The diagnosis and management of anaphylaxis practice parameter: 2010 Update

Abstract

These parameters were developed by the Joint Task Force on Practice Parameters, representing the American Academy of Allergy, Asthma & Immunology (AAAAI); the American College of Allergy, Asthma & Immunology (ACAAI); and the Joint Council of Allergy, Asthma and Immunology.The AAAAI and the ACAAI have jointly accepted responsibility for establishing “The Diagnosis and Management of Anaphylaxis Practice Parameter: 2010 Update.” This is a complete and comprehensive document at the current time. The medical environment is a changing environment, and not all recommendations will be appropriate for all patients. Because this document incorporated the efforts of many participants, no single individual, including those who served on the Joint Task Force, is authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Any request for information about or an interpretation of these practice parameters by the AAAAI or ACAAI should be directed to the Executive Offices of the AAAAI, the ACAAI, or the Joint Council of Allergy, Asthma and Immunology. These parameters are not designed for use by pharmaceutical companies in drug promotion. These parameters were developed by the Joint Task Force on Practice Parameters, representing the American Academy of Allergy, Asthma & Immunology (AAAAI); the American College of Allergy, Asthma & Immunology (ACAAI); and the Joint Council of Allergy, Asthma and Immunology. The AAAAI and the ACAAI have jointly accepted responsibility for establishing “The Diagnosis and Management of Anaphylaxis Practice Parameter: 2010 Update.” This is a complete and comprehensive document at the current time. The medical environment is a changing environment, and not all recommendations will be appropriate for all patients. Because this document incorporated the efforts of many participants, no single individual, including those who served on the Joint Task Force, is authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Any request for information about or an interpretation of these practice parameters by the AAAAI or ACAAI should be directed to the Executive Offices of the AAAAI, the ACAAI, or the Joint Council of Allergy, Asthma and Immunology. These parameters are not designed for use by pharmaceutical companies in drug promotion. To read the Practice Parameter in its entirety, please download the online version of this article fromwww.jacionline.org. The full document follows the Executive Summary.Executive summaryEvaluation and management of the patient with a history of episodes of anaphylaxisThe history is the most important tool to determine whether a patient has had anaphylaxis and the cause of the episode (C). A thorough differential diagnosis should be considered, and other conditions should be ruled out (C). Laboratory tests can be helpful to confirm a diagnosis of anaphylaxis or rule out other causes. Proper timing of such tests (eg, serum tryptase) is essential (B). In the management of a patient with a previous episode of anaphylaxis, education is necessary. Emphasis on early treatment, specifically the self-administration of epinephrine, is essential (C). The patient can be instructed to wear and/or carry identification denoting the condition (eg, MedicAlert bracelet; MedicAlert Foundation of the United States, Turlock, Calif) and can also be instructed to have telephone numbers for paramedic rescue squads and ambulance services on hand. A written action plan can be helpful in this regard (C).Office management of anaphylaxisAnaphylaxis is an acute, life-threatening systemic reaction with varied mechanisms, clinical presentations, and severity that results from the sudden systemic release of mediators from mast cells and basophils. (B) The more rapidly anaphylaxis develops, the more likely the reaction is to be severe and potentially life-threatening. (C) Prompt recognition of signs and symptoms of anaphylaxis is crucial. If there is any doubt, it is generally better to administer epinephrine. (C) Epinephrine and oxygen are the most important therapeutic agents administered in anaphylaxis. Epinephrine is the drug of choice, and the appropriate dose should be administered promptly at the onset of apparent anaphylaxis. (C) Appropriate volume replacement either with colloid or crystalloids and rapid transport to the hospital are essential for patients who are unstable or refractory to initial therapy for anaphylaxis in the office setting. (B) Medical facilities should have an established plan of action to deal with anaphylaxis that is regularly practiced and the appropriate equipment to treat anaphylaxis. (B) Physicians and office staff should maintain clinical proficiency in anaphylaxis management. (D) In addition, telephone numbers for paramedical rescue squads and ambulance services might be helpful to have on hand. (C)Specific triggers/setting for anaphylaxisAnaphylaxis to foodsFood is the most