Long-term stability of epinephrine dispensed in unsealed syringes for the first-aid treatment of anaphylaxis

BACKGROUND

When epinephrine autoinjectors are unavailable or unaffordable, patients at risk for anaphylaxis in the community are sometimes provided with an unsealed syringe containing a premeasured epinephrine dose for use in first-aid treatment of anaphylaxis episodes.

OBJECTIVES

To study the stability of epinephrine solution in unsealed syringes under conditions of high ambient temperature, low vs high humidity, and light vs dark.

METHODS

Forty unsealed syringes each containing an epinephrine dose of 0.3 mg (as a 1-mg/mL epinephrine solution) were stored at 38 degrees C for 5 months, with 10 syringes at each of 4 different standardized storage conditions: dark and light at low (15%) humidity and dark and light at high (95%) humidity. Duplicate syringes were removed monthly from each storage environment and analyzed for epinephrine content vs control syringes.

RESULTS

The epinephrine dose, expressed as the percentage remaining of the mean control dose, was below compendial limits (90% to 115% of label claim) by 3 months after storage at 38 degrees C and low humidity and by 4 months after storage at 38 degrees C and high humidity. Light had no significant effect.

CONCLUSION

In hot climates, if an unsealed syringe prefilled with an epinephrine dose is provided for the first-aid treatment of anaphylaxis, it should be replaced every few months on a regular basis with a new syringe containing a fresh dose of epinephrine.

DISTINCT ROLES OF IL-10 IN REGULATION OF PEANUT ALLERGY (140.10)

Objective: To evaluate the role of IL-10 in regulation of peanut-driven cytokine production in peanut allergic, sensitized, and clinically tolerant human populations.

Methods: Eighteen clinically peanut allergic, 8 sensitized, and 29 peanut non-allergic individuals between 6-45y were studied. PBMC were stimulated with peanut Ag alone, and in the presence of rIL-10 or anti-IL-10R neutralising Ab in short-term primary cultures. Peanut-driven Type 1, Type 2, and regulatory cytokine response profiles were quantified by ELISA.

Results: IL-10 production in response to peanut-specific stimulation was higher in peanut allergic than non-allergic individuals. Exogenous rIL-10 abrogates peanut-driven cytokine production in peanut allergics. Blocking endogenous IL-10 function has no impact on recall Type 2 cytokine responses in non-allergics. Among peanut allergics, anti-IL-10R treatment during Ag stimulation enhanced both Th2 and Th1 recall responses.

Conclusion: IL-10 and the IL-10R play no detectable role in preventing initiation of peanut specific food allergy, but may be important in limiting the intensity of peanut specific Th2 and pro-inflammatory responses in peanut allergic individuals.

Adrenaline for the treatment of anaphylaxis: cochrane systematic review

BACKGROUND

Anaphylaxis is a serious allergic reaction that is rapid in onset and may cause death. Adrenaline is recommended as the initial treatment of choice for anaphylaxis.

OBJECTIVES

To assess the benefits and harms of adrenaline in the treatment of anaphylaxis.

METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 1), MEDLINE (1966 to March 2007), EMBASE (1966 to March 2007), CINAHL (1982 to March 2007), BIOSIS (to March 2007), ISI Web of Knowledge (to March 2007) and LILACS (to March 2007). We also searched websites listing ongoing trials: http://www.clinicaltrials.gov/, http://www.controlledtrials.com and http://www.actr.org.au/ and contacted pharmaceutical companies and international experts in anaphylaxis in an attempt to locate unpublished material. Randomized and quasi-randomized controlled trials comparing adrenaline with no intervention, placebo or other adrenergic agonists were eligible for inclusion. Two authors independently assessed articles for inclusion.

RESULTS

We found no studies that satisfied the inclusion criteria.

CONCLUSIONS

On the basis of this review, we are unable to make any new recommendations on the use of adrenaline for the treatment of anaphylaxis. In the absence of appropriate trials, we recommend, albeit on the basis of less than optimal evidence, that adrenaline administration by intramuscular injection should still be regarded as first-line treatment for the management of anaphylaxis.

The allergic sensitization in infants with atopic eczema from different countries

BACKGROUND

No study has compared allergic sensitization patterns in infants with atopic eczema from different countries. The aim of this study was to investigate the patterns of allergic sensitization in a cohort of infants with atopic eczema participating in a multicentre, international study.

