Anaphylaxis epidemiology in patients with and patients without asthma: a United Kingdom database review

Drug-Induced Anaphylaxis Uncommon in Mastocytosis: Findings From Two Large Cohorts

BACKGROUND

Anaphylaxis is a common feature of patients with mastocytosis, particularly with Hymenoptera venoms. Hence, it is hypothesized that patients with mastocytosis may have an increased susceptibility to developing drug-induced anaphylaxis (DIA). Patients and medical practitioners are therefore concerned when there is a need to use various drugs. However, this issue has not been systematically investigated.

OBJECTIVE

To investigate the prevalence and clinical characteristics of anaphylaxis to various types of drugs among patients with mastocytosis.

METHODS

A retrospective study was conducted among 470 consecutive patients (18 years and older) with confirmed clonal mast cell diseases recruited from 2 independent mastocytosis reference centers. All patients underwent a comprehensive, individualized allergy workup with evaluation of the (self)reported drug hypersensitivity.

RESULTS

The overall prevalence of DIA was 6.3%, accounting for one-third of the confirmed drug hypersensitivity reactions. Nonsteroidal anti-inflammatory drugs were the most common elicitors of DIA (56%), followed by perioperative agents (23%) and antibiotics (13%). Anaphylactic reactions were severe in most cases, with 43% of patients experiencing hypotensive syncope. All drug-related hypersensitivity reactions occurred before mastocytosis was diagnosed.

CONCLUSIONS

The prevalence of DIA in mastocytosis tends to be higher than in the general population, but is overall low. However, its severity is more pronounced. Our results suggest that patients with mastocytosis with a previous reaction to drugs should undergo a thorough allergy workup. Well-tolerated drugs can be further used without specific precautions.

The Application of Knowledge-Based Clinical Decision Support Systems to Detect Antibiotic Allergy

Prevention of drug allergies is important for patient safety. The objective of this study was to evaluate the outcomes of antibiotic allergy-checking clinical decision support system (CDSS), K-CDSTM. A retrospective chart review study was performed in 29 hospitals and antibiotic allergy alerts data were collected from May to August 2022. A total of 15,535 allergy alert cases from 1586 patients were reviewed. The most frequently prescribed antibiotics were cephalosporins (48.5%), and there were more alerts of potential cross-reactivity between beta-lactam antibiotics than between antibiotics with the same ingredients or of the same class. Regarding allergy symptoms, dermatological disorders were the most common (38.8%), followed by gastrointestinal disorders (28.4%). The 714 cases (4.5%) of immune system disorders included 222 cases of anaphylaxis and 61 cases of severe cutaneous adverse reactions. Alerts for severe symptoms were reported in 6.4% of all cases. This study confirmed that K-CDS can effectively detect antibiotic allergies and prevent the prescription of potentially allergy-causing antibiotics among patients with a history of antibiotic allergies. If K-CDS is expanded to medical institutions nationwide in the future, it can prevent an increase in allergy recurrence related to drug prescriptions through cloud-based allergy detection CDSSs.

Predictors of Clonality and Underlying Mastocytosis in Mast Cell Activation Syndromes

PURPOSE OF REVIEW

Mast cell (MC) activation can present with a wide range of symptoms. The mechanisms that cause such activation are varied. One of them is the presence of clonal MCs which is defined, within other possible changes, by the presence of a somatic, activating mutation in the KIT gene. The clinical course and prognosis of patients with this underlying disease may be different from other causes of MC activation (MCA). For this reason, it is important to early diagnose, or at least suspect, which patients with MCA are due to clonal MCs.

RECENT FINDINGS

The diagnosis of clonality must be made in a comprehensive manner. However, this paper reviews chronologically each of the stages from the patient's first visit to the doctor's office which can be indicative of clonality: clinical presentation of MCA, physical examination, analytical determinations of tryptase, and/or KIT mutational analysis and bone involvement, among others. The different clonality predictive scores proposed are also reviewed and compared. Although the gold standard for the diagnosis of certainty of MC clonality is the performance of a bone marrow (BM) biopsy, there are clinical symptoms, signs, and biological parameters suggestive of clonality, as well as predictive scores, which can guide (or rule out) an early diagnosis and avoid unnecessary BM biopsies.

Risk factors for allergy documentation in electronic health record: A retrospective study in a tertiary health center in Switzerland

BACKGROUND

Most hospitals use electronic health records (EHR) to warn health care professionals of drug hypersensitivity (DH) and other allergies. Indiscriminate recording of patient self-reported allergies may bloat the alert system, leading to unjustified avoidances and increases in health costs. The aim of our study was to analyze hypersensitivities documented in EHR of patients at Lausanne University Hospital (CHUV).

METHODS

We conducted a retrospective study on patients admitted at least 24 h to CHUV between 2011 and 2021. After ethical clearance, we obtained anonymized data. Because culprit allergen could be either manually recorded or selected through a list, data was harmonized using a reference allergy database before undergoing statistical analysis.

RESULTS

Of 192,444 patients, 16% had at least one allergy referenced. DH constituted 60% of all allergy alerts, mainly beta-lactam antibiotics (BLA) (30%), NSAID (11%) and iodinated contrast media (ICM) (7%). Median age at first hospitalization and hospitalization length were higher in the allergy group. Female to male ratio was 2:1 in the allergic group. Reactions were limited to the skin in half of patients, and consistent with anaphylaxis in 6%. In those deemed allergic to BLA, culprit drug was specified in 19%, 'allergy to penicillin' otherwise. It was impossible to distinguish DH based on history alone or resulting from specialized work-up.

CONCLUSIONS

Older age, longer hospital stays, and female sex increase the odds of in-patient allergy documentation. Regarding DH, BLA were referenced in 4% of inpatient records. Specific delabeling programs should be implemented to increase data reliability and patient safety.

Effect of Gender and Special Considerations for Women in Mastocytosis and Anaphylaxis

This article reviews the effects of gender on anaphylaxis in general and focuses on mastocytosis-specific issues. Incidence of anaphylaxis is increased in female compared with male patients during the pubertal years through the fifth decade of life, in which these disparities decrease. Estrogen is thought to increase the severity of anaphylaxis through increased endothelial nitric oxide synthase release. Despite this, all-cause fatal anaphylaxis does not appear to show a gender predilection. Systemic mastocytosis incidence is higher in women; however, mortality is increased in men owing to increased molecular and cytogenetic abnormalities.

Trends and Hospital Outcomes in HOSPITAL Admissions for Anaphylaxis in Children with and without Asthma in Spain (2016-2021)

(1) Background: To assess and compare the temporal trends in the incidence, characteristics and hospital outcomes among children with and without asthma who were hospitalized with anaphylaxis in Spain from 2016 to 2021, and identify the variables associated with severe anaphylaxis among children with asthma. (2) Methods: An observational, retrospective study was conducted using a population-based database. The study population included pediatric patients with anaphylaxis. This population was stratified based on whether they had asthma. (3) Results: The number of hospital admissions was stable from 2016 to 2019, dropping in 2020 and raising to the highest number in 2021. A total of 60.63% of hospitalizations occurred in boys and the most common anaphylactic reactions were due to food consumption (67.28%), increasing over time. The in-hospital mortality (IHM) remained stable and under 1% in all the years studied. The incidence of anaphylaxis was 2.14 times higher in children with asthma than in those without asthma (IRR 2.14; 95% CI 1.87-2.44). Furthermore, it was 1.79 times higher in boys with asthma than in those without asthma (IRR 1.79; 95% CI 1.06-2.45) and 2.68 times higher in girls with asthma than in those without asthma (IRR 2.68; 95% CI 2.23-3.12). Asthma was not associated with severe anaphylaxis (OR 1.31; 95% CI 0.88-1.96). (4) Conclusions: The number of hospitalizations for anaphylaxis in children remained stable from 2016 to 2019, dropping in 2020 and recovering in 2021. IHM was low and remained stable during the study period. The incidence of hospitalizations for anaphylaxis was higher in asthmatic children than in non-asthmatics, but there were no differences in the occurrence of severe anaphylaxis among them.