common cause of anaphylaxis in the outpatient setting, and food allergens account for 30% of fatal cases of anaphylaxis. (D) The most commonly implicated foods responsible for food-induced anaphylaxis include peanuts, tree nuts, fish, shellfish, cow's milk, soy, and egg. In addition, sesame seed has recently been identified as a significant cause of food-induced anaphylaxis. (C) Common themes associated with fatal food anaphylaxis include the following: reactions commonly involve peanuts and tree nuts; cutaneous and respiratory symptoms are frequently observed; victims are typically teenagers and young adults; patients have a previous history of food allergy and asthma; and there is a failure to administer epinephrine promptly. (C) As is the case of anaphylaxis following other agents, asthma is a risk factor for more severe food-induced anaphylaxis. (C) Biphasic anaphylactic reactions can occur in up to 25% of fatal and near-fatal food reactions. (C) Serum tryptase measurements may not be elevated in cases of food-induced anaphylaxis. (C) The rapid use of injectable epinephrine has been shown to be effective in the initial management of food-induced anaphylaxis, but subsequent doses may be needed. (C) Patients who experience anaphylaxis should be observed for longer periods if they have experienced food-induced anaphylaxis. (C) Food-dependent, exercise-induced anaphylaxis is a unique clinical syndrome in which anaphylaxis occurs within a few hours of specific food ingestion or any meal, and exercise. (C) Patients with food allergy should pay close attention to food advisory labeling (eg, “may contain”), which has become more prevalent. (C)Natural rubber latex–induced anaphylaxisThere are 3 groups at high risk of reaction to latex: health care workers, children with spina bifida and genitourinary abnormalities, and workers with occupational exposure to latex. (C) In vitro assays for IgE to natural rubber latex (NRL) are typically recommended as a first step in evaluating latex sensitivity. However, because of their suboptimal diagnostic predictive value, positive and negative results must be interpreted on the basis of the history. If the test is positive with a high clinical likelihood, latex sensitivity would be reasonable to pursue. In contrast, if the test is negative with a high clinical likelihood, latex sensitivity still must be considered. (C) A standardized commercial skin test reagent for NRL is not available in the United States. Allergists have prepared NRL extracts from gloves to use for clinical testing. It should be noted, however, that such extracts prepared from gloves demonstrate tremendous variability in the content of NRL allergen. Nevertheless, skin prick tests with NRL extract to identify IgE-mediated sensitivity should be considered if patients are members of high-risk groups or have a clinical likelihood of NRL allergy and have negative in vitro tests. (C) Patients with spina bifida (regardless of a history of NRL allergy) and patients with a positive history of NRL allergy ideally should have all medical-surgical-dental procedures performed in a NRL-safe environment. (D) A NRL-safe environment is an environment in which no NRL gloves are used in the room or surgical suite and there are limited NRL accessories (catheters, adhesives, tourniquets, and anesthesia equipment or devices) that come in contact with the patient. (D) In health care settings, general use of NRL gloves with negligible allergen content, powder-free NRL gloves, and nonlatex gloves and medical articles should be considered in an effort to minimize patient exposure to latex. Such an approach can minimize NRL sensitization of health care workers and patients and reduce the risk of reactions to NRL in previously sensitized individuals. (D) Patients with a diagnosis of NRL allergy by history and/or skin testing can wear a medical identification bracelet, carry a medical identification card, or both. If patients have a history of anaphylaxis to NRL, it is important for them to carry autoinjectable epinephrine. (D)Anaphylaxis during general anesthesia, the intraoperative period, and the postoperative periodThe incidence of anaphylaxis during anesthesia has been reported to range from 1 in 4000 to 1 in 25,000. Anaphylaxis during anesthesia can present as cardiovascular collapse, airway obstruction, and/or skin manifestation. (C) It can be difficult to differentiate between immune and nonimmune mast cell–mediated reactions and pharmacologic effects from the variety of medications administered during general anesthesia. In addition, cutaneous manifestations of anaphylaxis are less likely to be apparent when anaphylaxis occurs in this setting. (B) The evaluation of IgE-mediated reactions to medications used during anesthesia can include skin testing to a variety of anesthetic agents. (B) Specifically, thiopental allergy has been documented by skin tests. (B) Neuromuscular blocking agents such as succinylcholine