Glucocorticoids for the treatment of anaphylaxis

IgE-mediated food allergy in children

Food allergy is a serious health issue affecting roughly 4% of children, with a substantial effect on quality of life. Prognosis is good for the most frequent allergens with almost all children outgrowing their allergy. However, the long-term implications for disease burden are substantial for children with persistent allergies (eg, peanuts, tree nuts, fish, and shellfish) and for those with high concentrations of milk, egg, and wheat IgE. Antigen avoidance has been the time-honoured approach both for prevention and treatment. However, findings from studies done in the past 5 years show that early contact with food can induce tolerance and desensitisation to foods. We review the epidemiology, natural history, and management of food allergy, and discuss the areas of controversy and future directions in research and clinical practice.

Implementation of anaphylaxis management guidelines: a register-based study

Background

Anaphylaxis management guidelines recommend the use of intramuscular adrenaline in severe reactions, complemented by antihistamines and corticoids; secondary prevention includes allergen avoidance and provision of self-applicable first aid drugs. Gaps between recommendations and their implementation have been reported, but only in confined settings. Hence, we analysed nation-wide data on the management of anaphylaxis, evaluating the implementation of guidelines.

Methods

Within the anaphylaxis registry, allergy referral centres across Germany, Austria and Switzerland provided data on severe anaphylaxis cases. Based on patient records, details on reaction circumstances, diagnostic workup and treatment were collected via online questionnaire. Report of anaphylaxis through emergency physicians allowed for validation of registry data.

Results

2114 severe anaphylaxis patients from 58 centres were included. 8% received adrenaline intravenously, 4% intramuscularly; 50% antihistamines, and 51% corticoids. Validation data indicated moderate underreporting of first aid drugs in the Registry. 20% received specific instructions at the time of the reaction; 81% were provided with prophylactic first aid drugs at any time.

Conclusion

There is a distinct discrepancy between current anaphylaxis management guidelines and their implementation. To improve patient care, a revised approach for medical education and training on the management of severe anaphylaxis is warranted.

Glucocorticoids for the treatment of anaphylaxis

BACKGROUND

Anaphylaxis is a serious hypersensitivity reaction that is rapid in onset and may result in death. Anaphylaxis guidelines recommend glucocorticoids for the treatment of people experiencing anaphylaxis.

OBJECTIVES

We sought to assess the benefits and harms of glucocorticoid treatment during episodes of anaphylaxis.

SEARCH METHODS

In our previous version we searched the literature until September 2009. In this version we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 3), MEDLINE (Ovid) (1956 to September 2011), EMBASE (Ovid) (1982 to September 2011), CINAHL (EBSCOhost) (to September 2011). We also searched the UK National Research Register and websites listing ongoing trials, and contacted international experts in anaphylaxis in an attempt to locate unpublished material.

SELECTION CRITERIA

We planned to include randomized and quasi-randomized controlled trials comparing glucocorticoids with any control (either placebo, adrenaline (epinephrine), an antihistamine, or any combination of these).

DATA COLLECTION AND ANALYSIS

Two authors independently assessed articles for inclusion.

MAIN RESULTS

We found no studies that satisfied the inclusion criteria.

AUTHORS' CONCLUSIONS

We are, based on this review, unable to make any recommendations for the use of glucocorticoids in the treatment of anaphylaxis.

Improving anaphylaxis management in a pediatric emergency department

BACKGROUND

The management of anaphylaxis in pediatric emergency units (PEU) is sometimes deficient in terms of diagnosis, treatment, and subsequent follow-up. The aims of this study were to assess the efficiency of an updated protocol to improve medical performance, and to describe the incidence of anaphylaxis and the safety of epinephrine use in a PEU in a tertiary hospital.

METHODS

We performed a before-after comparative study with independent samples through review of the clinical histories of children aged <14 years old diagnosed with anaphylaxis in the PEU according to the criteria of the European Academy of Allergy and Clinical Immunology (EAACI). Two allergists and a pediatrician reviewed the discharge summaries codified according to the International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) as urticaria, acute urticaria, angioedema, angioneurotic edema, unspecified allergy, and anaphylactic shock. Patients were divided into two groups according to the date of implantation of the protocol (2008): group A (2006-2007; the period before the introduction of the protocol) and group B (2008-2009; after the introduction of the protocol). We evaluated the incidence of anaphylaxis, epinephrine administration, prescription of self-injecting epinephrine (SIE), other drugs administered, the percentage of admissions and length of stay in the pediatric emergency observation area (PEOA), referrals to the allergy department, and the safety of epinephrine use.

RESULTS

During the 4 years of the study, 133,591 children were attended in the PEU, 1673 discharge summaries were reviewed, and 64 cases of anaphylaxis were identified. The incidence of anaphylaxis was 4.8 per 10,000 cases/year. After the introduction of the protocol, significant increases were observed in epinephrine administration (27% in group A and 57.6% in group B) (p = 0.012), in prescription of SIE (6.7% in group A and 54.5% in group B) (p = 0.005) and in the number of admissions to the PEOA (p = 0.003) and their duration (p = 0.005). Reductions were observed in the use of corticosteroid monotherapy (29% in group A, 3% in group B) (p = 0.005), and in patients discharged without follow-up instructions (69% in group A, 22% in group B) (p = 0.001). Thirty-three epinephrine doses were administered. Precordial palpitations were observed in one patient.

CONCLUSION

The application of the anaphylaxis protocol substantially improved the physicians' skills to manage this emergency in the PEU. Epinephrine administration showed no significant adverse effects.

Anaphylaxis: a history with emphasis on food allergy

In the century since Paul Portier and Charles Richet described their landmark findings of severe fatal reactions in dogs re-exposed to venom after vaccination with sea anemone venom, treatment for anaphylaxis continues to evolve. The incidence of anaphylaxis continues to be difficult to measure. Underreporting due to patients not seeking medical care as well as failure to identify anaphylaxis affects our understanding of the magnitude of the disease. Treatment with intramuscular epinephrine continues to be the recommended first-line therapy, although studies indicate that education of both the patients and the medical community is needed. Adverse food reactions continue to be the leading cause of anaphylaxis presenting for emergency care. Current therapy for food-induced anaphylaxis is built on the foundation of strict dietary avoidance, rapid access to injectable epinephrine, and education to recognize signs and symptoms of anaphylaxis. Investigation into therapy with oral and sublingual immunotherapy as well as other modalities holds hope for improved treatment of food-induced anaphylaxis.

World allergy organization guidelines for the assessment and management of anaphylaxis

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.