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Yang BC. Biologics to treat anaphylaxis. Curr Opin Allergy Clin Immunol 2023; 23:370-375. [PMID: 37527059 DOI: 10.1097/aci.0000000000000940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2023]
Abstract
PURPOSE OF REVIEW The purpose of this literature review was to review the latest use of biologics in the management of anaphylaxis. The methodology was to highlight both the nonbiologic management of anaphylaxis and the biologic management and how they can be used in conjunction with each other. RECENT FINDINGS As the phenotypes and endotypes of anaphylaxis are better portrayed, it furthers our understanding of the mechanisms of anaphylaxis. New applications of existing biologics to the prevention of anaphylaxis are described. SUMMARY Anaphylaxis is a potentially life-threatening acute hypersensitivity reaction affecting up to 16.8% of the U.S. population. Acute management entails swift identification, removal of the causative agent, and the prevention of cardiovascular collapse, firstly with epinephrine. Adjunctive treatments such as antihistamines work to prevent anaphylaxis from recurring. Biologic management of anaphylaxis involves the use of large-molecule drugs such as monoclonal antibodies. Omalizumab, an IgG1 monoclonal antibody targeting unbound IgE, is the most prevalent and widely studied biologic in the prevention of anaphylaxis. Other monoclonal antibodies in development or approved for other indications, such as ligelizumab, quilizumab, MEDI4212, and dupilumab, may also have potential for preventing anaphylaxis through various mechanisms.
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Tanno LK, Worm M, Ebisawa M, Ansotegui IJ, Senna G, Fineman S, Geller M, Gonzalez-Estrada A, Campbell DE, Leung A, Muraro A, Levin M, Ortega Martell JA, Caminati M, Kolkhir P, Le Pham D, Darlenski R, Esteban-Gorgojo I, Rial M, Filipovic I, Chiarella SE, Cuervo-Pardo L, Kwong C, Pozo-Beltran CF, Trinh THK, Greenberger PA, Turner PJ, Thong BYH, Martin B, Cardona V. Global disparities in availability of epinephrine auto-injectors. World Allergy Organ J 2023; 16:100821. [PMID: 37915955 PMCID: PMC10616381 DOI: 10.1016/j.waojou.2023.100821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 09/05/2023] [Accepted: 09/11/2023] [Indexed: 11/03/2023] Open
Abstract
Background Anaphylaxis is the most severe clinical presentation of acute systemic allergic reactions and can cause death. Given the prevalence of anaphylaxis within healthcare systems, it is a high priority public health issue. However, management of anaphylaxis - both acute and preventative - varies by region. Methods The World Allergy Organization (WAO) Anaphylaxis Committee and the WAO Junior Members Steering Group undertook a global online survey to evaluate local practice in the diagnosis and management of anaphylaxis across regions. Results Responses were received from WAO members in 66 countries. While intramuscular epinephrine (adrenaline) is first-line treatment for anaphylaxis, some countries continue to recommend alternative routes in contrast to guidelines. Epinephrine auto-injector (EAI) devices, prescribed to individuals at ongoing risk of anaphylaxis in the community setting, are only available in 60% of countries surveyed, mainly in high-income countries. Many countries in South America, Africa/Middle-East and Asian-Pacific regions do not have EAI available, or depend on individual importation. In countries where EAIs are commercially available, national policies regarding the availability of EAIs in public settings are limited to few countries (16%). There is no consensus regarding the time patients should be observed following emergency treatment of anaphylaxis. Conclusion This survey provides a global snapshot view of the current management of anaphylaxis, and highlights key unmet needs including the global availability of epinephrine for self-injection as a key component of anaphylaxis management.