can cause nonimmunologic histamine release, but there have also been reports of IgE-mediated reactions in some patients. (B) Reactions to opioid analgesics are usually caused by direct mast cell mediator release rather than IgE-dependent mechanisms. (B) Antibiotics that are administered perioperatively can cause immunologic or nonimmunologic reactions. (B) Protamine can cause severe systemic reactions through IgE-mediated or nonimmunologic mechanisms. (B) Blood transfusions can elicit a variety of systemic reactions, some of which might be IgE-mediated or mediated through other immunologic mechanisms. (B) Methylmethacrylate (bone cement) has been associated with hypotension and various systemic reactions, although no IgE mechanism has been documented. (C) The management of anaphylactic reactions that occur during general anesthesia is similar to the management of anaphylaxis in other situations. (B)Seminal fluid–induced anaphylaxisCoital anaphylaxis caused by human seminal fluid has been shown to be a result of IgE-mediated sensitization to seminal plasma proteins of varying molecular weight. (C) Postcoital local reactions to human seminal plasma are probably IgE-mediated on the basis of the successful response to rapid seminal plasma desensitization. (C) A history of atopic disease is the most consistent risk factor for seminal fluid–induced anaphylaxis. (C) The diagnosis of seminal plasma anaphylaxis may be confirmed by skin testing with fresh whole human seminal plasma or its fractions obtained from the male partner. It is essential to exclude other underlying causes such as allergens in natural rubber latex condoms or in drugs or foods passively transferred via seminal plasma. (D) Greater than 90% of the allergenic proteins range between 12 and 75 kd. Prostate-specific antigen has been demonstrated to be a relevant allergen in some cases. (C) Systemic and localized reactions to seminal plasma can be prevented by correct use of condoms. Nevertheless, in the event of barrier failure, sexual partners should be prepared to treat acute anaphylaxis. (C) Subcutaneous immunotherapy to properly prepared fractions of seminal plasma collected from male partners has been successful in preventing anaphylaxis to seminal plasma. (C) Successful intravaginal graded challenge with whole seminal plasma of the male partner has been reported in a few cases, but the duration of protection is unknown. This treatment approach is advocated before pursuing desensitization using relevant seminal plasma protein fractions. (C) Patients with seminal plasma allergy may be able to conceive without undergoing desensitization, by artificial insemination with washed spermatozoa. (C)Exercise-induced anaphylaxisExercise-induced anaphylaxis is a heterogeneous form of anaphylaxis in which exercise is the immediate trigger for the development of symptoms. Typical symptoms include extreme fatigue, warmth, flushing, pruritus, and urticaria, occasionally progressing to angioedema, wheezing, upper airway obstruction, and collapse. (A) The pathophysiologic events during exercise that precipitate symptoms are not known, although promising lines of research exist. (C) Some patients experience symptoms only if other contributing factors or cotriggers are present in association with exercise. These cotriggers include ingestion of specific foods—or in some patients, ingestion of any food—nonsteroidal anti-inflammatory drugs, and high pollen levels. (C) The clinical history should focus on identification of these possible cotriggers. Evaluation for sensitization to food allergens, particularly grains and seafood, can be performed. The diagnosis is usually made on the basis of the history and exclusion of other disorders. Exercise challenge testing does not consistently reproduce symptoms. (C) All patients with exercise-induced anaphylaxis must be advised to stop exercising immediately at the first sign of symptoms because continued exertion causes the attacks to worsen. In addition, all patients should carry epinephrine autoinjectors and exercise with a partner who can recognize symptoms and administer epinephrine if necessary. (D) Prophylactic medications are not effective for preventing attacks in the majority of patients, although a small subset does appear to benefit from daily administration of H1 antihistamines. (D) The prognosis of patients with exercise-induced anaphylaxis is generally favorable, although at least 1 fatality has been reported. Most patients experience fewer and less severe attacks over time. It is unclear whether this is the result of trigger avoidance or a change in the underlying condition. (C)Idiopathic anaphylaxisThe symptoms of idiopathic anaphylaxis are identical to those of episodes related to known causes. (C) Patients with idiopathic anaphylaxis should receive an intensive evaluation, including a meticulous history to rule out a definite cause of the events. (C) There might be a need for specific laboratory