaxis, there are limited data
on the appropriate dose, timing, route, or frequency of
administration. H
1
-andH
2
-antihistamines, corticosteroids,
or both are commonly used in the treatment of anaphy-
laxis, but there are virtually no data demonstrating their
functional role or effectiveness. Prospective controlled
trials to establish the appropriate dosing of these medica-
tions and the role of other therapeutic interventions, such
as the optimal type and rate of fluid replacement, and
the use of vasopressors, glucagon, nebulized albuterol or
epinephrine, leukotriene inhibitors, and cytokine antago-
nists (eg, anti-TNF) also are warranted. Ideally, therapeutic
measures could be studied in appropriate animal models be-
fore initiating clinical trials. Before any clinical studies,
clinically useful severity scoring and outcome measure-
ment tools need to be validated.
There is also a need for outcomes research in well-
characterized patients. Little information is available
on the benefits and risks of providing epinephrine auto-
injectors, antihistamines, corticosteroids, and written
medical instructions to patients with food and insect
venom allergy and their caregivers (eg, parents and school,
day care, and restaurant personnel) and first-line emer-
gency personnel. Studies of long-term sequelae, adher-
ence to follow-up referral, subsequent reactions, and
quality of life in patients experiencing anaphylactic reac-
tions also are lacking. As outcome data are becoming
available, evaluation of the most effective means of
disseminating information about the prevention and
management of anaphylaxis to patients, primary care
physicians, first responders, and emergency department
personnel should help alleviate the tremendous disparities
in therapeutic approaches seen in the United States and
around the world.
A number of studies from around the world suggest that
anaphylactic reactions commonly occur both inside and
out of the hospital environment.
46,47
In light of the general
increase in IgE-dependent allergic disorders in the devel-
oped world over the past several decades, there is an urgent
need to understand better the basic immunology and path-
ophysiology of anaphylaxis and to optimize therapy on
the basis of well-controlled clinical trials. In addition, the
characterization of clinical features and discovery of bio-
markers that would identify patients at risk for anaphylaxis
or for biphasic or prolonged severe reactions would greatly
enhance the care of these patients, decrease patient and
family anxieties, and reduce the risk of unfavorable out-
comes. The universal acceptance of specific clinical crite-
ria to identify anaphylaxis, as proposed here, will facilitate
and expedite research in this critical area.
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J ALLERGY CLIN IMMUNOL
VOLUME 117, NUMBER 2
Sampson et al 397
Food allergy, dermatologic
diseases, and anaphylaxis
Page 7
  • Source
    • "Anaphylaxis is a severe, progressive, allergic reaction that is rapid in onset and can cause death [1]. Anaphylaxis in the community is common, and increasing as severe allergies to food and insect venom rise2345. "
    [Show abstract] [Hide abstract] ABSTRACT: Background Successful treatment of anaphylaxis in the community relies on early and correct use of epinephrine autoinjectors. Community pharmacists supply these devices and have a crucial role teaching patients how to use them. Supply of epinephrine autoinjectors in Australia increased 70-fold in the past decade. New EpiPen and Anapen autoinjectors were launched in Australia in 2011 and 2012, with the potential to cause confusion. However there is no information about how pharmacists demonstrate epinephrine autoinjectors to patients. Therefore the aim of this study was to assess real-world community pharmacist demonstrations of EpiPen and Anapen. We also sought to identify consultation-based predictors of accurate demonstration. Methods Demonstration accuracy was assessed in simulated patient visits to 300 randomly selected pharmacies. Pharmacists were asked by the simulated patient how to use original EpiPen, new-look EpiPen or Anapen, and assessed against the relevant Australasian Society of Clinical Immunology and Allergy (ASCIA) Action Plan for Anaphylaxis. Other anaphylaxis advice provided by the pharmacist was also recorded. Accuracy was analysed descriptively. Binary logistic regression was used to identify predictors of accurate demonstration. Results All 300 pharmacies were visited. Of 250 pharmacist demonstrations, 46 (18.4%) accurately demonstrated all four steps on ASCIA Action Plan. Failure to state ‘do not touch the needle’ (74.8%) or ‘massage injection site’ (68.8%) reduced accuracy. However 163 (65.2%) accurately demonstrated the three steps required to inject epinephrine (no difference by device, p = 0.15). Associations with accurate demonstration were: checking if the patient had an anaphylaxis action plan (odds ratio, OR = 16.1; 95% CI: 3.86-67.3); stating to call an ambulance after use (OR = 4.0; 95% CI: 1.44-11.1); or explaining side effects of epinephrine (OR = 4.5; 95% CI: 1.48-13.4). Conclusions It is critical that anaphylaxis patients know how to use their prescribed epinephrine autoinjector correctly. Pharmacists have acceptable rates of EpiPen and Anapen demonstration accuracy, although more is needed to improve this. Those who pay attention to the need for action plans, emergency care after epinephrine use, and informing patients about the side effects of epinephrine may have better knowledge about anaphylaxis, and in turn significantly improve demonstration accuracy.
