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Ellis AK, Casale TB, Kaliner M, Oppenheimer J, Spergel JM, Fleischer DM, Bernstein D, Camargo CA, Lowenthal R, Tanimoto S. Development of neffy, an Epinephrine Nasal Spray, for Severe Allergic Reactions. Pharmaceutics 2024; 16:811. [PMID: 38931932 PMCID: PMC11207568 DOI: 10.3390/pharmaceutics16060811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Revised: 06/04/2024] [Accepted: 06/08/2024] [Indexed: 06/28/2024] Open
Abstract
Epinephrine autoinjectors (EAIs) are used for the treatment of severe allergic reactions in a community setting; however, their utility is limited by low prescription fulfillment rates, failure to carry, and failure to use due to fear of needles. Given that delayed administration of epinephrine is associated with increased morbidity/mortality, there has been a growing interest in developing needle-free, easy-to-use delivery devices. neffy (epinephrine nasal spray) consists of three Food and Drug Administration (FDA)-approved components: epinephrine, Intravail A3 (absorption enhancer), and a Unit Dose Spray (UDS). neffy's development pathway was established in conjunction with the FDA and the European Medicines Agency and included multiple clinical trials to evaluate pharmacokinetic and pharmacodynamic responses under a variety of conditions, such as self-administration and allergic and infectious rhinitis, as well as an animal anaphylaxis model of severe hypotension, where neffy demonstrated a pharmacokinetic profile that is within the range of approved injection products and a pharmacodynamic response that is as good or better than injections. The increased pulse rate (PR) and blood pressure (BP) observed even one minute following the administration of neffy confirm the activation of α and β adrenergic receptors, which are the key components of epinephrine's mechanism of action. The results suggest that neffy will provide a safe and effective needle-free option for the treatment of severe allergic reactions, including anaphylaxis.
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Affiliation(s)
- Anne K. Ellis
- Division of Allergy and Immunology, Department of Medicine, Queen’s University, Kingston, ON K7L 3N6, Canada
| | - Thomas B. Casale
- Morsani College of Medicine, University of South Florida, Tampa, FL 33602, USA
| | - Michael Kaliner
- Institute for Asthma and Allergy, Chevy Chase, MD 20815, USA
| | - John Oppenheimer
- Department of Internal Medicine, University of Medicine and Dentistry of New Jersey-Rutgers New Jersey Medical School, Newark, NJ 07103, USA
| | - Jonathan M. Spergel
- Division of Allergy and Immunology, Children’s Hospital of Philadelphia, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - David M. Fleischer
- Section of Allergy and Immunology, Department of Pediatrics, Children’s Hospital Colorado, School of Medicine, University of Colorado, Aurora, CO 80045, USA
| | - David Bernstein
- Bernstein Clinical Research Center, Division of Immunology, Allergy and Rheumatology, College of Medicine, University of Cincinnati, Cincinnati, OH 45236, USA
| | - Carlos A. Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
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Novembre E, Gelsomino M, Liotti L, Barni S, Mori F, Giovannini M, Mastrorilli C, Pecoraro L, Saretta F, Castagnoli R, Arasi S, Caminiti L, Klain A, Del Giudice MM. Fatal food anaphylaxis in adults and children. Ital J Pediatr 2024; 50:40. [PMID: 38439086 PMCID: PMC10913226 DOI: 10.1186/s13052-024-01608-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 02/11/2024] [Indexed: 03/06/2024] Open
Abstract
Anaphylaxis is a life-threatening reaction characterized by the acute onset of symptoms involving different organ systems and requiring immediate medical intervention. The incidence of fatal food anaphylaxis is 0.03 to 0.3 million/people/year. Most fatal food-induced anaphylaxis occurs in the second and third decades of life. The identified risk factors include the delayed use of epinephrine, the presence of asthma, the use of recreational drugs (alcohol, nicotine, cannabis, etc.), and an upright position. In the United Kingdom (UK) and Canada, the reported leading causal foods are peanuts and tree nuts. In Italy, milk seems to be the most common cause of fatal anaphylaxis in children < 18 years. Fatal food anaphylaxis in Italian children and adolescents almost always occurs outside and is characterized by cardiorespiratory arrest; auto-injectable adrenaline intramuscular was available in few cases. Mortality from food anaphylaxis, especially in children, is a very rare event with stable incidence, but its risk deeply impacts the quality of life of patients with food allergy and their families. Prevention of fatal food anaphylaxis must involve patients and their families, as well as the general public, public authorities, and patients' associations.
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Affiliation(s)
- Elio Novembre
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, 50139, Italy
| | - Mariannita Gelsomino
- Department of Life Sciences and Public Health, Pediatric Allergy Unit, University Foundation Policlinico Gemelli IRCCS Catholic University of the Sacred Heart, Rome, Italy.
| | - Lucia Liotti
- Department of Mother and Child Health, Pediatric Unit, Salesi Children's Hospital, Ancona, 60123, Italy
| | - Simona Barni
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, 50139, Italy
| | - Francesca Mori
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, 50139, Italy
| | - Mattia Giovannini
- Allergy Unit, Meyer Children's Hospital IRCCS, Florence, 50139, Italy
- Department of Health Sciences, University of Florence, Florence, 50139, Italy
| | - Carla Mastrorilli
- Pediatric Hospital Giovanni XXIII, Pediatric and Emergency Department, AOU Policlinic of Bari, Bari, 70126, Italy
| | - Luca Pecoraro
- Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, Pediatric Unit, University of Verona, Verona, 37126, Italy
| | - Francesca Saretta
- Pediatric Department, Latisana-Palmanova Hospital, Azienda Sanitaria Universitaria Friuli Centrale, Udine, 33100, Italy
| | - Riccardo Castagnoli
- Department of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia, Pavia, 27100, Italy
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, Pavia, 27100, Italy
| | - Stefania Arasi
- Translational Research in Pediatric Specialties Area, Division of Allergy, Bambino Gesù Children's Hospital, IRCCS, Rome, 00165, Italy
| | - Lucia Caminiti
- Department of Pediatrics, Allergy Unit, AOU Policlinico Gaetano Martino, Messina, 98124, Italy
| | - Angela Klain
- Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, 80138, Italy
| | - Michele Miraglia Del Giudice
- Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, 80138, Italy
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Höfer V, Dölle-Bierke S, Francuzik W, Ruëff F, Sabouraud-Leclerc D, Treudler R, Moeser A, Hartmann K, Pföhler C, Wagner N, Ensina LF, Wedi B, Cardona V, Worm M. Fatal and Near-Fatal Anaphylaxis: Data From the European Anaphylaxis Registry and National Health Statistics. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:96-105.e8. [PMID: 37816460 DOI: 10.1016/j.jaip.2023.09.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 09/20/2023] [Accepted: 09/29/2023] [Indexed: 10/12/2023]
Abstract
BACKGROUND Anaphylaxis is a serious systemic reaction-data on fatal and near-fatal reactions are limited. OBJECTIVE To better understand clinical patterns and risks factors of severe anaphylaxis by a deep analysis of data from fatal and near-fatal anaphylaxis. METHODS Data from the European Anaphylaxis Registry on fatal/near-fatal anaphylactic reactions and national data on anaphylaxis fatalities were investigated. RESULTS A total of 305 fatal/near-fatal reactions among children and adults including 35 fatalities from the European Anaphylaxis Registry were identified. The most frequent elicitors were drugs, insects, and food. Male patients (66%/60%) were more frequently affected. Male sex, higher age, concomitant mastocytosis, and cardiovascular disease were associated with a more severe outcome. With increasing reaction severity, skin symptoms were less frequently observed (45% of fatal reactions). In parallel, anaphylaxis mortality rates were studied. The data show that anaphylaxis mortality rates increased in Germany from 0.48 (2009) to 0.59 per 1,000,000 population per year (2020). This increase was apparent only in the female population. In this data set, drugs were the most frequent elicitor of anaphylaxis fatalities, and the rate for this increased over time. CONCLUSIONS We identified not only elicitors but also individual factors to be associated with an increased risk of fatal anaphylaxis. Such patients should be recognized and managed with great caution. The increase in drug-induced fatalities points to the need for a better allergological care of patients suffering from drug hypersensitivity.
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Affiliation(s)
- Veronika Höfer
- Division of Allergy and Immunology, Department of Dermatology, Venerology and Allergy, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Sabine Dölle-Bierke
- Division of Allergy and Immunology, Department of Dermatology, Venerology and Allergy, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Wojciech Francuzik
- Division of Allergy and Immunology, Department of Dermatology, Venerology and Allergy, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Franziska Ruëff
- Department of Dermatology and Allergy, University Hospital, LMU Munich, Munich, Germany
| | - Dominique Sabouraud-Leclerc
- Allergy Vigilance Network, Vandoeuvre les Nancy, France; American Memorial Hospital, Pediatrics Department, Reims University Hospital, Reims, France
| | - Regina Treudler
- Department of Dermatology, Venerology and Allergology, University of Leipzig Medical Center, Leipzig, Germany; Leipzig Interdisciplinary Allergy Center (LICA) - Comprehensive Allergy Center, University of Leipzig Medical Center, Leipzig, Germany
| | - Anne Moeser
- Institute for Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
| | - Karin Hartmann
- Division of Allergy, Department of Dermatology, University Hospital Basel and University of Basel, Basel, Switzerland; Department of Biomedicine, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Claudia Pföhler
- Saarland University Medical Center, Department of Dermatology, Homburg/Saar, Germany
| | - Nicola Wagner
- Department of Dermatology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Luis Felipe Ensina
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, Federal University of São Paulo, São Paulo, Brazil
| | - Bettina Wedi
- Department of Dermatology and Allergy, Comprehensive Allergy Center, Hannover Medical School, Hannover, Germany
| | - Victoria Cardona
- Allergy Section, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Barcelona, Spain; ARADyAL Research Network, Spain
| | - Margitta Worm
- Division of Allergy and Immunology, Department of Dermatology, Venerology and Allergy, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany.
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4
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Rangaswamy VV, Velmurugan A, Balaji S. Arrhythmia During Anaphylaxis-An Intrinsic or Extrinsic Cause? JAMA Intern Med 2023; 183:1158-1159. [PMID: 37603359 DOI: 10.1001/jamainternmed.2023.2259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
Abstract
A patient in their 50s presented to the emergency department (ER) within 30 minutes of ingestion of prawns at a restaurant with complaints of an itchy skin rash, and generalized weakness; his pulse rate was 79 bpm, his blood pressure was 50/30 mm Hg, and his respiratory rate was 20 per minute. What is your diagnosis?
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Affiliation(s)
| | - Aparna Velmurugan
- Registrar, Department of Cardiology, Sri Ramakrishna Hospital, Coimbatore, India
| | - S Balaji
- Consultant Cardiologist, Department of Cardiology, Sri Ramakrishna Hospital, Coimbatore, India
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5
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Foong RX, Patel NB, Turner P, Roberts GC, Fox AT. Preventing food allergy fatalities. Arch Dis Child 2023; 108:698-702. [PMID: 36690425 DOI: 10.1136/archdischild-2022-324911] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 12/11/2022] [Indexed: 01/24/2023]
Abstract
Fatal anaphylaxis to food is thankfully rare, but every death is a potentially avoidable tragedy. Usually, there will be a coronial inquest to establish the 'how and why' for each death. Reviewing these food allergy-related deaths identifies a number of common themes and risk factors. While some are non-modifiable (such as age, gender and ethnicity), others are and include delayed epinephrine administration and communication difficulties in allergen avoidance. This review highlights the key messages in food allergy-related fatality prevention for healthcare professionals and patients alike, and where available, we explain the evidence behind such recommendations. We describe the data behind the good practice points to facilitate their adoption in routine practice without generating additional anxiety for what is a comparatively rare event. We also propose an information leaflet for patients and carers, developed with patients and endorsed by two major allergy charities, to facilitate dissemination of the recommendations in this review.
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Affiliation(s)
- Ru-Xin Foong
- Paediatric Allergy Department, Evelina London Children's Hospital, London, UK
- Department of Women and Children's Health, King's College London, London, UK
| | | | - Paul Turner
- Section of Paediatrics, Imperial College London, London, UK
- Paediatrics and Child Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Graham C Roberts
- University Child Health, Southampton University Hospitals NHS Trust, Southampton, UK
| | - Adam T Fox
- Paediatric Allergy Department, Evelina London Children's Hospital, London, UK
- Department of Women and Children's Health, King's College London, London, UK
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Dribin TE, Motosue MS, Campbell RL. Overview of Allergy and Anaphylaxis. Immunol Allergy Clin North Am 2023; 43:435-451. [PMID: 37394251 DOI: 10.1016/j.iac.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Allergic reactions and anaphylaxis occur on a severity continuum from mild and self-limited to potentially life-threatening or fatal reactions. Anaphylaxis is typically a multiorgan phenomenon involving a broad range of effector cells and mediators. Emergency department visits for anaphylaxis are increasing, especially among children. There is a broad differential diagnosis for anaphylaxis, and the diagnosis of anaphylaxis can be aided by the use of the National Institutes of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network clinical diagnostic criteria. Risk factors for severe anaphylaxis include older age, delayed epinephrine administration, and cardiopulmonary comorbidities.
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Affiliation(s)
- Timothy E Dribin
- Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Avenue, MLC 2008, Cincinnati, OH 45229-3039, USA
| | - Megan S Motosue
- Department of Allergy and Immunology, University of Hawaii, Kaiser Honolulu Clinic, 1010 Pensacola Street, Honolulu, HI 96814, USA; Department of Medicine, University of Hawaii, Kaiser Honolulu Clinic, 1010 Pensacola Street, Honolulu, HI 96814, USA
| | - Ronna L Campbell
- Department of Emergency Medicine, Mayo Clinic, 200 First Street Southwest, Generose Building G-410, Rochester, MN, USA.