studies to exclude systemic disorders such as indolent systemic mastocytosis. This might include a measurement of serum tryptase when the patient is asymptomatic, measurement of total tryptase during or within 4 hours of an acute episode, and the ratio of mature (β) tryptase to total tryptase during an episode. To exclude hereditary angioedema or acquired C1 inhibitor deficiency, a C4 concentration can be obtained because it will be reduced during or in the absence of severe angioedema in those conditions but normal in idiopathic anaphylaxis. (C) There might be a need for selective skin testing for detection of antifood IgE antibodies when foods have been ingested within 2 hours of the onset of an episode. (C) Empiric use of oral corticosteroids combined with H1 antagonists has been demonstrated to reduce the frequency/severity of episodes. (C) Patients with idiopathic anaphylaxis should carry epinephrine, should know the indications for self-administration, and can carry information denoting their condition. (C)Anaphylaxis and allergen immunotherapyThere is a small risk of near-fatal and fatal anaphylactic reactions to allergen immunotherapy. (C) Patients with asthma, particularly if poorly controlled, are at higher risk for serious potentially life-threatening anaphylaxis to allergen immunotherapy injections. (C) There is concern that patients taking β-adrenergic blocking agents may be at an increased risk of having a systemic reaction to allergen immunotherapy injections that is difficult to treat. (B) Allergen immunotherapy vaccines should be administered only by health care professionals trained in the recognition and treatment of anaphylaxis, only in health care facilities with the proper equipment for the treatment of anaphylaxis, and in clinics with policies and procedures that minimize the risk of anaphylaxis. (D)Anaphylaxis to drugs and biological modifiersLow-molecular-weight medications induce an IgE-mediated reaction only after combining with a carrier protein to produce a complete multivalent antigen. (B) Penicillin is the most common cause of drug-induced anaphylaxis. (C) Penicillin spontaneously degrades to major and minor antigenic determinants, both of which should be included in skin testing for penicillin hypersensitivity. (B) The negative predictive value of penicillin skin testing with both major and minor determinants (for immediate-type reactions) is between 97% and 99% (depending on the reagents used), and the positive predictive value is at least 50%. (B) The extent of allergic cross-reactivity between penicillin and cephalosporins is unknown but appears to be low. Four percent of patients proven to have penicillin allergy by means of penicillin skin testing react to cephalosporin challenges. (C) Patients with a history of penicillin allergy who have negative penicillin skin test responses can safely receive cephalosporins. (B) Patients who need to receive a cephalosporin and who have a history of penicillin allergy and a positive penicillin skin test response can (1) receive an alternate (non–β-lactam) antibiotic, (2) receive a cephalosporin through graded challenge, or (3) receive a cephalosporin through rapid desensitization. (C) Aztreonam does not cross-react with other β-lactams, except ceftazidime, with which it shares a common R-group side chain. (B) The degree of cross-reactivity between penicillin and carbapenems appears to be low. (C) Diagnosis of IgE-mediated reactions to non–β-lactam antibiotics is limited by a lack of knowledge of the relevant allergenic determinants and/or metabolites. (C) Aspirin and nonsteroidal anti-inflammatory drugs are the second most common cause of drug-induced anaphylaxis. (C) Anaphylactic reactions to aspirin and other nonsteroidal anti-inflammatory drugs appear to be medication-specific. (D)Anaphylactic reactions to omalizumab have occurred, and postmarketing data indicate that there is an incidence of approximately 0.2% in treated patients. These reactions have been unusual in that they can be delayed in onset and progressive. (C) On the basis of the fact that anaphylactic reactions to omalizumab can be delayed, an observation period of 2 hours for the first 3 injections and 30 minutes for subsequent injections is indicated. (D) All patients receiving omalizumab should be prescribed an automatic epinephrine injector and instructed in its use. Physicians should ensure that patients have such an injector with them at the time of the visits to the office for injection. (D) A preassessment (before the injection of omalizumab) of the patient's current health status should be made. This should include vital signs, an assessment of asthma control, and a measurement of lung function. (D)Insect sting anaphylaxisAnaphylaxis to insect stings has occurred in 3% of adults and 1% of children who have been stung and can be fatal even on the first reaction. (B) Cutaneous systemic reactions are more common in children, hypotensive shock is more