    Full-text · Article · Sep 2014 · Allergy Asthma and Clinical Immunology
  • Source
    • "Anaphylaxis is a severe systemic allergic reaction that is rapid in onset and can potentially result in death [1]. It is triggered by the sudden release of chemical mediators such as histamine and leukotrienes from sensitized mast cells and basophils coated with immunoglobulin E antibodies, cumulating in a type 1 hypersensitivity reaction. "
    [Show abstract] [Hide abstract] ABSTRACT: BackgroundAnaphylaxis is an emergency condition that requires immediate, accurate diagnosis and appropriate management. However, little is known about the level of knowledge of doctors and nurses treating these patients in the Emergency Department.ObjectiveTo determine the knowledge of doctors and nurses in the Emergency Department on the recent definition and treatment recommendations of anaphylaxis.MethodsWe surveyed doctors and nurses of all grades in a tertiary Hospital Emergency Department using a standardized anonymous questionnaire.ResultsWe had a total of 190 respondents-47 doctors and 143 nurses. The response rate was 79.7% for doctors and 75.3% for nurses. Ninety-seven point eight percent of the doctors and 83.7% of the nurses chose the accepted definition of anaphylaxis. High proportions of doctors (89-94%) and nurses (65-72%) diagnose anaphylaxis in the three scenarios demonstrating anaphylaxis and anaphylactic shock. Forty-two point six percent of the doctors and 76.9% of the nurses incorrectly diagnosed single organ involvement without hypotension as anaphylaxis. As for treatment, 89.4% of the doctors indicated adrenaline as the drug of choice and 85.1% chose intramuscular route for adrenaline administration. Among the nurses, 40.3% indicated adrenaline as the drug of choice and 47.4% chose the intramuscular route for adrenaline.ConclusionHigh proportion of doctors and nurses are able to recognize the signs and symptoms of anaphylaxis, although there is a trend towards over diagnosis. There is good knowledge on drug of choice and the accepted route of adrenaline among the doctors. However, knowledge of treatment of anaphylaxis among nurses was moderate and can be improved.
    Full-text · Article · Jul 2014
  • Source
    • "We classified the reported symptoms according to the affected organs: 1) reactions on skin, mucosal tissue or both, such as an urticaria, rash, itching, redness, and angioedema; 2) gastrointestinal symptoms if the reactions involved vomiting, nausea, abdominal pain, or diarrhea; and 3) respiratory symptoms such as cough, dyspnea, and wheezing.9 Anaphylaxis was defined as symptoms that developed rapidly after exposure and affected at least 2 major organs.9 "
    [Show abstract] [Hide abstract] ABSTRACT: There are scanty epidemiologic data on the prevalence of food allergy (FA) among preschool children in Asia. We performed this study to determine the prevalence and causative foods of immediate-type FA in early childhood in Korea. A questionnaire-based, cross-sectional study was performed between September and October 2011. Children aged 0-6 years were recruited from 301 public child care centers in Seoul. Parents were asked to complete a questionnaire on FA. Children with FA were classified into "perceived FA, ever," "immediate-type FA, ever," and "immediate-type FA, current" according to the algorithm. A total of 16,749 children were included in this study. The prevalence of "perceived FA, ever," "immediate-type FA, ever," and "immediate-type FA, current" was 15.1%, 7.0%, and 3.7%, respectively. "Immediate-type FA, current" was reported by 182 (4.9%) out of 3,738 children aged ≤2 years, 262 (3.4%) of 7,648 children aged 3-4 years, and 177 (3.3%) of 5,363 children aged 5-6 years. Hen's egg (126/621) was the most frequent cause as the individual food item, followed by cow's milk (82/621) and peanut (58/621). Among the food groups, fruits (114/621), tree nuts (90/621) and crustaceans (85/621) were the most common offending foods. The three leading causes of food-induced anaphylaxis were hen's egg (22/47), cow's milk (15/47), and peanut (14/47). The prevalence of immediate-type FA in early childhood is 3.7%, and is higher in younger children. The most common offending foods differed with age.
    Full-text · Article · Mar 2014 · Allergy, asthma & immunology research
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