Combined cetirizine-montelukast preventive treatment for food-dependent exercise-induced anaphylaxis

Food-Dependent Exercise-Induced Wheals, Angioedema, and Anaphylaxis: A Systematic Review

BACKGROUND

Food-dependent exercise-induced wheals, angioedema, and anaphylaxis remain insufficiently characterized.

OBJECTIVE

We systematically reviewed the literature on clinical manifestations, laboratory investigations, culprit foods, triggering exercise, comorbidities, and treatment outcomes.

METHODS

Using predefined search terms and Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) recommendations, we searched 3 electronic databases to identify relevant literature published before July 2021.

RESULTS

Of 722 patients (median age 25 years; 55.4% male) from 231 studies (43 cohort studies, 15 cases series, and 173 case reports), 79.6% and 3.7% had anaphylaxis with and without wheals and/or angioedema, respectively. The remaining 16.6% had wheals and/or angioedema without anaphylaxis. The duration from eating to exercising and from exercising to symptom onset ranged from 5 minutes to 6 hours (median 1 hour) and from 5 minutes to 5 hours (median 30 minutes), respectively, and virtually all patients exercised within 4 hours after eating and developed symptoms within 1 hour after exercising. Wheat was the most common culprit food. Running was the most common trigger exercise. Most patients were atopic, and 1 in 3 had a history of urticaria. Aspirin and wheat-based products were the most frequent augmenting factors. On-demand antihistamines, corticosteroids, and epinephrine were commonly used and reported to be effective. Patients who stopped eating culprit foods before exercise no longer developed food-dependent exercise-induced allergic reactions.

CONCLUSIONS

Food-dependent exercise-induced allergic reactions are heterogeneous in their clinical manifestations, triggers, and response to treatment. Patients benefit from avoidance of culprit foods before exercise, which highlights the need for allergological diagnostic workup and guidance.

Idiopathic anaphylaxis: Diagnosis and management

Introduction: Idiopathic anaphylaxis (IA) is a diagnosis of exclusion and is based on the inability to identify a causal relationship between a trigger and an anaphylactic event, despite a detailed patient history and careful diagnostic assessment. The prevalence of IA among the subset of people who experienced anaphylaxis is challenging to estimate and varies widely, from 10 to 60%; most commonly noted is ∼20% in the adult anaphylactic population. Comorbid atopic conditions, such as food allergy, allergic rhinitis, and asthma, are present in up to 48% of patients with IA. Improved diagnostic technologies and an increased understanding of conditions that manifest with symptoms associated with anaphylaxis have improved the ability to determine a more accurate diagnosis for patients who may have been initially diagnosed with IA. Methods: Literature search was conducted on PubMed, Google Scholar and Embase. Results: Galactose-α-1,3-galactose (α-gal) allergy, mast cell disorders, and hereditary a-tryptasemia are a few differential diagnoses that should be considered in patients with IA. Unlike food allergy, when anaphylaxis occurs within minutes to 2 hours after allergen consumption, α-gal allergy is a 3-6-hour delayed immunoglobulin E-mediated anaphylactic reaction to a carbohydrate epitope found in red meat (e.g., beef, lamb, pork). The more recently described hereditary α-tryptasemia is an inherited autosomal dominant genetic trait caused by increased germline copies of tryptase human gene alpha-beta 1 (TPSAB1), which encodes α tryptase and is associated with elevated baseline serum tryptase. Acute management of IA consists of carrying an epinephrine autoinjector to be administered immediately at the first signs of anaphylaxis. Long-term management for IA with antihistamines and other agents aims to potentially reduce the frequency and severity of the anaphylactic reactions, although the evidence is limited. Biologics are potentially steroid-sparing for patients with IA; however, more research on IA therapies is needed. Conclusion: The lack of diagnostic criteria, finite treatment options, and intricacies of making a differential diagnosis make IA challenging for patients and clinicians to manage.

Current perspective on eicosanoids in asthma and allergic diseases: EAACI Task Force consensus report, part I

Eicosanoids are biologically active lipid mediators, comprising prostaglandins, leukotrienes, thromboxanes, and lipoxins, involved in several pathophysiological processes relevant to asthma, allergies, and allied diseases. Prostaglandins and leukotrienes are the most studied eicosanoids and established inducers of airway pathophysiology including bronchoconstriction and airway inflammation. Drugs inhibiting the synthesis of lipid mediators or their effects, such as leukotriene synthesis inhibitors, leukotriene receptors antagonists, and more recently prostaglandin D₂ receptor antagonists, have been shown to modulate features of asthma and allergic diseases. This review, produced by an European Academy of Allergy and Clinical Immunology (EAACI) task force, highlights our current understanding of eicosanoid biology and its role in mediating human pathology, with a focus on new findings relevant for clinical practice, development of novel therapeutics, and future research opportunities.