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7
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Lin YY, Chang HA, Kao YH, Chuu CP, Chiang WF, Chang YC, Li YK, Chu CM, Chan JS, Hsiao PJ. Investigation of the underuse of adrenaline (epinephrine) and prognosis among patients with anaphylaxis at emergency department admission. Front Med (Lausanne) 2023; 10:1163817. [PMID: 37484849 PMCID: PMC10360193 DOI: 10.3389/fmed.2023.1163817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Accepted: 06/01/2023] [Indexed: 07/25/2023] Open
Abstract
Background Anaphylaxis is a potentially fatal condition; in severe cases of anaphylaxis, the cardiovascular system is often heavily involved. Adrenaline (epinephrine) is a cornerstone of the initial treatment of anaphylaxis. The use of epinephrine remains below expectations in clinical practice. Whether the underuse of epinephrine affects the prognosis of patients with anaphylaxis is still unclear. Materials and methods This retrospective study included patients with anaphylaxis between 2011 and 2020 who were admitted to an emergency department (ED) in Taiwan. All patients were divided into two groups based on the use of epinephrine (or not), and we compared the demographic characteristics, allergens, clinical manifestations, management, and patient outcomes. Results We reviewed the records of 314 subjects (216 males, 98 females; mean age: 52.78 ± 16.02 years) who visited our ED due to anaphylaxis; 107 (34.1%) and 207 (65.9%) patients were categorized into the epinephrine use group and the non-epinephrine use group, respectively. Arrival via ambulance (p = 0.019), hypotension (p = 0.002), airway compromise (p < 0.001) and altered consciousness (p < 0.001) were the deciding factors for epinephrine use among anaphylactic patients in the ED. The epinephrine use group had higher rates of other inotropic agent usage and fluid challenge. More than 90% of patients received bed rest, steroids, antihistamines, and monitoring. The epinephrine use group had a longer ED length of stay (387.64 ± 374.71 vs. 313.06 ± 238.99 min, p = 0.03) and a greater need of hospitalization. Among all severe symptoms, hypotension was the most tolerated decision factor for not using epinephrine. In this retrospective analysis, some patients with serious anaphylaxis did not experience adverse outcomes or death even without the use of epinephrine at ED admission. Emergent care focuses first on the airway, breathing, and circulation (ABC) and may compensate for the underusage of epinephrine. This could be the reason why epinephrine was underused among patients with anaphylaxis in the ED. Conclusion In summary, early ABC management continues to play an important role in treating patients with severe anaphylaxis, even when epinephrine is not immediately available in clinical scenarios.
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Affiliation(s)
- Yen-Yue Lin
- Department of Emergency, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan
- Department of Emergency, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
- Department of Life Sciences, National Central University, Taoyuan, Taiwan
| | - Hsin-An Chang
- Department of Psychiatry, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yung-Hsi Kao
- Department of Life Sciences, National Central University, Taoyuan, Taiwan
| | - Chih-Pin Chuu
- Institute of Cellular and System Medicine, National Health Research Institutes, Zhunan, Taiwan
- Graduate Program for Aging, China Medical University, Taichung, Taiwan
| | - Wen-Fang Chiang
- Division of Nephrology, Department of Internal Medicine, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan
- Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Ya-Chieh Chang
- Division of Nephrology, Department of Internal Medicine, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan
- Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Yuan-Kuei Li
- Division of Colorectal Surgery, Department of Surgery, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan
- Department of Biomedical Sciences and Engineering, National Central University, Taoyuan, Taiwan
| | - Chi-Ming Chu
- School of Public Health, National Defense Medical Center, Taipei, Taiwan
- Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei, Taiwan
- Department of Public Health, School of Public Health, China Medical University, Taichung, Taiwan
| | - Jenq-Shyong Chan
- Division of Nephrology, Department of Internal Medicine, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan
- Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Po-Jen Hsiao
- Department of Life Sciences, National Central University, Taoyuan, Taiwan
- Institute of Cellular and System Medicine, National Health Research Institutes, Zhunan, Taiwan
- Division of Nephrology, Department of Internal Medicine, Taoyuan Armed Forces General Hospital, Taoyuan, Taiwan
- Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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8
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Navalpakam A, Thanaputkaiporn N, Poowuttikul P. Anaphylaxis: Long-term management and resources. Allergy Asthma Proc 2023; 44:35-44. [PMID: 36719689 DOI: 10.2500/aap.2023.44.220089] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background: Anaphylaxis is an acute life-threatening event that requires emergent diagnosis and treatment. However, focus on prevention of anaphylaxis is essential in reducing anaphylaxis recurrences and associated mortality. Objective: This literature review was aimed to be a comprehensive resource for practicing allergists in managing anaphylaxis in the long term. We discussed the role of the allergist in the long-term outpatient management of anaphylaxis through identifying risk factors, allergen avoidance, prevention of recurrences, and patient education. Methods: A medical literature search that focused on several areas of long-term management of anaphylaxis was conducted. Results: Patients evaluated by an allergist are more likely to have their anaphylaxis trigger identified, to have their underlying mast cell disorder diagnosed, and to receive desensitization or allergen immunotherapy. Allergists can prevent fatal anaphylaxis by preventing and treating anaphylaxis in patients with ischemic heart disease and by optimally treating patients with comorbid asthma. Allergists can offer specific prevention strategies for allergenic trigger and cofactor avoidance. Education should be focused on patients with a higher risk for recurrence of anaphylaxis, such as those patients with a history of severe symptoms or anaphylaxis, with a peanut and/or tree nut trigger, or with a history of asthma, or female gender. Patient counseling involves providing individualized action plans at each visit and discussing proper use, storage, and safety of epinephrine autoinjectors. Multiple doses of epinephrine need to be prescribed to those who are at risk for severe food-induced, venom immunotherapy-related, or venom-induced anaphylaxis. Wording on medical identification products should be reviewed by the allergist. Anaphylaxis resources for health-care providers are summarized in the article. Conclusion: Ongoing education, providing personalized anaphylaxis action plans, reducing risk factors, and avoiding triggers are key to anaphylaxis prevention and long-term management.
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Carlson JC, Hajirawala M, Hein N. Diagnosis and Management of Insect Allergy: Barriers and Facilitators in the United States. J Asthma Allergy 2022; 15:1773-1781. [PMID: 36544562 PMCID: PMC9762263 DOI: 10.2147/jaa.s364867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022] Open
Abstract
While guidelines recommend testing and treatment for patients with venom-induced anaphylaxis to prevent morbidity and mortality, significant barriers prevent most patients from receiving the evaluation and treatments that they need. This review examines these barriers in the United States along with the facilitators that can be used to overcome them.
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Affiliation(s)
- John C Carlson
- Department of Pediatrics, Ochsner Health System, New Orleans, LA, USA,Correspondence: John C Carlson, Department of Pediatrics, Ochsner Health System, 1315 Jefferson Hwy, New Orleans, LA, 20121, USA, Tel +1-504-842-3900, Fax +1-504-842-5848, Email
| | - Monica Hajirawala
- Department of Pediatric Allergy and Immunology, University of South Florida, St. Petersburg, FL, USA
| | - Nina Hein
- Department of Allergy and Clinical Immunology, Tulane University, New Orleans, LA, USA
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10
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Stiles SL, Roche I, Said M, Clifford RM, Sanfilippo FM, Loh R, Salter SM. Overview of registries for anaphylaxis: a scoping review. JBI Evid Synth 2022; 20:2656-2696. [PMID: 35942638 DOI: 10.11124/jbies-21-00182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE This review aimed to describe the scope and operational features of anaphylaxis registries, and to assess their contribution to improving knowledge of anaphylaxis and care of patients who experience anaphylaxis by measuring their research output. INTRODUCTION Structured data collection and reporting systems, such as registries, are needed to better understand the burden of anaphylaxis and to protect the growing number of patients with severe allergy. There is a need to characterize current anaphylaxis registries to identify their value in anaphylaxis surveillance, management, and research. Information synthesized in this review will provide knowledge on benefits and gaps in current registries, which may inform the implementation and global standardization of future anaphylaxis reporting systems. INCLUSION CRITERIA This scoping review considered literature describing registries worldwide that enroll patients who have experienced anaphylaxis. Published and gray literature sources were included if they described the scope and operational features of anaphylaxis registries. METHODS This review followed the JBI methodology for scoping reviews. Embase, MEDLINE, Scopus, and CINAHL were searched for relevant articles. Identified keywords and index terms were adapted for searches of gray literature sources, using Google advanced search functions. Only full-text studies in English were considered for inclusion. Two independent reviewers conducted title and abstract screening and those that did not meet the inclusion criteria were excluded. The full text of potentially relevant articles were retrieved; full-text screening and data extraction were also conducted by two independent reviewers. Any discrepancies were resolved through discussion or with a third reviewer. Tables and a narrative summary were used to describe and compare the scope and features (eg, inclusion criteria, patient demographics, clinical symptoms) of the identified anaphylaxis registries, and to outline their output to assess their contribution to research and clinical practice for anaphylaxis. RESULTS A total of 77 full-text publications and eight gray literature sources were used to extract data. The literature search identified 19 anaphylaxis registries, with sites in 28 countries including Europe, the United Kingdom, Canada, the United States, Korea, and Australia. The main purposes of the identified registries were to collect clinical data for research; provide clinical support tools to improve patient care; and operate as allergen surveillance systems to protect the wider community with allergies. Differences in inclusion and health care settings exist, with 11 collecting data on anaphylaxis of any cause, two on food reactions alone, three on fatal anaphylaxis, one on perioperative anaphylaxis, and two on allergic reactions (including anaphylaxis). Five registries enroll cases in allergy centers, five in hospital settings, one in schools, and others target a combination of general practitioners, specialists in emergency departments, and other relevant hospital departments and allergy outpatient clinics. Only three registries operate under a mandatory framework. A total of 57 publications were considered research outputs from registries. All registries except two have published studies from collected data, with the greatest number of articles published from 2019 to the present. Publications mostly addressed questions regarding demographic profile, causes and cofactors, severity, fatal reactions, and gaps in management. CONCLUSIONS This review demonstrated that anaphylaxis registries differ in their scope and operation, having been established for different purposes. Importantly, registries have contributed significantly to research, which has highlighted gaps in anaphylaxis management, provoking allergens, and informed targets for prevention for severe and fatal events. Beyond this, registries relay information about anaphylaxis to clinicians and regulatory bodies to improve patient care and protect the community. The ability to link registry data with other health datasets, standardization of data across registries, and incorporation of clinical care indicators to promote quality health care across the health system represent important targets for future systems.
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Affiliation(s)
| | | | - Maria Said
- The University of Western Australia, Perth, WA, Australia.,Allergy and Anaphylaxis Australia, Sydney, NSW, Australia.,National Allergy Strategy, Sydney, NSW, Australia
| | | | | | - Richard Loh
- The University of Western Australia, Perth, WA, Australia.,Perth Children's Hospital, Perth, WA, Australia.,Australasian Society of Clinical Immunology and Allergy (ASCIA), Sydney, NSW, Australia
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11
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Stiles SL, Vale SL, Salter SM. Monitoring anaphylaxis in Australia: a case in point informed by worldwide experience, driven by partnerships and collaborations. JBI Evid Synth 2022; 20:2607-2608. [PMID: 36379511 DOI: 10.11124/jbies-22-00383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Samantha L Stiles
- The University of Western Australia, Perth, WA, Australia.,National Allergy Strategy, Sydney, NSW, Australia
| | - Sandra L Vale
- The University of Western Australia, Perth, WA, Australia.,National Allergy Strategy, Sydney, NSW, Australia.,Allergy & Anaphylaxis Australia, Sydney, NSW, Australia.,Australasian Society of Clinical Immunology and Allergy (ASCIA), Sydney, NSW, Australia
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12
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Do No Harm: Risk vs. Benefit of the Approach to Childhood Food Allergy. CURRENT TREATMENT OPTIONS IN ALLERGY 2022. [DOI: 10.1007/s40521-022-00322-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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13
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Epinephrine Auto-Injector Prescription and Use: A Retrospective Analysis and Clinical Risk Assessment of Adult Patients Sensitized to Lipid Transfer Protein. Nutrients 2022; 14:nu14132706. [PMID: 35807887 PMCID: PMC9269022 DOI: 10.3390/nu14132706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 06/25/2022] [Accepted: 06/28/2022] [Indexed: 02/04/2023] Open
Abstract
Lipid transfer proteins (LTPs) are widely widespread plant food allergens which represents the main cause of food allergy in adults living in the Mediterranean basin. The purpose of this study was to investigate in LTP patients the actual use of prescribed epinephrine auto-injector and appropriateness of its prescription. In addition, we investigated in these patients: (1) occurrence of new food reaction in the following three years after to diagnosis; (2) need and number of access to emergency services; (3) presence of possible predictive factors to further food reactions. One-hundred sixty-five adult patients sensitized to LTPs have been included. During follow-up, we recorded 68 further reactions, most of them (77.9%) characterized by local symptoms; rarely the patients required an emergency-department visits (16.1%) and only one patient (1.7%) used the epinephrine auto-injector. The patients with a previous history of anaphylaxis at baseline turned back to access to emergency services also during the follow-up (p = 0.006). The majority of patients with recorded systemic reactions (p = 0.004) and treated in an emergency room (p = 0.028) did not have any co-factor-enhanced at diagnosis. We noted an association between platanus pollen sensitization and severity of further reactions during the follow-up (p = 0.026). Epinephrine auto-injector were prescribed to 108/165 patients (65.5%) with an over-prescription rate of 25%. The unforeseeable clinical presentation of LTP allergic reactions and the eventual role played by the cofactor make necessary schedule a follow-up to monitor the patients over time and to assess the actual use of epinephrine auto injectors prescribed.