Disease Spectrum of Anaphylaxis Disorders

Anaphylaxis results from massive mast cell activation. Mechanisms of mast cell activation may involve IgE- and non-IgE-mediated triggers, clonal mast cell disease, or be idiopathic and may be modified by several factors including but not restricted to hormonal status, stress, heritable factors, mast cell burden, and simultaneous exposure to more than 1 factor. Patients with recurrent anaphylaxis with a nonidentifiable trigger present a particular challenge in diagnosis and management. Presence of clonal disease may be suggested by hypotensive episodes with urticaria and angioedema, and high baseline tryptase levels. A number of scoring systems have been developed to identify patients who are at high risk to have underlying mastocytosis. This review provides an overview of anaphylaxis disorders and our current understanding of their mechanisms of action, evaluation, and management.

Identifying and Managing Those at Risk for Vaccine-Related Allergy and Anaphylaxis

Immediate hypersensitivity reactions to vaccines, the most severe of which is anaphylaxis, are uncommon events occurring in fewer than 1 in a million doses administered. These reactions are infrequently immunoglobulin E-mediated. Because they are unlikely to recur, a reaction to a single dose of a vaccine is rarely a contraindication to redosing. This narrative review article contextualizes the recent knowledge we have gained from the coronavirus 2019 (COVID-19) pandemic rollout of the new mRNA platform with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines within the much broader context of what is known about immediate reactions to other vaccinations of routine and global importance. We focus on what is known about evidence-based approaches to diagnosis and management and what is new in our understanding of mechanisms of immediate vaccine reactions. Specifically, we review the epidemiology of immediate hypersensitivity vaccine reactions, differential diagnosis for immune-mediated and nonimmune reaction clinical phenotypes, including how to recognize immunization stress-related responses. In addition, we highlight what is known about mechanisms and review the rare but important contribution of excipient allergies and specifically when to consider testing for them as well as other key features that contribute to safe evaluation and management.

Latin American anaphylaxis registry

Background

Recent data about clinical features, triggers and management of anaphylaxis in Latin America is lacking.

Objective

To provide updated and extended data on anaphylaxis in this region.

Method

An online questionnaire was used, with 67 allergy units involved from 12 Latin-American countries and Spain. Among data recorded, demographic information, clinical features, severity, triggering agents, and treatment were received.

Results

Eight hundred and seventeen anaphylactic reactions were recorded. No difference in severity, regardless of pre-existing allergy or asthma history was found. Drug induced anaphylaxis (DIA) was most frequent (40.6%), followed by food induced anaphylaxis (FIA) (32.9%) and venom induced anaphylaxis (VIA) (12%). FIA and VIA were more common in children-adolescents. Non-steroidal anti-inflammatory drugs (NSAIDs) and beta-lactam antibiotics (BLA) were the most frequent drugs involved. Milk (61.1% of FIA) and egg (15.4% of FIA) in children, and shellfish (25.5% of FIA), fresh fruits (14.2% of FIA), and fish (11.3% of FIA) in adults were the most common FIA triggers. Fire ants were the most frequent insect triggers, and they induced more severe reactions than triggers of FIA and DIA (p < 0.0001). Epinephrine was used in 43.8% of anaphylaxis episodes. After Emergency Department treatment, epinephrine was prescribed to 13% of patients.

Conclusions

Drugs (NSAIDs and BLA), foods (milk and egg in children and shellfish, fruits and fish in adults) and fire ants were the most common inducers of anaphylaxis. Epinephrine was used in less than half of the episodes emphasizing the urgent need to improve dissemination and implementation of anaphylaxis guidelines.

Anaphylaxis in Children

ABSTRACT

Anaphylaxis is a potentially life-threatening event in children, commonly encountered in the prehospital and emergency department settings. Recently published clinical guidelines emphasize early recognition of anaphylaxis and administration of epinephrine as the mainstay of management. Literature regarding adjuvant therapies, biphasic reactions, observation times, and disposition of patients with anaphylaxis remains controversial. In this article, we will review the background and pathophysiology of anaphylaxis, as well as the diagnostic approach, management, and future directions of anaphylaxis in children.

Anaphylaxis in Chinese Children: Different Clinical Profile Between Children with and without a History of Asthma/Recurrent Wheezing

Purpose

Asthma and recurrent wheezing (RW) have been identified as risk factors for anaphylaxis; however, little is known about the characteristics of anaphylaxis in children with a history of asthma or RW in Chinese children.

Patients and Methods

This was a retrospective, observational chart review of children who were diagnosed with anaphylaxis in a tertiary children's hospital between 2014 and 2021. Patients' demographics, symptoms, triggers and presence of physician-diagnosed asthma/RW history were collected from medical charts.

Results

A total of 399 anaphylactic reactions in 264 patients were analyzed; 119 patients (45.1%) had a history of asthma/RW. Food was the most common cause (85.5%, 341/399). Compared with patients without a history of asthma/RW, buckwheat-induced anaphylaxis was significantly more common in the asthma/RW group (9.4% vs 0.5%, p < 0.001), patients with a history of asthma/RW had higher rates of oropharyngeal symptoms (17.3% vs 8.6%, p = 0.011) and wheezing (34.5% vs 15.9%, p < 0.001). Ninety-one reactions (22.8%, 91/399) presented as severe anaphylaxis, but no difference existed between asthma/RW and non-asthma/RW groups. Children with a history of asthma/RW were more likely to receive inhaled β agonists than children without a history of asthma/RW (11.8% vs 2.5%, p = 0.003). A larger proportion of children without asthma/RW history were treated with epinephrine (11.7%) than children with asthma/RW history (6.9%).

Conclusion

Our finding revealed that different clinical profiles of anaphylaxis in children with and without a history of asthma/RW. Our study did not find that children with a history of asthma/RW have more severe anaphylactic reactions compared with children without asthma/RW. Buckwheat-induced anaphylaxis was more common in the asthma/RW group, wheezing and oropharyngeal symptoms affected a higher proportion of the asthma/RW group.

Characteristics of anaphylaxis patients who visited emergency departments in Korea: Results from a national emergency department information system

Background

Anaphylaxis is an allergic disease with fatal respiratory or cardiovascular symptoms that require immediate emergency treatment. We aimed to understand the characteristics and frequency of emergency department (ED) visits of patients with anaphylaxis in Korea.

Methods

Between 2007 and 2013, using data from 147 ED from the National Emergency Department Information System in Korea, we retrospectively evaluated patients with a primary diagnosis of anaphylaxis.

Results

During the study, a total 23,313 patients visited the ED due to anaphylaxis. The number of patients with anaphylaxis who visited the ED increased from 3.0 per 100,000 population in 2007 to 11.6 per 100,000 population in 2013 (P<0.001). Overall, the frequency of anaphylaxis emergency department visits increased by 1.24 times each year (95% CI 1.23–1.25). The risk of visiting ED due to anaphylaxis by population-based age-specific group was highest in the 60–69 years old (OR 2.30, 95% CI 1.96–2.70). Deaths from anaphylaxis increased by 1.35 times per year (95% CI 1.13–1.62). The causes of anaphylaxis were unknown (80.8%; 95% CI 80.35–81.38), drugs (8.9%; 95% CI 8.47–9.24), food (4.1%; 95% CI 3.87–4.39), bees (3.2%; 95% CI 3.02–3.48) and arthropods (2.3%; 95% CI 2.11–2.48). In 2009, drugs were the most common cause of anaphylaxis in November (35.5%), followed by food in May (15.5%) (P<0.001). Between July and September, stings from insects were the most common causes (P<0.001). By age, food was the most common cause in children aged <6 years (7.6%, <12 months; 9.0%, 1–6 years) and drugs in those aged ≥7 years. The 7-year overall mortality rate was 0.104 case per 1,000,000 population; men accounted for 77.8% of the deaths. By region, the number of cases was the highest in metropolitan areas, Gyeonggi and Seoul; however, the number of anaphylaxis cases per 100,000 population was the highest in Jeju and Gangwon.