Idiopathic anaphylaxis yardstick: Practical recommendations for clinical practice

Anaphylaxis is considered idiopathic when there is no known trigger. The signs and symptoms of idiopathic anaphylaxis (IA) are identical to those of anaphylaxis because of a known cause and can include cutaneous, circulatory, respiratory, gastrointestinal, and neurologic symptoms. Idiopathic anaphylaxis can be a frustrating disease for patients and health care providers. Episodes are unpredictable, and differential diagnosis is challenging. Current anaphylaxis guidelines have little specific guidance regarding differential diagnosis and long-term management of IA. Therefore, the objective of the Idiopathic Anaphylaxis Yardstick is to use published data and the authors' combined clinical experience to provide practical recommendations for the diagnosis and management of patients with IA.

How to manage food dependent exercise induced anaphylaxis (FDEIA)

PURPOSE OF REVIEW

In recent years, the number of reports on food-dependent exercise-induced anaphylaxis (FDEIA) has been increasing. This review aims to describe the standard management of FDEIA including provocation tests and identify the issues that remain unclear.

RECENT FINDINGS

Provocation tests with aspirin for FDEIA enable us to confirm the definitive diagnosis and to make differential diagnosis. In some cases, FDEIA symptoms can be induced by aspirin and the causative food without exercise. Exercise may only be an augmenting factor of FDEIA, similar to aspirin or alcohol.

SUMMARY

The mechanisms of FDEIA development remain unclear. It has been suggested that in FDEIA, exercise lowers the threshold of a food allergy. Further research is needed to elucidate the mechanism of FDEIA and to establish strategies for effective disease management.

Data on various allergen specific IgEs and prospective treatments on food-dependent exercise-induced anaphylaxis

Food-dependent exercise-induced anaphylaxis (FDEIAn) is an anaphylactic reaction induced by physical exercise after ingestion of certain meals. FDEIAn is not very frequent, but recent case reports associated with various meals indicate an upward trend. Here, we report the data of various food specific IgEs and the clinical course of an experience with a patient who exhibited a unique FDEIAn reaction. Various food specific IgEs including staple food were positive with high levels. We could not find out the cause food of FDEIAn. Therefore we started preventive drug treatment. Specifically, only the skin symptoms (urticaria) were prevented by administering anti-histamine (hydroxyzine) daily, and respiratory symptoms (wheezing and distress) were prevented by daily administration of a leukotriene receptor antagonist (montelukast).

Anaphylaxis attributed to exercise: considerations for sports medicine specialists

Anaphylaxis is an unanticipated, acute, and sometimes life-threatening systemic reaction with variable clinical presentations that is typically mediated by immunoglobulin E and causes degranulation of mast cells and basophils. The onset of symptoms can occur within minutes or hours after exposure to a known or suspected trigger, and reactions sometimes progress very rapidly, which can lead to death. One trigger of anaphylaxis in younger adults is moderately intense physical exercise, which has been termed exercise-induced anaphylaxis (EIA). Although rare, EIA should be recognized as a distinct and potentially life-threatening form of physical allergy, and is often undetected or inadequately treated. The ingestion of specific foods, including seafood, tree nuts, and wheat, or a nonspecific meal consisting of multiple food components shortly before or after physical exertion, is sometimes, but not always, the principal precipitant of EIA. This article briefly explores the current hypotheses on the role of immunoglobulin E, response mediators, and physiologic changes that bring on EIA, and discusses the current recommendations for diagnosis, including allergen challenge and laboratory testing, emergency care, and long-term prevention and patient follow-up. Accurate diagnosis of EIA is critical to providing lifesaving therapy and care plans to patients at risk. With respect to the medical management of EIA, mainstay therapy with epinephrine is described. For those with a known history of EIA, a comprehensive anaphylaxis action plan is central to successful patient management. Furthermore, patient education is necessary to heighten awareness of the signs and symptoms of EIA and appropriate strategies for allergen avoidance and self-management of anaphylactic episodes with self-injectable epinephrine.

Review article: the diagnosis and management of food allergy and food intolerances

BACKGROUND

Adverse reactions to food include immune mediated food allergies and non-immune mediated food intolerances. Food allergies and intolerances are often confused by health professionals, patients and the public.

AIM

To critically review the data relating to diagnosis and management of food allergy and food intolerance in adults and children.

METHODS

MEDLINE, EMBASE and the Cochrane Database were searched up until May 2014, using search terms related to food allergy and intolerance.

RESULTS

An estimated one-fifth of the population believe that they have adverse reactions to food. Estimates of true IgE-mediated food allergy vary, but in some countries it may be as prevalent as 4-7% of preschool children. The most common food allergens are cow's milk, egg, peanut, tree nuts, soy, shellfish and finned fish. Reactions vary from urticaria to anaphylaxis and death. Tolerance for many foods including milk and egg develops with age, but is far less likely with peanut allergy. Estimates of IgE-mediated food allergy in adults are closer to 1-2%. Non-IgE-mediated food allergies such as Food Protein-Induced Enterocolitis Syndrome are rarer and predominantly recognised in childhood. Eosinophilic gastrointestinal disorders including eosinophilic oesophagitis are mixed IgE- and non-IgE-mediated food allergic conditions, and are improved by dietary exclusions. By contrast food intolerances are nonspecific, and the resultant symptoms resemble other common medically unexplained complaints, often overlapping with symptoms found in functional disorders such as irritable bowel syndrome. Improved dietary treatments for the irritable bowel syndrome have recently been described.