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14
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Jones CJ, Paudyal P, West RM, Mansur AH, Jay N, Makwana N, Baker S, Krishna MT. Burden of allergic disease among ethnic minority groups in high-income countries. Clin Exp Allergy 2022; 52:604-615. [PMID: 35306712 PMCID: PMC9324921 DOI: 10.1111/cea.14131] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 03/10/2022] [Accepted: 03/14/2022] [Indexed: 12/19/2022]
Abstract
The COVID‐19 pandemic raised acute awareness regarding inequities and inequalities and poor clinical outcomes amongst ethnic minority groups. Studies carried out in North America, the UK and Australia have shown a relatively high burden of asthma and allergies amongst ethnic minority groups. The precise reasons underpinning the high disease burden are not well understood, but it is likely that this involves complex gene–environment interaction, behavioural and cultural elements. Poor clinical outcomes have been related to multiple factors including access to health care, engagement with healthcare professionals and concordance with advice which are affected by deprivation, literacy, cultural norms and health beliefs. It is unclear at present if allergic conditions are intrinsically more severe amongst patients from ethnic minority groups. Most evidence shaping our understanding of disease pathogenesis and clinical management is biased towards data generated from white population resident in high‐income countries. In conjunction with standards of care, it is prudent that a multi‐pronged approach towards provision of composite, culturally tailored, supportive interventions targeting demographic variables at the individual level is needed, but this requires further research and validation. In this narrative review, we provide an overview of epidemiology, sensitization patterns, poor clinical outcomes and possible factors underpinning these observations and highlight priority areas for research.
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Affiliation(s)
- Christina J Jones
- School of Psychology, Faculty of Health & Medical Sciences, University of Surrey, Guildford, UK
| | - Priyamvada Paudyal
- Department of Primary Care & Public Health, Brighton & Sussex Medical School, Brighton, UK
| | - Robert M West
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Adel H Mansur
- Birmingham Regional Severe Asthma Service, University Hospitals Birmingham NHS Foundation Trust, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Nicola Jay
- Sheffield Children's Hospital NHS Foundation Trust, Sheffield, UK
| | - Nick Makwana
- Department of Child Health, Sandwell and West Birmingham Hospitals, Birmingham, UK
| | | | - Mamidipudi T Krishna
- Department of Allergy and Immunology, University Hospitals Birmingham NHS Foundation Trust, Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
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15
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Epidemiology of Anaphylaxis Induced by Food: Incidence, Trends, Natural History, and Bias. CURRENT TREATMENT OPTIONS IN ALLERGY 2022. [DOI: 10.1007/s40521-022-00305-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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16
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Fatal Food Anaphylaxis: Distinguishing Fact From Fiction. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:11-17. [PMID: 34656799 DOI: 10.1016/j.jaip.2021.10.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 10/05/2021] [Accepted: 10/05/2021] [Indexed: 11/21/2022]
Abstract
Although there is a general perception that the prevalence of food allergy is increasing, data supporting this are limited. Food is the least common cause of fatal anaphylaxis, and fortunately, it is a very rare event; however, it is also unpredictable. There is widespread consensus that severe reactions cannot be predicted in a clinically meaningful way. Certain food triggers are more frequently associated with fatal anaphylaxis than others. In observational studies, peanut and tree nuts account for at least 30% to 50% of fatalities, with seafood and cow's milk also associated with fatal reactions. Fatal food-induced anaphylaxis is most likely to occur during adolescence and young adulthood, although the reasons for this are unclear. International guidelines agree that intramuscular (IM) epinephrine is the treatment of choice for managing food-triggered anaphylaxis and has a good safety profile when given by the IM route. However, fatalities still occur despite the timely administration of epinephrine. Food-allergic individuals must navigate a world that requires daily vigilance for allergens and preparedness for allergic reactions. Although the actual risk of fatal reactions is minimal, it is not zero, and severe reactions are unpredictable. Clinicians need to help patients better understand the very low but real risk of fatal reaction and enable them to lead as normal a life as possible through appropriate education, safety netting, and risk reduction.
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17
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Abstract
The key to managing anaphylaxis is early epinephrine administration. This can improve outcomes and prevent progression to severe and fatal anaphylaxis. Delayed or lack of administration of epinephrine is associated with fatal reactions. Positioning in a recumbent supine position, airway management, and intravenous fluids are essential in its management. Antihistamines and glucocorticosteroids should not be prescribed in place of epinephrine. β-adrenergic agonists by inhalation are indicated for bronchospasm associated with anaphylaxis despite optimal epinephrine treatment. Long-term management of anaphylaxis includes the identification and avoidance of triggers; identification of cofactors, such as mast cell disorders; patient, parent, and caregiver education, and interventions to reduce allergen sensitivity, such as the use of venom immunotherapy for Hymenoptera hypersensitivity. Long-term management is covered in other articles. Consultation with an allergist/immunologist is recommended when necessary.
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Affiliation(s)
- Aishwarya Navalpakam
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University College of Medicine, 3950 Beaubien Boulevard, Detroit, MI 48201, USA
| | - Narin Thanaputkaiporn
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University College of Medicine, 3950 Beaubien Boulevard, Detroit, MI 48201, USA
| | - Pavadee Poowuttikul
- Division of Allergy, Immunology and Rheumatology, Department of Pediatrics, Children's Hospital of Michigan, Central Michigan University College of Medicine, 3950 Beaubien Boulevard, Detroit, MI 48201, USA.
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18
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Abstract
Anaphylaxis-related emergency department (ED) visits and hospitalizations are increasing. Triggers for anaphylaxis include food, medications, and stinging insects. Idiopathic anaphylaxis accounts for 30% to 60% of cases of anaphylaxis in adults and up to 10% of cases in children with novel allergens such as galactose-α-1,3 galactose reclassifying these cases. Recent practice guidelines have recommended against the routine use of systemic corticosteroids and antihistamines for the prevention of biphasic reactions and recommend an extended observation, up to 6 hours, for those with risk factors for biphasic anaphylaxis and those with lack of access to epinephrine and to emergency medical services.
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Affiliation(s)
- Megan S Motosue
- Department of Allergy and Immunology, Kaiser Honolulu Clinic, 1010 Pensacola Street, Honolulu, HI, USA.
| | - James T Li
- Division of Allergic Diseases, Mayo Clinic, 200 First Street Southwest Mayo Clinic, Rochester, MN, USA
| | - Ronna L Campbell
- Department of Emergency Medicine, Mayo Clinic, 200 First Street Southwest Generose Building G-410, Rochester, MN, USA
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19
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Abstract
Allergic reactions and anaphylaxis occur on a severity continuum from mild and self-limited to potentially life-threatening or fatal reactions. Anaphylaxis is typically a multiorgan phenomenon involving a broad range of effector cells and mediators. Emergency department visits for anaphylaxis are increasing, especially among children. There is a broad differential diagnosis for anaphylaxis, and the diagnosis of anaphylaxis can be aided by the use of the National Institutes of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network clinical diagnostic criteria. Risk factors for severe anaphylaxis include older age, delayed epinephrine administration, and cardiopulmonary comorbidities.
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Affiliation(s)
- Timothy E Dribin
- Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Avenue, MLC 2008, Cincinnati, OH 45229-3039, USA
| | - Megan S Motosue
- Department of Allergy and Immunology, University of Hawaii, Kaiser Honolulu Clinic, 1010 Pensacola Street, Honolulu, HI 96814, USA; Department of Medicine, University of Hawaii, Kaiser Honolulu Clinic, 1010 Pensacola Street, Honolulu, HI 96814, USA
| | - Ronna L Campbell
- Department of Emergency Medicine, Mayo Clinic, 200 First Street Southwest, Generose Building G-410, Rochester, MN, USA.
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20
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Symptomberichte von Patienten mit Anaphylaxie mit besonderem Fokus auf Nahtoderfahrungen. ALLERGO JOURNAL 2021. [DOI: 10.1007/s15007-021-4906-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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21
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Gouel-Cheron A, Neukirch C, Kantor E, Malinovsky JM, Tacquard C, Montravers P, Mertes PM, Longrois D. Clinical reasoning in anaphylactic shock: addressing the challenges faced by anaesthesiologists in real time: A clinical review and management algorithms. Eur J Anaesthesiol 2021; 38:1158-1167. [PMID: 33973926 DOI: 10.1097/eja.0000000000001536] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Acute hypersensitivity reactions to drugs occur infrequently during anaesthesia and the peri-operative period. When clinical presentation includes the classical triad, erythema, cardiovascular abnormalities and increased airway pressure, the diagnosis is evident and the challenge is to prescribe a therapeutic regimen according to guidelines and to manage refractory signs in a timely manner. In many situations, however, the initial clinical signs are isolated, such as increased airway pressure or arterial hypotension. Rendering a differential diagnosis with causes and mechanisms other than acute hypersensitivity reactions (AHRs) is difficult, delaying treatment with possible worsening of the clinical signs, and even death, in previously healthy individuals. In these difficult diagnostic situations, clinical reasoning is mandatory, and guidelines do not explicitly explain the elements on which clinical reasoning can be built. In this article, based on clinical evidence whenever available, experimental data and pathophysiology, we propose algorithms that have been evaluated by experts. The goal of these algorithms is to provide explicit elements on which the differential diagnosis of AHRs can be made, accelerating the implementation of adequate therapy.
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Affiliation(s)
- Aurelie Gouel-Cheron
- From the Anaesthesiology and Critical Care Medicine Department, DMU PARABOL, Bichat Hospital, AP-HP (AGC, EK, PM, DL), Antibody in Therapy and Pathology, Pasteur Institute, UMR 1222 INSERM, Paris, France (AGC), Biostatistics Research Branch, Division of Clinical Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA (AGC), Pulmonology Department, Bichat Hospital, AP-HP, Paris University (CN), INSERM UMR 1152, Paris University, DHU FIRE, Paris (CN, PM), Anaesthesiology and Critical Care Medicine Department, Maison Blanche Hospital, Centre Hospitalier Universitaire de Reims, Reims (JM-M), Anaesthesiology and Critical Care Medicine Department, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg (CT, PM-M), Paris University (PM, DL), EA 3072, Institut de Physiologie, FMTS, Faculté de Médecine de Strasbourg, Université de Strasbourg, Strasbourg (PM-M) and INSERM1148, Paris, France (DL)
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22
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Poowuttikul P, Seth D. Anaphylaxis in Children and Adolescents. Immunol Allergy Clin North Am 2021; 41:627-638. [PMID: 34602233 DOI: 10.1016/j.iac.2021.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Anaphylaxis is an acute, potentially life-threatening systemic hypersensitivity reaction. Classically, anaphylaxis is an immunoglobulin (Ig) E-mediated reaction; however, IgG or immune complex complement-related immunologic reactions that lead to degranulation of mast cells can also cause anaphylaxis. Food allergy is the most common cause of anaphylaxis, followed by drugs. Patients with anaphylaxis commonly present with symptoms involving skin or mucous membranes, followed by respiratory and gastrointestinal symptoms. Epinephrine is the drug of choice for treating anaphylaxis. Patients and caregivers should be educated on the use of epinephrine autoinjectors with periodic review of symptoms and emergency action plan for anaphylaxis.
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Affiliation(s)
- Pavadee Poowuttikul
- Children's Hospital of Michigan, Wayne State University School of Medicine, 3950 Beaubien, Detroit, MI 48201, USA.
| | - Divya Seth
- Children's Hospital of Michigan, Wayne State University School of Medicine, 3950 Beaubien, Detroit, MI 48201, USA
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23
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Blanca-Lopez N, Atanaskovic-Markovic M, Gomes ER, Kidon M, Kuyucu S, Mori F, Soyer O, Caubet JC. An EAACI Task Force report on allergy to beta-lactams in children: Clinical entities and diagnostic procedures. Pediatr Allergy Immunol 2021; 32:1426-1436. [PMID: 33931922 DOI: 10.1111/pai.13529] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 04/24/2021] [Indexed: 12/14/2022]
Abstract
Beta-lactam (BL) allergy suspicion is common in children and constitutes a major public health problem, with an impact on patient's health and on medical costs. However, it has been found that most of these reactions are not confirmed by a complete allergic workup. The diagnostic value of the currently available allergy tests has been investigated intensively recently by different groups throughout the world. This has led to major changes in the management of children with a suspected BL allergy. Particularly, it is now well accepted that skin tests can be skipped before the drug provocation test in children with a benign non-immediate reaction to BL. However, there is still a debate on the optimal allergic workup to perform in children with a benign immediate reaction. In addition, management of children with severe cutaneous adverse drug reactions remains difficult. In this review, based on a selection of the most relevant studies found in the literature, we will review and discuss the diagnosis of different forms of BL allergy in children.
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Affiliation(s)
| | | | - Eva R Gomes
- Allergy Unit, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Mona Kidon
- Safra Children's Hospital and the Clinical Immunology, Angioedema and Allergy Unit, Chaim Sheba Medical Center, Tel Hashomer, Faculty of Pediatric Medicine, Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - Semanur Kuyucu
- Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Francesca Mori
- Allergy Unit, Department of Pediatric, Meyer Children's Hospital, Florence, Italy
| | - Ozge Soyer
- Department of Pediatric Allergy, School of Medicine, Hacettepe University, Ankara, Turkey
| | - Jean-Christoph Caubet
- Pediatric Allergy Unit, Department of Child and Adolescent, Geneva University Hospital, Geneva, Switzerland
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24
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Anagnostou A. Addressing Common Misconceptions in Food Allergy: A Review. CHILDREN-BASEL 2021; 8:children8060497. [PMID: 34207962 PMCID: PMC8230601 DOI: 10.3390/children8060497] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/04/2021] [Accepted: 06/08/2021] [Indexed: 12/15/2022]
Abstract
Background: Food allergies are common, affecting 1 in 13 school children in the United States and their prevalence is increasing. Many misconceptions exist with regards to food allergy prevention, diagnosis and management. Objective: The main objective of this review is to address misconceptions with regards to food allergies and discuss the optimal, evidence-based approach for patients who carry this diagnosis. Observations: Common misconceptions in terms of food allergy prevention include beliefs that breastfeeding and delayed introduction of allergenic foods prevent the development of food allergies. In terms of diagnosis, statements such as ‘larger skin prick tests or/and higher levels of food-specific IgE can predict the severity of food-induced allergic reactions’, or ‘Tryptase is always elevated in food-induced anaphylaxis’ are inaccurate. Additionally, egg allergy is not a contraindication for receiving the influenza vaccine, food-allergy related fatalities are rare and peanut oral immunotherapy, despite reported benefits, is not a cure for food allergies. Finally, not all infants with eczema will develop food allergies and epinephrine auto-injectors may unfortunately be both unavailable and underused in food-triggered anaphylaxis. Conclusions and relevance: Healthcare professionals must be familiar with recent evidence in the food allergy field and avoid common misunderstandings that may negatively affect prevention, diagnosis and management of this chronic disease.