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Affiliation(s)
- Luciana Kase Tanno
- Division of Allergy, Department of Pulmonology, Allergy and Thoracic Oncology, University Hospital of Montpellier, Montpellier, France
- Desbrest Institute of Epidemiology and Public Health, UMR UA11 University of Montpellier - INSERM, France
- WHO Collaborating Centre on Scientific Classification Support, Montpellier, France
- Department of Pulmonology, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, 371, av. du Doyen Gaston Giraud, 34295 Cedex 5, Montpellier, France
| | - Margitta Worm
- Allergie-Centrum-Charité, Klinik für Dermatologie, Venerologie und Allergologie, Campus Charité Mitte, Universitätsmedizin Berlin, Germany
| | - Motohiro Ebisawa
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Sagamihara, Japan
| | - Ignacio J. Ansotegui
- Department of Allergy and Immunology, Hospital Quironsalud Bizkaia, Bilbao, Spain
| | - Gianenrico Senna
- Department of Medicine, Allergy Asthma and Clinical Immunology Section, University of Verona, Verona, Italy
| | - Stanley Fineman
- Atlanta Allergy & Asthma, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Mario Geller
- Section of Medicine of the Brazilian Academy of Medicine of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Alexei Gonzalez-Estrada
- Division of Allergy, Asthma and Clinical Immunology, Department of Medicine, Mayo Clinic, Scottsdale, AZ, USA
| | | | - Agnes Leung
- The Chinese University of Hong Kong, Department of Pediatrics, Prince of Wales Hospital, Hong Kong Special Administrative Region of China
| | - Antonella Muraro
- Department of Mother and Child Health University of Padua Padua, Italy
| | - Michael Levin
- Division of Paediatric Allergology, University of Cape Town, Cape Town, South Africa
| | | | - Marco Caminati
- Department of Medicine, University of Verona, Verona, Italy
| | - Pavel Kolkhir
- Institute of Allergology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany
| | - Duy Le Pham
- Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Viet nam
| | - Razvigor Darlenski
- Department of Dermatology and Venereology, Acibadem City Clinic Tokuda Hospital Sofia, 51B Nikola Vaptsarov Blvd., 1407, Sofia, Bulgaria
- Department of Dermatology and Venereology, Trakia University-Stara Zagora, Stara Zagora, Bulgaria
| | | | - Manuel Rial
- Allergology Section, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | | | | | - Lyda Cuervo-Pardo
- Division of Rheumatology, Allergy and Clinical Immunology, Department of Medicine, University of Florida, USA
| | | | | | - Tu HK. Trinh
- Center for Molecular Biomedicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Viet nam
| | - Paul A. Greenberger
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Ill, USA
| | - Paul J. Turner
- National Heart & Lung Institute, Imperial College London, London, UK
| | - Bernard Yu-Hor Thong
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore
| | - Bryan Martin
- Medicine and Pediatrics, The Ohio State University in Columbus, Ohio, USA
| | - Victoria Cardona
- Allergy Section, Department of Internal Medicine, Hospital Vall d'Hebron, and ARADyAL Research Network, Spain
| | - the WAO Anaphylaxis Committee and the WAO Junior Members Steering Group
- Division of Allergy, Department of Pulmonology, Allergy and Thoracic Oncology, University Hospital of Montpellier, Montpellier, France
- Desbrest Institute of Epidemiology and Public Health, UMR UA11 University of Montpellier - INSERM, France
- WHO Collaborating Centre on Scientific Classification Support, Montpellier, France
- Department of Pulmonology, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, 371, av. du Doyen Gaston Giraud, 34295 Cedex 5, Montpellier, France
- Allergie-Centrum-Charité, Klinik für Dermatologie, Venerologie und Allergologie, Campus Charité Mitte, Universitätsmedizin Berlin, Germany
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Sagamihara, Japan
- Department of Allergy and Immunology, Hospital Quironsalud Bizkaia, Bilbao, Spain
- Department of Medicine, Allergy Asthma and Clinical Immunology Section, University of Verona, Verona, Italy
- Atlanta Allergy & Asthma, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
- Section of Medicine of the Brazilian Academy of Medicine of Rio de Janeiro, Rio de Janeiro, Brazil
- Division of Allergy, Asthma and Clinical Immunology, Department of Medicine, Mayo Clinic, Scottsdale, AZ, USA
- The University of Sydney, New South Wales, Australia
- The Chinese University of Hong Kong, Department of Pediatrics, Prince of Wales Hospital, Hong Kong Special Administrative Region of China
- Department of Mother and Child Health University of Padua Padua, Italy
- Division of Paediatric Allergology, University of Cape Town, Cape Town, South Africa
- Department of Immunology, Universidad Autónoma del Estado de Hidalgo, Pachuca, Hidalgo, Mexico
- Department of Medicine, University of Verona, Verona, Italy
- Institute of Allergology, Charité – Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Allergology and Immunology, Berlin, Germany
- Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Viet nam
- Department of Dermatology and Venereology, Acibadem City Clinic Tokuda Hospital Sofia, 51B Nikola Vaptsarov Blvd., 1407, Sofia, Bulgaria
- Department of Dermatology and Venereology, Trakia University-Stara Zagora, Stara Zagora, Bulgaria
- Department of Allergy, Hospital General de Villalba, Madrid, Spain
- Allergology Section, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
- University Hospital Dr Dragisa Misovic, Serbia
- Division of Allergic Diseases, Mayo Clinic, Rochester, MN, USA
- Division of Rheumatology, Allergy and Clinical Immunology, Department of Medicine, University of Florida, USA
- Phoenix Children's Hospital, Phoenix, AZ, USA
- Hospital Infantil de México Federico Gómez, Mexico
- Center for Molecular Biomedicine, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Viet nam
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Ill, USA
- National Heart & Lung Institute, Imperial College London, London, UK
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore
- Medicine and Pediatrics, The Ohio State University in Columbus, Ohio, USA
- Allergy Section, Department of Internal Medicine, Hospital Vall d'Hebron, and ARADyAL Research Network, Spain
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Trends and determinants of epinephrine prescriptions: a proxy of anaphylaxis epidemiology? Curr Opin Allergy Clin Immunol 2022; 22:441-449. [PMID: 36165443 DOI: 10.1097/aci.0000000000000861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW Epinephrine autoinjectors (EAIs) are recommended to all patients previously experiencing anaphylaxis reaction in order to prevent further reactions and fatalities. Under that perspective, EAI prescription could be considered as a proxy of anaphylaxis epidemiology. Nevertheless EAI prescription rates are still unacceptably low. RECENT FINDINGS The review focuses on potential determinants, in addition to clinical indications, which might impact EAI prescription rates by exploring the scientific literature published within the past 18 months, wherever available. Although some controversial results, age, sex, ethnicity, geographical setting and socioeconomic conditions might influence both physician prescription behaviour and EAIs' accessibility from the patient's side, which hampers the accuracy of EAI prescription as a proxy of anaphylaxis. Low EAI prescription and refill rates have been recorded even in the absence of significant socioeconomic barriers, suggesting that economical limitations only partially account for the issue, and cultural restrictions have also to be considered and addressed. SUMMARY In addition to providing the same opportunities in terms of EAI availability in all countries worldwide, implementing the resources for anaphylaxis management in terms of practical knowledge, education, and allergy specialist networks is an urgent need, even in the absence of socioeconomic barriers.