CONCLUSIONS

Food allergies are more common in children, can be life-threatening and are distinct from food intolerances. Food intolerances may pose little risk but since functional disorders are so prevalent, greater efforts to understand adverse effects of foods in functional disorders are warranted.

Specific Oral Tolerance Induction Using IFN-Gamma in 2 Cases of Food-Dependent Exercise-Induced Anaphylaxis

Anaphylaxis induced by exercise after the intake of certain foods is referred to as food-dependent exercise-induced anaphylaxis (FDEIA). Only the preventive medication such as oral sodium cromoglycate and oral combined cetirizine-montelukast was tried in FDEIA. Specific oral tolerance induction (SOTI) using IFN-gamma was tried in 2 cases of FDEIA for wheat. Merely, exercise accompanied every treatment just after the intake of allergenic foods during treatment. Patients acquired tolerance for wheat in both cases successfully. After treatment, two patients take wheat in their food living freely. Conclusively, SOTI using IFN-gamma was effective as the causative treatment for allergenic foods in FDEIA.

Exercise-induced anaphylaxis: A clinical view

Exercise-induced anaphylaxis (EIA) is a distinct form of physical allergy. The development of anaphylaxis during exertion often requires the concomitant exposure to triggering factors such as intake of foods (food dependent exercise-induced anaphylaxis) or drugs prior to exercise, extreme environmental conditions. EIA is a rare, but serious disorder, which is often undetected or inadequately treated. This article summarizes current evidences on pathophysiology, diagnosis and management. We reviewed recent advances in factors triggering the release of mediators from mast cells which seems to play a pathogenetic role. A correct diagnosis is essential to avoid unnecessary restricted diet, to allow physical activity in subjects with EIA dependent from triggering factors such as food, and to manage attacks. An algorithm for diagnosing EIA based on medical history, IgE tests and exercise challenge test has been provided. In the long-term management of EIA, there is a need for educating patients and care-givers to avoid exposure to precipitating factors and to recognize and treat episodes. Future researches on existing questions are discussed.

Anaphylaxis on reperfusion during liver transplantation with coagulopathy

We present a case in which anaphylaxis on hepatic reperfusion during liver transplantation presented only with hypotension and coagulopathy. There were no cutaneous manifestations or clinical features distinguishing anaphylaxis from postreperfusion syndrome. The recipient regularly consumed seafood, and the organ donor died of anaphylaxis to shellfish. The trigger for anaphylaxis was postulated to be passive transfer of immunoglobulin to the recipient. Anesthesiologists should be notified of donor factors to anticipate anaphylaxis. In this report, we discuss coagulopathy of anaphylaxis and contrast it with disseminated intravascular coagulation.

An update on epidemiology of anaphylaxis in children and adults

PURPOSE OF REVIEW

The purpose of the present review is to describe the epidemiology of food-induced, medication-induced, drug-induced, and insect sting-induced anaphylaxis; to summarize recent changes in the incidence of anaphylaxis internationally; and to discuss recent insights into potential risk factors for anaphylaxis.

RECENT FINDINGS

Recent studies confirm that the incidence of anaphylaxis, particularly food-induced anaphylaxis, is increasing world-wide. The rise in anaphylaxis incidence appears most pronounced in children under the age of 5 years, which is also the age group most at risk of hospitalization for food-induced anaphylaxis. Identification of factors that may increase the risk of episodes of anaphylaxis remains an important research priority. Recently, two large cohort studies using data from electronic medical records confirmed that individuals with asthma are at higher risk of anaphylaxis and those with severe asthma have the highest risk of all. With respect to modifiable lifestyle factors, several studies have demonstrated a link between latitude and anaphylaxis, with areas with less year-round sunlight reporting a higher prevalence of food-induced anaphylaxis.

SUMMARY

Reports of an increasing incidence of anaphylaxis internationally highlight the need for identification of modifiable risk factors for anaphylaxis. Emerging evidence suggests that low vitamin D levels may be associated with risk of anaphylaxis and food allergy; however, further studies are required to confirm this.

Exercise-induced anaphylaxis: an update on diagnosis and treatment

Exercise-induced anaphylaxis (EIA) and food-dependent, exercise-induced anaphylaxis (FDEIA) are rare but potentially life-threatening clinical syndromes in which association with exercise is crucial. The range of triggering physical activities is broad, including as mild an effort as a stroll. EIA is not fully repeatable (ie, the same exercise may not always result in anaphylaxis in a given patient). In FDEIA, the combined ingestion of sensitizing food and exercise is necessary to precipitate symptoms. Clinical features and management do not differ significantly from other types of anaphylaxis. The pathophysiology of EIA and FDEIA is not fully understood. Different hypotheses concerning the possible influence of exercise on the development of anaphylactic symptoms are taken into consideration. These include increased gastrointestinal permeability, blood flow redistribution, and most likely increased osmolality. This article also describes current diagnostic and therapeutic possibilities, including changes in lifestyle and preventive properties of antiallergic drugs as well as acute treatment of these dangerous syndromes.