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Affiliation(s)
- Aikaterini Anagnostou
- Section of Immunology, Allergy and Retrovirology, Department of Pediatrics, Baylor College of Medicine, Houston, TX 77030, USA; ; Tel.: +1-832-824-1319; Fax: +1-832-825-1260
- Section of Immunology, Allergy and Retrovirology, Department of Pediatrics, Texas Children’s Hospital, Houston, TX 77030, USA
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25
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Sokolowska M, Eiwegger T, Ollert M, Torres MJ, Barber D, Del Giacco S, Jutel M, Nadeau KC, Palomares O, Rabin RL, Riggioni C, Vieths S, Agache I, Shamji MH. EAACI statement on the diagnosis, management and prevention of severe allergic reactions to COVID-19 vaccines. Allergy 2021; 76:1629-1639. [PMID: 33452689 PMCID: PMC8013422 DOI: 10.1111/all.14739] [Citation(s) in RCA: 91] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 01/12/2021] [Accepted: 01/12/2021] [Indexed: 12/11/2022]
Abstract
The first approved COVID‐19 vaccines include Pfizer/BioNTech BNT162B2, Moderna mRNA‐1273 and AstraZeneca recombinant adenoviral ChAdOx1‐S. Soon after approval, severe allergic reactions to the mRNA‐based vaccines that resolved after treatment were reported. Regulatory agencies from the European Union, Unites States and the United Kingdom agree that vaccinations are contraindicated only when there is an allergy to one of the vaccine components or if there was a severe allergic reaction to the first dose. This position paper of the European Academy of Allergy and Clinical Immunology (EAACI) agrees with these recommendations and clarifies that there is no contraindication to administer these vaccines to allergic patients who do not have a history of an allergic reaction to any of the vaccine components. Importantly, as is the case for any medication, anaphylaxis may occur after vaccination in the absence of a history of allergic disease. Therefore, we provide a simplified algorithm of prevention, diagnosis and treatment of severe allergic reactions and a list of recommended medications and equipment for vaccine centres. We also describe potentially allergenic/immunogenic components of the approved vaccines and propose a workup to identify the responsible allergen. Close collaboration between academia, regulatory agencies and vaccine producers will facilitate approaches for patients at risks, such as incremental dosing of the second injection or desensitization. Finally, we identify unmet research needs and propose a concerted international roadmap towards precision diagnosis and management to minimize the risk of allergic reactions to COVID‐19 vaccines and to facilitate their broader and safer use.
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Affiliation(s)
- Milena Sokolowska
- Swiss Institute of Allergy and Asthma Research (SIAF University of Zurich Zurich Switzerland
| | - Thomas Eiwegger
- Division of Immunology and Allergy Food Allergy and Anaphylaxis ProgramThe Hospital for Sick Children Toronto ON Canada
- Translational Medicine Program, Research InstituteThe Hospital for Sick Children Toronto ON Canada
- Department of Immunology University of Toronto Toronto ON Canada
| | - Markus Ollert
- Department of Infection and Immunity Luxembourg Institute of Health Esch‐sur‐Alzette Luxembourg
- Department of Dermatology and Allergy Center Odense Research Center for AnaphylaxisOdense University HospitalUniversity of Southern Denmark Odense Denmark
| | - Maria J. Torres
- AllergyClinical UnitHospital Regional Universitario de Málaga‐UMA‐ARADyAL Málaga Spain
| | - Domingo Barber
- Departamento de Ciencias Médicas Básicas Facultad de Medicina Instituto de Medicina Molecular Aplicada (IMMAUniversidad San Pablo‐CEUCEU Universities Madrid España
| | - Stefano Del Giacco
- Department of Medical Sciences and Public Health University of Cagliari Cagliari Italy
| | - Marek Jutel
- Department of Clinical Immunology Wrocław Medical University Wrocław Poland
| | - Kari C. Nadeau
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University Stanford University Stanford CA USA
- Department of Medicine Division of Pulmonary and Critical Care Medicine Stanford University Stanford CA USA
- Department of Medicine Division of Allergy, Immunology and Rheumatology Stanford University Stanford CA USA
| | - Oscar Palomares
- Department of Biochemistry and Molecular Biology Chemistry School Complutense University of Madrid Madrid Spain
| | - Ronald L. Rabin
- Office of Vaccines Research and Review Center for Biologics Evaluation and Research US Food and Drug Administration Silver Spring MD USA
| | - Carmen Riggioni
- Allergy and Clinical Immunology Department of Paediatrics Yong Loo Lin School of MedicineNational University of Singapore Singapore Singapore
- Institut de Recerca Sant Joan de Déu Barcelona Spain
| | - Stefan Vieths
- Paul‐Ehrlich‐Institut Paul‐Ehrlich‐Str. 51‐59 Langen63225Germany
| | | | - Mohamed H. Shamji
- Immunomodulation and Tolerance Group, Allergy and Clinical Immunology Inflammation, Repair and DevelopmentNational Heart and Lung InstituteImperial College London. Asthma UK Centre in Allergic Mechanisms of Asthma London UK
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26
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Klimek L, Bergmann KC, Brehler R, Pfützner W, Worm M, Hartmann K, Jakob T, Novak N, Ring J, Hamelmann E, Ankermann T, Schmidt SM, Untersmayr E, Hötzenecker W, Jensen-Jarolim E, Zuberbier T. Praktischer Umgang mit allergischen Reaktionen auf COVID-19-Impfstoffe. ALLERGO JOURNAL 2021; 30:22-43. [PMID: 33967401 PMCID: PMC8091634 DOI: 10.1007/s15007-021-4773-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Hintergrund: Zur vorbeugenden Behandlung von COVID-19 (Coronaviruserkrankung 2019) wurden in einer beispiellosen weltweiten Forschungsanstrengung Sicherheit und Wirksamkeit neuer Impfstoffplattformen studiert, die noch nie zuvor am Menschen eingesetzt wurden. Weniger als ein Jahr nach der Entdeckung der SARS-CoV-2-Virussequenz (SARS-CoV-2, "severe acute respiratory syndrome coronavirus type 2") wurden diese in zahlreichen Ländern für den Einsatz zugelassen und es wurde mit Massenimpfungen begonnen. Die bislang in der Europäischen Union (EU) zugelassenen mRNA-Impfstoffe (mRNA, "messenger"-RNA) gegen SARS-CoV-2 BNT162b2 und mRNA-1273 basieren auf einer ähnlichen lipidbasierten Nanopartikelträgertechnologie; die Lipidkomponenten unterscheiden sich jedoch. Schwere allergische Reaktionen und Anaphylaxien nach COVID-19-Impfungen sind sehr seltene unerwünschte Nebenwirkungen, die aber aufgrund potenziell letaler Ausgänge viel Aufmerksamkeit erhalten und ein hohes Maß an Verunsicherung ausgelöst haben. Methoden: Das aktuelle Wissen zu anaphylaktischen Reaktionen auf Impfstoffe und speziell zu den derzeit neuen mRNA-COVID-19-Impfstoffen wurde zusammengestellt mittels einer Literaturanalyse durch Recherchen in Medline, Pubmed sowie den nationalen und internationalen Studien- und Leitlinienregistern, der Cochrane Library und dem Internet unter besonderer Berücksichtigung offizieller Webseiten der World Health Oranization (WHO), der Centers for Disease Control and Prevention (CDC), der European Medicines Agency (EMA), des Robert-Koch-Instituts (RKI) und des Paul-Ehrlich-Instituts (PEI). Ergebnisse: Basierend auf der internationalen Literatur und bisheriger Erfahrungen zu schweren allergischen Reaktionen im Kontext der COVID-19-Impfungen werden von einem Expertengremium Empfehlungen für Prophylaxe, Diagnostik und Therapie dieser allergischen Reaktionen gegeben. Schlussfolgerung: Vor einer COVID-19-Impfung mit den derzeit zugelassenen Impfstoffen sind Allergietests für die allermeisten Allergiker nicht notwendig. Bei allergischer/anaphylaktischer Reaktion auf den verabreichten COVID-19-Impfstoff wird eine allergologische Abklärung empfohlen, wie auch für eine kleine potenzielle Risikopopulation vor der ersten Impfung. Die Evaluierung und Zulassung von Testverfahren sollten hierfür erfolgen. Zitierweise: Klimek L, Bergmann K-C, Brehler R, Pfützner W, Zuberbier T, Hartmann K, Jakob T, Novak N, Ring J, Merk H; Hamelmann E, Ankermann T, Schmidt S, Untersmayr E, Hötzenecker W, Jensen-Jarolim E, Brockow K, Mahler V, Worm M. Practical Handling of Allergic Reactions to COVID-19 vaccines. A Position Paper from German and Austrian Allergy Societies AeDA, DGAKI, GPA and ÖGAI. Allergo J Int 2021;30:79-95 https: //doi.org/10.1007/s40629-021-00165-7
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Affiliation(s)
- Ludger Klimek
- Zentrum f. Rhinologie und Allergologie, An den Quellen 10, 65183 Wiesbaden, Germany
| | | | - Randolf Brehler
- Wilhelm-Univ. Münster, Abtlg. Dermatologie, Von-Esmarch-Str. 58, 48149 Münster, Germany
| | - Wolfgang Pfützner
- Klinik für Dermatologie und Allergologie, Baldingerstraße, 35043 Marburg, Germany
| | - Margitta Worm
- Allergie-Centrum-Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | | | - Thilo Jakob
- Universitäts-Hautklinik Gießen, Gießen, Germany
| | - Natalija Novak
- Klinik u. Poliklinik f. Dermatologie u. Allergologie, Sigmund-Freud-Str. 25, 53105 Bonn, Germany
| | - Johannes Ring
- Haut- und Laserzentrum an der Oper, Perusastraße 5, 80333 München, Germany
| | - Eckard Hamelmann
- Evangelisches Krankenhaus Bielefeld gGmbH, Grenzweg 10, 33617 Bielefeld, Germany
| | - Tobias Ankermann
- Klinik f. Allg. Pädiatrie, Univ. Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105 Kiel, Germany
| | | | - Eva Untersmayr
- Department of Pathophysiology and Allergy Research, Waehringer Gürtel 18-20, 1090 Wien, Österreich
| | - Wolfram Hötzenecker
- Kepler Universitätsklinikum \/ Med Campus III., Krankenhausstr. 9, 4021 Linz, Österreich
| | - Erika Jensen-Jarolim
- Institut für Pathophysiologie AKH Wien, Ebene 3 Q, Währinger Gürtel 18-20, 1090 Wien, Österreich
| | - Torsten Zuberbier
- Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
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Lieberman JA, Gupta RS, Knibb RC, Haselkorn T, Tilles S, Mack DP, Pouessel G. The global burden of illness of peanut allergy: A comprehensive literature review. Allergy 2021; 76:1367-1384. [PMID: 33216994 PMCID: PMC8247890 DOI: 10.1111/all.14666] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 10/30/2020] [Accepted: 11/14/2020] [Indexed: 01/05/2023]
Abstract
Peanut allergy (PA) currently affects approximately 2% of the general population of Western nations and may be increasing in prevalence. Patients with PA and their families/caregivers bear a considerable burden of self‐management to avoid accidental peanut exposure and to administer emergency medication (adrenaline) if needed. Compared with other food allergies, PA is associated with higher rates of accidental exposure, severe reactions and potentially fatal anaphylaxis. Approximately 7%–14% of patients with PA experience accidental peanut exposure annually, and one‐third to one‐half may experience anaphylaxis, although fatalities are rare. These risks impose considerably high healthcare utilization and economic costs for patients with PA and restrictions on daily activities. Measures to accommodate patients with PA are often inadequate, with inconsistent standards for food labelling and inadequate safety policies in public establishments such as restaurants and schools. Children with PA are often bullied, resulting in sadness, humiliation and anxiety. These factors cumulatively contribute to significantly reduced health‐related quality of life for patients with PA and families/caregivers. Such factors also provide essential context for risk/benefit assessments of new PA therapies. This narrative review comprehensively assessed the various factors comprising the burden of PA.
