Anaphylaxis in Elderly Patients-Data From the European Anaphylaxis Registry

Epidemiology and Risk Factor Analysis of Systemic Allergic Reaction to Bee Venom in the Slovenian Population of Beekeepers

Objectives

To estimate the lifetime prevalence of first and recurrent systemic allergic reaction to bee venom among Slovenian beekeepers. Additionally, we aimed to elucidate the risk factors predisposing beekeepers to developing systemic allergic reaction to bee venom.

Methods

A nationwide cross-sectional study was conducted among 1,080 beekeepers who are members of the Slovenian beekeeper's association, between 1 November 2021 and 31 May 2023. Epidemiological data were collected using a validated questionnaire, with the clinician-confirmed observed health outcome.

Results

The estimated overall lifetime prevalence of self-reported first systemic allergic reaction to bee venom was 9.4% (102/1,080), with 40.7% (24/59) of the clinician-confirmed cases being severe (grade III-IV according to the Mueller classification). The estimated overall lifetime prevalence of reported recurrent systemic allergic reaction to bee venom was lower at 3.7% (40/1,080), with 60.0% (9/15) of the clinician-confirmed cases being severe (grade III-IV according to the Mueller classification). Risk factors associated with the first systemic allergic reaction to bee venom included age, male sex, number of bee stings per season, a history of large local reaction and experiencing nasal symptoms while working at hives. Younger male beekeepers, with a low number of bee stings per season, a history of large local reaction and nasal symptoms while working at hives, are at a high risk of having systemic allergic reaction to bee venom.

Conclusions

High lifetime prevalence of clinician-confirmed severe first and recurrent systemic allergic reaction to bee venom underscored the importance of targeted public health strategies and clinical interventions to protect this high-risk population.

Registries in allergy: Structure, target groups, and key findings of allergy-focused registries in Germany

In allergology, clinical registries fill knowledge gaps of epidemiology, mechanisms of allergic diseases, and real-world treatment outcomes. Considering the continuous rise of allergic diseases worldwide, registries become increasingly important for the optimization and harmonization of patient care. In the current review, we present four ongoing allergy-focused registries initiated in Germany. We conducted a focused literature search and discussed their structure, main purposes, and findings. Registries included are the "Information Network of Departments of Dermatology", the "European Anaphylaxis Registry", the "GAN Severe Asthma Registry", and "TREATgermany". Despite differences in scope and operation, all registries gather harmonized real-world data that is indispensable for evidence-based decision making in clinical practice and ultimately improves patient care in allergology.

Symptomatology and Management of Adult Anaphylaxis according to Trigger: A Cross-Sectional Study

INTRODUCTION

Anaphylaxis is an acute life-threatening allergy, most commonly provoked by food, venom, or drugs. There is limited data regarding differences in symptomatology between anaphylaxis provoked by different triggers. This study aimed to assess sociodemographic characteristics, clinical symptoms, and management of anaphylaxis, according to triggers in adults.

METHODS

We conducted a cross-sectional study recruiting adult patients with anaphylactic reactions across 8 emergency departments (EDs) and 1 electronic medical service (EMS) in Canada. Univariate and multivariate regression models were used to evaluate symptoms involving all patients with the outcome of drug-induced anaphylaxis (DIA), venom-induced anaphylaxis (VIA), peanut-induced anaphylaxis (PIA), shellfish-induced anaphylaxis, tree-nut induced anaphylaxis (TIA) and nut-induced anaphylaxis (NIA). We assessed comorbidities associated with severe reactions, stratified by triggers listed above. Additionally, we evaluated the association of each trigger with treatment through regression models involving all patients with medications used as outcome and anaphylaxis triggers used as independent variables.

RESULTS

From April 2011 to November 2023, 1,135 adults presenting with anaphylaxis to EDs were recruited. The median age was 35.5 (interquartile range 25.3-51.1). Most of the patients presented with FIA (50.3%). Regarding symptomatology, hypotension was more likely associated with DIA (aOR = 1.20, 95% CI = 1.11-1.30, p < 0.01). When adjusted for age at reaction and male sex, alcohol was more likely associated (aOR = 1.51, 95% CI = 1.04-2.19, p = 0.035) with NIA. Regarding management, TIA was more likely associated with inpatient epinephrine (aOR = 2.05, 95% CI = 1.16-3.64, p = 0.014). DIA was less likely associated with outpatient antihistamine (aOR = 0.68, 95% CI = 0.48-0.89, p < 0.01) whereas TIA was more likely associated with outpatient antihistamine (aOR = 1.81, 95% CI = 1.03-3.19, p = 0.040).

CONCLUSION

Our study underscores associations between specific triggers, clinical manifestations and managements, such as the potential link between TIA and throat tightness and hypotension and VIA. Identifying such associations can aid with the prompt diagnosis of anaphylaxis in patients presenting to the ED, leading to swifter treatment initiation and improving overall outcomes.

Preventing Overrides of Severe Drug Allergy Alerts Initiative: an Implemented System Upgrade

Administering medications to patients with documented drug hypersensitivity reactions (DHR) poses a significant risk for adverse events, ranging from mild reactions to life-threatening incidents. Electronic healthcare systems have revolutionized the modern clinical decision-making process, with built in warnings. However, as these alerts become a routine part of healthcare provider's workflow, alert fatigue becomes a challenge. This study was conducted within the Ministry of National Guard Health Affairs (MNGHA), a government healthcare system in Saudi Arabia. A taskforce of experts was formed to develop an electronic path that would prevent unintentional overrides of severe drug allergy alerts. The system underwent rigorous testing, and monitoring parameters were established. We outline the implementation of a system upgrade designed to trigger an alternative interruption in the computerized physician order entry (CPOE) process, distinct from the regular allergy pop-up alerts. The alternate path is activated upon a CPOE with a drug-to-drug match and a documented severe drug allergy symptom, necessitating co-signature form another prescriber before proceeding. The adopted upgrade is a proactive approach to enhance medication safety in electronic healthcare systems, ensuring that serious allergy-related warnings are not overridden, ultimately enhancing patient safety. Further monitoring will confirm the safety and effectiveness of this measure. This study provides a model for institutions seeking to prevent allergy-related harm within their patient population.

Epinephrine, Pregabalin, and Crizotinib as Three Medicines with Polish Implications over Three Last Centuries and in View of Three Different Drug Discovery Approaches

The discovery of epinephrine (adrenaline) and its subsequent implications in medicine owes significant contributions to Cybulski across different centuries, who, in 1894, was pivotal in identifying the adrenal medulla's role in blood pressure regulation and naming the active substance "nadnerczyna", known today as adrenaline. His work demonstrated the adrenal glands' critical function in the body's regulatory mechanisms beyond the nervous system. Cybulski's groundbreaking research laid foundational knowledge for future endocrinological studies and pharmaceutical advancements. In the late 20th century, Andruszkiewicz collaborated with Silverman at Northwestern University to develop pregabalin, the active ingredient in Lyrica. Their innovative synthesis of gamma-aminobutyric acid derivatives led to a significant advancement in treating epilepsy, neuropathic pain, and fibromyalgia. Andruszkiewicz's expertise in organic chemistry and enzymology was crucial in this collaborative effort, resulting in the successful development and commercialization of Lyrica. Additionally, Mroczkowski's leadership at Pfizer contributed to the development of crizotinib, a notable anaplastic lymphoma kinase and proto-oncogene 1 tyrosine-protein kinase inhibitor used to treat specific types of non-small cell lung cancer. Her work exemplifies the continuing influence of Polish researchers in pioneering drug discovery and advancing therapeutic treatments over the past three centuries. These contributions highlight Poland's significant role in global pharmaceutical innovations and medical research.