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Triage Grading and Correct Diagnosis Are Critical for the Emergency Treatment of Anaphylaxis. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9121794. [PMID: 36553239 PMCID: PMC9776430 DOI: 10.3390/children9121794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 11/18/2022] [Accepted: 11/19/2022] [Indexed: 11/24/2022]
Abstract
Introduction: Anaphylaxis is one of the most frequent and misdiagnosed emergencies in the pediatric emergency department (PED). We aimed to assess which factors play a major role for a correct diagnosis and an appropriate therapy. Methods: We reviewed the records of children discharged with a diagnosis of anaphylaxis or an allergic reaction over 11 years from 3 hospitals in the Bologna city area. Results: One hundred and sixteen cases matched the criteria (0.03% of the total admittances) and were divided according to the patients’ symptoms at arrival: active acute patients [AP], n = 50, or non-acute patients ([NAP], n = 66). At the patients’ discharge, anaphylaxis was diagnosed in 39 patients (33.6%). Some features seemed to favor a correct diagnosis: active symptoms at arrival (AP vs. NAP, p < 0.01), high-priority triage code (p < 0.01), and upper airway involvement (p < 0.01). Only 14 patients (12.1%), all in the AP group, received epinephrine, that was more likely administered to patients recognized to have anaphylaxis (p < 0.01) and with cardiovascular, respiratory, or persistent gastrointestinal symptoms (p < 0.02), as confirmed by logistic regression analysis. Conclusions: Anaphylaxis is still under-recognized and under-treated. Correct triage coding and a proper diagnosis seem to foster an appropriate treatment. Physicians often prefer third-line interventions. Specific training for nurses and physicians might improve the management of this disease.
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Asthma and Anaphylaxis—interconnected entities. CURRENT TREATMENT OPTIONS IN ALLERGY 2022. [DOI: 10.1007/s40521-022-00324-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Collins K, Rueter K, Lucas M, Sommerfield D, Sommerfield A, Khan N, von Ungern‐Sternberg BS. Penicillin allergy SHACK: Survey of hospital and community knowledge. J Paediatr Child Health 2022; 58:1414-1419. [PMID: 35502826 PMCID: PMC9546145 DOI: 10.1111/jpc.16007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 04/14/2022] [Accepted: 04/21/2022] [Indexed: 11/30/2022]
Abstract
AIM Penicillin allergy accounts for the majority of all reported adverse drug reactions in adults and children. Foregoing first-line antibiotic therapy due to penicillin allergy label is associated with an increased prevalence of infections by resistant organisms and longer hospitalisation. Clinician awareness of allergy assessment, referral indications, management of allergy and anaphylaxis is therefore vital but globally lacking. We aim to assess the knowledge of penicillin allergy, assessment and management in Western Australian health professionals. METHODS An anonymous survey was distributed to pharmacists, nurses and physicians within Western Australian paediatric and adult Hospitals, Community and General Practice. RESULTS In total, 487/611 were completed and included in the statistical analysis. Only 62% (301/487) of respondents routinely assessed for patient medication allergies. Of those who assessed allergy, 9% (28/301) of respondents met the Australian standards for allergy assessment. Only 22% (106/487) of participants correctly cited all indications for management with adrenaline in anaphylaxis to antibiotics and 67% (197/292) of physicians rarely or never referred to an allergy service. Paediatric clinicians had an increased understanding of allergy assessment and anaphylaxis management. Recent penicillin allergy education within a 5-year period led to significant improvements in allergy knowledge. CONCLUSION Overall, knowledge, assessment and management of penicillin allergies among practitioners in Western Australia are currently inadequate in adults and paediatric clinicians to provide safe and effective clinical care. The implementation of a targeted education program for WA health professionals is urgently required and is expected to improve clinician knowledge and aid standardised penicillin assessment (de-labelling) practices.