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Affiliation(s)
- Jay A. Lieberman
- University of Tennessee Health Science Center/Le Bonheur Children’s Hospital Memphis TN USA
| | - Ruchi S Gupta
- Institute for Public Health and Medicine Ann & Robert H. Lurie Children's Hospital of ChicagoNorthwestern School of Medicine Chicago IL USA
| | | | | | | | - Douglas P. Mack
- Department of Pediatrics McMaster University Hamilton ON Canada
| | - Guillaume Pouessel
- Pneumology and Allergology Unit Children's HospitalLille University Hospital Jeanne de Flandre France
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28
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Klimek L, Bergmann KC, Brehler R, Pfützner W, Zuberbier T, Hartmann K, Jakob T, Novak N, Ring J, Merk H, Hamelmann E, Ankermann T, Schmidt S, Untersmayr E, Hötzenecker W, Jensen-Jarolim E, Brockow K, Mahler V, Worm M. Practical handling of allergic reactions to COVID-19 vaccines: A position paper from German and Austrian Allergy Societies AeDA, DGAKI, GPA and ÖGAI. ALLERGO JOURNAL INTERNATIONAL 2021; 30:79-95. [PMID: 33898162 PMCID: PMC8054127 DOI: 10.1007/s40629-021-00165-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 01/25/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND For the preventive treatment of the 2019 coronavirus disease (COVID-19) an unprecedented global research effort studied the safety and efficacy of new vaccine platforms that have not been previously used in humans. Less than one year after the discovery of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) viral sequence, these vaccines were approved for use in the European Union (EU) as well as in numerous other countries and mass vaccination efforts began. The so far in the EU approved mRNA vaccines BNT162b2 and mRNA-1273 are based on similar lipid-based nanoparticle carrier technologies; however, the lipid components differ. Severe allergic reactions and anaphylaxis after COVID-19 vaccination are very rare adverse events but have drawn attention due to potentially lethal outcomes and have triggered a high degree of uncertainty. METHODS Current knowledge on anaphylactic reactions to vaccines and specifically the new mRNA COVID-19 vaccines was compiled using a literature search in Medline, PubMed, as well as the national and international study and guideline registries, the Cochrane Library, and the Internet, with special reference to official websites of the World Health Organization (WHO), US Centers for Disease Control and Prevention (CDC), Robert Koch Institute (RKI), and Paul Ehrlich Institute (PEI). RESULTS Based on the international literature and previous experience, recommendations for prophylaxis, diagnosis and therapy of these allergic reactions are given by a panel of experts. CONCLUSION Allergy testing is not necessary for the vast majority of allergic patients prior to COVID-19 vaccination with currently licensed vaccines. In case of allergic/anaphylactic reactions after vaccination, allergy workup is recommended, as it is for a small potential risk population prior to the first vaccination. Evaluation and approval of diagnostic tests should be done for this purpose.
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Affiliation(s)
- Ludger Klimek
- Center for Rhinology and Allergology, Wiesbaden, Germany
| | - Karl-Christian Bergmann
- Clinic for Dermatology, Venereology and Allergy, Charité—University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Berlin Institute of Health, Charité—Medical University Berlin, Berlin, Germany
| | - Randolf Brehler
- Outpatient Clinic for Allergology, Occupational Dermatology and Environmental Medicine, General Dermatology and Venereology, Department of Skin Diseases, Münster University Hospital, Münster, Germany
| | - Wolfgang Pfützner
- Department of Dermatology and Allergology, University Hospital Marburg, UKGM, Philipps University Marburg, Marburg, Germany
| | - Torsten Zuberbier
- Clinic for Dermatology, Venereology and Allergy, Charité—University Medicine Berlin, Charitéplatz 1, 10117 Berlin, Germany
- Berlin Institute of Health, Charité—Medical University Berlin, Berlin, Germany
| | - Karin Hartmann
- Department of Dermatology and Allergology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Thilo Jakob
- Department of Dermatology and Allergology, Giessen University Hospital, UKGM, Justus Liebig University Giessen, Giessen, Germany
| | - Natalija Novak
- Clinic and Polyclinic for Dermatology and Allergology, University Hospital Bonn, Bonn, Germany
| | - Johannes Ring
- Clinic and Polyclinic for Dermatology and Allergology at Biederstein, Technical University of Munich, Munich, Germany
| | - Hans Merk
- Department of Dermatology and Allergology, RWTH Aachen University Hospital, Aachen, Germany
| | - Eckard Hamelmann
- Pediatric and Adolescent Medicine, Bethel Children’s Center, OWL University Hospital, Bielefeld University, Bielefeld, Germany
| | - Tobias Ankermann
- Clinic for Pediatric and Adolescent Medicine, Municipal Hospital Kiel GmbH, Kiel, Germany
| | - Sebastian Schmidt
- Center for Pediatric and Adolescent Medicine, Clinic and Polyclinic for Pediatric and Adolescent Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Eva Untersmayr
- Institute for Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria
| | - Wolfram Hötzenecker
- Clinic for Dermatology and Venereology, Allergy Center, Kepler University Hospital GmbH, Linz, Austria
| | - Erika Jensen-Jarolim
- Institute for Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria
- Inter-university Messerli Research Institute Vienna, Vienna, Austria
| | - Knut Brockow
- Clinic and Polyclinic for Dermatology and Allergology at Biederstein, Technical University of Munich, Munich, Germany
| | | | - Margitta Worm
- Allergology and Immunology, Department of Dermatology, Venereology and Allergology, Charité—University Medicine Berlin, Berlin, Germany
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29
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Sharma V, Garcez T, Fox AT. Fatal anaphylaxis: making sure all cases are counted. BMJ 2021; 372:n691. [PMID: 33722848 DOI: 10.1136/bmj.n691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Vibha Sharma
- Department of Paediatric Allergy and Immunology, Royal Manchester Children's Hospital, Manchester M13 9WL, UK
- University of Manchester, Manchester, UK
| | - Tomaz Garcez
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Adam T Fox
- Guy's and St Thomas' Hospitals NHS Foundation Trust, London, UK
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30
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Ring J, Beyer K, Biedermann T, Bircher A, Fischer M, Heller A, Huttegger I, Jakob T, Klimek L, Kopp MV, Kugler C, Lange L, Pfaar O, Rietschel E, Rueff F, Schnadt S, Seifert R, Stöcker B, Treudler R, Vogelberg C, Werfel T, Worm M, Sitter H, Brockow K. Leitlinie zu Akuttherapie und Management der Anaphylaxie - Update 2021. ALLERGO JOURNAL 2021; 30:20-49. [PMID: 33612982 PMCID: PMC7878028 DOI: 10.1007/s15007-020-4750-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Johannes Ring
- Haut- und Laserzentrum an der Oper, Perusastraße 5, 80333 München, Germany
| | - Kirsten Beyer
- Klinik für Pädiatrie - Pneumologie und Immunologie, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Tilo Biedermann
- Klinik und Poliklinik für Dermatologie und Allergologie, Biedersteiner Str. 29, 80802 München, Germany
| | - Andreas Bircher
- Universitätskliniken Basel, Petersgraben 4, 4031 Basel, Schweiz
| | - Matthias Fischer
- Klinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und, ALB FILS Kliniken Göppingen,, Göppingen, Germany
| | - Axel Heller
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Augsburg, Augsburg, Germany
| | - Isidor Huttegger
- Klinik für Pädiatrie, Universitätsklinikum Salzburg, Salzburg, Österreich
| | - Thilo Jakob
- Klinik für Dermatologie, Venerologie und Allergologie, Gaffkystraße 14, 35392 Gießen, Germany
| | - Ludger Klimek
- Zentrum f. Rhinologie und Allergologie, An den Quellen 10, 65183 Wiesbaden, Germany
| | | | - Claudia Kugler
- TU München, Biedersteiner Straße 29, 80802 München, Germany
| | - Lars Lange
- Klinik für Pädiatrie - Pneumologie und Immunologie, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Oliver Pfaar
- Sektion für Rhinologie und Allergologie, Baldingerstraße, 35043 Marburg, Germany
| | - Ernst Rietschel
- Pädiatrische Pneumologie u. Allergologie, Klinikum der Univ. Köln, Kerpener Str. 62, 50924 Köln, Germany
| | - Franziska Rueff
- Dermatologische Klinik u. Poliklinik der LMU, Frauenlobstr. 9-11, 80337 München, Germany
| | - Sabine Schnadt
- Deutscher Allergie- und Asthmabund (DAAB), An der Eickesmühle 15 - 19, 41238 Mönchengladbach, Germany
| | - Roland Seifert
- Institut für Pharmakologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - Britta Stöcker
- Kinderpneumologie u. Allergologie, Robert-Koch-Str. 1, 53115 Bonn, China
| | - Regina Treudler
- Universitätsklinikum Leipzig, Philipp-Rosenthal-Str. 23, 4103 Leipzig, Germany
| | | | - Thomas Werfel
- Klinik für Dermatologie, Allergologie und Venerologie, Carl-Neuberg-Str. 1, 30449 Hannover, Germany
| | - Margitta Worm
- Allergie-Centrum-Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Helmut Sitter
- Klinik für Dermatologie und Allergologie, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Knut Brockow
- Klinik f. Dermatologie und Allergologie am Biederstein, Biedersteiner Str. 29, 80802 München, Germany
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31
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Ganti A, Pilkerton R, Falsgraf E, Vanwert E, Brouwer N, Beyer A, Byrne B. Retrieval of Additional Epinephrine from Adrenaclick-Style Epinephrine Autoinjectors. Wilderness Environ Med 2021; 32:55-58. [PMID: 33516624 DOI: 10.1016/j.wem.2020.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 08/09/2020] [Accepted: 09/04/2020] [Indexed: 01/23/2023]
Abstract
Anaphylaxis is a life-threatening allergic reaction involving multiple organ systems that can result in significant morbidity and mortality if left untreated. Epinephrine is the mainstay of treatment. Most episodes of anaphylaxis resolve after a single dose of epinephrine, but biphasic and protracted courses of anaphylaxis are well described. The need for additional doses of epinephrine poses a significant challenge in the wilderness setting, because patients and providers may only carry a single autoinjector. Prior work has demonstrated successful disassembly of various brands of epinephrine autoinjectors to retrieve additional drug product for repeat dosing. We describe 2 techniques to retrieve additional doses of epinephrine from Adrenaclick-style epinephrine autoinjectors. The techniques described are off-label and are not approved by the manufacturer or the Food and Drug Administration. Wilderness providers should familiarize themselves with techniques for retrieval of additional epinephrine from various autoinjectors in light of significant differences in product design.
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Affiliation(s)
- Arun Ganti
- Department of Emergency Medicine, UCSF Fresno, Fresno, CA.
| | - Rebecca Pilkerton
- Department of Emergency Medicine, University of Utah, Salt Lake City, UT
| | - Erika Falsgraf
- Department of Emergency Medicine, UCSF Fresno, Fresno, CA
| | | | - Nathan Brouwer
- Department of Emergency Medicine, Michigan Medicine, Ann Arbor, MI
| | - Alexander Beyer
- Department of Emergency Medicine, Michigan Medicine, Ann Arbor, MI
| | - Brendan Byrne
- Department of Emergency Medicine, Michigan Medicine, Ann Arbor, MI
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32
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Ring J, Beyer K, Biedermann T, Bircher A, Fischer M, Fuchs T, Heller A, Hoffmann F, Huttegger I, Jakob T, Klimek L, Kopp MV, Kugler C, Lange L, Pfaar O, Rietschel E, Rueff F, Schnadt S, Seifert R, Stöcker B, Treudler R, Vogelberg C, Werfel T, Worm M, Sitter H, Brockow K. Guideline (S2k) on acute therapy and management of anaphylaxis: 2021 update: S2k-Guideline of the German Society for Allergology and Clinical Immunology (DGAKI), the Medical Association of German Allergologists (AeDA), the Society of Pediatric Allergology and Environmental Medicine (GPA), the German Academy of Allergology and Environmental Medicine (DAAU), the German Professional Association of Pediatricians (BVKJ), the Society for Neonatology and Pediatric Intensive Care (GNPI), the German Society of Dermatology (DDG), the Austrian Society for Allergology and Immunology (ÖGAI), the Swiss Society for Allergy and Immunology (SGAI), the German Society of Anaesthesiology and Intensive Care Medicine (DGAI), the German Society of Pharmacology (DGP), the German Respiratory Society (DGP), the patient organization German Allergy and Asthma Association (DAAB), the German Working Group of Anaphylaxis Training and Education (AGATE). ALLERGO JOURNAL INTERNATIONAL 2021; 30:1-25. [PMID: 33527068 PMCID: PMC7841027 DOI: 10.1007/s40629-020-00158-y] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Johannes Ring
- Department Dermatology and Allergology Biederstein, Technical University Munich, Biedersteiner Straße 29, 80802 Munich, Germany
| | - Kirsten Beyer
- Department of Pediatrics, Division of Pulmonology, Immunology and Critical Care Medicine, Charité—University Hospital Berlin, Berlin, Germany
| | - Tilo Biedermann
- Department Dermatology and Allergology Biederstein, Technical University Munich, Biedersteiner Straße 29, 80802 Munich, Germany
| | - Andreas Bircher
- Department of Dermatology, University Hospital of Basel, Basel, Switzerland
| | - Matthias Fischer
- Clinic for Anaesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, ALB FILS Hospitals Göppingen, Göppingen, Germany
| | - Thomas Fuchs
- Department of Dermatology, University Hospital Göttingen, Göttingen, Germany
| | - Axel Heller
- Department of Anesthesiology and Operative Intensive Care Medicine, Medical Faculty, University of Augsburg, Augsburg, Germany
| | - Florian Hoffmann
- Dr. von Hauner Children’s Hospital, Ludwig Maximilians University, Munich, Germany
| | - Isidor Huttegger
- Department of Pediatrics, University Hospital Salzburg, Salzburg, Austria
| | - Thilo Jakob
- Department of Dermatology and Allergology, University Medical Center Gießen (UKGM), Justus-Liebig-University Gießen, Gießen, Germany
| | - Ludger Klimek
- Center of Rhinology and Allergology, Wiesbaden, Germany
| | - Matthias V. Kopp
- Pediatric Respiratory Medicine, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Claudia Kugler
- Department Dermatology and Allergology Biederstein, Technical University Munich, Biedersteiner Straße 29, 80802 Munich, Germany
| | | | - Oliver Pfaar
- Section of Rhinology and Allergy, Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Marburg, Philipps-University Marburg, Marburg, Germany
| | - Ernst Rietschel
- Department of Pediatrics, University Hospital Cologne, Cologne, Germany
| | - Franziska Rueff
- Department of Dermatology and Allergology, Hospital of the Ludwig Maximilians University, Munich, Germany
| | - Sabine Schnadt
- German Allergy and Asthma Association, Mönchengladbach, Germany
| | - Roland Seifert
- Institute of Pharmacology, Hannover Medical School, Hannover, Germany
| | - Britta Stöcker
- Medical practice for pediatrics and youth medicine, Poppelsdorfer Allee, Bonn, Germany
| | - Regina Treudler
- Department of Dermatology, Venereology, and Allergology, Leipzig Interdisciplinary Allergy Center, University Hospital Leipzig, Leipzig, Germany
| | - Christian Vogelberg
- Department of Pediatric Pneumology and Allergology, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany
| | - Thomas Werfel
- Immunodermatology and Experimental Allergology Unit, Department of Dermatology, Allergology, and Venereology, Medical University Hannover, Hannover, Germany
| | - Margitta Worm
- Department of Dermatology, Venereology, and Allergology, Charité—University Hospital Berlin, Berlin, Germany
| | - Helmut Sitter
- Institute for Surgical Research, Philipps-University Marburg, Marburg, Germany
| | - Knut Brockow
- Department Dermatology and Allergology Biederstein, Technical University Munich, Biedersteiner Straße 29, 80802 Munich, Germany
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Mahr TA, Lieberman JA, Haselkorn T, Damle V, Ali Y, Chidambaram A, Griffin NM, Sublett JW. Characteristics of Peanut Allergy Diagnosis in a US Health Care Claims Database (2011-2017). THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:1683-1694.e5. [PMID: 33346150 DOI: 10.1016/j.jaip.2020.12.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 11/24/2020] [Accepted: 12/03/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Peanut allergy is the most common food allergy among children. Studies assessing the burden of peanut allergy in a real-world setting are limited. OBJECTIVE To estimate annual incidence and prevalence of peanut allergy cases among children aged 4 to 17 years and assess severe reaction and associated health care utilization rates. METHODS Patient longitudinal data between January 2011 and December 2017 from a geographically and payer-type representative US health care claims database were used. Peanut allergy cases were identified using diagnostic codes and/or services indicating peanut-allergy-associated severe reactions/anaphylaxis. Estimated annual incidence was defined as peanut-allergic births as a proportion of all 1-year-olds and adjusted for less than 100% data set capture, undercoding, patient underpresenting rates, and spontaneous outgrowth. Prevalence was calculated on the basis of incidence. To assess rates of severe reactions to peanut and associated health care utilization, the cohort of 720,490 peanut allergy cases identified in 2011 was evaluated over a 6-year period from 2011 to 2017. RESULTS Annual incidence increased from 1.7% to 5.2% between 2001 and 2017. Estimated prevalence in 4- to 17-year-olds was 1.25 million (2.2%) in 2017. Atopic comorbidities (asthma, 60.8%; atopic dermatitis, 61.7%) and other food allergies (35.3%) were common. Severe reactions (≥1) were observed in more than half (n = 399,806) the patients, and 37.9% were triggered by an accidental exposure. One in 5 patients (n = 144,883) visited the emergency department due to peanut exposure. CONCLUSIONS Claims data suggest that the incidence and prevalence of peanut allergy in the United States may be increasing. Estimated severe reaction rates and health care utilization were high, suggesting that the burden of peanut allergy may be considerable.