Food allergies in older people: An emerging health problem

The prevalence of food allergy (FA) is steadily increasing worldwide. Literature about FA in older people is very scarce since this is predominantly considered as a pediatric condition. However, FA can persist and/or develop across the life course. Given the growing increase in prevalence as well as their persistence, it can be expected that FA will soon represent an important issue in older people. Several age-related factors may potentially mask FA symptoms and/or mediate them in older people. These include mechanisms related to immune senescence, inflammation, and changes in gastrointestinal function as well as micronutrient deficiencies and the use of multiple medications. A multidimensional approach, taking into account the complexity in older people, it is thus important in the evaluation and management of FA during aging. The main and safest strategy in the management of FA is the allergen avoidance since their ingestion may lead to reactions ranging from mild to life-threatening. However, food restrictions should be carefully evaluated, especially in older people, for the risk of nutritional deficiencies and undernutrition.

Anaphylaxis in a country where Asia and Europe meet: Evaluation according to World Allergy Organization (WAO) and European Academy of Allergy and Clinical Immunology (EAACI) diagnostic criteria

Background

Anaphylaxis is an acute-onset, life-threatening clinical emergency involving more than one system. The World Allergy Organization (WAO) published anaphylaxis guidelines in 2020. The European Academy of Allergy and Clinical Immunology (EAACI) published anaphylaxis guidelines in 2021 and reviewed the diagnosis of anaphylaxis, risk factors, comorbid diseases, treatment management, and prevention studies.In this study, clinical features, demographic characteristics, risk factors, treatment management, and evaluations according to EAACI and WAO diagnostic criteria were analysed in patients diagnosed with anaphylaxis. In this way, it was aimed to provide a perspective on the diagnosis, etiology, and treatment management in patients with anaphylaxis and to open a window for new studies.

Methods

We retrospectively analysed the data recording system of patients who were evaluated with a history of systemic allergic reaction in the Allergy and Immunology outpatient clinic of our tertiary referral hospital in a ninety-month period between January 2016 and June 2023. The total number of patients admitted to our Allergy and Immunology Clinic between January 2016 and June 2023 was 14,9425. Among these patients, 1032 patients were evaluated in the outpatient clinic according to the ICD-10 (International Statistical Classification of Diseases and Related Health Problems) coding system and diagnosed as T78.2 Anaphylaxis by Allergy and Immunology Specialist. Each patient file was re-evaluated by the authors of the study and 689 eligible patients were included.

Results

Included in the study were 689 patients. The mean age of the patients was 46.2 ± 14.2 (35-57) years. 64.4% (n = 444) of the patients were female. Venom, drugs, and food were the 3 leading causes of anaphylaxis. In our study, younger age was determined as a statistically significant risk factor for food-induced anaphylaxis, female gender for drug-induced anaphylaxis and male gender for venom-induced anaphylaxis. (p < 0.001) If the cause of anaphylaxis can be identified, such as venom, drug or food, the frequency of anaphylaxis decreases statistically significantly compared to idiopathic anaphylaxis. (p < 0.001) The rate of acute hypotension, bronchospasm, or laryngeal involvement without skin involvement according to WAO and the rate of WAO severity classification grade 5 were significantly higher in patients who developed anaphylaxis due to venom compared to other patients (p < 0.001). The rate of Grade 3 in the EAACI classification was significantly higher in patients who developed anaphylaxis due to venom compared to other cases (p < 0.001).

Conclusion

Our study was conducted in a city such as Istanbul, which connects both Asian and European continents. Moreover, it is important because it was conducted in a centre with the highest number of Allergy and Immunology outpatients per year in our country. It is important because it gives the prevalence of anaphylaxis and emphasises the risk factors for each allergen separately.

Quality of Life in the Management of Anaphylaxis in Food-Allergic Adults

Background

Anaphylaxis is a life-threatening allergic reaction that can significantly affect the quality of life of those affected. Factors including undiagnosed allergies, lack of allergen information, and insufficient emergency training can impact the quality of life for food-allergic individuals. Well-informed patients are less likely to experience severe allergic responses, ensuring their safety and quality of life.

Aim

This study aims to evaluate the effectiveness of following preventive behavior, focusing on routine counseling and training provided by healthcare professionals in preventing anaphylaxis and assessing the impact of strict adherence to an allergen avoidance regimen against anaphylaxis.

Methods

This study was a descriptive, cross-sectional survey conducted in the Makkah region of Saudi Arabia. It involved adults aged 18 and above who had food allergies. A structured online questionnaire of seven items was developed and distributed to achieve the study's goals from October 2023 to January 2024. The data collected was automatically exported to Excel and then analyzed using the Statistical Package for the Social Sciences.

Results

The study involved 93 participants, 65.6% female and 34.4% male. Among those with food allergies, 34.4% had experienced anaphylaxis, with 50% allergic to eggs and seafood. The study found no significant association between specific food allergens and a history of anaphylaxis, but strict allergen avoidance was linked to lower anaphylaxis rates. Counseling or training for managing food allergy reactions also showed potential benefits. The research indicated that males were less likely to have anaphylaxis than females, and age increased the severity of anaphylaxis reactions regardless of gender.

Conclusion

The study emphasizes the importance of preventive behaviors and healthcare professional support in reducing the risk of anaphylactic reactions for food-allergic adults. Future research could focus on improving their quality of life through education programs, policy development, and better access to emergency medications and psychosocial support strategies.

Identifying patients at risk of anaphylaxis

Anaphylaxis is an acute, potentially fatal, systemic hypersensitivity reaction that warrants prompt diagnosis and management. It continues to be challenging to anticipate who may be at risk of a severe, life-threatening allergic reaction. Anaphylaxis can be caused by a range of allergens, such as certain foods, medications, latex, insect stings, etc. Cofactors that augment the severity of clinical symptoms and increase the risk of poor outcomes include exercise, stress, infectious diseases, underlying mast cell disease, active allergic disease such as asthma, advanced age, intake of certain medications, history of previous anaphylaxis, and delayed or missed administration of adrenaline. According to the European Anaphylaxis Registry, food is the major elicitor of anaphylaxis, especially eggs, cow milk, and nuts, in children and adolescents. Reaction to insect venom has also been noted in young adulthood. Early recognition of signs and symptoms and prompt treatment are crucial in anaphylaxis management to avoid serious and even fatal outcomes. It is crucial for both individuals and clinicians to identify the cause of anaphylaxis. Biomarkers of anaphylaxis, such as histamine, tryptase, platelet activation factor (PAF), chymase, carboxypeptidase A3, dipeptidyl peptidase I (DPPI), basogranulin, CCL-2, hsa-miR-451a, may be useful in diagnosis and management. The purpose of this review article is to present a comprehensive overview of current evidence and expert opinions regarding the risk factors that predispose individuals to anaphylaxis. Additionally, it provides insights into potential biomarkers and genetic markers for accurate diagnosis and management. This review underscores the significance of expert guidance in enhancing patient outcomes and enabling self-management of anaphylactic episodes.

Elderly Patients and Insect Venom Allergy: Are the Clinical Pictures and Immunological Parameters of Venom Allergy Age-Dependent?