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Affiliation(s)
- Katherine Collins
- Department of Anaesthesia and Pain ManagementPerth Children's HospitalPerthWestern AustraliaAustralia
| | - Kristina Rueter
- Department of Emergency MedicinePerth Children's HospitalPerthWestern AustraliaAustralia,Department of ImmunologyPerth Children's HospitalPerthWestern AustraliaAustralia,School of MedicineThe University of Western AustraliaPerthWestern AustraliaAustralia
| | - Michaela Lucas
- Department of ImmunologyPerth Children's HospitalPerthWestern AustraliaAustralia,School of MedicineThe University of Western AustraliaPerthWestern AustraliaAustralia,Department of ImmunologySir Charles Gairdner HospitalPerthWestern AustraliaAustralia,Institute for Immunology and Infectious DiseasesMurdoch UniversityMurdochWestern AustraliaAustralia,PathWest Laboratory MedicinePerthWestern AustraliaAustralia
| | - David Sommerfield
- Department of Anaesthesia and Pain ManagementPerth Children's HospitalPerthWestern AustraliaAustralia,School of MedicineThe University of Western AustraliaPerthWestern AustraliaAustralia,Perioperative MedicineTelethon Kids InstitutePerthWestern AustraliaAustralia
| | - Aine Sommerfield
- Department of Anaesthesia and Pain ManagementPerth Children's HospitalPerthWestern AustraliaAustralia,Perioperative MedicineTelethon Kids InstitutePerthWestern AustraliaAustralia
| | - Nazim Khan
- Department of Mathematics and StatisticsUniversity of Western AustraliaPerthWestern AustraliaAustralia
| | - Britta S von Ungern‐Sternberg
- Department of Anaesthesia and Pain ManagementPerth Children's HospitalPerthWestern AustraliaAustralia,School of MedicineThe University of Western AustraliaPerthWestern AustraliaAustralia,Perioperative MedicineTelethon Kids InstitutePerthWestern AustraliaAustralia
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Patrignani P, Steinhilber D. Editorial: Insights in Inflammation Pharmacology: 2021. Front Pharmacol 2022; 13:928535. [PMID: 35712698 PMCID: PMC9197213 DOI: 10.3389/fphar.2022.928535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 05/18/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Paola Patrignani
- Department of Neuroscience, Imaging and Clinical Science, and CAST, “G. d’Annunzio” University, Chieti, Italy
- *Correspondence: Paola Patrignani,
| | - Dieter Steinhilber
- Institut fuer Pharmazeutische Chemie, Universitaet Frankfurt, Frankfurt am Main, Germany
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Nuñez-Borque E, Fernandez-Bravo S, Yuste-Montalvo A, Esteban V. Pathophysiological, Cellular, and Molecular Events of the Vascular System in Anaphylaxis. Front Immunol 2022; 13:836222. [PMID: 35371072 PMCID: PMC8965328 DOI: 10.3389/fimmu.2022.836222] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 02/07/2022] [Indexed: 01/10/2023] Open
Abstract
Anaphylaxis is a systemic hypersensitivity reaction that can be life threatening. Mechanistically, it results from the immune activation and release of a variety of mediators that give rise to the signs and symptoms of this pathological event. For years, most of the research in anaphylaxis has focused on the contribution of the immune component. However, approaches that shed light on the participation of other cellular and molecular agents are necessary. Among them, the vascular niche receives the various signals (e.g., histamine) that elicit the range of anaphylactic events. Cardiovascular manifestations such as increased vascular permeability, vasodilation, hypotension, vasoconstriction, and cardiac alterations are crucial in the pathophysiology of anaphylaxis and are highly involved to the development of the most severe cases. Specifically, the endothelium, vascular smooth muscle cells, and their molecular signaling outcomes play an essential role downstream of the immune reaction. Therefore, in this review, we synthesized the vascular changes observed during anaphylaxis as well as its cellular and molecular components. As the risk of anaphylaxis exists both in clinical procedures and in routine life, increasing our knowledge of the vascular physiology and their molecular mechanism will enable us to improve the clinical management and how to treat or prevent anaphylaxis. Key Message Anaphylaxis, the most severe allergic reaction, involves a variety of immune and non-immune molecular signals that give rise to its pathophysiological manifestations. Importantly, the vascular system is engaged in processes relevant to anaphylactic events such as increased vascular permeability, vasodilation, hypotension, vasoconstriction, and decreased cardiac output. The novelty of this review focuses on the fact that new studies will greatly improve the understanding of anaphylaxis when viewed from a vascular molecular angle and specifically from the endothelium. This knowledge will improve therapeutic options to treat or prevent anaphylaxis.