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Affiliation(s)
- Todd A Mahr
- Division of Allergy, Asthma, and Immunology, Gundersen Health System, La Crosse, Wis.
| | - Jay A Lieberman
- Department of Pediatrics, Division of Pulmonology, Allergy, & Immunology, The University of Tennessee Health Science Center, Memphis, Tenn
| | | | - Varsha Damle
- Aimmune Therapeutics, a Nestle Health Science Company, Brisbane, Calif
| | - Yasser Ali
- Aimmune Therapeutics, a Nestle Health Science Company, Brisbane, Calif
| | | | - Noelle M Griffin
- Aimmune Therapeutics, a Nestle Health Science Company, Brisbane, Calif
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Yonkof JR, Mikhail IJ, Prince BT, Stukus D. Delayed and Severe Reactions to Baked Egg and Baked Milk Challenges. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:283-289.e2. [PMID: 33049390 DOI: 10.1016/j.jaip.2020.09.059] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 09/21/2020] [Accepted: 09/26/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Although many egg- and milk-allergic children tolerate baked egg (BE) and baked milk (BM), reactions elicited by these oral food challenges (OFCs) can be severe. Previous studies comparing BE and BM reactions to other OFC reactions are limited. OBJECTIVE To compare the clinical features of reactions to BE and BM with other OFCs to promote challenge safety. METHODS A retrospective review of OFCs eliciting objective reactions to BE, BM, lightly cooked egg (CE), fresh cow's milk (CM), peanut (PN), and tree nuts (TN) which were performed at a tertiary referral center from June 1, 2017, to June 1, 2019. RESULTS We identified 174 OFCs conducted in 158 subjects, age 6 to 187 months (34 BE, 19 BM, 14 CE, 25 CM, 52 PN, and 30 TN). TN reactors were older than BE (P = .049) and PN (P < .01) reactors and had a higher frequency of persistent asthma than PN-reactive subjects (P = .02). Mucocutaneous symptoms occurred less frequently during BE (56%) and BM (42%) OFCs compared with other OFCs (P < .05). Lower respiratory tract reactions were increased during BM (37%) versus BE (12%), CM (8%), and PN (12%) OFCs (P < .05). Epinephrine was administered to more BE (44%) and TN (50%) than PN (17%) OFCs (P < .01). New reaction manifestations developed 60 minutes or later after OFC termination during 29% BE and 21% BM versus 0% PN OFCs (P < .05). One-third of anaphylactic reactions to BE began more than 60 minutes after OFC termination. CONCLUSIONS BE and BM challenge reactions differed phenotypically from other OFC reactions, including significantly increased frequencies of new symptoms beginning 60 minutes or later after challenge termination. Consider amended dose-escalation and prolonged observation after BE and BM OFCs.
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Affiliation(s)
- Jennifer R Yonkof
- Division of Allergy and Immunology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio; Division of Allergy and Immunology, Department of Otolaryngology, The Ohio State University Wexner Medical Center, Columbus, Ohio.
| | - Irene J Mikhail
- Division of Allergy and Immunology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - Benjamin T Prince
- Division of Allergy and Immunology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
| | - David Stukus
- Division of Allergy and Immunology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
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Martelli A, Ippolito R, Votto M, De Filippo M, Brambilla I, Calvani M, Cardinale F, Chiappini E, Duse M, Manti S, Marseglia GL, Caffarelli C, Cravidi C, Miraglia Del Giudice M, Tosca MA. What is new in anaphylaxis? ACTA BIO-MEDICA : ATENEI PARMENSIS 2020; 91:e2020005. [PMID: 33004775 PMCID: PMC8023066 DOI: 10.23750/abm.v91i11-s.10308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 07/22/2020] [Indexed: 11/23/2022]
Abstract
Available information suggests that anaphylaxis must be promptly recognized keeping in mind the airway patency, breathing (ventilation and respiration), circulation and mental status and treated. The first treatment is adrenaline. After successful treatment of an anaphylactic episode, attention must be paid to the prevention of early recurrences (biphasic anaphylaxis) and assessment of causes. Children should not be discharged before prescribing self-injectable adrenaline and explain how and under what circumstances it must be injected, An action plan must be communicated to their communities. Inform the school about potential reactions, how to prevent them and avoidance measures. (www.actabiomedica.it)
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Affiliation(s)
- Alberto Martelli
- Department of Pediatrics, G. Salvini Hospital, Garbagnate Milanese, Milan - Italy.
| | - Rosario Ippolito
- Pediatric Clinic Department of Pediatrics, Fondazione IRCCS Policlinico S. Matteo, University of Pavia, Pavia, Italy.
| | - Martina Votto
- Pediatric Clinic Department of Pediatrics, Fondazione IRCCS Policlinico S. Matteo, University of Pavia, Pavia, Italy.
| | - Maria De Filippo
- Pediatric Clinic Department of Pediatrics, Fondazione IRCCS Policlinico S. Matteo, University of Pavia, Pavia, Italy.
| | - Ilaria Brambilla
- Pediatric Clinic Department of Pediatrics, Fondazione IRCCS Policlinico S. Matteo, University of Pavia, Pavia, Italy.
| | - Mauro Calvani
- UOC di Pediatria. Azienda Ospedaliera S. Camillo Forlanini, Roma, Italy.
| | - Fabio Cardinale
- Department of Pediatrics and Emergency, Pediatric Allergy and Pulmunology Unit, Azienda Ospedaliera-Universitaria Consorziale-Policlinico, Ospedale Pediatrico Giovanni XXIII, Bari, Italy..
| | - Elena Chiappini
- Division of Paediatric Infectious Disease, Anna Meyer Children's University Hospital, Department of Health Sciences, University of Florence, Florence, Italy.
| | - Marzia Duse
- Department of Pediatrics, Sapienza University, Rome, Italy.
| | - Sara Manti
- UOC Broncopneumologia Pediatrica e Fibrosi Cistica, AOUP "Vittorio-Emanuele", San Marco Hospital, Università di Catania, Catania, Italy.
| | - Gian Luigi Marseglia
- Pediatric Clinic Department of Pediatrics, Fondazione IRCCS Policlinico S. Matteo, University of Pavia, Pavia, Italy.
| | - Carlo Caffarelli
- Clinica Pediatrica, Dipartimento di Medicina e Chirurgia, Università di Parma, Italy.
| | - Claudio Cravidi
- Agenzia Tutela della Salute, ATS (National Healthcare System), Pavia, Italy.
| | - Michele Miraglia Del Giudice
- Department of Woman, Child and of General and Specialized Surgery. University of Campania"Luigi Vanvitelli" Naples, Italy.
| | - Maria Angela Tosca
- Allergy Center, Department of Pediatrics, Istituto G. Gaslini, Genoa, Italy.
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Penicillin causes non-allergic anaphylaxis by activating the contact system. Sci Rep 2020; 10:14160. [PMID: 32843685 PMCID: PMC7447753 DOI: 10.1038/s41598-020-71083-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 08/02/2020] [Indexed: 12/18/2022] Open
Abstract
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.
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Percival E, Bhatia R, Preece K, McEvoy M, Collison A, Mattes J. Change in exhaled nitric oxide during peanut challenge is related to severity of reaction. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2020; 16:64. [PMID: 32834829 PMCID: PMC7386245 DOI: 10.1186/s13223-020-00464-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 07/10/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Peanut allergy affects 3% of Australian children and has a higher risk of anaphylaxis than most food allergies. Predicting who is likely to develop anaphylaxis is still an inexact science. The fraction of exhaled nitric oxide (FeNO) shows promise as a biomarker involved in peanut allergy, as nitric oxide plays a role in inhibiting mast cell degranulation which is relevant in anaphylaxis, where mast cell degranulation plays a mediator role. The aim of this study was to assess the change in FeNO in children during peanut challenge. METHODS Thirty-six children aged from 5 to 17 years were recruited for open-labelled peanut challenge. Participants had skin prick test to peanut performed, and serum collected for Ara h2 specific IgE and peanut specific IgE. FeNO was measured by portable device (NIOX VERO) prior to and throughout the peanut challenge. RESULTS When grouped according to reaction type at peanut challenge (anaphylaxis, clinical allergy not anaphylaxis and tolerant), there were significant differences in the mean change in FeNO measurement between the anaphylaxis group and the clinical allergy, not anaphylaxis group (p = 0.005), and between the anaphylaxis group and tolerant group (p < 0.0001). CONCLUSIONS FeNO decreased more significantly in those who subsequently developed anaphylaxis than in those with clinical allergy, not anaphylaxis or negative peanut challenge (tolerance). As a bedside test that can be used in children, it has potential for further research into mechanisms of anaphylaxis in food allergy and potentially assists in predicting an imminent anaphylactic reaction in some patients.Trial registration ClinicalTrials.gov: PEAnut Anaphylaxis Predictors (PEAAP) NCT02424136.