Conclusion

Based on ICD-10 codes, the number of ED visits due to anaphylaxis is increasing in Korea, and the incidence of anaphylaxis varies by region, season, and age.

A systematic literature review of burden of illness in adults with uncontrolled moderate/severe asthma

BACKGROUND

There are limited published data on the burden of moderate/severe uncontrolled asthma.

METHODS

We conducted a systematic literature review to better understand the impact of moderate-to-severe asthma in the US, the UK, Germany, France, Italy, Spain, Canada, Japan, and Australia in terms of prevalence, clinical measures, health-related quality of life (HRQoL) and economic burden, for patients whose asthma is uncontrolled despite inhaled corticosteroid/long-acting β₂-agonist (ICS/LABA) therapy.

RESULTS

The prevalence of uncontrolled asthma among patients with moderate/severe disease varied but was as high as 100% in some subgroups. Patients with uncontrolled asthma generally had poor lung function (mean/median pre-bronchodilator forced expiratory volume in 1 second [FEV₁]: 1.69-2.45 L; mean/median pre-bronchodilator percent predicted FEV₁: 57.2-79.7). There was also a substantial but variable exacerbation burden associated with uncontrolled asthma, with the annualised rate of exacerbations ranging from 1.30 to 7.30 when considering various patient subgroups. Furthermore, the annualised rate of severe exacerbations ranged from 1.66 to 3.60. The HRQoL burden measured using disease-specific and generic instruments consistently demonstrated substantial impairment of HRQoL for those with uncontrolled asthma; Asthma Quality of Life Questionnaire scores ranged from 3.00 to 5.20, whilst EurQol-5 Dimensions index scores ranged from 0.53 to 0.59. Direct, indirect and total costs together with consumption of other healthcare resources associated with managing uncontrolled asthma were also substantial in the population studied; no caregiver burden was identified.

CONCLUSIONS

Our findings suggest that significant unmet needs exist for patients with uncontrolled asthma despite the availability of ICS/LABA therapy. Novel treatments are needed to help reduce the burden to patients, healthcare systems and society.

Anaphylaxis in children and adolescents: The Portuguese Anaphylaxis Registry

BACKGROUND

Anaphylaxis is increasing at pediatric age; however, its characterization is hampered by underdiagnosis and underreporting. The aim of this study was to identify the causes of anaphylaxis in children and adolescents in Portugal, thus contributing to a better knowledge of its etiology, clinical manifestations, and management.

METHODS

During a 10-year period, a nationwide notification system for anaphylaxis was implemented, with voluntary reporting by allergists. Data on 533 patients under 18 years of age with anaphylaxis were included.

RESULTS

Mean age was 8.5 ± 4.9 years, 61% were male; 45% had asthma. Mean age at the first anaphylaxis episode was 5.3 ± 4.7 years (ranging from 1 month to 17 years of age), 63% at pre-school age. Most reactions occurred at home (57%). Food-induced anaphylaxis was the leading cause (77%). The main culprit foods were cow's milk (32%), tree nuts (16%), shellfish (13%), egg (12%), fresh fruits (11%), fish (8%), and peanut (8%). Other causes included drugs (11%), insect sting (5%), cold-induced anaphylaxis (4%), exercise-induced anaphylaxis (2%), latex (1%), and idiopathic anaphylaxis (1%). Most patients (83%) were admitted to the emergency department; only 46% received adrenaline treatment. Recurrence of anaphylaxis occurred in 41% of the patients (3 or more episodes in 21%). An adrenaline autoinjector was used in 9% of the patients.

CONCLUSIONS

In the Portuguese pediatric population, food is the leading cause of anaphylaxis. Undertreatment with adrenaline and high recurrence of anaphylaxis highlight the need to improve both the diagnosis and the therapeutic management of this life-threatening entity.

Food anaphylaxis in the United Kingdom: analysis of national data, 1998-2018

OBJECTIVE

To describe time trends for hospital admissions due to food anaphylaxis in the United Kingdom over the past 20 years.

DESIGN

Analysis of national data, 1998-2018.

SETTING

Data relating to hospital admissions for anaphylaxis and deaths, and prescription data for adrenaline autoinjector devices.

PARTICIPANTS

UK population as a whole and devolved nations (England, Scotland, Wales, and Northern Ireland).

MAIN OUTCOME MEASURES

Time trends, age, and sex distributions for hospital admissions for anaphylaxis due to food and non-food triggers, and how these admission rates compare with the case fatality rate (number of fatalities as a proportion of hospital admissions).

RESULTS

Between 1998 and 2018, 101 891 people were admitted to hospital for anaphylaxis. Of these admissions, 30 700 (30.1%) were coded as due to a food trigger. Food anaphylaxis admissions increased from 1.23 to 4.04 per 100 000 population per year (from 1998 to 2018), an annual increase of 5.7% (95% confidence interval 5.5% to 5.9%, P<0.001). The largest increase in hospital admissions was observed in children younger than 15 years, with an increase from 2.1 to 9.2 admissions per 100 000 population per year (an annual increase of 6.6%, 95% confidence interval 6.3% to 7.0%). For comparison, the annual increase was 5.9% (5.6% to 6.2%) in people aged 15-59 years and 2.1% (1.8% to 3.1%) in those aged 60 years and older. 152 deaths were identified where the fatal event was probably caused by food induced anaphylaxis. The case fatality rate decreased from 0.7% to 0.19% for confirmed fatal food anaphylaxis (rate ratio 0.931, 95% confidence interval 0.904 to 0.959, P<0.001) and to 0.30% for suspected fatal food anaphylaxis (0.970, 0.945 to 0.996, P=0.024). At least 46% (86 of 187, which also includes 35 deaths in 1992-98) of deaths were triggered by peanut or tree nut. Cow's milk was responsible for 17 of 66 (26%) deaths in school aged children. Over the same time period, prescriptions for adrenaline autoinjectors increased by 336% (estimated rate ratio 1.113, 95% confidence interval 1.112 to 1.113; an increase of 11% per year).

CONCLUSIONS

Hospital admissions for food induced anaphylaxis have increased from 1998 to 2018, however the case fatality rate has decreased. In school aged children, cow's milk is now the most common single cause of fatal anaphylaxis.

Anaphylactic Death: A New Forensic Workflow for Diagnosis

Anaphylaxis is a life-threatening or fatal clinical emergency characterized by rapid onset, and death may be sudden. The margin of certainty about the diagnosis of anaphylactic death is not well established. The application of immunohistochemical techniques combined with the evaluation of blood tryptase concentrations opened up a new field of investigation into anaphylactic death. The present study investigated eleven autopsy cases of anaphylactic death, carried out between 2005 and 2017, by the Departments of Forensic Pathology of the Universities of Foggia and Catania (Italy). An analysis of the medical records was carried out in all autopsies. Seven autopsies were carried out on males and four on females. Of the eleven cases, one showed a history of asthma, one of food ingestion, two of oral administration of medications, six did not refer any allergy history, and one subject was unknown. All cases (100%) showed pulmonary congestion and edema; 7/11 (64%) of the cases had pharyngeal/laryngeal edema and mucus plugging in the airway; only one case (9%) had a skin reaction that was found during external examination. Serum tryptase concentration was measured in ten cases, and the mean value was 133.5 µg/L ± 177.9. The immunohistochemical examination using an anti-tryptase antibody on samples from the lungs, pharynx/larynx, and skin site of medication injection showed that all cases (100%) were strongly immunopositive for anti-tryptase antibody staining on lung samples; three cases (30%) were strongly immunopositive for anti-tryptase antibody staining on pharyngeal/laryngeal samples; and eight cases (80%) were strongly immunopositive for anti-tryptase antibody staining on skin samples. We conclude that a typical clinical history, blood tryptase level >40 µg/L, and strongly positive anti-tryptase antibody staining in the immunohistochemical investigation may represent reliable parameters in the determination of anaphylactic death with the accuracy needed for forensic purposes.