Insect venom is one of the most common triggers of anaphylaxis in the elderly population. Venom immunotherapy (VIT) remains the only treatment for Hymenoptera venom allergy (HVA). However, little is known about the differences in indication for VIT in the group of patients aged 60 years and older. The objective of this study was to assess the clinical and diagnostic differences of HVA in elderly patients. The study compared data from patients aged ≥ 60 (N = 132) to data from patients aged from 11 to 60 years (N = 750) in terms of HVA severity, comorbidities, and immunological parameters, namely, intradermal testing (IDT), specific IgE (sIgE) levels against extracts and major allergenic molecules, and serum tryptase level (sBT). The severity of systemic HVA (I-IV Müller scale) did not differ between adults and seniors. However, the severity of cardiovascular reactions (IV) increased with age, while the frequency of respiratory reactions (III) decreased. No differences were found in the immunological parameters of sensitization IDT, venom-specific IgE concentrations, or sIgE against Api m 1, 2, 4, 5, and 10 between patients below and above 60 or 65 years of age. Differences were noted for sIgE against Ves v1 and Ves v5; they were higher and lower, respectively, in seniors. In the seniors group, sBT levels were higher. Elevated tryptase levels, along with the aging process, can represent a risk factor within this age category. Nevertheless, advanced age does not influence the immunological parameters of immediate HVA reactions, nor does it impact the diagnosis of HVA.

Physician adherence to anaphylaxis guidelines among different age groups in emergency departments: 20-Year observational study

BACKGROUND

Anaphylaxis is an acute and serious allergic reaction. Little is known about physician adherence to anaphylaxis guidelines among patients across different age groups.

OBJECTIVE

To investigate real-world physician adherence to anaphylaxis guidelines among children, adults, and older adults in emergency departments.

METHODS

This study retrospectively analyzed all consecutive patients with anaphylaxis who presented to 2 emergency departments at 2 branches of the largest tertiary hospital in Taiwan, between 2001 and 2020. Patients who met the diagnostic criteria for anaphylaxis were enrolled and grouped by age: children (<18 years), adults (18-64 years), and older adults (≥65 years).

RESULTS

We enrolled 771 patients with anaphylaxis (159 children, 498 adults, and 114 older adults). Intramuscular epinephrine was administered in 294 cases (38.1%). There was a significant age-group difference in the rate of intramuscular epinephrine administration (46.5% in children, 37.3% in adults, and 29.8% in older adults; P trend = .004). When stratified by severity, 14.3% of older adults with moderate reactions received intramuscular epinephrine, whereas 35.2% of adults and 55.3% of children received intramuscular epinephrine (P trend < .001), whereas such difference was not found in patients with severe reactions. Upon discharge from emergency departments, 15.3% received allergist referral (52.2% in children, 6.6% in adults, and 1.8% in older adults; P trend < .001); 12.5% received education on avoidance of triggers (18.9%, 11.4%, and 7.9%; P trend = .01), and 16.1% received education on alarm symptoms (21.4%, 15.1%, and 13.2%; P trend = .05).

CONCLUSION

The real-world physician adherence to anaphylaxis guidelines remains suboptimal in emergency departments, particularly among older adults. Physician continuing education is needed to improve the gap between anaphylaxis guidelines and clinical practice.

Emerging and Novel Elicitors of Anaphylaxis: Collegium Internationale Allergologicum Update 2024

BACKGROUND

Anaphylaxis represents the most severe end of the spectrum of allergic reactions. Frequent elicitors of anaphylaxis are insects, foods, and drugs. This paper summarizes recent development with regard to emerging and novel elicitors of anaphylaxis.

SUMMARY

Food allergens on the rise include pulses (like pea, chickpea), seeds (hemp, chia), nuts (cashew), pseudograins (buckwheat, quinoa), fruits, and microalgae. Novel foods are foods that were not consumed to any significant extent in the European Union before May 1997, which includes four edible insects (mealworm, migratory locust, house cricket, and buffalo worm). Recent investigations have pointed out the risk of anaphylaxis associated with the consumption of yellow mealworm for people allergic to shellfish and house dust mites. In Europe, fire ants (mostly Solenopsis invicta) and Vespa velutina nigrithorax represent invasive species, which account for increasing numbers of anaphylactic reactions. Also, several new drugs, especially biologicals, have been associated with anaphylaxis.

KEY MESSAGES

Elicitors of anaphylaxis are changing as a result of (i) increase in demand for plant-based food, (ii) introduction of novel foods, (iii) spreading of allergens by climate changes and globalization, or (iv) due to exposure to newly developed drugs.

Predictors of severe and recurrent adult anaphylaxis, and gaps in the cascade of care: a retrospective, single-centre study 2009-2018

BACKGROUND

Anaphylaxis is a severe, potentially fatal, systemic allergic reaction. Understanding predictors of recurrent and severe anaphylaxis in adults, and identifying gaps in ongoing anaphylaxis care, is needed to minimise its impact.

AIMS

To evaluate the risk factors in adults with severe and recurrent anaphylaxis presentations and to evaluate the management of patients in regard to the recommended cascade of care.

METHODS

We completed a retrospective audit of adults with confirmed anaphylaxis who presented to an inner-city emergency department from 1 January 2009 through 31 December 2018. Data recorded included demographics, background history, medication use, severity, co-factors, triggers, management, discharge disposition and referral for follow-up. Data were managed in REDCap and analysed using Stata. Associations were assessed through odds ratios (ORs) and t tests.

RESULTS

Six hundred sixteen individuals had 689 episodes of anaphylaxis over the audit period. Age over 65 (OR: 5.4 (95% confidence interval, CI: 2.3-13.2), P < 0.0001) and history of asthma (OR: 1.6 (95% CI: 1.03-2.5), P = 0.03) were independent risk factors for severe anaphylaxis. History of food allergy (P < 0.001) and food as the trigger were associated with recurrent presentations (OR: 2.1, 95% CI: 1.1-3.9, P = 0.01). Only 19% of patients met the recommended cascade of care, with post-adrenaline monitoring and recommending follow-up with an allergy specialist demonstrating the largest gaps. There were increased presentations with time but no difference in triggers or severity.

CONCLUSIONS

Increased age and asthma were identified as risk factors for severe presentations. History of food allergy was a risk factor for recurrent presentations. Further research is needed on the gaps in care for adults with anaphylaxis to identify the reasons why, so we can better care for these patients.

Contemporary trends in anaphylaxis burden and healthcare utilisation in Western Australia: A linked data study

Background

Anaphylaxis is a growing public health problem in Australia. To determine the extent of the problem, we linked multiple health datasets to examine temporal trends in anaphylaxis events across the health system in Western Australia (WA).

Methods

We identified an anaphylaxis cohort from 1980 to 2020 using linked datasets from ambulance, emergency departments, hospital inpatients and deaths. Age-standardised anaphylaxis event rates were calculated from 2010 to 2020. Dataset-specific rates for anaphylaxis were also examined, to show differences in health care utilisation. Annual percent change in rates (2010-2019) were estimated using age-adjusted Poisson regression models.