METHODS

Two thousand one hundred and eighty-four infants (mean age 17.6 months) with atopic eczema from allergic families were screened in 94 centres in 12 countries to participate in a randomized trial for the early prevention of asthma. Clinical history, Severity Scoring of Atopic Dermatitis Index, measurements for total serum IgE and specific IgE antibodies to eight food and inhalant allergens were entered into a database before randomization to treatment. A history of type of feeding in the first weeks of life and exposure to animals was recorded.

RESULTS

A total of 52.9% of the infants had raised total IgE, and 55.5% were sensitized to at least one allergen. There was a wide difference in the total IgE values and in the sensitization rates to foods and aeroallergens among infants from different countries. The highest prevalence rates of allergen-sensitized infants were found in Australia (83%), the UK (79%) and Italy (76%). Infants from Belgium and Poland consistently had the lowest sensitization rates. In each country, a characteristic pattern of sensitization was found for aeroallergens (house dust mite > cat > grass pollen > Alternaria), but not for food allergens.

CONCLUSIONS

In infants with atopic eczema, there is a wide variation in the pattern of allergic sensitization between countries, and data from one country are not necessarily generalizable to other countries.

Adrenaline (epinephrine) for the treatment of anaphylaxis with and without shock

BACKGROUND

Anaphylaxis is a serious hypersensitivity reaction that is rapid in onset and may cause death. Adrenaline is recommended as the initial treatment of choice for anaphylaxis.

OBJECTIVES

To assess the benefits and harms of adrenaline (epinephrine) in the treatment of anaphylaxis.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 1), MEDLINE (1966 to March 2007), EMBASE (1966 to March 2007), CINAHL (1982 to March 2007), BIOSIS (to March 2007), ISI Web of Knowledge (to March 2007) and LILACS (to March 2007). We also searched websites listing ongoing trials: http://clinicaltrials.gov/, http://www.controlledtrials.com and http://www.actr.org.au/; and contacted pharmaceutical companies and international experts in anaphylaxis in an attempt to locate unpublished material.

SELECTION CRITERIA

Randomized and quasi-randomized controlled trials comparing adrenaline with no intervention, placebo or other adrenergic agonists were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed articles for inclusion.

MAIN RESULTS

We found no studies that satisfied the inclusion criteria.

AUTHORS' CONCLUSIONS

Based on this review, we are unable to make any new recommendations on the use of adrenaline for the treatment of anaphylaxis. Although there is a need for randomized, double-blind, placebo-controlled clinical trials of high methodological quality in order to define the true extent of benefits from the administration of adrenaline in anaphylaxis, such trials are unlikely to be performed in individuals with anaphylaxis. Indeed, they might be unethical because prompt treatment with adrenaline is deemed to be critically important for survival in anaphylaxis. Also, such studies would be difficult to conduct because anaphylactic episodes usually occur without warning, often in a non-medical setting, and differ in severity both among individuals and from one episode to another in the same individual. Consequently, obtaining baseline measurements and frequent timed measurements might be difficult, or impossible, to obtain. In the absence of appropriate trials, we recommend, albeit on the basis of less than optimal evidence, that adrenaline administration by intramuscular (i.m.) injection should still be regarded as first-line treatment for the management of anaphylaxis.

Hydroxyzine- and Cetirizine-Loaded Liposomes: Effect of Duration of Thin Film Hydration, Freeze-Thawing, and Changing Buffer pH on Encapsulation and Stability

PURPOSE

To assess the effect of the duration of film hydration, freeze-thawing, and changing buffer pH on the extent of entrapment of hydroxyzine and cetirizine, H1-antihistamines with different polarity, into liposomes, and the stability of these liposomes.