Association Between Allergen Sensitization and Anaphylaxis in Patients Visiting a Pediatric Emergency Department

Background and Objectives: Anaphylaxis, a severe allergic disease, can be triggered by various causes. This study investigated the association between allergic sensitization and anaphylactic symptoms and the severity of anaphylaxis in children. Patients and Methods: A retrospective review of 107 pediatric patients with anaphylaxis was performed between January 1, 2015, and December 31, 2017; 74 patients underwent allergen testing for specific immunoglobulin E. Allergic sensitizations and associations with anaphylactic symptoms and severity were investigated. Results: Overall, 64 (86.5%) patients were sensitized to food or inhalant allergens. In children under 2 years of age, 90.5% were sensitized to food (P = 0.001); in those over 6 years of age, 84.6% were sensitized to inhalant allergens (P = 0.001). Milk sensitization was significantly associated with severe anaphylaxis (P = 0.036). The following symptoms showed significant associations with certain allergen sensitizations: facial edema with food; wheezing with milk; dyspnea with mite, etc. Certain allergen sensitizations presenting as risk factors for anaphylactic symptoms: wheat (adjusted odds ratio [aOR] = 4.644, P = 0.044) and nuts (aOR=3.614, P = 0.041) for wheezing, nuts (aOR=5.201, P = 0.026) for dyspnea, and milk (aOR=4.712, P = 0.048) for vomiting. Conclusion: The allergen sensitization status differed according to the age of the children experiencing anaphylaxis. The severity, symptoms, and signs of anaphylaxis differed depending on the allergen sensitization status.

Increasing anaphylaxis events in Western Australia identified using four linked administrative datasets

Background

Anaphylaxis events are increasing worldwide, based on studies of single administrative datasets including hospital admissions, emergency room presentations, and prescription and medical claims data. Linking multiple administrative datasets may provide better epidemiological estimates, by capturing a greater number of anaphylaxis events occurring at the individual level. In this linked data study in Western Australia, we combined 4 population-based datasets to identify anaphylaxis events, factors influencing occurrence, and change in event rates from 2002 to 2013.

Methods

Four linked administrative datasets from the Western Australian Data Linkage System were used, representing ambulance attendances, emergency department presentations, hospital inpatient admissions and death registrations. An anaphylaxis cohort was identified using ICD-9-CM, ICD-10-AM and additional anaphylaxis diagnosis codes, with event rates calculated. We explored the impact of age, gender, cause, Indigenous status and socioeconomic index on event rates. Standard Poisson regression models were used to examine the significance of the change in anaphylaxis event rates over time.

Results

A total 12,637 individuals (mean age 31.8 years, 49.6% female) experienced 15,462 anaphylaxis events between 2002 and 2013 (97.5% in non-Indigenous patients and 59.5% residing in the area of greatest socioeconomic advantage). Anaphylaxis event rates increased from 15.4 to 82.5/10⁵ population between 2002 and 2013. The greatest increase in anaphylaxis events was seen in those coded as unspecified anaphylaxis (all ages, males and females combined, p < 0.001), with the highest rates of unspecified anaphylaxis in males 0–4 years (171.9/10⁵ population in 2013), and females 15–19 years (104.0/10⁵ in 2013). The average annual percent increase (95% CI) for food-related anaphylaxis was 9.2% (6.6–12.0); for medication-related anaphylaxis was 5.8% (4.5–7.1); and for unspecified anaphylaxis was 10.4% (9.8–11.0); all p < 0.001. There was a significant increase in ambulance attendance, emergency presentations and inpatient admissions for anaphylaxis between 2002 and 2013, with emergency presentations (56.0/10⁵ population), inpatient admissions (43.2/10⁵), and ambulance attendance (21.6/10⁵) highest in 2013. Only 25 anaphylaxis-related deaths were recorded in the mortality register with no significant change in rates over time.

Conclusion

Using multiple linked administrative datasets, we identified significantly higher rates of total anaphylaxis than previously reported, with more than 5-fold increases in anaphylaxis events between 2002 and 2013. While the combination of 4 population-level datasets provides a more comprehensive capture of cases, even at the individual dataset level, admission rates for anaphylaxis in Western Australia are substantially higher than those previously reported for similar time periods, both in Australia and worldwide.

Vaccine-related Anaphylaxis Cases Confirmed by KCDC from 2001-2016

BACKGROUND

A national immunization program (NIP) to prevent disease and reduce mortality from vaccine preventable diseases (VPD) is very important.

METHODS

We analyzed only the anaphylaxis cases that occurred between 2001 and 2016 that Korea Centers for Disease Control and Prevention (KCDC) determined had a definite causal relationship with a vaccine. The clinical symptoms were assessed according to the Brighton Collaboration case definition (BCCD) level.

RESULTS

During the period, there were 13 cases of vaccine-related anaphylaxis. The median age was 9 years (range, 1 month to 59 years). The incidence of anaphylaxis per million doses was 0.090 in 2005, 0.079 in 2012, 0.071 in 2013, 0.188 in 2015, and 0.036 in 2016. Of those cases, 23.1% were influenza vaccines, and 76.9% were BCCD level 2. Epinephrine was used in 46.2%.

CONCLUSION

Vaccine-related anaphylaxis seems to have been very rare in the past, but health care professionals must always be aware of anaphylaxis.

Perinatal androgens organize sex differences in mast cells and attenuate anaphylaxis severity into adulthood

Mast cell (MC)-associated diseases, including allergy/anaphylaxis and neuroinflammatory pain disorders, exhibit a sex bias, with females at increase risk. While much attention has been directed toward adult sex hormones as drivers of sex differences, that female sex bias in MC-associated diseases is evident in prepubertal children, suggesting early-life origins of sex differences which have yet to be explored. Utilizing rodent models of MC-mediated anaphylaxis, our data here reveal that, 1) compared with females, males exhibit significantly reduced severity of MC-mediated anaphylactic responses that emerge prior to puberty and persist into adulthood, 2) reduced severity of MC-mediated anaphylaxis in males is linked with the naturally high level of perinatal androgens and can be recapitulated in females by perinatal exposure to testosterone proprionate, 3) perinatal androgen exposure guides bone marrow MC progenitors toward a masculinized tissue MC phenotype characterized by decreased concentration of prestored MC granule mediators (e.g., histamine, serotonin, and proteases) and reduced mediator release upon degranulation, and 4) engraftment of MC-deficient Kit W-sh/W-sh mice with adult male, female, or perinatally androgenized female MCs results in MC-mediated anaphylaxis response that reflects the MC sex and not host sex. Together, these data present evidence that sex differences in MC phenotype and resulting disease severity are established in early life by perinatal androgens. Thus, factors affecting levels of perinatal androgens could have a significant impact on MC development and MC-associated disease risk across the life span.