Results

A total of 19 140 individuals (mean age 31 years; 51% female) experienced 24 239 anaphylaxis events between 2010 and 2020. From 2010 to 2019, the average annual percent increase (95% CI) in rates was 5.3% (4.8-5.8%), from 70.3 to 113.9, with rates reducing to 76.5/100 000 population in 2020. Adolescents and young adults aged 5-14 years and 15-24 years had the greatest increase of 6.9% (5.6-8.1%) and 6.8% (5.6-8.0) respectively, with those over 25 years increasing by approximately 5% per year and children 1-4 years showing the lowest annual increase of 2.6% (1.1-4.2%). The highest absolute rates were seen in under 1 year (269.7/100 000; 2019). There has been an acceleration of trends from 2015 to 2019, underpinned by large increases in 15-24 and 25-34 years. All databases, show similar increasing trends, with ambulance attendance (33.7 per 100 000), emergency presentation (89.8 per 100 000) and hospital admissions (46.2 per 100 000), for anaphylaxis highest in 2019. However, whilst ambulance and emergency presentations have grown by 8.9% (95%CI 7.9-9.8%) and 6.6% per year (95%CI 6.0-7.2%), respectively, hospitalisations appear to be steadying with only a 0.9% (95%CI 0.2-1.6%) yearly rise.

Conclusion

Rates of anaphylaxis continue to increase, with WA having higher rates than previous estimates for Australia. Whilst rates are still high in infants, lower trends in children compared to older ages may indicate better prevention of allergy. Results show more people experiencing anaphylaxis now receive care in emergency and ambulance, rather than hospital. Further exploration of the patient care journey through prehospital and inpatient care is required, to understand the changing health demands of people who experience anaphylaxis.

Extracorporeal membrane oxygenation support in refractory anaphylactic shock after bee stings: A case report

An allergy to insect stings is one of the most frequent causes of anaphylactic reactions. Such reactions can be fatal, even on the first reaction, although it very rarely happens. The use of veno-arterial extracorporeal membrane oxygenation (VA ECMO) in refractory anaphylactic shock was previously described. We report a case of a 31-year-old female who presented with refractory anaphylactic shock after bee stings without the presence of cutaneous manifestations other than the rashes in her neck. The toxic component of bee venom and systemic allergic response plays a vital role in pathophysiology. She did not respond to conventional advanced life support, but following urgent VA ECMO, she survived neurologically intact. Despite an uncommon indication for anaphylaxis, ECMO support may be possible and effective in patients with refractory shock.

Comparison of two diagnostic criteria in the diagnosis of anaphylaxis in a tertiary adult allergy clinic

Background

Anaphylaxis is a very dynamic issue with its incidence and trigger profile changing over the years. We aimed to compile the characteristics of anaphylaxis cases diagnosed in our clinic prospectively and to make a comparison between diagnostic criteria proposed by National Institute of Allergy and Infectious Diseases/Food Allergy and Anaphylaxis Network (NIAID/FAAN) and World Allergy Organization (WAO).

Method

Three-item diagnostic criteria recommended by NIAID/FAAN (2006) were used in the diagnosis of anaphylaxis. The clinical features of the cases, risk factors, etiologies, severity of anaphylaxis, and treatment approach were determined. The same patients were also classified by current WAO diagnostic criteria.

Results

A total of 204 patients (158F/46 M, median age 45.3 years) were included. Drugs (65.2%), venom (9.8%) and food allergies (9.3%) were the top 3 etiologies. Among drug triggers, chemotherapeutics were the most common (17.7%), followed by antibiotics (15.3%) and non-steroidal anti-inflammatory drugs (14.2%). The patients were mostly diagnosed with the second criterion (84.8%), followed by the first criterion (11.8%) and the third criterion (3.4%) of the NIAID/FAAN criteria. In terms of WAO criteria, 82.8% of the patients were diagnosed with the first criterion, and 14.3% with the second criterion while 2.9% of the patients did not meet the WAO criteria. The severity of anaphylaxis was evaluated as grade-2, 3 and 4 in 30.9%, 64.2%, and 4.9% of the patients, respectively. Adrenaline was administered to 31.9% of the patients especially who had angioedema and bronchospasm (p = 0.04).

Conclusion

Our data suggest that covering more details in patient's history may prevent possible underdiagnosis and WAO diagnostic criteria seem to be insufficient in some patients. We believe that our results will contribute to the literature on anaphylaxis and would be groundwork for future studies.

Ten-year outcomes of Perioperative Anaphylaxis Workup Study in Hong Kong (PAWS-HK): Performance of diagnostic modalities

BACKGROUND

Studies on perioperative anaphylaxis (PA) in Asia are lacking. Furthermore, allergy workup for PA has largely been limited to the "silver standard" of skin tests (ST). Using in vitro tests as an adjunct to ST may improve and overcome these diagnostic challenges.

OBJECTIVE

To evaluate the clinical characteristics and diagnostic tests of patients with suspected PA through the Perioperative Anaphylaxis Workup Study in Hong Kong cohort.

METHODS

Patients with a diagnosis of PA over a 10-year period were recruited into the Perioperative Anaphylaxis Workup Study in Hong Kong. We reviewed the medical records, tryptase elevation, and diagnostic tests including ST, specific immunoglobulin E, and basophil activation tests (BAT).

RESULTS

In 151 patients with PA, diagnosis was reached in three-fourths of the cases (113/151, 74.8%). The most common culprits identified were neuromuscular blocking agents (25.8%), β lactams (17.2%) and chlorhexidine (13.9%). Severe anaphylaxis was associated with female sex, older age, elevated acute tryptase levels, and more cardiovascular manifestations during induction. Skin tests remained the most sensitive diagnostic modality overall (66.2%). BAT showed better performance for chlorhexidine and gelofusine anaphylaxis, with sensitivity of 80.0% and 79.6%, respectively. Specific Immunoglobulin E indicated even higher sensitivity (95.2%) than did ST (85.0%) and BAT (80.0%) for chlorhexidine anaphylaxis but performed poorly for other drugs.

CONCLUSION

Neuromuscular blocking agents remain the most common culprit in PA. There was a higher prevalence of gelofusine anaphylaxis in our cohort than was seen in the literature. Skin tests remain the most sensitive testing modality. In vitro tests for chlorhexidine and gelofusine showed promising results, but more studies to further elucidate its use are warranted.

Food anaphylaxis in the elderly: Analysis of allergy vigilance network data from 2002 to 2021

BACKGROUND

Few studies have focused on food allergies in the elderly, even though it may persist or appear de novo.

METHODS

We reviewed data for all cases of food-induced anaphylaxis in people age ≥ 60 reported to the French "Allergy Vigilance Network" (RAV) between 2002 and 2021. RAV collates data reported by French-speaking allergists regarding cases of anaphylaxis graded II to IV according to the Ring and Messmer classification.

RESULTS

In total, 191 cases were reported, with an even sex distribution and mean age was 67.4 years (range 60 to 93). The most frequent allergens were mammalian meat and offal (31 cases, 16.2%), often associated with IgE to α-Gal. Legumes were reported in 26 cases (13.6%), fruits and vegetables in 25 cases (13.1%), shellfish 25 cases (13.1%), nuts 20 cases (10.5%), cereals 18 cases (9.4%), seeds 10 cases (5.2%), fish 8 cases (4.2%) and anisakis 8 cases (4.2%). Severity was grade II in 86 cases (45%), grade III in 98 cases (52%) and grade IV in 6 cases (3%) with one death. Most episodes occurred at home or in a restaurant and in most cases adrenaline was not used to treat the acute episode. Potentially relevant cofactors such as beta-blocker, alcohol or non-steroidal anti-inflammatory drug intake were present in 61% of cases. Chronic cardiomyopathy, present in 11.5% of the population, was associated with greater, grade III or IV reaction severity (OR 3.4; 1.24-10.95).

CONCLUSION

Anaphylaxis in the elderly has different causes to younger people and requires detailed diagnostic testing and individualized care plans.