METHODS

Multilamellar vesicles (MLV) were prepared by thin-lipid film hydration using L-alpha-phosphatidylcholine (PC) and buffer containing 80 mg hydroxyzine at pH 7. For MLV containing hydroxyzine, the liposomes were subjected to 1) hydration for 1 h, 24 h, or 48 h for the control batch, batch B, or batch D respectively; and 2) hydration for 1 h, 24 h, or 48 h with freeze-thawing for 5-cycles for batch A, batch C, or batch E, respectively. These formulations were stored at 10 +/- 2 degrees C and 37 +/- 0.1 degrees C. Small unilamellar vesicles (SUV) and MLV were prepared using L-alpha-phosphatidylcholine (PC), and buffer at pH 5.0, 5.5, 6.0, 6.5, and 7.0, containing 80 mg hydroxyzine or 82 mg cetirizine by the ethanol injection and thin-lipid film hydration methods, respectively. These formulations were stored at 10 +/- 2 degrees C. Liposomes were evaluated immediately after preparation and after storage by determining percent entrapment of hydroxyzine (PETH) or of cetirizine (PEC) and by observing changes in the physical appearance (PA). Particle size (PSA) of the liposomes freshly prepared at pH=6.5 was measured from transmission electron micrographs (TEM).

RESULTS

Increasing thin-film hydration time or repeated freeze-thawing did not affect the initial PETH or long-term stability of control, A, B, C, D, and E batches of MLV containing hydroxyzine stored at 10 +/- 2 degrees C. At 37 +/- 0.1 degrees C, PETH of all MLV batches decreased considerably after 1 month. This was more evident in batches B, C, and E exposed to freeze-thawing. The PETH of SUV increased markedly from 53.0% to 84.0% when the pH of the buffer was increased from 5.0 to 5.5. As pH increased from 6.0 to 7.0, PETH continued to increase from 84% to 94%. The initial PETH of MLV increased slightly from 82.0% to 94.0% as the buffer pH values increased from 5.0 to 7.0. There was no effect of pH on initial PEC, and stability of SUV or initial PEC of MLV, which ranged from 92% to 94%, as buffer pH values increased from 5.0 to 6.5. After storage at 10 +/- 2 degrees C PEC in MLV decreased from 94% to 74%.

CONCLUSIONS

The freeze-thawing processes had some effect on the stability of liposomes stored at temperatures higher than ambient temperature, 37 +/- 0.1 degrees C. The effect of changing the buffer pH from 5.5 to 7.0, and from 5.0 to 6.5 on initial PETH and PEC, respectively, was minimal. After 24 months at l0 +/- 2 degrees C, pH had no effects on PETH; however, PEC of MLV decreased.

Fast-Disintegrating Sublingual Epinephrine Tablets: Effect of Tablet Dimensions on Tablet Characteristics

The purpose of this study was to evaluate the effect of changing dimensions on the hardness (H), disintegration time (DT), and wetting time (WT) of fast-disintegrating epinephrine tablets for sublingual administration as potential first aid treatment for anaphylaxis. Tablet formulations I and II, containing 0% and 10% epinephrine bitartrate, respectively, and weighing 150 mg were prepared by direct compression. Formulations were compressed at a range of forces using an 8/32'' die with concave punches (CP); a 10/32'' and an 11/32'' die with CP and flat punches (FP). Tablet weight variation, content uniformity, thickness, H, DT, and WT were measured. The 8/32'', 10/32'', and 11/32'' dies resulted in tablet thickness of ranges 0.25-0.19'', 0.17-0.1'', and 0.16-0.08'', respectively. The DT and WT using the 8/32'' die were<or=10 and<or=30 sec, respectively, at H<or=5.4+/-0.2 kg for formulation I, and H<or=5.4+/-0.3 kg for formulation II. The DT and WT were<or=10 and<or=30 sec, respectively, using 10/32'' die/CP, 10/32'' die/FP, 11/32'' die/CP, and 11/32'' die/FP at H<or=6.2+/-0.6 kg, <or=6.8+/-0.4 kg, <or=4.9+/-0.1 kg, and<or=7.2+/-0.3 kg, respectively, for formulation I. For formulation II, the DT and WT were<or=10 sec and<or=30 sec, respectively, when H<4 kg. No difference in DT and WT was observed between concave and flat tablets. The 11/32'' and 10/32'' dies resulted in more ideal tablet dimensions for sublingual administration, but H must be maintained<4 kg to ensure rapid DT and WT.