Penicillin causes non-allergic anaphylaxis by activating the contact system

Immediate hypersensitivity reaction (IHR) can be divided into allergic- and non-allergic-mediated, while “anaphylaxis” is reserved for severe IHR. Clinically, true penicillin allergy is rare and most reported penicillin allergy is “spurious”. Penicillin-initiated anaphylaxis is possible to occur in skin test- and specific IgE-negative patients. The contact system is a plasma protease cascade initiated by activation of factor XII (FXII). Many agents with negative ion surface can activate FXII to drive contact system. Our data showed that penicillin significantly induced hypothermia in propranolol- or pertussis toxin-pretreated mice. It also caused a rapid and reversible drop in rat blood pressure, which did not overlap with IgE-mediated hypotension. These effects could be countered by a bradykinin-B2 receptor antagonist icatibant, and consistently, penicillin indeed increased rat plasma bradykinin. Moreover, penicillin not only directly activated contact system FXII-dependently, but also promoted bradykinin release in plasma incubated-human umbilical vein endothelial cells. In fact, besides penicillin, other beta-lactams also activated the contact system in vitro. Since the autoactivation of FXII can be affected by multiple-factors, plasma from different healthy individuals showed vastly different amidolytic activity in response to penicillin, suggesting the necessity of determining the potency of penicillin to induce individual plasma FXII activation. These results clarify that penicillin-initiated non-allergic anaphylaxis is attributed to contact system activation, which might bring more effective diagnosis options for predicting penicillin-induced fatal risk and avoiding costly and inappropriate treatment clinically.

Gender differences in anaphylaxis

PURPOSE OF REVIEW

Is sexual dimorphism also true in anaphylaxis as described in other allergic diseases? Possible gender differences in the epidemiology, triggers, severity, outcomes of anaphylaxis as well as in the pathogenesis of the disease are discussed.

RECENT FINDINGS

Hormonal status and the X-chromosome-coded factors deeply involved in the regulation of T-cell and B-cell responses may influence the gender difference noticed in allergic diseases, such as asthma and rhinitis. Little is known if sex is also relevant for anaphylaxis, although the description of catamenial anaphylaxis is intriguing. However, epidemiologic bias, lack of reliable animal models for the human disease, differences into diagnostic codes and not harmonized clinical grading unfortunately represent hurdles to obtain meaningful information on this topic.

SUMMARY

The female sex predisposes to a dysregulation of the immune response as suggested by the increased prevalence of autoimmunity and atopy. In anaphylaxis, pathomechanisms are not fully disclosed, triggers are numerous and IgE-dependent mast cell degranulation only represents a part of the story. Improvement into the definition of the disease including a more careful coding system and better investigations about triggers seem the only way to allow a more precise assessment of the possible different risk for women to develop anaphylaxis.

Apigenin Attenuates the Allergic Reactions by Competitively Binding to ER With Estradiol

Apigenin (API) is a natural phytoestrogen with properties including anti-inflammatory and other abilities. This study aims to 1) systematically validate that excessive estrogen exacerbates allergic reactions; 2) explore the anti-allergic effects and mechanisms of API. We conduct a survey of college students, indicating that of the 505 effective results, 70 individuals were self-reported allergic and 74.1% of them were women, which proved the gender difference in allergic reactions. BALB/c mice are grouped into the negative control group (N-Ctrl), the OVA-sensitized group (P-Ctrl), the estrogenized OVA-sensitized group (E2), and three treatment groups administrating different dose of API (E2 + API/L/M/H). In vivo data indicated that API treatment significantly inhibited the enhancement of estradiol on clinical symptoms. Moreover, we found that high doses of API inhibited Th2 type humoral response and mast cell degranulation levels in vivo and in vitro. Additionally, medium, and high doses of API significantly reduced the potentiation of estradiol on ER expression, attenuated the transmission of estrogen/ER signaling, thereby inhibiting the phosphorylation of ERK1/2 and JNK1/2/3 in the MAPK. Besides, we found that API competitively bound to ER with estradiol, and showed a weak selectivity to ERβ. Overall, we identified API can be beneficial in allergic disease.

Drug-Induced Anaphylaxis: An Update on Epidemiology and Risk Factors

Drug hypersensitivity is one of the most frequent causes of anaphylaxis, particularly in adults and in hospitalized patients. Drug-induced anaphylaxis (DIA) is also associated with more severe outcomes than other anaphylaxis triggers, and drugs are responsible for the majority of deaths due to anaphylaxis. We here review the current knowledge on the incidence, prevalence, drugs involved, mortality, and mortality risk factors for DIA. The incidence of both anaphylaxis and DIA seems to be increasing worldwide. Antibiotics and analgesics are the most frequently reported triggers of DIA. However, the importance of other drug groups should be taken into account, especially in particular settings (e.g., peri-operative and oncology). The identification of risk factors, geographical variables, and drugs associated with higher risk for DIA may improve the outcomes of this entity.

Drug-Induced Anaphylaxis in a Vietnamese Pharmacovigilance Database: Trends and Specific Signals from a Disproportionality Analysis

INTRODUCTION

Despite the numerous studies investigating drug-induced anaphylaxis (DIA), understanding and quantitative data analysis in developing countries remain limited. The aim of our study is to describe and quantify DIA using the National Pharmacovigilance Database of Vietnam (NPDV).

METHODS

Spontaneous reporting of adverse drug reactions (ADRs) recorded between 2010 and 2016 were retrospectively analysed to identify DIA reports. The trend and characteristics of DIA cases were described. Multivariate disproportionality analysis was used for signal generation.

RESULTS

Overall, 4873 DIA cases (13.2% of total ADRs) were recorded in the NPDV, 111 of which resulted in death (82% of total ADR-induced deaths) over a 7-year period. There was a remarkable increase in DIA reporting over time (p < 0.001). The incidence rates of DIA reporting per total ADRs and per 100,000 inhabitants remained high (mean rates [95% CI] of 12.06 [9.88-14.24] and 0.77 [0.33-1.20], respectively). Concerning suspected drugs, systemic antibiotics (n = 3318, 68%) were mostly reported with a reporting odds ratio (ROR) and 95% CI of 2.35 [2.20-2.51]. In the case of antibiotic-induced anaphylaxis, the third-generation cephalosporins were predominant (n = 1961, 40.2%, ROR 2.39 [2.24-2.55]). We also noted drugs generally associated with DIA such as contrast agents (ROR 2.43 [2.04-2.88]) and anaesthetics (ROR 4.02 [3.30-4.89]). Furthermore, unexpected signals were observed for alpha-chymotrypsin (ROR 1.75 [1.23-2.44]) and amoxicillin/sulbactam (ROR 1.59 [1.18-2.10]), uncommonly reported in western countries.

CONCLUSION

In recent years, cases of drug-induced DIA have increased in Vietnam, mostly due to antibiotics and third-generation cephalosporins. The inappropriate use of these drugs should be taken into account. Our findings also highlighted typical Vietnamese signals for alpha-chymotrypsin- and amoxicillin/sulbactam-induced anaphylaxis, which may relate to a specific sociological context in resource-limited countries.

Adverse drug reaction profile in Amravati region of India: A pharmacovigilance study

Background:

This pharmacovigilance study was conducted in Amravati region of central India to identify the nature and prevalence of adverse drug reactions, which will be helpful for better drug prescription practice and management of diseases.

Materials and Methods:

Adverse drug reaction reporting forms from April 2016 to March 2019, were collected from the pharmacovigilance center, which include details of demographics, investigations, concomitant drug history, and details of present complaints including reaction details, onset, recovery, drug information, hospitalization, management, and assessment.

Results:

A total of 19 cases were reported. Approximately 47.4% male and 52.6% female experienced the reactions with age-group ranging from 15 to 75 years. The most common adverse drug reactions were caused by antimicrobial agents (47.6%) followed by other group of drugs (37%) and nonsteroidal anti-inflammatory drugs (15.9%). Polypharmacy was the most common cause (31.6%) with the most common route being intravenous (42.1%). Skin reactions were the most common (84.2%). Antitubercular drugs were more commonly responsible for exfoliative lesions, whereas paracetamol and unknown drugs were responsible for multiple ulcerative lesions. Reactions to antitubercular drugs were considered as possible (15.8%), whereas with other drugs (63.2%), it was probable.

Conclusion:

It is a tip of the iceberg, which provides important demographic details in which adverse drug reactions were reported. Cutaneous reactions due to common drugs are responsible for hospitalization of the patients. There is an urgent need of training for health-care providers so that reporting can be improved and better picture can emerge.