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Affiliation(s)
- Emilio Nuñez-Borque
- Department of Allergy and Immunology, Instituto en Investigación Sanitaria - Fundación Jiménez Díaz (IIS-FJD), Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - Sergio Fernandez-Bravo
- Department of Allergy and Immunology, Instituto en Investigación Sanitaria - Fundación Jiménez Díaz (IIS-FJD), Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - Alma Yuste-Montalvo
- Department of Allergy and Immunology, Instituto en Investigación Sanitaria - Fundación Jiménez Díaz (IIS-FJD), Universidad Autónoma de Madrid (UAM), Madrid, Spain
| | - Vanesa Esteban
- Department of Allergy and Immunology, Instituto en Investigación Sanitaria - Fundación Jiménez Díaz (IIS-FJD), Universidad Autónoma de Madrid (UAM), Madrid, Spain.,Faculty of Medicine and Biomedicine, Alfonso X El Sabio University, Madrid, Spain
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Murakami Y, Kaneko S, Yokoyama H, Ishizaki H, Sekino M, Murata H, Hara T. Successful treatment of severe adrenaline-resistant anaphylactic shock with glucagon in a patient taking a beta-blocker: a case report. JA Clin Rep 2021; 7:86. [PMID: 34907487 PMCID: PMC8671579 DOI: 10.1186/s40981-021-00490-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 11/29/2021] [Accepted: 12/04/2021] [Indexed: 01/19/2023] Open
Abstract
Background The efficacy of glucagon for adrenaline-resistant anaphylactic shock in patients taking β-blockers is controversial. However, understanding the efficacy of glucagon is important because adrenaline-resistant anaphylactic shock is fatal. We present a case of severe adrenaline-resistant anaphylactic shock in a patient taking a β-blocker, and glucagon was effective in improving hemodynamics. Case presentation An 88-year-old woman with severe aortic stenosis and taking a selective β-1 blocker underwent transcatheter aortic valve implantation under general anesthesia. Postoperatively, she received 100 mg sugammadex, but 2 min later developed severe hypotension and bronchospasm. Suspecting anaphylactic shock, we intervened by administering adrenaline, fluid loading, and an increased noradrenaline dose. Consequently, the bronchospasm improved, but her blood pressure only increased minimally. Therefore, we administered 1 mg glucagon intravenously, and the hypotension resolved immediately. Conclusions Glucagon may improve hemodynamics in adrenaline-resistant anaphylactic shock patients taking β-blockers; however, its efficacy must be further evaluated in more cases.
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Affiliation(s)
- Yu Murakami
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Shohei Kaneko
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan.
| | - Haruka Yokoyama
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Hironori Ishizaki
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Motohiro Sekino
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Hiroaki Murata
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Tetsuya Hara
- Department of Anesthesiology and Intensive Care Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
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Cho H, Park J, Kim HK, Hwang ES, Lee K. Dimerized Translationally Controlled Tumor Protein-Binding Peptide 2 Attenuates Systemic Anaphylactic Reactions Through Direct Suppression of Mast Cell Degranulation. Front Pharmacol 2021; 12:764321. [PMID: 34737708 PMCID: PMC8560797 DOI: 10.3389/fphar.2021.764321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 10/04/2021] [Indexed: 11/13/2022] Open
Abstract
Dimerized translationally controlled tumor protein (dTCTP) amplifies allergic responses through activation of several types of immune cells and release of inflammatory mediators. In particular, dTCTP plays an important role in histamine release by triggering mast cells and has been proposed as a target in the treatment of allergic diseases. dTCTP-binding peptide 2 (dTBP2) is known to attenuate severe allergic rhinitis and asthma through inhibition of dTCTP activity on airway epithelial cells and T cells; however, it is unclear whether dTBP2 affects mast cell function and mast cell disease. In this study, we explored the effects of dTBP2 on mast cell degranulation and allergen-induced anaphylactic reactions. We found that bacterial product lipopolysaccharide increased the expression of dTCTP in mast cells and rapidly released dTCTP by the mast cell stimulator compound 48/80. Interestingly, the released dTCTP further promoted mast cell degranulation in an autocrine activation manner and increased calcium mobilization in mast cells, which is essential for degranulation. Furthermore, dTBP2 directly and dose-dependently inhibited in vitro mast cell degranulation enhanced by compound 48/80, suggesting a direct and potent anti-anaphylactic activity of dTBP2. dTBP2 also significantly suppressed the dTCTP-induced degranulation and histamine release through inhibition of the p38 MAPK signaling pathway and suppression of lysosomal expansion and calcium mobilization in mast cells. More importantly, in vivo administration of dTBP2 decreased mortality and significantly attenuated histamine release and inflammatory cytokine production in compound 48/80-induced systemic anaphylactic reactions. These results suggest that dTBP2 is beneficial for the control of anaphylaxis with increased dTCTP.