Epinephrine: the drug of choice for anaphylaxis. A statement of the World Allergy Organization

Anaphylaxis is an acute and potentially lethal multi-system allergic reaction. Most consensus guidelines for the past 30 years have held that epinephrine is the drug of choice and the first drug that should be administered in acute anaphylaxis. Some state that properly administered epinephrine has no absolute contraindication in this clinical setting. A committee of anaphylaxis experts assembled by the World Allergy Organization has examined the evidence from the medical literature concerning the appropriate use of epinephrine for anaphylaxis. The Committee strongly believes that epinephrine is currently underutilized and often dosed suboptimally to treat anaphylaxis, is under-prescribed for potential future self-administration, that most of the reasons proposed to withhold its clinical use are flawed, and that the therapeutic benefits of epinephrine exceed the risk when given in appropriate i.m. doses.

New visions for anaphylaxis: an iPAC summary and future trends

Anaphylaxis is an increasing emergency in Western countries, especially in children. In the last decade, efforts have been attempted to widely understand anaphylaxis from several angles but at present, there are still numerous issues to be clarified and tackled for its earlier identification. The discrepancies in the operational definitions and diagnostic criteria of anaphylaxis represent one of the most controversial issues in casting light upon its epidemiology. Furthermore, the lack of reliable markers of the disease hampers its diagnosis. Further basic and clinical research is urgently needed to confirm the recent promising results derived from studies on animal models, and to clarify the key role of selected mediators and markers in the different steps of the reaction, in its severity and in the recurrences. The underuse of adrenaline is another important issue, as available data demonstrate physicians' preference for steroids and anti-histamines despite the current lack of evidence of their effectiveness. In the near future, the management of anaphylaxis will be strongly influenced by the development of a stepwise approach, as well as by the creation of a system improving transmission of good quality data between the emergency room, the allergist and the family doctor. This process will certainly be enhanced by the establishment of a network of Centres of Excellence collaborating for high quality research and care and involved in the dissemination of new knowledge at a primary care level. This review will seek to briefly overview our current knowledge and highlight the key questions that need to be addressed in the next decade to improve clinical care to children and will focus on the epidemiology of anaphylaxis, the identification of individuals at risk of anaphylaxis, the special issues related to infants, community management of children at risk of anaphylaxis and school related issues.

Epinephrine: the drug of choice for anaphylaxis-a statement of the world allergy organization

Anaphylaxis is an acute and potentially lethal multisystem allergic reaction. Most consensus guidelines for the past 30 years have held that epinephrine is the drug of choice and the first drug that should be administered in acute anaphylaxis. Some state that properly administered epinephrine has no absolute contraindication in this clinical setting. A committee of anaphylaxis experts assembled by the World Allergy Organization has examined the evidence from the medical literature concerning the appropriate use of epinephrine for anaphylaxis. The committee strongly believes that epinephrine is currently underused and often dosed suboptimally to treat anaphylaxis, is underprescribed for potential future self-administration, that most of the reasons proposed to withhold its clinical use are flawed, and that the therapeutic benefits of epinephrine exceed the risk when given in appropriate intramuscular doses.

IgE antibody responses in young children with atopic dermatitis

In 2184 young children aged 13-24 months with atopic dermatitis (SCORAD 5-59) serum IgE antibodies to a standard panel of food and inhalant allergens were assayed. The frequency of positive IgE responses (>0.35 kU/l) increased with greater severity of skin disease. A significant minority of infants had levels of IgE antibody to foods to suggest they were at risk of acute reaction to those foods (7% to hen's egg, 3% to cow's milk, 4% to peanut). Our findings indicate that the frequency of positive IgE responses is related to disease severity and suggest that differences in the time course of the development of IgE responses to food, which are at maximum prevalence within the first year of life, while inhalant allergies, are still developing between 1 and 2 yr and beyond.

Emergency treatment of anaphylaxis

Revised UK guidelines are a concise evidence based resource

9. Anaphylaxis

Anaphylaxis is an acute-onset, potentially fatal systemic allergic reaction. It is usually triggered by an agent such as an insect sting, food, or medication, through a mechanism involving IgE and the high-affinity IgE receptor on mast cells or basophils. Less commonly, it is triggered through other immunologic mechanisms, or through nonimmunologic mechanisms. It often occurs in community settings. Anaphylaxis episodes range in severity from those that are mild and resolve spontaneously to those that are fatal within minutes. The clinical diagnosis is based on a meticulous history and physical examination, sometimes, but not necessarily, supported by a laboratory test such as an elevated serum total tryptase level. Sensitization to allergen triggers suggested by the history needs to be confirmed by skin testing and measurement of allergen-specific IgE. In some sensitized individuals, additional tests are needed to assess the risk of future anaphylaxis episodes. Prompt injection of epinephrine is life-saving. H1-antihistamines and inhaled beta2-adrenergic agonists cannot be depended on to prevent fatality. Long-term risk reduction is an integral part of management.