Estrogen and estrogen receptor signaling promotes allergic immune responses: Effects on immune cells, cytokines, and inflammatory factors involved in allergy

Hypersensitivity occurs when the body is stimulated by an antigen, resulting in an immune response, and leads to a physiological disorder or abnormal tissue trauma. Various immune cells, cytokines, and inflammatory mediators are involved in the immune responses related to allergic diseases, which are the core of anaphylaxis. Estrogen receptors are widely distributed in immune cells, which combine with estrogen and participate in allergic responses by affecting immune cells, cytokines, and inflammatory factors. We aimed to summarize the association between estrogen and allergic reactions to provide a scientific basis for understanding and studying the mechanisms of allergic diseases.

Component-Resolved Diagnosis in Food Allergies

Component-resolved diagnostics (CRD) in food allergies is an approach utilized to characterize the molecular components of each allergen involved in a specific IgE (sIgE)-mediated response. In the clinical practice, CRD can improve diagnostic accuracy and assist the physician in many aspects of the allergy work-up. CRD allows for discriminatory co-sensitization versus cross-sensitization phenomena and can be useful to stratify the clinical risk associated with a specific sensitization pattern, in addition to the oral food challenge (OFC). Despite this, there are still some unmet needs, such as the risk of over-prescribing unnecessary elimination diets and adrenaline auto-injectors. Moreover, up until now, none of the identified sIgE cutoff have shown a specificity and sensitivity profile as accurate as the OFC, which is the gold standard in diagnosing food allergies. In light of this, the aim of this review is to summarize the most relevant concepts in the field of CRD in food allergy and to provide a practical approach useful in clinical practice.

Vaccine-associated hypersensitivity

Vaccine-associated hypersensitivity reactions are not infrequent; however, serious acute-onset, presumably IgE-mediated or IgG and complement-mediated anaphylactic or serious delayed-onset T cell-mediated systemic reactions are considered extremely rare. Hypersensitivity can occur because of either the active vaccine component (antigen) or one of the other components. Postvaccination acute-onset hypersensitivity reactions include self-limited localized adverse events and, rarely, systemic reactions ranging from urticaria/angioedema to full-blown anaphylaxis with multisystem involvement. Risk of anaphylaxis after all vaccines is estimated to be 1.31 (95% CI, 0.90-1.84) per million vaccine doses, respectively. Serious hypersensitivity reactions after influenza vaccines are particularly important because of the large number of persons vaccinated annually. Influenza vaccines are unique in requiring annual changes in the vaccines' antigenic composition to match the predicted circulating influenza strains. Recently, novel influenza vaccine types were introduced in the United States (recombinant vaccines, some with higher antigen content and a new adjuvanted vaccine). Providers should be aware of changing recommendations on the basis of recent published evidence for persons with a history of egg allergy to receive annual influenza vaccination. Further research is needed to elucidate the pathophysiology and risk factors for reported vaccine-associated adverse events. Further research is also needed to determine whether repeated annual inactivated influenza vaccination, the number of vaccine antigens administered at the same time, and the current timing of routine infant vaccinations are optimal for overall population well-being.

Diagnosis and management of drug-induced anaphylaxis in children: An EAACI position paper

Drug hypersensitivity reactions (DHR) constitute a major and common public health problem, particularly in children. One of the most severe manifestations of DHR is anaphylaxis, which might be associated with a life-threatening risk. During those past decades, anaphylaxis has received particularly a lot of attention and international consensus guidelines have been recently published. Whilst drug-induced anaphylaxis is more commonly reported in adulthood, less is known about the role of drugs in pediatric anaphylaxis. Betalactam antibiotics and non-steroidal anti-inflammatory drugs are the most commonly involved drugs, probably related to high prescription rates. Diagnosis relies on the recognition of symptoms pattern and is based on complete allergic workup, particularly including skin tests and/or specific IgE. However, the real diagnostic value of those tests to diagnose immediate reactions in children remains not well defined for a significant number of the drugs. Generally, a drug provocation test is discussed to confirm or exclude an immediate-onset drug-induced hypersensitivity. Although avoidance of the incriminated drug (and related drug) is the rule, rapid desensitization is useful in selected subgroups of patients. There is a need for large, multicentric studies, to evaluate the real diagnostic value of the currently available skin tests. Moreover there is also a need to develop new diagnostic tests in the future to improve the management of these children.

Potential cofactors in accidental food allergic reactions are frequently present but may not influence severity and occurrence

BACKGROUND

Cofactors, such as physical exercise and alcohol intake, might be associated with the severity or occurrence of food allergic reactions.

OBJECTIVE

To gain insight into the frequency of presence of potential cofactors in accidental food allergic reactions in adults and to what extent these factors influence the severity and occurrence of allergic reactions.

METHODS

A prospective cohort study was conducted, with a 1-year follow-up in adult patients with a physician-diagnosed food allergy. Patients were required to fill in a questionnaire after every accidental allergic reactions to food over a 1-year period. The primary outcome measure was the frequency that potential cofactors were present in these allergic reactions.

RESULTS

A total of 157 patients were included, of which 46% reported a total of 153 reactions during a 1-year follow-up period. In 74% of the reactions, ≥1 potential cofactor was reported to be present: tiredness (38%), alcohol intake (16%), stress (14%), symptoms of pollinosis (16%), symptoms of asthma (9%), sickness/flu (3%), physical exercise (3%) and use of analgesics (2%). More than one potential cofactor was reported in almost half of all reactions (47%). There was no significant difference in the presence of these factors between mild, moderate and severe reactions (P = 0.522). In the total study population, 9% of the patients used medication that might act as cofactor (antacids, angiotensin receptor blockers [ARBs], beta blockers and angiotensin-converting enzyme inhibitors [ACEIs]) on a daily basis, which however did not influence the occurrence of reactions. Furthermore, 38% daily used allergy-suppressing medication.

CONCLUSIONS

Although factors suggested to be cofactors were frequently present during accidental food allergic reactions, we found no evidence for an association between the potential cofactors examined and reaction severity, in a population where most reactions were of mild to moderate severity.

The Epidemiology of Anaphylaxis

Anaphylaxis is a dramatic expression of systemic allergy. The lifetime prevalence of anaphylaxis is currently estimated at 0.05-2 % in the USA and ~3 % in Europe. Several population-specific studies have noted a rise in the incidence, particularly in the hospitalizations and ER visits due to anaphylaxis. The variable signs and symptoms that constitute the diagnostic criteria for anaphylaxis, the differences in diagnostic algorithms, and the limitations in the current coding systems have made summarizing epidemiologic data and comparing study results challenging. Nevertheless, across all studies, the most common triggers continue to be medications, food, and venom. Various risk factors for more severe reactions generally include older age, history of asthma, and having more comorbid diseases. Interesting seasonal, geographic, and latitude differences have been observed in anaphylaxis prevalence and incidence rates, suggesting a possible role of vitamin D and sun exposure in modifying anaphylaxis risk. While the incidence and prevalence of anaphylaxis appear to be increasing in certain populations, the overall fatality rate remains relatively low.

Increasing trends of anaphylaxis-related events: an analysis of anaphylaxis using nationwide data in Taiwan, 2001-2013

Background

Anaphylaxis is a severe, potentially fatal, and systemic allergic reaction. Previous studies document increasing trends in incidence rates of anaphylaxis-related events in Western countries, yet little is known about the incidence and trend of anaphylaxis in Asia. In this study, we aimed to determine time trends in incidence rates of anaphylaxis-related events in Taiwan from 2001 through 2013.

Methods

We utilized medical claims data from the National Health Insurance Research Databases in Taiwan. We identified anaphylaxis-related events (ICD-9-CM-codes: 995.0, 995.60–995.69, 999.41–999.42, and 999.49) and calculated incidence rates. Poisson regression models were applied to examine trends and incidence rates.