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Affiliation(s)
- Hyunsoo Cho
- Graduate School of Pharmaceutical Sciences, College of Pharmacy, Ewha Womans University, Seoul, South Korea
| | - Jiyoung Park
- Graduate School of Pharmaceutical Sciences, College of Pharmacy, Ewha Womans University, Seoul, South Korea.,Fluorescence Core Imaging Center, Department of Life Science, Ewha Womans University, Seoul, South Korea
| | - Hyo Kyeong Kim
- Graduate School of Pharmaceutical Sciences, College of Pharmacy, Ewha Womans University, Seoul, South Korea
| | - Eun Sook Hwang
- Graduate School of Pharmaceutical Sciences, College of Pharmacy, Ewha Womans University, Seoul, South Korea
| | - Kyunglim Lee
- Graduate School of Pharmaceutical Sciences, College of Pharmacy, Ewha Womans University, Seoul, South Korea
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Abstract
PURPOSE OF REVIEW To provide the most recent insights in the use of biologicals in the treatment of patients with anaphylaxis. RECENT FINDINGS There is evidence that biologics such as omalizumab may be safe and effective in preventing anaphylactic reactions in patients at high risk mainly because of severe food allergy or desensitization procedures to food, airborne allergen, drugs, or hymenoptera venom. SUMMARY Further knowledge will guide the adoption and implementation of any new therapy including biologics for anaphylaxis according to the stratification of risk/benefits.
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Abstract
PURPOSE OF REVIEW Epinephrine is the agreed-upon first line treatment for anaphylaxis, yet it continues to be underused by patients/caregivers and providers alike. RECENT FINDINGS There are unfortunately limited data on how epinephrine can best be utilized in anaphylaxis, which hinders how best to inform patients and providers. Studies reporting underuse suggest various barriers and themes on why this may happen. SUMMARY Continued education of patients, caregivers, and providers is needed; however, is not likely to be enough to close the gap. Thus, novel studies on how to increase use; increase availability in a cost-effective manner; and newer, effective delivery routes are still needed.
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Van de Voorde P, Turner NM, Djakow J, de Lucas N, Martinez-Mejias A, Biarent D, Bingham R, Brissaud O, Hoffmann F, Johannesdottir GB, Lauritsen T, Maconochie I. [Paediatric Life Support]. Notf Rett Med 2021; 24:650-719. [PMID: 34093080 PMCID: PMC8170638 DOI: 10.1007/s10049-021-00887-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 12/11/2022]
Abstract
The European Resuscitation Council (ERC) Paediatric Life Support (PLS) guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR). This section provides guidelines on the management of critically ill or injured infants, children and adolescents before, during and after respiratory/cardiac arrest.
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Affiliation(s)
- Patrick Van de Voorde
- Department of Emergency Medicine, Faculty of Medicine UG, Ghent University Hospital, Gent, Belgien
- Federal Department of Health, EMS Dispatch Center, East & West Flanders, Brüssel, Belgien
| | - Nigel M. Turner
- Paediatric Cardiac Anesthesiology, Wilhelmina Children’s Hospital, University Medical Center, Utrecht, Niederlande
| | - Jana Djakow
- Paediatric Intensive Care Unit, NH Hospital, Hořovice, Tschechien
- Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno, Medical Faculty of Masaryk University, Brno, Tschechien
| | | | - Abel Martinez-Mejias
- Department of Paediatrics and Emergency Medicine, Hospital de Terassa, Consorci Sanitari de Terrassa, Barcelona, Spanien
| | - Dominique Biarent
- Paediatric Intensive Care & Emergency Department, Hôpital Universitaire des Enfants, Université Libre de Bruxelles, Brüssel, Belgien
| | - Robert Bingham
- Hon. Consultant Paediatric Anaesthetist, Great Ormond Street Hospital for Children, London, Großbritannien
| | - Olivier Brissaud
- Réanimation et Surveillance Continue Pédiatriques et Néonatales, CHU Pellegrin – Hôpital des Enfants de Bordeaux, Université de Bordeaux, Bordeaux, Frankreich
| | - Florian Hoffmann
- Pädiatrische Intensiv- und Notfallmedizin, Kinderklinik und Kinderpoliklinik im Dr. von Haunerschen Kinderspital, Ludwig-Maximilians-Universität, München, Deutschland
| | | | - Torsten Lauritsen
- Paediatric Anaesthesia, The Juliane Marie Centre, University Hospital of Copenhagen, Kopenhagen, Dänemark
| | - Ian Maconochie
- Paediatric Emergency Medicine, Faculty of Medicine Imperial College, Imperial College Healthcare Trust NHS, London, Großbritannien
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Van de Voorde P, Turner NM, Djakow J, de Lucas N, Martinez-Mejias A, Biarent D, Bingham R, Brissaud O, Hoffmann F, Johannesdottir GB, Lauritsen T, Maconochie I. European Resuscitation Council Guidelines 2021: Paediatric Life Support. Resuscitation 2021; 161:327-387. [PMID: 33773830 DOI: 10.1016/j.resuscitation.2021.02.015] [Citation(s) in RCA: 151] [Impact Index Per Article: 50.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
These European Resuscitation Council Paediatric Life Support (PLS) guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the management of critically ill infants and children, before, during and after cardiac arrest.