Latin American anaphylaxis registry

Background

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

Objective

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

Method

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

Results

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

Conclusions

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

Recent developments in the immunopathology of COVID-19

There has been an important change in the clinical characteristics and immune profile of Coronavirus disease 2019 (COVID-19) patients during the pandemic thanks to the extensive vaccination programs. Here, we highlight recent studies on COVID-19, from the clinical and immunological characteristics to the protective and risk factors for severity and mortality of COVID-19. The efficacy of the COVID-19 vaccines and potential allergic reactions after administration are also discussed. The occurrence of new variants of concerns such as Omicron BA.2, BA.4, and BA.5 and the global administration of COVID-19 vaccines have changed the clinical scenario of COVID-19. Multisystem inflammatory syndrome in children (MIS-C) may cause severe and heterogeneous disease but with a lower mortality rate. Perturbations in immunity of T cells, B cells, and mast cells, as well as autoantibodies and metabolic reprogramming may contribute to the long-term symptoms of COVID-19. There is conflicting evidence about whether atopic diseases, such as allergic asthma and rhinitis, are associated with a lower susceptibility and better outcomes of COVID-19. At the beginning of pandemic, the European Academy of Allergy and Clinical Immunology (EAACI) developed guidelines that provided timely information for the management of allergic diseases and preventive measures to reduce transmission in the allergic clinics. The global distribution of COVID-19 vaccines and emerging severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants with reduced pathogenic potential dramatically decreased the morbidity, severity, and mortality of COVID-19. Nevertheless, breakthrough infection remains a challenge for disease control. Hypersensitivity reactions (HSR) to COVID-19 vaccines are low compared to other vaccines, and these were addressed in EAACI statements that provided indications for the management of allergic reactions, including anaphylaxis to COVID-19 vaccines. We have gained a depth knowledge and experience in the over 2 years since the start of the pandemic, and yet a full eradication of SARS-CoV-2 is not on the horizon. Novel strategies are warranted to prevent severe disease in high-risk groups, the development of MIS-C and long COVID-19.

Anaphylaxis in elderly people

PURPOSE OF REVIEW

Anaphylaxis is common in old-age adults but is insufficiently understood by physicians, and may be underdiagnosed. This review discusses the specificities of anaphylaxis in this age group and stresses the importance of adrenaline in its management.

RECENT FINDINGS

Data from the European Anaphylaxis Registry on elderly patients is a major finding. Other findings include the prevention of possible anaphylactic reactions in coronavirus disease 2019 vaccination as well as some new epidemiologic data.

SUMMARY

The most common risk factors are hymenoptera venom and food and drug allergy. Cardiovascular symptoms are the most important ones to reverse in old-age adults, especially due to the multiple comorbidities. Anaphylaxis in old-age adults has a more severe outcome than in younger ones. Polypharmacy is a specific factor to be considered. The Airway, Breathing, Circulation, Disability, Exposure (ABCDE) algorithm is applicable in all clinical emergencies for immediate assessment and treatment, and should be considered for all patients. Adrenaline is the mainstay of the management of the condition. There are no absolute contraindications to the prescription of self-injectable adrenaline in elderly individuals at risk of anaphylaxis.

Overview of registries for anaphylaxis: a scoping review

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.

Ocular Inflammatory Reactions following an Inactivated SARS-CoV-2 Vaccine: A Four Case Series

PURPOSE

To report a four-case series of ocular adverse events post an inactivated COVID-19 vaccination in China.

METHODS

The four patients exhibited ocular inflammatory reactions on the same day after receiving an inactivated SARS-CoV-2 vaccine.

RESULTS

All patients underwent detailed ophthalmic examinations, with the medical diagnosis of Vogt-Koyanagi-Harada, Ponser-Schlossman, secondary post-inflammatory glaucoma, and iridocyclitis, respectively. No patients had any other underlying medical conditions causing the ocular complications. The ocular inflammatory reactions of these four patients were resolved with the administration of oral or topical corticosteroids.

CONCLUSION

Our cases remind the ophthalmologist that adverse ocular events may happen after the administration of SARS-CoV-2 vaccine. Since the ocular complications could be resolved with the corticosteroid treatment, the events were considered to be inflammatory reactions caused by the SARS-CoV-2 vaccine.

Anaphylaxis in older adult patients: a 10-year retrospective experience

Background

Despite the worldwide increase in life expectancy and the elderly population, very little is known about the characteristics of anaphylaxis in older adults.

Methods

A retrospective scan was made of the files of patients who presented at the Allergy Unit of our clinic between October 2011 and October 2021. The study included 971 patients aged ≥18 years who met the criteria for diagnosis of anaphylaxis. The patients were separated into 2 groups of adults (18–64 years) and older adults (≥65 years).

Results

The adult group included 887 (91.3%) patients and the older adult group, 84 (8.7%) patients. Comorbid diseases were seen more frequently in the older adults than in the adult group (p < 0.001). Drugs were seen to be the most common trigger of anaphylaxis in both groups, and this was more common in the older adult group (p = 0.039). Food was a more common trigger of anaphylaxis in the adult group than in the older adult group (p = 0.017). In both groups, the skin was the organ most affected, and was less affected in the older adults than in the adults (p = 0.020). Cardiovascular symptoms were seen significantly more and respiratory symptoms significantly less in the older adult group (p < 0.001, p = 0.002, respectively). Admission to the hospital and the intensive care unit was more frequent in the older adult group and rates of adrenalin administration were higher compared to the adult group (p < 0.001 for all).

Conclusion

Anaphylaxis in the older adults is generally caused by drugs. Older adults were found to have more cardiovascular symptoms and more frequent adrenalin injections, hospitalizations and intensive care unit admissions.

Anaphylaxis among elderly emergency department patients in a large health system in New York

BACKGROUND

Anaphylaxis in the elderly is poorly understood.

OBJECTIVE

To elucidate demographic, clinical, and management characteristics of older adults presenting to emergency departments (EDs) with National Institute of Allergy and Infectious Diseases (NIAID) criteria-confirmed anaphylaxis vs milder, non-anaphylactic acute allergic reactions (AARs).

METHODS

A retrospective analysis of ED patients more than or equal to 65 years was conducted, using anaphylaxis International Classification of Diseases, Ninth Revision (ICD-9) codes or ICD-9-based algorithms incorporating the NIAID diagnostic criteria. Descriptive statistics were generated, and the abovementioned characteristics were compared between cohorts.

RESULTS

Of 164 eligible visits, 71 (43.3%), 90 (54.9%), and 3 (1.8%) cases were identified by ICD-9 codes, the algorithms, or both, respectively. Only half fulfilled NIAID diagnostic criteria. Compared with the non-anaphylactic AAR group, criteria-confirmed anaphylaxis group had lower drug allergy rates (43.9% vs 61.0%, P = .03) but higher food allergy rates (26.8% vs 12.2%, P = .02). For the criteria-confirmed anaphylaxis group, presenting signs and symptoms in descending frequency were mucocutaneous, respiratory, cardiovascular, and gastrointestinal. Criteria-confirmed anaphylaxis group had higher rates of prior anaphylaxis (13.4% vs 2.4%, P = .009), pre-ED (12.2% vs 0.0%, P = .001) or ED (72.0% vs 4.9%, P < .001) epinephrine administration, and allergy referral (17.1% vs 2.4%, P = .002). Tryptase levels were rarely ordered, occurring once in the criteria-confirmed anaphylaxis group and never in the non-anaphylactic AAR group. Despite low mortality (n = 1), 64.6% of the criteria-confirmed anaphylaxis cohort required hospitalization, with 23.2% admitted to intensive care unit.