Results

A total of 2496 patients (mean age, 45.11 years; 56% male) with first-time anaphylaxis were identified during 34,430,000 person-years of observation time. The overall incidence of anaphylaxis was 7.25 (95% confidence interval (CI) = 6.97–7.53) per 100,000 person-years, increasing from 4.79 in 2001 to 8.20 in 2013, with an incidence rate ratio (IRR) of 1.05 (95%CI = 1.04–1.06). Over the 13-year period, the increasing trends were found in incident diagnosis of anaphylaxis-related outpatient or emergency department visits (IRR = 1.06, 95%CI = 1.05–1.08) and admissions to intensive care units (IRR = 1.06, 95%CI = 1.03–1.10), whereas the trends in incidence of anaphylaxis-related hospitalizations remained steady. The proportion of patients requiring hospitalizations among all patients with anaphylaxis (p_{_trend} = 0.01), as well as the proportion requiring intensive care treatment among patients who were hospitalized (p_{_trend} = 0.01), both increased with age.

Conclusion

The incidence rate of anaphylaxis in Taiwan has increased at an average rate of 5% annually since 2001, paralleling the rising trends in several Western countries.

Electronic supplementary material

The online version of this article (10.1186/s40413-018-0202-7) contains supplementary material, which is available to authorized users.

Risk factors for recurrent anaphylaxis-related emergency department visits in the United States

BACKGROUND

Anaphylaxis is a potentially life-threatening allergic reaction with a strong risk of recurrence.

OBJECTIVE

To assess risk factors associated with recurrent anaphylaxis-related emergency department (ED) visits within 1 year of an ED visit for anaphylaxis in a large observational cohort study.

METHODS

We used an administrative claims database to identify patients seen from 2008 through 2012 in the ED for anaphylaxis based on an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code algorithm. Patients with at least 2 years of continuous enrollment in a health plan were included. Multivariable logistic regression analysis was used to determine associations with recurrence of anaphylaxis within 1 year.

RESULTS

During the 5-year study period, 7,367 patients (median age, 42 years; <18 years old, 23.3%) met the inclusion criteria. The most common anaphylaxis trigger was unspecified (56.2%), followed by food (25.3%), medication (14.6%), and venom (3.9%). Overall, 3.0% of patients had an additional anaphylaxis-related ED visit within 1 year (3.61 episodes per 100 patient-years). On multivariable analysis, risk factors associated with anaphylaxis recurrence were food trigger (odds ratio [OR], 2.31; 95% confidence interval [CI], 1.34-3.99), history of asthma (OR, 1.30; 95% CI, 1.13-1.51), and intensive care unit admission at the index anaphylaxis event (OR, 1.95; 95% CI, 1.41-2.69).

CONCLUSION

In this contemporary cohort study, history of asthma, food trigger, and greater index anaphylaxis severity, as measured by intensive care unit admission, were associated with a higher likelihood of a recurrent anaphylaxis-related ED visit within 1 year.

Association between sugammadex and anaphylaxis in pediatric patients: A nested case-control study using a national inpatient database

BACKGROUND

Sugammadex is used as a reversal drug during anesthesia. Although several case reports have described anaphylaxis following sugammadex infusion, little is known about the relationship between sugammadex and anaphylaxis, particularly in pediatric patients.

AIMS

The aim of this retrospective study was to investigate the association between sugammadex and in-hospital anaphylaxis in pediatric patients who underwent general anesthesia.

METHODS

We identified patients who underwent general anesthesia in a Japanese national inpatient database between July 2010 and March 2016. We conducted 1-4 case-control matching between patients with and without perioperative anaphylaxis. We calculated the adjusted odds ratio for sugammadex use and occurrence of anaphylaxis, using a conditional logistic regression analysis with adjustment for duration of anesthesia, antibiotics, and blood transfusions.

RESULTS

Among 835 405 patients who underwent general anesthesia, we identified 149 (0.018%) patients with anaphylactic shock and 472 (0.056%) with a combination of anaphylaxis associated signs/symptoms and skin lesions. Sugammadex use was not significantly associated with anaphylactic shock (odds ratio, 0.80; 95% confidence interval, 0.53-1.21; P = .29) or the combination of anaphylaxis associated signs/symptoms and skin lesions (odds ratio, 1.25; 95% confidence interval, 0.97-1.60; P = .08).

CONCLUSION

The present study showed no significant association between sugammadex and perioperative anaphylaxis in pediatric patients who underwent general anesthesia.

BSACI guideline for the diagnosis and management of peanut and tree nut allergy

Peanut nut and tree nut allergy are characterised by IgE mediated reactions to nut proteins. Nut allergy is a global disease. Limited epidemiological data suggest varying prevalence in different geographical areas. Primary nut allergy affects over 2% of children and 0.5% of adults in the UK. Infants with severe eczema and/or egg allergy have a higher risk of peanut allergy. Primary nut allergy presents most commonly in the first five years of life, often after the first known ingestion with typical rapid onset IgE-mediated symptoms. The clinical diagnosis of primary nut allergy can be made by the combination of a typical clinical presentation and evidence of nut specifc IgE shown by a positive skin prick test (SPT) or specific IgE (sIgE) test. Pollen food syndrome is a distinct disorder, usually mild, with oral/pharyngeal symptoms, in the context of hay fever or pollen sensitisation, which can be triggered by nuts. It can usually be distinguish clinically from primary nut allergy. The magnitude of a SPT or sIgE relates to the probability of clinical allergy, but does not relate to clinical severity. SPT of ≥ 8 mm or sIgE ≥ 15 KU/L to peanut is highly predictive of clinical allergy. Cut off values are not available for tree nuts. Test results must be interpreted in the context of the clinical history. Diagnostic food challenges are usually not necessary but may be used to confirm or refute a conflicting history and test result. As nut allergy is likely to be a long-lived disease, nut avoidance advice is the cornerstone of management. Patients should be provided with a comprehensive management plan including avoidance advice, patient specific emergency medication and an emergency treatment plan and training in administration of emergency medication. Regular re-training is required.

ImmunoCAP® ISAC and Microtest for multiplex allergen testing in people with difficult to manage allergic disease: a systematic review and cost analysis

BACKGROUND

Allergy is a form of immune-mediated exaggerated sensitivity (hypersensitivity) to a substance that is either inhaled, swallowed, injected or comes into contact with the skin. Foreign substances that provoke allergies are called allergens. It has been claimed that multiplex allergen testing may help in diagnosing the cause of symptoms in patients with an unclear cause of allergy or who are allergic to more than one substance.

OBJECTIVES

To evaluate multiplex allergen testing [devices that can measure the presence of multiple immunoglobulin E (IgE) antibodies in a patient's blood at the same time], by assessing (1) clinical effectiveness (allergy symptoms, incidence of acute exacerbations, mortality, adverse events of testing and treatment, health-care presentations or admissions, health-related quality of life); (2) effects on treatment (diet, immunotherapy medications, other potential testing); (3) any additional diagnostic information provided by multiplex allergen testing; and (4) cost-effectiveness (cost of different assessment strategies).

METHODS

Fifteen databases were searched from 2005 to April 2015, including MEDLINE (via OvidSp), MEDLINE In-Process Citations, MEDLINE Daily Update, PubMed (National Library of Medicine), EMBASE, Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Register of Controlled Trials (CENTRAL), Database of Abstracts of Reviews of Effects (DARE), Health Technology Assessment (HTA) database, Science Citation Index (SCI), Conference Proceedings Citation Index-Science (CPCI-S), BIOSIS Previews, Latin American and Caribbean Health Sciences Literature (LILACS), National Institute for Health Research (NIHR) HTA programme, and the US Food and Drug Administration (FDA); supplementary searches of conference proceedings and trials registries were performed. Review methods followed published guidance from the Cochrane Collaboration and the Centre for Reviews and Dissemination, University of York, UK. The methodological quality of included studies was assessed using appropriate published tools or a review-specific tool designed by the project team. Studies were summarised in a narrative synthesis. Owing to a lack of data on the clinical effectiveness of multiplex allergen testing, no long-term cost-effectiveness model was developed. A conceptual model structure was developed and cost analyses were performed to examine the short-term costs of various possible diagnostic pathways.