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Affiliation(s)
- Patrick Van de Voorde
- Department of Emergency Medicine Ghent University Hospital, Faculty of Medicine UG, Ghent, Belgium; EMS Dispatch Center, East & West Flanders, Federal Department of Health, Belgium.
| | - Nigel M Turner
- Paediatric Cardiac Anesthesiology, Wilhelmina Children's Hospital, University Medical Center, Utrecht, Netherlands
| | - Jana Djakow
- Paediatric Intensive Care Unit, NH Hospital, Hořovice, Czech Republic; Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno, Medical Faculty of Masaryk University, Brno, Czech Republic
| | | | - Abel Martinez-Mejias
- Department of Paediatrics and Emergency Medicine, Hospital de Terassa, Consorci Sanitari de Terrassa, Barcelona, Spain
| | - Dominique Biarent
- Paediatric Intensive Care & Emergency Department, Hôpital Universitaire des Enfants, Université Libre de Bruxelles, Brussels, Belgium
| | - Robert Bingham
- Hon. Consultant Paediatric Anaesthetist, Great Ormond Street Hospital for Children, London, UK
| | - Olivier Brissaud
- Réanimation et Surveillance Continue Pédiatriques et Néonatales, CHU Pellegrin - Hôpital des Enfants de Bordeaux, Université de Bordeaux, Bordeaux, France
| | - Florian Hoffmann
- Paediatric Intensive Care and Emergency Medicine, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University, Munich, Germany
| | | | - Torsten Lauritsen
- Paediatric Anaesthesia, The Juliane Marie Centre, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Ian Maconochie
- Paediatric Emergency Medicine, Imperial College Healthcare Trust NHS, Faculty of Medicine Imperial College, London, UK
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Critical Care Management of the Patient With Anaphylaxis: A Concise Definitive Review. Crit Care Med 2021; 49:838-857. [PMID: 33653974 DOI: 10.1097/ccm.0000000000004893] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Anaphylaxis is a rapidly progressive life-threatening syndrome manifesting as pruritus, urticaria, angioedema, bronchospasm and shock. The goal of this synthetic review is to provide a practical, updated approach to the evaluation and management of this disorder and associated complications. DATA SOURCES A MEDLINE search was conducted with the MeSH of anaphylaxis, anaphylactic reaction, anaphylactic shock, refractory anaphylaxis and subheadings of diagnosis, classification, epidemiology, complications and pharmacology. The level of evidence supporting an intervention was evaluated based on the availability of randomized studies, expert opinion, case studies, reviews, practice parameters and other databases (including Cochrane). STUDY SELECTION Selected publications describing anaphylaxis, clinical trials, diagnosis, mechanisms, risk factors and management were retrieved (reviews, guidelines, clinical trials, case series) and their bibliographies were also reviewed to identify relevant publications. DATA EXTRACTION Data from the relevant publications were reviewed, summarized and the information synthesized. DATA SYNTHESIS This is a synthetic review and the data obtained from a literature review was utilized to describe current trends in the diagnosis and management of the patient with anaphylaxis with a special emphasis on newer evolving concepts of anaphylaxis endotypes and phenotypes, management of refractory anaphylaxis in the ICU setting and review of therapeutic options for the elderly patient, or the complicated patient with severe cardiorespiratory complications. Most of the recommendations come from practice parameters, case studies or expert opinions, with a dearth of randomized trials to support specific interventions. CONCLUSION Anaphylaxis is a rapidly progressive life-threatening disorder. The critical care physician needs to be familiar with the diagnosis, differential diagnosis, evaluation, and management of anaphylaxis. Skilled intervention in ICUs may be required for the patient with complicated, severe, or refractory anaphylaxis.
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A Proposal from the Montpellier World Health Organization Collaborating Centre for Better Management and Prevention of Anaphylaxis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:676-683.e1. [PMID: 33059097 DOI: 10.1016/j.jaip.2020.09.062] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/29/2020] [Accepted: 09/30/2020] [Indexed: 12/23/2022]
Abstract
Since the first description of anaphylaxis in 1902, its clinical importance as an emergency condition has been recognized worldwide. Anaphylaxis is a severe, potentially life-threatening systemic hypersensitivity reaction characterized by rapid onset and the potential to endanger life through respiratory or circulatory compromise. It is usually, although not always, associated with skin and mucosal changes. Although the academic/scientific communities have advocated to promote greater awareness and protocols for the management of anaphylaxis based on best evidence, there are few efforts documenting feedback as to the success of these efforts. In this article, we review the key unmet needs related to the diagnosis and management of anaphylaxis, and propose a public health initiative for prevention measures and a timetable action plan that intends to strengthen the collaboration among health professionals and especially primary care physicians dealing with anaphylaxis, which can encourage enhanced quality of care of patients with anaphylaxis. More than calling for a harmonized action for the best management of anaphylaxis to prevent undue morbidity and mortality, the Montpellier World Health Organization Collaborating Centre here proposes an action plan as a baseline for a global initiative against anaphylaxis. We strongly believe that these collaborative efforts are a strong public health and societal priority that is consistent with the overarching goals of providing optimal care of allergic patients and best practices of allergology.