CONCLUSION

Diagnosis of elderly ED patients with anaphylaxis remains suboptimal. Identifying NIAID criteria-confirmed cases remain challenging, using the existing methods. Management of these patients poorly adheres to current guidelines.

A Clinical Practice Guideline for the Emergency Management of Anaphylaxis (2020)

Background: For anaphylaxis, a life-threatening allergic reaction, the incidence rate was presented to have increased from the beginning of the 21st century. Underdiagnosis and undertreatment of anaphylaxis are public health concerns. Objective: This guideline aimed to provide high-quality and evidence-based recommendations for the emergency management of anaphylaxis. Method: The panel of health professionals from fifteen medical areas selected twenty-five clinical questions and formulated the recommendations with the supervision of four methodologists. We collected evidence by conducting systematic literature retrieval and using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. Results: This guideline made twenty-five recommendations that covered the diagnosis, preparation, emergency treatment, and post-emergency management of anaphylaxis. We recommended the use of a set of adapted diagnostic criteria from the American National Institute of Allergy and Infectious Diseases and the Food Allergy and Anaphylaxis Network (NIAID/FAAN), and developed a severity grading system that classified anaphylaxis into four grades. We recommended epinephrine as the first-line treatment, with specific doses and routes of administration for different severity of anaphylaxis or different conditions. Proper dosage is critical in the administration of epinephrine, and the monitor is important in the IV administration. Though there was only very low or low-quality evidence supported the use of glucocorticoids and H1 antagonists, we still weakly recommended them as second-line medications. We could not make a well-directed recommendation regarding premedication for preventing anaphylaxis since it is difficult to weigh the concerns and potential effects. Conclusion: For the emergency management of anaphylaxis we conclude that: • NIAID/FAAN diagnostic criteria and the four-tier grading system should be used for the diagnosis • Prompt and proper administration of epinephrine is critical.

Serological profiling reveals hsa-miR-451a as a possible biomarker of anaphylaxis

Background

There is a need to support the diagnosis of anaphylaxis by objective markers. miRNAs are promising noncoding RNA species that may serve as serological biomarkers, but their use in diagnosing anaphylaxis has not been systematically studied to our knowledge. We aimed to comprehensively investigate serum biomarker profiles (proteins, lipids, and miRNAs) to support the diagnosis of anaphylaxis.

Methods

Adult patients admitted to the emergency room with a diagnosis of anaphylaxis (<3 hours) were included. Blood samples were taken upon emergency room arrival and 1 month later.

Results

Next-generation sequencing of 18 samples (6 patients with anaphylaxis in both acute and nonacute condition, for 12 total samples, and 6 healthy controls) identified hsa-miR-451a to be elevated during anaphylaxis, which was verified by quantitative real-time PCR in the remaining cohort. The random forest classifier enabled us to classify anaphylaxis with high accuracy using a composite model. We identified tryptase, 9α,11β-PGF2, apolipoprotein A1, and hsa-miR-451a as serological biomarkers of anaphylaxis. These predictors qualified as serological biomarkers individually but performed better in combination.

Conclusion

Unexpectedly, hsa-miR-451a was identified as the most relevant biomarker in our data set. We were also able to distinguish between patients with a history of anaphylaxis and healthy individuals with higher accuracy than any other available model. Future studies will need to verify miRNA biomarker utility in real-life clinical settings.

Funding

This work is funded by the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation) as part of the clinical research unit (CRU339): Food Allergy and Tolerance (FOOD@) (project number 409525714) and a grant to MW (Wo541-16-2, project number 264921598), as well as by FOOD@ project numbers 428094283 and 428447634.

EAACI guidelines: Anaphylaxis (2021 update)

Anaphylaxis is a clinical emergency which all healthcare professionals need to be able to recognize and manage. The European Academy of Allergy and Clinical Immunology Anaphylaxis multidisciplinary Task Force has updated the 2014 guideline. The guideline was developed using the AGREE II framework and the GRADE approach. The evidence was systematically reviewed and recommendations were created by weighing up benefits and harms. The guideline was peer-reviewed by external experts and reviewed in a public consultation. The use of clinical criteria to identify anaphylaxis is suggested with blood sampling for the later measurement of tryptase. The prompt use of intramuscular adrenaline as first-line management is recommended with the availability of adrenaline autoinjectors to patients in the community. Pharmacokinetic data should be provided for adrenaline autoinjector devices. Structured, comprehensive training for people at risk of anaphylaxis is recommended. Simulation training and visual prompts for healthcare professionals are suggested to improve the management of anaphylaxis. It is suggested that school policies reflect anaphylaxis guidelines. The evidence for the management of anaphylaxis remains mostly at a very low level. There is an urgent need to prioritize clinical trials with the potential to improve the management of patients at risk of anaphylaxis.

The 2020 update on anaphylaxis in paediatric population

The objective of the review is to present recent updates on anaphylaxis in paediatric population worldwide. The article summarizes the results of epidemiological studies, diagnostic methods and treatments. We present a new WAO definition of anaphylaxis (2019), which broader criteria excluding dermal symptoms should facilitate faster life-saving adrenaline use. Adrenaline remains the best treatment to manage severe symptoms and to prevent biphasic reactions. There is ongoing effort to increase adrenaline use, such as modified autoinjectors, individual training, and diversified dosing. There are five independent risk factors of lethal anaphylaxis in children, including history of asthma, almost immediate onset of symptoms, unwell appearance, tachycardia and hypotension. We also report improvements in diagnostics, like component-resolved diagnostics, and novel therapies stimulating immunotolerance. We signal the development of ICD-11 with updated coding of anaphylaxis, which corresponds better to clinical observations.

Global patterns in anaphylaxis due to specific foods: A systematic review

BACKGROUND

There are increasing global data relating to prevalence of food allergy and food-induced anaphylaxis; however, this is often based on surrogate measures of sensitization rather than objective symptoms at food challenge. In terms of protecting food-allergic consumers from reactions, to our knowledge, there has been no global survey assessing geographic differences in the proportion of anaphylaxis triggered by specific foods.

OBJECTIVE

We sought to identify common triggers for food-induced anaphylaxis and how these vary from country to country.

METHODS

Systematic review of relevant reports published between January 2010 and November 2020. Results were reported following PRISMA guidelines. Publications were screened and data extracted by 2 independent reviewers, and the risk of bias was assessed.

RESULTS

Sixty-five studies (encompassing 41 countries and all 6 regions as defined by the Food and Agriculture Organization of the United Nations) were included. Significant regional variations in the most common triggers of food anaphylaxis were seen; however, in general, there was good agreement between local legislative requirements for allergen disclosure and the most common allergens for each region or nation.

CONCLUSIONS

Local legislation for allergen disclosure generally reflects those allergens commonly responsible for food anaphylaxis. Cow's milk and crustaceans appear to cause a higher proportion of anaphylaxis compared to peanut in some regions.

Antimicrobial-associated anaphylaxis at a tertiary care medical city

BACKGROUND

Antimicrobial-associated anaphylaxis occurs at different rates and can lead to worsening infection-related outcomes, we sought to describe the incidence and complications of such episodes at a tertiary care hospital.