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Affiliation(s)
- Elizabeth Percival
- GrowUpWell Priority Research Centre, Hunter Medical Research Institute, University of Newcastle, Lot 1 Kookaburra Circuit, New Lambton Heights, Newcastle, NSW 2305 Australia
- Department of Paediatric Medicine, John Hunter Children’s Hospital, Newcastle, NSW Australia
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW Australia
| | - Rani Bhatia
- Department of Paediatric Allergy & Immunology, John Hunter Children’s Hospital, Newcastle, NSW Australia
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW Australia
| | - Kahn Preece
- Department of Paediatric Allergy & Immunology, John Hunter Children’s Hospital, Newcastle, NSW Australia
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW Australia
| | - Mark McEvoy
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW Australia
| | - Adam Collison
- GrowUpWell Priority Research Centre, Hunter Medical Research Institute, University of Newcastle, Lot 1 Kookaburra Circuit, New Lambton Heights, Newcastle, NSW 2305 Australia
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW Australia
| | - Joerg Mattes
- GrowUpWell Priority Research Centre, Hunter Medical Research Institute, University of Newcastle, Lot 1 Kookaburra Circuit, New Lambton Heights, Newcastle, NSW 2305 Australia
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW Australia
- Department of Paediatric Respiratory & Sleep Medicine, John Hunter Children’s Hospital, Newcastle, NSW Australia
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Regateiro FS, Marques ML, Gomes ER. Drug-Induced Anaphylaxis: An Update on Epidemiology and Risk Factors. Int Arch Allergy Immunol 2020; 181:481-487. [PMID: 32396909 DOI: 10.1159/000507445] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 03/23/2020] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
- Frederico S Regateiro
- Allergy and Clinical Immunology Unit, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal, .,Institute of Immunology, Faculty of Medicine, University of Coimbra, Coimbra, Portugal, .,Coimbra Institute for Clinical and Biomedical Research (iCBR), Faculty of Medicine, University of Coimbra, Coimbra, Portugal,
| | - Maria Luís Marques
- Allergy and Clinical Immunology Department, Centro Hospitalar e Universitário do Porto, Porto, Portugal
| | - Eva Rebelo Gomes
- Allergy and Clinical Immunology Department, Centro Hospitalar e Universitário do Porto, Porto, Portugal
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Brown JC, Simons E, Rudders SA. Epinephrine in the Management of Anaphylaxis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:1186-1195. [DOI: 10.1016/j.jaip.2019.12.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 12/13/2019] [Accepted: 12/18/2019] [Indexed: 10/24/2022]
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Shaker MS, Wallace DV, Golden DBK, Oppenheimer J, Bernstein JA, Campbell RL, Dinakar C, Ellis A, Greenhawt M, Khan DA, Lang DM, Lang ES, Lieberman JA, Portnoy J, Rank MA, Stukus DR, Wang J, Riblet N, Bobrownicki AMP, Bontrager T, Dusin J, Foley J, Frederick B, Fregene E, Hellerstedt S, Hassan F, Hess K, Horner C, Huntington K, Kasireddy P, Keeler D, Kim B, Lieberman P, Lindhorst E, McEnany F, Milbank J, Murphy H, Pando O, Patel AK, Ratliff N, Rhodes R, Robertson K, Scott H, Snell A, Sullivan R, Trivedi V, Wickham A, Shaker MS, Wallace DV, Shaker MS, Wallace DV, Bernstein JA, Campbell RL, Dinakar C, Ellis A, Golden DBK, Greenhawt M, Lieberman JA, Rank MA, Stukus DR, Wang J, Shaker MS, Wallace DV, Golden DBK, Bernstein JA, Dinakar C, Ellis A, Greenhawt M, Horner C, Khan DA, Lieberman JA, Oppenheimer J, Rank MA, Shaker MS, Stukus DR, Wang J. Anaphylaxis-a 2020 practice parameter update, systematic review, and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) analysis. J Allergy Clin Immunol 2020; 145:1082-1123. [PMID: 32001253 DOI: 10.1016/j.jaci.2020.01.017] [Citation(s) in RCA: 371] [Impact Index Per Article: 92.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 12/21/2019] [Accepted: 01/02/2020] [Indexed: 12/18/2022]
Abstract
Anaphylaxis is an acute, potential life-threatening systemic allergic reaction that may have a wide range of clinical manifestations. Severe anaphylaxis and/or the need for repeated doses of epinephrine to treat anaphylaxis are risk factors for biphasic anaphylaxis. Antihistamines and/or glucocorticoids are not reliable interventions to prevent biphasic anaphylaxis, although evidence supports a role for antihistamine and/or glucocorticoid premedication in specific chemotherapy protocols and rush aeroallergen immunotherapy. Evidence is lacking to support the role of antihistamines and/or glucocorticoid routine premedication in patients receiving low- or iso-osmolar contrast material to prevent recurrent radiocontrast media anaphylaxis. Epinephrine is the first-line pharmacotherapy for uniphasic and/or biphasic anaphylaxis. After diagnosis and treatment of anaphylaxis, all patients should be kept under observation until symptoms have fully resolved. All patients with anaphylaxis should receive education on anaphylaxis and risk of recurrence, trigger avoidance, self-injectable epinephrine education, referral to an allergist, and be educated about thresholds for further care.
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Affiliation(s)
- Marcus S Shaker
- Section of Allergy and Clinical Immunology, Dartmouth-Hitchcock Medical Center, Geisel School of Medicine at Dartmouth, Lebanon, NH.
| | - Dana V Wallace
- Nova Southeastern Allopathic Medical School, Fort Lauderdale, Fla
| | - David B K Golden
- Division of Allergy-Clinical Immunology, Johns Hopkins University, Baltimore, Md
| | - John Oppenheimer
- Department of Internal Medicine, Pulmonary and Allergy, University of Medicine and Dentistry of New Jersey-Rutgers New Jersey Medical School and Pulmonary and Allergy Associates, Morristown, NJ
| | - Jonathan A Bernstein
- Department of Internal Medicine, Division of Immunology, Allergy Section, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Chitra Dinakar
- Allergy, Asthma, and Immunodeficiency, Division of Pulmonary, Allergy, and Critical Care Medicine, Stanford University School of Medicine, Stanford, Calif
| | - Anne Ellis
- Division of Allergy and Immunology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - Matthew Greenhawt
- Section of Allergy and Immunology, Children's Hospital Colorado, University of Colorado School of Medicine, Denver, Colo
| | - David A Khan
- Department of Internal Medicine, Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas, Tex
| | - David M Lang
- Department of Allergy and Clinical Immunology, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eddy S Lang
- Department of Emergency Medicine, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Jay A Lieberman
- Department of Pediatrics, The University of Tennessee Health Science Center, Memphis, Tenn
| | - Jay Portnoy
- Pediatric Allergy and Immunology, Children's Mercy Hospital, Kansas City School of Medicine, Kansas City, Mo
| | - Matthew A Rank
- Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic in Arizona, Scottsdale, Ariz
| | - David R Stukus
- Division of Allergy and Immunology, Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio
| | - Julie Wang
- Division of Allergy and Immunology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Natalie Riblet
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH
| | | | - Teresa Bontrager
- Office of Evidence-Based Practice, Children's Mercy Hospital, Kansas City, Mo
| | - Jarrod Dusin
- Office of Evidence-Based Practice, Children's Mercy Hospital, Kansas City, Mo
| | - Jennifer Foley
- Office of Evidence-Based Practice, Children's Mercy Hospital, Kansas City, Mo
| | - Becky Frederick
- Office of Evidence-Based Practice, Children's Mercy Hospital, Kansas City, Mo
| | - Eyitemi Fregene
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH
| | - Sage Hellerstedt
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH
| | - Ferdaus Hassan
- Office of Evidence-Based Practice, Children's Mercy Hospital, Kansas City, Mo
| | - Kori Hess
- Office of Evidence-Based Practice, Children's Mercy Hospital, Kansas City, Mo
| | - Caroline Horner
- Department of Pediatrics, Division of Allergy, Immunology, and Pulmonary Medicine, Washington University School of Medicine, St. Louis, Mo
| | - Kelly Huntington
- Office of Evidence-Based Practice, Children's Mercy Hospital, Kansas City, Mo
| | - Poojita Kasireddy
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH
| | - David Keeler
- Office of Evidence-Based Practice, Children's Mercy Hospital, Kansas City, Mo
| | - Bertha Kim
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH
| | - Phil Lieberman
- Department of Pediatrics, The University of Tennessee Health Science Center, Memphis, Tenn
| | - Erin Lindhorst
- Office of Evidence-Based Practice, Children's Mercy Hospital, Kansas City, Mo
| | - Fiona McEnany
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH
| | - Jennifer Milbank
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH
| | - Helen Murphy
- Office of Evidence-Based Practice, Children's Mercy Hospital, Kansas City, Mo
| | - Oriana Pando
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH
| | - Ami K Patel
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH
| | - Nicole Ratliff
- Office of Evidence-Based Practice, Children's Mercy Hospital, Kansas City, Mo
| | - Robert Rhodes
- Office of Evidence-Based Practice, Children's Mercy Hospital, Kansas City, Mo
| | - Kim Robertson
- Office of Evidence-Based Practice, Children's Mercy Hospital, Kansas City, Mo
| | - Hope Scott
- Office of Evidence-Based Practice, Children's Mercy Hospital, Kansas City, Mo
| | - Audrey Snell
- Office of Evidence-Based Practice, Children's Mercy Hospital, Kansas City, Mo
| | - Rhonda Sullivan
- Office of Evidence-Based Practice, Children's Mercy Hospital, Kansas City, Mo
| | - Varahi Trivedi
- The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH
| | - Azadeh Wickham
- Office of Evidence-Based Practice, Children's Mercy Hospital, Kansas City, Mo
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Abstract
Anaphylaxis is an acute, potentially life-threatening systemic hypersensitivity reaction. Classically, anaphylaxis is an immunoglobulin (Ig) E-mediated reaction; however, IgG or immune complex complement-related immunologic reactions that lead to degranulation of mast cells can also cause anaphylaxis. Food allergy is the most common cause of anaphylaxis, followed by drugs. Patients with anaphylaxis commonly present with symptoms involving skin or mucous membranes, followed by respiratory and gastrointestinal symptoms. Epinephrine is the drug of choice for treating anaphylaxis. Patients and caregivers should be educated on the use of epinephrine autoinjectors with periodic review of symptoms and emergency action plan for anaphylaxis.
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Affiliation(s)
- Pavadee Poowuttikul
- Children's Hospital of Michigan, Wayne State University School of Medicine, 3950 Beaubien, Detroit, MI 48201, USA.
| | - Divya Seth
- Children's Hospital of Michigan, Wayne State University School of Medicine, 3950 Beaubien, Detroit, MI 48201, USA
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Affiliation(s)
- Johannes Ring
- Klinik und Poliklinik für Dermatologie und Allergologie am Biederstein der TU München, Biedersteinerstr. 29, D-80802, München, Deutschland.
| | - Andreas Weins
- Klinik und Poliklinik für Dermatologie und Allergologie am Biederstein der TU München, Biedersteinerstr. 29, D-80802, München, Deutschland
| | - Martine Grosber
- Klinik und Poliklinik für Dermatologie und Allergologie am Biederstein der TU München, Biedersteinerstr. 29, D-80802, München, Deutschland
| | - Knut Brockow
- Klinik und Poliklinik für Dermatologie und Allergologie am Biederstein der TU München, Biedersteinerstr. 29, D-80802, München, Deutschland
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Asthma and Food Allergy: Which Risks? ACTA ACUST UNITED AC 2019; 55:medicina55090509. [PMID: 31438462 PMCID: PMC6780261 DOI: 10.3390/medicina55090509] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 08/15/2019] [Accepted: 08/16/2019] [Indexed: 11/16/2022]
Abstract
Over the past few decades, an increase in the prevalence of asthma and food allergy has been observed in the pediatric population. In infants, food sensitization, particularly to egg, has increased the risk of developing allergic asthma. This is even more likely if sensitization to food allergens occurs early within the first few years of life. It is indeed known that both diseases may be present simultaneously in the pediatric population, but coexistence may negatively influence the severity of both conditions by increasing the risk of life-threatening asthmatic episodes as well as food-related anaphylaxis. Therefore, an accurate clinical and phenotype characterization of this high-risk group of children with both asthma and food allergy and a more aggressive management might lead to reducing related morbidity and mortality. The aim of this review is to provide an updated overview on the close link between food allergy and asthma and their negative mutual influence.
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Hyeon CW, Lee JY, Jang S, Cho SI, Kim S, Lee W, Shin S. Medical malpractice related to drug-induced anaphylaxis: An analysis of lawsuit judgments in South Korea. Medicine (Baltimore) 2019; 98:e15996. [PMID: 31169740 PMCID: PMC6571263 DOI: 10.1097/md.0000000000015996] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Drug-induced anaphylaxis (DIA) is a highly paradoxical disorder involving a fatal response to medicines prescribed for therapeutic purposes. This study aimed to improve the awareness on DIA and to prevent errors through an analysis of lawsuit judgments.Sentenced judgments involving DIA from 1998 to 2017 using the database of the Korean Supreme Court Judgment System were collected. General characteristics, results, and recognized negligence of DIA litigation cases were analyzed.Of 27 lawsuit cases included, antibiotics (n = 6, 22.2%), radiocontrast media (n = 6, 22.2%), and non-steroidal anti-inflammatory drugs (n = 5, 18.5%) were the most common drugs that had caused DIA. Cardiac arrest was reported in 23 cases (85.2%). The median time interval from drug administration to diagnosis and from diagnosis to cardiac arrest were 7 (interquartile range, IQR = 0-35) and 5 minutes (IQR = 0-33), respectively, suggesting insufficient time to cope with anaphylaxis. Consequently, either death (n = 18, 66.7%) or ischemic brain injury (n = 9, 33.3%) occurred in all cases. Violation of duty of care was recognized in 19 cases (70.4%) with median awarded amount of $106,060 (IQR = $70,296-$168,363). The recognized negligence included inadequate observation after drug administration (n = 6), delayed or missed epinephrine administration (n = 6), ignoring a history of allergy or drug hypersensitivity (n = 6), and prescription error (n = 5).It is necessary to improve the awareness on DIA, because making a trivial error in any process of history taking, drug prescription and administration, observation, and/or emergency treatment may have fatal consequences that can lead to indemnity.
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Affiliation(s)
- Cheol Won Hyeon
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine
| | - Ji Young Lee
- Department of Pediatrics, Hallym University, Hangang Sacred Heart Hospital, Seoul
- Allergy and Clinical Immunology Research Center, Hallym University College of Medicine, Chunchun
| | - SeungGyeong Jang
- Asian Institute for Bioethics and Health Law
- Doctoral Program in Medical Law and Ethics, Yonsei University
| | - Soo Ick Cho
- Department of Dermatology, Seoul National University College of Medicine
| | - SoYoon Kim
- Asian Institute for Bioethics and Health Law
- Division of Medical Law and Bioethics, Department of Medical Humanities and Social Sciences, Yonsei University College of Medicine
| | - Won Lee
- Asian Institute for Bioethics and Health Law
- Division of Medical Law and Bioethics, Department of Medical Humanities and Social Sciences, Yonsei University College of Medicine
| | - SuHwan Shin
- Doctoral Program in Medical Law and Ethics, Yonsei University
- Blue Urology Clinic, Seoul, South Korea
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Anagnostou K, Turner PJ. Myths, facts and controversies in the diagnosis and management of anaphylaxis. Arch Dis Child 2019; 104:83-90. [PMID: 29909382 PMCID: PMC6317446 DOI: 10.1136/archdischild-2018-314867] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 05/29/2018] [Accepted: 05/30/2018] [Indexed: 12/22/2022]
Abstract
Anaphylaxis is a serious systemic allergic reaction that is rapid in onset and may cause death. Despite numerous national and international guidelines and consensus statements, common misconceptions still persist in terms of diagnosis and appropriate management, both among healthcare professionals and patient/carers. We address some of these misconceptions and highlight the optimal approach for patients who experience potentially life-threatening allergic reactions.