RESULTS

Fifteen studies were included in the review. The very limited available data indicated that the addition of multiplex allergen testing [ImmunoCAP(®) Immuno Solid-phase Allergen Chip (ISAC), Thermo Fisher Scientific/Phadia AB, Uppsala, Sweden] to standard diagnostic work-up can change the clinicians' views on the diagnosis, management and treatment of patients. There was some indication that the use of ImmunoCAP ISAC testing may be useful to guide decisions on the discontinuation of restrictive diets, the content of allergen-specific immunotherapy (SIT) prescriptions, and whether or not patients should receive SIT. However, none of the studies that we identified reported any information on clinical outcomes subsequent to changes in treatment or management. There was some evidence that ImmunoCAP ISAC may be useful for discriminating allergens that are structurally similar and are recognised by the same IgE antibody (cross-immunoreactive). No data were available for Microtest (Microtest Matrices Ltd, London, UK). Detailed cost analyses suggested that multiplex allergen testing would have to result in a substantial reduction of the proportions of patients receiving single IgE testing and oral food challenge tests in order to be cost-saving in the short term.

CONCLUSIONS

No recommendations for service provision can be made based on the analyses included in this report. It is suggested that a consensus-based protocol for the use of multiplex allergen testing be developed. The clinical effectiveness and cost-effectiveness of the proposed protocol should then be assessed by comparing long-term clinical and quality of life outcomes and resource use in patients managed using the protocol with those managed using a standard diagnostic pathway.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42015019739.

FUNDING

This project was a Diagnostic Assessment Report commissioned by the NIHR HTA programme on behalf of the National Institute for Health and Care Excellence.

Clinical features and treatment of pediatric patients with drug-induced anaphylaxis: a study based on pharmacovigilance data

We assessed the clinical features and treatment of pediatric patients with drug-induced anaphylaxis in clinical settings. Pediatric drug-induced anaphylaxis cases collected by the Beijing Pharmacovigilance Database from 2004 to 2014 were analyzed. A total of 91 cases were identified. Drug-induced anaphylaxis was primarily caused by antibiotics (53%). Children of 0-5 years were more likely to develop cyanosis symptoms than children of 13-17 years (OR = 5.14, 95%CI [1.74, 15.20], P = 0.002). Children of 13-17 years were more likely to develop hypotension than children of 6-12 years (OR = 11.79, 95%CI [2.28, 60.87], P = 0.002), and to manifest both neurological symptoms (OR = 3.56, 95%CI [1.26, 10.08], P = 0.015) and severe anaphylaxis than children of 0-5 years (OR = 15.46, 95%CI [1.85, 129.33], P = 0.002). Supratherapeutic doses of epinephrine were more likely with intravenous (IV) bolus (92%) in contrast to either intramuscular (IM) (36%, OR = 19.25, 95%CI [1.77, 209.55], P = 0.009) or subcutaneous (SC) injections (36%, OR = 19.80, 95% CI [1.94, 201.63], P = 0.005). Only 62 (68%) patients received epinephrine treatment as the first-line therapy.

CONCLUSION

This study demonstrates that antibiotics were the most common cause of pediatric drug-induced anaphylaxis. Children may present with different anaphylactic signs/symptoms based on age groups. Epinephrine is under-utilized and provider education on the proper management of drug-induced anaphylaxis is warranted. What is Known: • The most common causes of anaphylaxis in children are allergies to foods. Drugs are the second most common cause of pediatric anaphylaxis. • IM epinephrine is the recommended initial treatment of anaphylaxis. What is New: • Drug-induced anaphylaxis in pediatric patients has age-related clinical features. • IV bolus epinephrine was overused and associated with supratherapeutic dosing.

Anaphylaxis to foods in a population of adolescents: incidence, characteristics and associated risks

BACKGROUND

Information about severe reactions to foods in adolescence is limited.

OBJECTIVE

To describe reactions to foods, including anaphylaxis, with regard to incidence, characteristics and associated risks, among 16-year-olds (adolescents) in a large, population-based birth cohort.

METHODS

Parent-reported questionnaire data from ages 2-3 months, and 1, 2 and 16 years were used (N = 3153). Anaphylaxis at age 16 years was defined per NIAID/FAAN criteria. Immunoglobulin E (IgE) antibodies to 14 common food and inhalant allergens were analysed at ages 4 (n = 2283) and 16 years (n = 2510). Among adolescents with food-related symptoms (FRS) and for whom blood was available (n = 221), 25 additional food allergen extracts or allergen components were analysed. Associations between reactions to foods, and sensitization and allergic multimorbidity were investigated.

RESULTS

In the 12 months prior to the 16-year assessment, 8.5% of adolescents had FRS. This included 0.8% (n = 24) adolescents who were classified as having anaphylaxis, yielding an incidence rate of 761/100 000 person-years. One-third of adolescents accessed health care during anaphylaxis. Allergic multimorbidity in infancy, as well as sensitization to foods and airborne allergens at age 4 years, was associated with an increased risk for FRS in adolescence. Peanuts and tree nuts were the most common culprit foods for anaphylaxis, and fruits and vegetables for non-anaphylactic reactions. Adolescents with anaphylaxis were significantly more likely to be sensitized to storage proteins (Ara h 2, Cor a 9, Cor a 14) and to be polysensitized to foods (P < 0.001 vs. non-anaphylactic reactions).

CONCLUSIONS AND CLINICAL RELEVANCE

The incidence of food-induced anaphylaxis during adolescence in our population-based birth cohort is higher than previously reported. Adolescents with anaphylaxis differ from adolescents with non-anaphylactic FRS with regard to culprit foods and sensitization. Adolescents with previous anaphylaxis are likely to be polysensitized to foods, particularly tree nut and peanut storage proteins, and which warrants consideration at follow-up.

Patterns of anaphylaxis after diagnostic workup: A follow-up study of 226 patients with suspected anaphylaxis

BACKGROUND

Most published studies on anaphylaxis are retrospective or register based. Data on subsequent diagnostic workup are sparse. We aimed to characterize patients seen with suspected anaphylaxis at the emergency care setting (ECS), after subsequent diagnostic workup at our Allergy Center (AC).

METHODS

Prospective study including patients from the ECS, Odense University Hospital, during May 2013-April 2014. Possible anaphylaxis cases were daily identified based on a broad search profile including history and symptoms in patient records, diagnostic codes and pharmacological treatments. At the AC, all patients were evaluated according to international guidelines.

RESULTS

Among 226 patients with suspected anaphylaxis, the diagnosis was confirmed in 124 (54.9%) after diagnostic workup; 118 of the 124 fulfilled WAO/EAACI criteria of anaphylaxis at the ECS, while six were found among 46 patients with clinical suspicion but not fulfilling the WAO/EAACI criteria at the ECS. The estimated incidence rate of anaphylaxis was 26 cases per 100 000 person-years and the one-year period prevalence was 0.04%. The most common elicitor was drugs (41.1%) followed by venom (27.4%) and food (20.6%). In 13 patients (10.5%), no elicitor could be identified. Mastocytosis was diagnosed in 7.7% of adult patients and was significantly associated with severe anaphylaxis. Atopic diseases were significantly associated only with food-induced anaphylaxis. Cofactors were present in 58.1% and were significantly associated with severe anaphylaxis.

CONCLUSION

A broad search profile in the ECS and subsequent diagnostic workup is important for identification and classification of patients with anaphylaxis. Evaluation of comorbidities and cofactors is important.