METHOD

A retrospective cohort study was conducted between January 2016 and December 2019. Cases of antimicrobial-associated anaphylaxis were identifiedusing the hospital's electronic healthcare records. Outcomes included: mortality related to anaphylaxis, infection-related mortality, hospitalization and impact on antimicrobial prescribing.

RESULTS

The estimated rate of antimicrobial-associated anaphylaxis was 18.6 (95% CI: 11.8-29.5) cases per 100,000 exposures, which required hospitalization in 23.8% of the cases and ICU admission in 19% of the cases.

CONCLUSION

Implications from antimicrobial-associated anaphylaxis is beyond the episode itself, and can be associated with poor clinical outcomes such as infection-related mortality and hospitalization.

Drug allergy management in the elderly

PURPOSE OF REVIEW

Drug allergy management has previously not been emphasized in the elderly. However, the geriatric population poses several unique characteristics, challenges for drug allergy testing and considerations in the management. Especially in the era of COVID-19, the elderly population is a vulnerable cohort and reviewing the management during this unprecedented time is both timely and relevant.

RECENT FINDINGS

In recent years, larger scale studies focusing on the epidemiology and prevalence trends of drug allergies among older adults has been summarized in this review. Emphasis on anaphylaxis in the older adults has been studied.

SUMMARY

There are many implications of these findings. Epidemiological studies are useful in realizing the burden and spectrum of drug allergies on our healthcare system. It has allowed us to identify certain barriers in drug allergy management and develop ways to overcome these challenges through. Lastly, we have proposed an approach to drug allergy management based on previous studies as well as from our perspective and local experience.

Characterization of anaphylaxis reveals different metabolic changes depending on severity and triggers

BACKGROUND

Despite the increasing incidence of anaphylaxis, its underlying molecular mechanisms and biomarkers for appropriate diagnosis remain undetermined. The rapid onset and potentially fatal outcome in the absence of managed treatment prevent its study. Up today, there are still no known biomarkers that allow an unequivocal diagnosis. Therefore, the aim of this study was to explore metabolic changes in patients suffering anaphylactic reactions depending on the trigger (food and/or drug) and severity (moderate and severe) in a real-life set-up.

METHODS

Eighteen episodes of anaphylaxis, one per patient, were analysed. Sera were collected during the acute phase (T1), the recovery phase (T2) and around 2-3 months after the anaphylactic reaction (T0: basal state). Reactions were classified following an exhaustive allergological evaluation for severity and trigger. Sera samples were analysed using untargeted metabolomics combining liquid chromatography coupled to mass spectrometry (LC-MS) and proton nuclear magnetic resonance spectroscopy (¹ H-NMR).

RESULTS

'Food T1 vs T2' and 'moderate T1 vs T2' anaphylaxis comparisons showed clear metabolic patterns during the onset of an anaphylactic reaction, which differed from those induced by drugs, food + drug or severe anaphylaxis. Moreover, the model of food anaphylaxis was able to distinguish the well-characterized IgE (antibiotics) from non-IgE-mediated anaphylaxis (nonsteroidal anti-inflammatory drugs), suggesting a differential metabolic pathway associated with the mechanism of action. Metabolic differences between 'moderate vs severe' at the acute phase T1 and at basal state T0 were studied. Among the altered metabolites, glucose, lipids, cortisol, betaine and oleamide were observed altered.

CONCLUSIONS

The results of this exploratory study provide the first evidence that different anaphylactic triggers or severity induce differential metabolic changes along time or at specific time-point, respectively. Besides, the basal status T0 might identify high-risk patients, thus opening new ways to understand, diagnose and treat anaphylaxis.

Management of anaphylaxis due to COVID-19 vaccines in the elderly

Older adults, especially men and/or those with diabetes, hypertension, and/or obesity, are prone to severe COVID‐19. In some countries, older adults, particularly those residing in nursing homes, have been prioritized to receive COVID‐19 vaccines due to high risk of death. In very rare instances, the COVID‐19 vaccines can induce anaphylaxis, and the management of anaphylaxis in older people should be considered carefully. An ARIA‐EAACI‐EuGMS (Allergic Rhinitis and its Impact on Asthma, European Academy of Allergy and Clinical Immunology, and European Geriatric Medicine Society) Working Group has proposed some recommendations for older adults receiving the COVID‐19 vaccines. Anaphylaxis to COVID‐19 vaccines is extremely rare (from 1 per 100,000 to 5 per million injections). Symptoms are similar in younger and older adults but they tend to be more severe in the older patients. Adrenaline is the mainstay treatment and should be readily available. A flowchart is proposed to manage anaphylaxis in the older patients.

Trends in Emergency Department Visits and Hospitalizations for Acute Allergic Reactions and Anaphylaxis Among US Older Adults: 2006-2014

BACKGROUND

The US older adult population (age ≥65 years) is increasing and may be at increased risk for severe anaphylaxis. Little is known about the health care use for acute allergic reactions (AAR), including anaphylaxis, among older adults.

OBJECTIVE

To characterize trends in emergency department (ED) visits and hospitalizations for AAR and anaphylaxis among US older adults from 2006 to 2014 and examine factors associated with severe anaphylaxis.

METHODS

We performed cross-sectional analyses of trends in ED visits and hospitalizations among older adults using data from the Nationwide Emergency Department Sample and the National (Nationwide) Inpatient Sample in 2006 to 2014. We used International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes to identify visits for AAR, including anaphylaxis. Multivariable logistic regression modeling was used to identify factors associated with severe anaphylaxis (cardiac arrest, intubation, and death).

RESULTS

In 2006 to 2014, older adults experienced approximately 1,019,967 AAR-related ED visits, 173,844 AAR-related hospitalizations, 93,795 anaphylaxis-related ED visits, and 72,677 anaphylaxis-related hospitalizations. Whereas AAR-related ED visit and hospitalization rates remained stable (P = .28 and .16, respectively), anaphylaxis-related ED visit and hospitalization rates increased significantly over time (37 visits/100,000 in 2006 to 51 in 2014, P < .001; and from 13 hospitalizations/100,000 in 2006 to 23 in 2014, P < .001), especially hospitalization rates for drug-related anaphylaxis (47 hospitalizations/100,000 in 2006 to 85 in 2014; P < .001). Risk factors for anaphylaxis-related death included older age and drug-related trigger.

CONCLUSIONS

In a nationally representative sample of US older adults, the rate of anaphylaxis-related ED visits and hospitalizations increased over time. Drug-related triggers represented a substantial portion of increased health care use and are a growing risk in this vulnerable population.

Anaphylaxis in middle-aged patients

Age is one of the most important factors influencing the course of anaphylaxis: moreover, the frequency of elicitors of anaphylaxis is age-associated. We analyzed 8,465 anaphylactic episodes in adult patients in three age groups with a focus on patients in the middle-age group (35 – 65 years old). Insect venom was the most frequent trigger in this age group (51.2%) followed by drugs (22.8%) and food (17.3%). Severe reactions were observed in 40.1% of middle-aged patients and occurred more frequently in this age group than in patients below 35 years (27.6%) and less frequently than in patients over 65 years (55.6%). The symptoms and comorbidity profile also changed with age, most significantly regarding the increase in rates of concomitant cardiologic diseases and (severe) cardiovascular symptoms.

Critical Care Management of the Patient With Anaphylaxis: A Concise Definitive Review

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.

