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Francuzik W, Dölle-Bierke S, Knop M, Scherer Hofmeier K, Cichocka-Jarosz E, García BE, Lang R, Maris I, Renaudin JM, Worm M. Refractory Anaphylaxis: Data From the European Anaphylaxis Registry. Front Immunol 2019; 10:2482. [PMID: 31749797 PMCID: PMC6842952 DOI: 10.3389/fimmu.2019.02482] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 10/04/2019] [Indexed: 12/12/2022] Open
Abstract
Refractory anaphylaxis (unresponsive to treatment with at least two doses of minimum 300 μg adrenaline) is a rare and often fatal hypersensitivity reaction. Comprehensive data on its definition, prevalence, and risk factors are missing. Using the data from the European Anaphylaxis Registry (11,596 cases in total) we identified refractory anaphylaxis cases (n = 42) and analyzed these in comparison to a control group of severe anaphylaxis cases (n = 4,820). The data show that drugs more frequently elicited refractory anaphylaxis (50% of cases, p < 0.0001) compared to other severe anaphylaxis cases (19.7%). Cases elicited by insects (n = 8) were more often due to bees than wasps in refractory cases (62.5 vs. 19.4%, p = 0.009). The refractory cases occurred mostly in a perioperative setting (45.2 vs. 9.05, p < 0.0001). Intramuscular adrenaline (as a first line therapy) was administered in 16.7% of refractory cases, whereas in 83.3% of cases it was applied intravenously (significantly more often than in severe anaphylaxis cases: 12.3%, p < 0.0001). Second line treatment options (e.g., vasopression with dopamine, methylene blue, glucagon) were not used at all for the treatment of refractory cases. The mortality rate in refractory anaphylaxis was significantly higher (26.2%) than in severe cases (0.353%, p < 0.0001). Refractory anaphylaxis is associated with drug-induced anaphylaxis in particular if allergens are given intravenously. Although physicians frequently use adrenaline in cases of perioperative anaphylaxis, not all patients are responding to treatment. Whether a delay in recognition of anaphylaxis is responsible for the refractory case or whether these cases are due to an overflow with mast cell activating substances—requires further studies. Reasons for the low use of second-line medication (i.e., methylene blue or dopamine) in refractory cases are unknown, but their use might improve the outcome of severe refractory anaphylaxis cases.
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Affiliation(s)
- Wojciech Francuzik
- Department of Dermatology, Venerology and Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Sabine Dölle-Bierke
- Department of Dermatology, Venerology and Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Macarena Knop
- Department of Dermatology and Allergology, Klinikum der Universität München, Munich, Germany
| | | | - Ewa Cichocka-Jarosz
- Department of Pediatrics, Jagiellonian University Medical College, Kraków, Poland
| | - Blanca E García
- Service of Allergology, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Roland Lang
- Department of Dermatology, Paracelsus Private Medical University Salzburg, Salzburg, Austria
| | - Ioana Maris
- Department of Paediatrics and Child Health, University College Cork, Cork, Ireland
| | - Jean-Marie Renaudin
- Réseau d'Allergo-Vigilance (Allergy Vigilance Network), Vandoeuvre les Nancy, France
| | - Margitta Worm
- Department of Dermatology, Venerology and Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
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