Diagnosis and treatment of asthma in childhood: a PRACTALL consensus report

Asthma is the leading chronic disease among children in most industrialized countries. However, the evidence base on specific aspects of pediatric asthma, including therapeutic strategies, is limited and no recent international guidelines have focused exclusively on pediatric asthma. As a result, the European Academy of Allergy and Clinical Immunology and the American Academy of Allergy, Asthma and Immunology nominated expert teams to find a consensus to serve as a guideline for clinical practice in Europe as well as in North America. This consensus report recommends strategies that include pharmacological treatment, allergen and trigger avoidance and asthma education. The report is part of the PRACTALL initiative, which is endorsed by both academies.

Platelet-activating factor, PAF acetylhydrolase, and severe anaphylaxis

BACKGROUND

Platelet-activating factor (PAF) is an important mediator of anaphylaxis in animals, and interventions that block PAF prevent fatal anaphylaxis. The roles of PAF and PAF acetylhydrolase, the enzyme that inactivates PAF, in anaphylaxis in humans have not been reported.

METHODS

We measured serum PAF levels and PAF acetylhydrolase activity in 41 patients with anaphylaxis and in 23 control patients. Serum PAF acetylhydrolase activity was also measured in 9 patients with peanut allergy who had fatal anaphylaxis and compared with that in 26 nonallergic pediatric control patients, 49 nonallergic adult control patients, 63 children with mild peanut allergy, 24 patients with nonfatal anaphylaxis, 10 children who died of nonanaphylactic causes, 15 children with life-threatening asthma, and 19 children with non-life-threatening asthma.

RESULTS

Mean (+/-SD) serum PAF levels were significantly higher in patients with anaphylaxis (805+/-595 pg per milliliter) than in patients in the control groups (127+/-104 pg per milliliter, P<0.001 after log transformation) and were correlated with the severity of anaphylaxis. The proportion of subjects with elevated PAF levels increased from 4% in the control groups to 20% in the group with grade 1 anaphylaxis, 71% in the group with grade 2 anaphylaxis, and 100% in the group with grade 3 anaphylaxis (P<0.001). There was an inverse correlation between PAF levels and PAF acetylhydrolase activity (P<0.001). The proportion of patients with low PAF acetylhydrolase values increased with the severity of anaphylaxis (P<0.001 for all comparisons). Serum PAF acetylhydrolase activity was significantly lower in patients with fatal peanut anaphylaxis than in control patients (P values <0.001 for all comparisons).

CONCLUSIONS

Serum PAF levels were directly correlated and serum PAF acetylhydrolase activity was inversely correlated with the severity of anaphylaxis. PAF acetylhydrolase activity was significantly lower in patients with fatal anaphylactic reactions to peanuts than in patients in any of the control groups. Failure of PAF acetylhydrolase to inactivate PAF may contribute to the severity of anaphylaxis.

Practical allergy (PRACTALL) report: risk assessment in anaphylaxis

Effector mechanisms in anaphylaxis were reviewed. Current approaches to confirmation of the clinical diagnosis were discussed. Improved methods for distinguishing between allergen sensitization (which is common in the general population) and clinical risk of anaphylaxis (which is uncommon) were deliberated. Innovative techniques that will improve risk assessment in anaphylaxis in the future were described.

Diagnosis and treatment of asthma in childhood: a PRACTALL consensus report

Asthma is the leading chronic disease among children in most industrialized countries. However, the evidence base on specific aspects of pediatric asthma, including therapeutic strategies, is limited and no recent international guidelines have focused exclusively on pediatric asthma. As a result, the European Academy of Allergy and Clinical Immunology and the American Academy of Allergy, Asthma and Immunology nominated expert teams to find a consensus to serve as a guideline for clinical practice in Europe as well as in North America. This consensus report recommends strategies that include pharmacological treatment, allergen and trigger avoidance and asthma education. The report is part of the PRACTALL initiative, which is endorsed by both academies.