Comorbidities and Cofactors of Anaphylaxis in Patients with Moderate to Severe Anaphylaxis. Analysis of Data from the Anaphylaxis Registry for West Pomerania Province, Poland

Anaphylaxis is a severe, potentially life-threatening systemic hypersensitivity reaction that is still rarely diagnosed. For safety reasons, patients should visit an allergologist to identify potential causes and cofactors of this reaction. This paper presents the analysis of data from the Anaphylaxis Registry gathered over ten years at the Allergy Clinic, Pomeranian Medical University (PMU). A questionnaire-based survey was used for patients visiting the Allergy Clinic to identify potential augmentation factors/comorbidities and/or cofactors of anaphylaxis in patients with a history of moderate to severe anaphylaxis. The registry comprised patients with grade II or higher anaphylaxis. The gathered data concerned chronic comorbidities (cardiovascular diseases, respiratory diseases, and others), recurrence of anaphylaxis, and potential cofactors in anaphylaxis. In the analyzed group, the incidence rate of anaphylaxis was the highest for women aged 19–60 years. Most common comorbidities in patients with moderate to severe anaphylaxis included: cardiovascular diseases, respiratory tract diseases, features of atopy, and thyroid diseases. More than 30% of drug-induced reactions were anaphylactic reactions due to the re-exposure to the same drug, which points to the need for educational initiatives in this area. The incidence rate of anaphylaxis induced by Hymenoptera stings was comparable in patients who had a previous generalized reaction and those who had good tolerance to the previous sting. It is important to take these cofactors into consideration when evaluating patients with anaphylaxis as they may play a role in future anaphylactic reactions.

A multicenter anaphylaxis registry in Korea: Clinical characteristics and acute treatment details from infants to older adults

Background

Although the prevalence of anaphylaxis is increasing worldwide, the large-scale studies in Asia evaluating anaphylaxis in all age groups are limited. We aimed to collect more precise and standardized data on anaphylaxis in Korea using the first multicenter web-based registry.

Methods

Twenty-two departments from 16 hospitals participated from November 2016 to December 2018. A web-based case report form, designed by allergy specialists, was used to collect anaphylaxis data.

Results

Within the 2-year period, 558 anaphylaxis cases were registered. The age of registered patients ranged from 2 months to 84 years, and 60% were aged <18 years. In children and adolescents, foods (84.8%) were the most common cause of anaphylaxis, followed by drugs (7.2%); in adults, drugs (58.3%) were the most common cause, followed by foods (28.3%) and insect venom (8.1%). The onset time was ≤10 min in 37.6% of patients. Among the 351 cases registered via the emergency department (ED) of participating hospitals, epinephrine was administered to 63.8% of patients. Among those receiving epinephrine in the ED, 13.8% required 2 or more epinephrine shots. Severe anaphylaxis accounted for 23.5% cases (38.1% in adults; 13.7% in children); patients with drug and insect venom-induced anaphylaxis had higher rates of severe anaphylaxis.

Conclusion

This multicenter registry provides data on anaphylaxis for all age groups for the first time in Asia. The major causes and severity of anaphylaxis were remarkably different according to age group, and the acute treatment features of anaphylaxis in the EDs were examined in detail.

New York State cases of anaphylaxis in elderly patients from 2000 to 2010

BACKGROUND

Limited information is available on the effect of anaphylaxis, a severe, potentially life-threatening allergic reaction, in the elderly population.

OBJECTIVE

To elucidate the frequency of anaphylaxis and the demographic characteristics of elderly patients admitted to New York hospitals from 2000 to 2010.

METHODS

A retrospective analysis of hospitalized patients aged 65 years and older in New York from 2000 to 2010 was conducted using the Statewide Planning and Research Cooperative System, a statewide administrative database. Cases were identified using anaphylaxis International Classification of Diseases, Ninth Revision (ICD-9) codes or an ICD-9-based diagnostic algorithm incorporating the National Institutes of Allergy and Infectious Disease diagnostic criteria. The χ² test was used to measure the association between demographic characteristics and group membership. Regression was used to model group and age as a function of hospital rates.

RESULTS

A total of 3673 hospitalizations were analyzed. Anaphylaxis ICD-9 codes identified 1790 cases (48.7%), the algorithms identified 1701 cases (46.3.%), and 182 cases (5.0%) were identified by both. Hospitalization rates increased significantly during this period (P < .001). Women comprised 61.5% and people of white race comprised 69.8% of the sample. Distribution by age differed by ascertainment method (ICD-9 vs algorithm) among the early-old group (65-74 years of age; 53.8% vs 41.8%) and among the late-old group (≥85 years of age; 11.2% vs 19.3%).

CONCLUSION

Hospitalization rates and anaphylaxis cases increased during the study period among the hospitalized elderly population of New York. Relying on anaphylaxis ICD-9 codes alone missed approximately half of possible cases. The identification and possibly the effect of anaphylaxis among the elderly population may differ, depending on age, race, payer, New York County, and disposition.

Secondary prevention measures in anaphylaxis patients: Data from the anaphylaxis registry

BACKGROUND

Patients with a history of anaphylaxis are at risk of future anaphylactic reactions. Thus, secondary prevention measures are recommended for these patients to prevent or attenuate the next reaction.

METHODS

Data from the Anaphylaxis Registry were analyzed to identify secondary prevention measures offered to patients who experienced anaphylaxis. Our analysis included 7788 cases from 10 European countries and Brazil.

RESULTS

The secondary prevention measures offered varied across the elicitors. A remarkable discrepancy was observed between prevention measures offered in specialized allergy centers (84% of patients were prescribed adrenaline autoinjectors following EAACI guidelines) and outside the centers: Here, EAACI guideline adherence was only 37%. In the multivariate analysis, the elicitor of the reaction, age of the patient, mastocytosis as comorbidity, severity of the reaction, and reimbursement/availability of the autoinjector influence physician's decision to prescribe one.

CONCLUSIONS

Based on the low implementation of guidelines concerning secondary prevention measures outside of specialized allergy centers, our findings highlight the importance of these specialized centers and the requirement of better education for primary healthcare and emergency physicians.

Food Allergies and Ageing

All over the world, there is an increase in the overall survival of the population and the number of elderly people. The incidence of allergic reactions is also rising worldwide. Until recently, allergies, and in particular food allergies (FAs), was regarded as a pediatric problem, since some of them start in early childhood and may spontaneously disappear in adulthood. It is being discovered that, on the contrary, these problems are increasingly affecting even the elderly. Along with other diseases that are considered characteristics of advanced age, such as cardiovascular, dysmetabolic, autoimmune, neurodegenerative, and oncological diseases, even FAs are increasingly frequent in the elderly. An FA is a pleiomorphic and multifactorial disease, characterized by an abnormal immune response and an impaired gut barrier function. The elderly exhibit distinct FA phenotypes, and diagnosis is difficult due to frequent co-morbidities and uncertainty in the interpretation of in vitro and in vivo tests. Several factors render the elderly susceptible to FAs, including the physiological changes of aging, a decline in gut barrier function, the skewing of adaptive immunity to a Th2 response, dysregulation of innate immune cells, and age-related changes of gut microbiota. Aging is accompanied by a progressive remodeling of immune system functions, leading to an increased pro-inflammatory status where type 1 cytokines are quantitatively dominant. However, serum Immunoglobulin E (IgE) levels and T helper type 2 (Th2 cytokine production have also been found to be increased in the elderly, suggesting that the type 2 cytokine pattern is not necessarily defective in older age. Dysfunctional dendritic cells in the gut, defects in secretory IgA, and decreased T regulatory function in the elderly also play important roles in FA development. We address herein the main immunologic aspects of aging according to the presence of FAs.