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Affiliation(s)
- Katherine Anagnostou
- Department of Pediatrics, Section of Immunology, Allergy and Rheumatology, Texas Children’s Hospital, Houston, Texas, USA
- Pediatrics, Section of Immunology, Allergy and Rheumatology, Baylor college of Medicine, Houston, TX, USA
| | - Paul J Turner
- Section of Paediatrics, Imperial College London, London, UK
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Clark S, Boggs KM, Balekian DS, Hasegawa K, Vo P, Rowe BH, Camargo CA. Changes in emergency department concordance with guidelines for the management of stinging insect-induced anaphylaxis: 1999-2001 vs 2013-2015. Ann Allergy Asthma Immunol 2018; 120:419-423. [PMID: 29407420 DOI: 10.1016/j.anai.2018.01.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 01/19/2018] [Accepted: 01/24/2018] [Indexed: 01/05/2023]
Abstract
BACKGROUND Changes in emergency department (ED) concordance with guidelines for the management of stinging insect-induced anaphylaxis (SIIA) are not known. OBJECTIVE To describe temporal changes in ED concordance with guidelines for the management of SIIAs. METHODS We analyzed data from 2 multicenter retrospective studies of patients with stinging insect-related acute allergic reactions seen in 1 of 14 North American EDs during 2 periods: 1999 through 2001 and 2013 through 2015. Visits were identified similarly across studies (eg, using International Classification of Diseases, Ninth Revision, Clinical Modification codes 989.5, 995.0, and 995.3). Anaphylaxis was defined as an acute allergic reaction with involvement of at least 2 organ systems or hypotension. We compared concordance between periods with 4 guideline recommendations: (1) treatment with epinephrine, (2) discharge prescription for epinephrine auto-injector, (3) referral to an allergist/immunologist, and (4) instructions to avoid the offending allergen. RESULTS We compared 182 patients with SIIA during 1999 to 2001 with 204 during 2013 to 2015. Any treatment with epinephrine (before arrival to the ED or in the ED) increased over time (30% vs 49%; P < .001). Prescriptions for epinephrine auto-injector at discharge increased significantly (34% vs 57%; P < .001), whereas documentation of referral to an allergist/immunologist decreased (28% vs 12%; P = .002), and instructions to avoid the offending allergen did not change (23% vs 24%; P = .94). Receipt of at least 3 guideline recommendations increased over time; however, the comparison was not statistically significant (10% vs 16%; P = .15). CONCLUSION During the nearly 15-year study interval, we observed increased ED concordance with epinephrine-related guideline recommendations for the management of SIIA. Reasons for the decrease in allergy/immunology referrals merit further study.
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Affiliation(s)
- Sunday Clark
- NewYork-Presbyterian Hospital/Weill Cornell Medical College, New York, New York.
| | | | - Diana S Balekian
- Massachusetts General Hospital, Boston, Massachusetts; Asthma and Allergy Affiliates, Salem, Massachusetts
| | | | - Phuong Vo
- Boston Medical Center, Boston, Massachusetts
| | - Brian H Rowe
- Department of Emergency Medicine and School of Public Health, University of Alberta, Edmonton, Alberta, Canada
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Demir S, Erdenen F, Gelincik A, Unal D, Olgac M, Coskun R, Colakoglu B, Buyukozturk S. Evaluation of the Potential Risk Factors for Drug-Induced Anaphylaxis in Adult Patients. Int Arch Allergy Immunol 2018; 178:167-176. [PMID: 30448840 DOI: 10.1159/000494130] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 09/28/2018] [Indexed: 11/19/2022] Open
Abstract
AIM To investigate the potential risk factors in patients who have experienced anaphylaxis from drugs. METHOD The study included 281 adult patients (median age 40 years; 76.5% female) who experienced immediate types of hypersensitivity reaction to a drug. The patients were divided into an anaphylaxis group and a nonanaphylaxis group. The anaphylaxis group was diagnosed according to the criteria of the World Allergy Organization. Skin testing with culprit drugs was performed. In the nonanaphylaxis group, drug provocation tests were performed with culprit drugs, including aspirin or diclofenac, to determine nonsteroidal anti-inflammatory drug (NSAID) hypersensitivity. Atopy was determined by skin prick tests with the common inhalant allergens. Patients' demographics, clinical features, and baseline tryptase and total IgE levels were compared between the 2 groups. RESULTS The median interval between the last reaction in the patient's history and the study evaluation was 7 months (range 1-120 months). In 52.3% of the patients, reactions were defined as anaphylaxis. The most common culprit drugs were NSAIDs (56.9%) and β-lactams (34.7%). The culprit drugs were used parenterally in 13.2% of the patients. 34.9% of the patients had comorbid diseases and 24.6% used additional drugs, the most common being antihypertensives (10%). Atopy was determined in 28.8% and 28.1% of the patients were smokers. The median serum level of baseline tryptase and total IgE was 3.5 µg/L and 77 kU/L, respectively. In 46.3% of the patients, skin tests with culprit drugs were positive and the positivity ratio was higher in the anaphylaxis group (p = 0.002). Anapyhlaxis was more common in patients who were: hypertensive, atopic, using angio-tensin-converting enzyme inhibitors/angiotensin receptor blockers, and received the culprit drug parenterally (p = 0.034, p = 0.04, p = 0.03, p = 0.035, p = 0.013, and p < 0.001). In the multivariate analysis, it was observed that the parenteral usage of the drug and the presence of atopy were significantly higher in the anaphylaxis group (p < 0.001, odds ratio [OR] = 20.05, confidence interval [CI] 4.75-88.64; p = 0.012, OR = 2.1, CI 1.17-3.74). Age, smoking, family history, and serum levels of baseline tryptase and total IgE did not differ between groups. CONCLUSION The parenteral route and atopy increase the risk of drug-induced anaphylaxis. IgE-mediated sensitivity to the culprit drug seems to facilitate anaphylaxis.
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Affiliation(s)
- Semra Demir
- Adult Allergy and Immunology Clinic, Istanbul Research and Training Hospital, Health Science University, Istanbul, Turkey,
| | - Fusun Erdenen
- Adult Allergy and Immunology Clinic, Istanbul Research and Training Hospital, Health Science University, Istanbul, Turkey
| | - Asli Gelincik
- Division of Immunology and Allergic Diseases, Department of Internal Medicine, Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Derya Unal
- Division of Immunology and Allergic Diseases, Department of Internal Medicine, Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Muge Olgac
- Division of Immunology and Allergic Diseases, Department of Internal Medicine, Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Raif Coskun
- Division of Immunology and Allergic Diseases, Department of Internal Medicine, Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Bahauddin Colakoglu
- Division of Immunology and Allergic Diseases, Department of Internal Medicine, Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Suna Buyukozturk
- Division of Immunology and Allergic Diseases, Department of Internal Medicine, Faculty of Medicine, Istanbul University, Istanbul, Turkey
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Demir S, Atici A, Coskun R, Olgac M, Unal D, Sarikaya R, Gelincik A, Colakoglu B, Oflaz H, Sonsoz MR, Buyukozturk S. Evaluation of the left venticular systolic function with the measurement of global longitudinal strain by Speckle tracking echocardiography in anaphylaxis. Asia Pac Allergy 2018; 8:e40. [PMID: 30402407 PMCID: PMC6209598 DOI: 10.5415/apallergy.2018.8.e40] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 10/13/2018] [Indexed: 12/20/2022] Open
Abstract
Background It is not known how cardiac functions are affected during anaphylaxis. Objective Our aim was to measure the cardiac functions shortly after an anaphylaxis attack using a new technique that detects subclinical left ventricular dysfunction. Methods Patients in our hospital who experienced anaphylaxis and urticaria (control group) due to any cause were included in the study. Tryptase levels were measured on the third hour of the reaction and 6 weeks later. Left ventricular systolic functions were evaluated with global strain measurement using echocardiography, approximately 4 hours and 6-week post reaction. Results Twelve patients were included in the anaphylaxis group (83.3% female; mean age, 43.25 ± 9.9 years). The causes of anaphylaxis were drug ingestion (n = 11) and venom immunotherapy. Eight of the anaphylactic reactions (66.7%) were severe and in 9 reactions (75%) tryptase levels increased. In the anaphylaxis group, strain values measured shortly after anaphylaxis were significantly lower than those calculated 6 weeks later (p < 0.001) and tryptase levels significantly increased (p = 0.002). The strain values measured both shortly after anaphylaxis and 6 weeks later did not differ according to severity of anaphylaxis. In severe anaphylaxis, tryptase levels during anaphylaxis and 6 weeks later were significantly higher (p = 0.019, p = 0.035). The control group evidenced no differences regarding strain and tryptase levels measured at reaction and 6 weeks later. At reaction, in the anaphylaxis group, the tryptase levels were higher and the strain values were lower than those in the urticaria group (p = 0.007, p = 0.003). Conclusion Cardiac dysfunction may develop during an anaphylaxis independent of severity of reaction.
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Affiliation(s)
- Semra Demir
- Department of Internal Medicine, Division of Immunology and Allergic Diseases, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Adem Atici
- Department of Cardiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Raif Coskun
- Department of Internal Medicine, Division of Immunology and Allergic Diseases, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Muge Olgac
- Department of Internal Medicine, Division of Immunology and Allergic Diseases, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Derya Unal
- Department of Internal Medicine, Division of Immunology and Allergic Diseases, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Remzi Sarikaya
- Department of Cardiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Aslı Gelincik
- Department of Internal Medicine, Division of Immunology and Allergic Diseases, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Bahattin Colakoglu
- Department of Internal Medicine, Division of Immunology and Allergic Diseases, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Huseyin Oflaz
- Department of Cardiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Mehmet Rasih Sonsoz
- Department of Cardiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Suna Buyukozturk
- Department of Internal Medicine, Division of Immunology and Allergic Diseases, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
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Tejedor‐Alonso MA, Martínez‐Fernandez P, Vallejo‐de‐Torres G, Navarro‐Escayola E, Moro‐Moro M, Alberti‐Masgrau N. Clinical and demographic characteristics of fatal anaphylaxis in Spain (1998‐2011): A comparison between a series from the hospital system and a national forensic series. Clin Exp Allergy 2018; 49:82-91. [DOI: 10.1111/cea.13272] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 08/26/2018] [Accepted: 09/01/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Miguel A. Tejedor‐Alonso
- Allergy Unit Hospital Universitario Fundación Alcorcón Madrid Spain
- Medicine and Surgery Area, Facultad Ciencias de la Salud Universidad Rey Juan Carlos Madrid Spain
| | | | | | | | - Mar Moro‐Moro
- Allergy Unit Hospital Universitario Fundación Alcorcón Madrid Spain
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Kounis NG, Cervellin G, Koniari I, Bonfanti L, Dousdampanis P, Charokopos N, Assimakopoulos SF, Kakkos SK, Ntouvas IG, Soufras GD, Tsolakis I. Anaphylactic cardiovascular collapse and Kounis syndrome: systemic vasodilation or coronary vasoconstriction? ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:332. [PMID: 30306071 DOI: 10.21037/atm.2018.09.05] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The first reported human anaphylactic death is considered to be the Pharaoh Menes death, caused by a wasp sting. Currently, anaphylactic cardiovascular events represent one of most frequent medical emergencies. Rapid diagnosis, prompt and appropriate treatment can be life saving. The main concept beyond anaphylaxis lies to myocardial damage and ventricular dysfunction, thus resulting in cardiovascular collapse. Cardiac output depression due to coronary hypoperfusion from systemic vasodilation, leakage of plasma and volume loss due to increased vascular permeability, as well as reduced venous return, are regarded as the main causes of cardiovascular collapse. Clinical reports and experiments indicate that the human heart, in general, and the coronary arteries, in particular, could be the primary target of the released anaphylactic mediators. Coronary vasoconstriction and thrombosis induced by the released mediators namely histamine, chymase, tryptase, cathepsin D, leukotrienes, thromboxane and platelet activating factor (PAF) can result to further myocardial damage and anaphylaxis associated acute coronary syndrome, the so-called Kounis syndrome. Kounis syndrome with increase of cardiac troponin and other cardiac biomarkers, can progress to heart failure and cardiovascular collapse. In experimental anaphylaxis, cardiac reactions caused by the intracardiac histamine and release of other anaphylactic mediators are followed by secondary cardiovascular reactions, such as cardiac arrhythmias, atrioventricular block, acute myocardial ischemia, decrease in coronary blood flow and cardiac output, cerebral blood flow, left ventricular developed pressure (LVdp/dtmax) as well as increase in portal venous and coronary vascular resistance denoting vascular spasm. Clinically, some patients with anaphylactic myocardial infarction respond satisfactorily to appropriate interventional and medical therapy, while anti-allergic treatment with antihistamines, corticosteroids and fluid replacement might be ineffective. Therefore, differentiating the decrease of cardiac output due to myocardial tissue hypoperfusion from systemic vasodilation and leakage of plasma, from myocardial tissue due to coronary vasoconstriction and thrombosis might be challenging during anaphylactic cardiac collapse. Combined antiallergic, anti-ischemic and antithrombotic treatment seems currently beneficial. Simultaneous measurements of peripheral arterial resistance and coronary blood flow with newer diagnostic techniques including cardiac magnetic resonance imaging (MRI) and myocardial scintigraphy may help elucidating the pathophysiology of anaphylactic cardiovascular collapse, thus rendering treatment more rapid and effective.
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Affiliation(s)
- Nicholas G Kounis
- Department of Cardiology University of Patras Medical School, Rion, Patras, Achaia, Greece
| | | | - Ioanna Koniari
- Department of Electrophysiology, Queen Elizabeth Hospital, Birmingham, England
| | - Laura Bonfanti
- Emergency Department, Academic Hospital of Parma, Parma, Italy
| | | | - Nikolaos Charokopos
- Division of Pneumology, Department of Internal Medicine, General Hospital of Pirgos, Pirgos, Greece
| | - Stelios F Assimakopoulos
- Department of Internal Medicine, Division of Infectious Diseases, University of Patras Medical School, Patras, Greece
| | - Stavros K Kakkos
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - Ioannis G Ntouvas
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
| | - George D Soufras
- Department of Cardiology, "Saint Andrews State General Hospital", Patras, Achaia, Greece
| | - Ioannis Tsolakis
- Department of Vascular Surgery, University of Patras Medical School, Patras, Greece
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