Clinical outcomes and adverse effect monitoring in allergic rhinitis

The subjective recording in diary cards of symptoms of itch, sneeze, nose running, and blockage, with the use of a rating scale to indicate the level of severity, is usual for clinical trials in allergic rhinitis. The primary outcome measure is usually a composite score that enables a single total symptoms score endpoint. It is appreciated, however, that rhinitis has a greater effect on the individual than is reflected purely by the recording of anterior nasal symptoms. Nasal obstruction is troublesome and may lead to sleep disturbance in addition to impaired daytime concentration and daytime sleepiness. These impairments affect school and work performance. Individuals with rhinitis find it socially embarrassing to be seen sneezing, sniffing, or blowing their nose. To capture these and other aspects of the disease-specific health-related quality of life, questionnaires such as the Rhinoconjunctivitis Quality of Life Questionnaire have been developed and validated for clinical trial use. The adoption of health-related quality of life questionnaires into clinical trials broadens the information obtained regarding the effect of the therapeutic intervention and helps focus on issues relevant to the individual patient. It must be appreciated that it is not only the disease that may adversely affect health-related quality of life; administered therapy, although intended to be beneficial, may also cause health impairment. Adverse-event monitoring is thus essential in clinical trials. The first-generation H 1 -histamines, because of their effect on central H 1 -receptors, are classically associated with central nervous system (CNS) effects such as sedation. Although this is not always perceived by the patient, it is clearly evident with objective performance testing, and positron emission tomography scanning has directly demonstrated the central H 1 -receptor occupancy. The second-generation H 1 -antihistamines have reduced central H 1 -receptor occupancy and considerably reduced or absent CNS sedative effects. Therefore, the CNS effects are entirely avoidable, and the first-generation H 1 -antihistamines should no longer be used in the management of allergic rhinitis. The considerably rarer but potentially very serious cardiac arrhythmogenic effects of H 1 -antihistamines are appreciated to be molecule-specific rather than class-specific. The in vitro screening of new compounds to eliminate the further development of those with cardiotoxicity ideally will lead to this adverse effect being historic. The incorporation of electrocardiogram recording in clinical trials provides direct information relating to prolongation of QT interval corrected for heart rate. Although administered at low doses, intranasal steroids still have the potential for systemic absorption and adverse consequences. However, it is appreciated that meaningful differences exist in the bioavailability of different steroid molecules, and although a small but statistically significant effect on growth in children has been identified with the long-term use of intranasal beclomethasone when administered twice daily for 1 year, this is not evident with all intranasal steroids. In addition, twice-daily intranasal steroid administration may have more effect--from the endocrinologic perspective--than once-daily administration in the morning, which coincides better with the natural diurnal variation in cortisol. Thus, once-daily intranasal steroid administration is preferable, and when used in studies in children, measurement of height change during the study period is an important outcome variable together with other indices of systemic steroid bioavailability (eg, tests of hypothalamic-pituitary-adrenal axis function). These considerations have even greater relevance if children are concurrently also receiving inhaled steroids for asthma, because the total steroid load will be greater.

American Academy of Allergy, Asthma & Immunology/American College of Allergy, Asthma and Immunology Joint Task Force Report on omalizumab-associated anaphylaxis

The American Academy of Allergy, Asthma & Immunology and the American College of Allergy, Asthma and Immunology Executive Committees formed the Omalizumab Joint Task Force with the purpose of reviewing the Genentech Xolair (omalizumab) clinical trials and postmarketing surveillance data on anaphylaxis and anaphylactoid reactions. Using the definition of anaphylaxis proposed at a 2005 multidisciplinary symposia, the Omalizumab Joint Task Force concluded that 35 patients had 41 episodes of anaphylaxis associated with Xolair (omalizumab) administration between June 1, 2003, and December 31, 2005. With 39,510 patients receiving Xolair (omalizumab) during the same period of time, this would correspond to an anaphylaxis-reporting rate of 0.09% of patients. Of those 36 events for which the time of reaction was known, 22 (61%) reactions occurred in the first 2 hours after one of the first 3 doses. Five (14%) of the events after the fourth or later doses occurred within 30 minutes. Considering the timing of these 36 events, an observation period of 2 hours for the first 3 injections and 30 minutes for subsequent injections would have captured 75% of the anaphylactic reactions. The OJTF report provides recommendations for physicians who prescribe Xolair (omalizumab) on (1) the suggested wait periods after administration and (2) patient education regarding anaphylaxis.