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Senna G, Caminati M, Castells M. Editorial: Anaphylaxis: advances and challenges besides allergy. Curr Opin Allergy Clin Immunol 2020; 19:415-416. [PMID: 31369415 DOI: 10.1097/aci.0000000000000576] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
| | - Marco Caminati
- Allergy Unit, Asthma Center, University-Hospital of Verona.,Department of Medicine, University of Verona, Verona, Italy
| | - Mariana Castells
- Drug Hypersensitivity and Desensitization Center - Mastocytosis Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Masachusetts, USA
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England E, Deakin CD, Nolan JP, Lall R, Quinn T, Gates S, Miller J, O'Shea L, Pocock H, Rees N, Scomparin C, Perkins GD. Patient safety incidents and medication errors during a clinical trial: experience from a pre-hospital randomized controlled trial of emergency medication administration. Eur J Clin Pharmacol 2020; 76:1355-1362. [PMID: 32535646 DOI: 10.1007/s00228-020-02887-z] [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: 12/24/2019] [Accepted: 04/30/2020] [Indexed: 10/24/2022]
Abstract
AIM To assess and evaluate patient safety incidents and in particular, medication errors, during a large multi-center pre-hospital trial of emergency therapy (PARAMEDIC2), in order to inform and improve future pre-hospital medicines trials. METHODS The PARAMEDIC2 trial was undertaken across five NHS Ambulance Services in England and Wales with randomisation between December 2014 and October 2017. Patients with an out -of-hospital cardiac arrest unresponsive to initial resuscitation were randomly assigned to 1 mg intravenous adrenaline or matching placebo. Records were reviewed to identify trial medication errors involving documentation and/or clinical protocol errors occurring in trial participants. Causes of medication errors, including root cause analysis where available, were reviewed to identify patterns and themes contributing to these errors. RESULTS Eight thousand sixteen patients were enrolled, of whom 4902 received trial medication. A total of 331 patient safety incidents was reported, involving 295 patients, representing an overall rate of 3.6% of these, 166 (50.2%) were documentation errors while 165 (49.8%) were clinical protocol/medication errors. An overall rate of 0-4.5% was reported across all five ambulance services, with a mean of 2.0%. These errors had no impact on patient care or the trial and were all resolved CONCLUSION: The overall medication error rate of 1.8% primarily consisted of administration of open-label adrenaline and confusion with trial medication packs. A similar number of patients had documentation errors. This study is the first to provide data on patient safety incidents relating to medication errors encountered during a pre-hospital trial of emergency medication administration and will provide supporting data for planning future trials in this area.
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Affiliation(s)
- Ed England
- South Central Ambulance Service NHS Foundation Trust, Otterbourne, SO21 2RU, UK
| | - Charles D Deakin
- South Central Ambulance Service NHS Foundation Trust, Otterbourne, SO21 2RU, UK.,NIHR Southampton Respiratory Biomedical Research Unit, Southampton, SO16 6YD, UK
| | - Jerry P Nolan
- Warwick Clinical Trials Unit, University of Warwick, Coventry, CV4 7AL, UK.,Royal United Hospital, Bath, BA1 3NG, UK
| | - Ranjit Lall
- Warwick Clinical Trials Unit, University of Warwick, Coventry, CV4 7AL, UK
| | - Tom Quinn
- Kingston University and St George's, University of London, 6th Floor, Hunter Wing, Cranmer Terrace, London, SW17 0RE, UK
| | - Simon Gates
- Cancer Research UK Clinical Trials Unit, University of Birmingham, Birmingham, B15 2TT, UK
| | - Joshua Miller
- West Midlands Ambulance Service University NHS Foundation Trust, Brierley Hill, West Midlands, DY5 1LX, UK
| | - Lyndsey O'Shea
- Welsh Ambulance Services NHS Trust, Swansea, Wales, SA2 8PP, UK
| | - Helen Pocock
- South Central Ambulance Service NHS Foundation Trust, Otterbourne, SO21 2RU, UK
| | - Nigel Rees
- Welsh Ambulance Services NHS Trust, Swansea, Wales, SA2 8PP, UK
| | | | - Gavin D Perkins
- Warwick Clinical Trials Unit, University of Warwick, Coventry, CV4 7AL, UK. .,Heartlands Hospital, University Hospitals Birmingham, Birmingham, B9 5SS, UK.
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