common in adults, and respiratory complaints occur equally in all age groups. (B) The chance of a systemic reaction to a sting is low (5% to 10%) in patients who have large local reactions and in children with mild (cutaneous) systemic reactions. (A) Recurrence rates of reactions in adults vary between 25% and 70% depending on the severity of the previous systemic sting reaction. (A)Venom skin tests are most accurate for diagnosis, but in vitro testing is an important complementary test. (A) The degree of sensitivity on skin or in vitro tests does not reliably predict the severity of a sting reaction. (B) Because asymptomatic venom sensitization can be detected in up to 25% of adults, diagnosis cannot be made on skin testing alone; the history is essential. (C) Patients discharged from emergency care for anaphylaxis should be given autoinjectable epinephrine, receive instruction in its proper use and indications for use, and be advised to set up an appointment with an allergist-immunologist. Patients should understand, however, that using autoinjectable epinephrine is not a substitute for emergency medical attention. (A) Venom immunotherapy should be recommended for patients with systemic sensitivity to stinging insects because this treatment is highly (90% to 98%) effective. (B) Most patients can discontinue venom immunotherapy after 5 years with low residual risk (<10%) of a severe sting reaction. (A) There is a need to develop tests that are (1) markers of susceptibility and can serve as screening tests to identify patients at high risk of sting anaphylaxis, and (2) markers of tolerance induction to identify patients who can safely discontinue venom immunotherapy. (D) In a retrospective study of patients experiencing anaphylaxis from hymenoptera venom, Angiotensin Converting Enzyme (ACE) inhibitor exposure was associated with a statistically significant increase in risk for more severe anaphylaxis (odds ratio, = 2.27; 95% CI, 1.13-4.56; P = .019). For patients who require an ACE inhibitor for an indication for which there is no equally effective alternative available, a management decision by the physician prescribing venom immunotherapy should be approached cautiously on an individualized risk-benefit basis.Prevention of anaphylaxisWhile atopy may be a risk factor for seminal fluid anaphylaxis, venom-induced and latex-induced anaphylaxis, and possibly anaphylactic reactions to radiographic contrast material, it does not appear to be a risk factor for anaphylactic reactions to medications. (C) Avoidance management should be individualized, taking into consideration factors such as age, activity, occupation, hobbies, residential conditions, access to medical care, and the patient's level of personal anxiety. (C) Even in cases in which the allergen is known, avoidance measures may not always be successful. Therefore, patients should be instructed in self-management of anaphylaxis. (C) When avoidance is ineffective or not possible, other approaches can be used. For example, venom immunotherapy is successful in preventing anaphylaxis in up to 98% of patients who have previously experienced venom-induced anaphylaxis. (A) Pharmacologic prophylaxis should be used in select situations, such as to prevent recurrent anaphylactic reactions to radiographic contrast material and fluorescein, as well as to prevent idiopathic anaphylaxis. In these specific situations, prophylaxis with glucocorticosteroids and antihistamines markedly reduces the occurrence of subsequent reactions. (C) Desensitization to medications that are known to have caused anaphylaxis can be effective. The desensitization is temporary, and if the medication is required in the future, the desensitization process must be repeated. (C) Patient education might be the most important preventive strategy. Education can emphasize hidden allergens, cross-reactivity between various allergens and drugs, unforeseen risks during medical procedures, and when and how to use self-administered epinephrine. Physicians should educate patients about the risks of future anaphylaxis as well as the benefits of avoidance measures. (B) Patients at increased risk for anaphylactic events, such as those with allergy to insect venom, should avoid drugs that might increase their susceptibility and/or complicate the management of an anaphylactic event. (C) To read the Practice Parameter in its entirety, please download the online version of this article fromwww.jacionline.org. The full document follows the Executive Summary. Executive summaryEvaluation and management of the patient with a history of episodes of anaphylaxisThe history is the most important tool to determine whether a patient has had anaphylaxis and the cause of the episode (C). A thorough differential diagnosis should be considered, and other conditions should be ruled out (C). Laboratory tests can be helpful to confirm a diagnosis of anaphylaxis or rule out other causes. Proper timing of such tests (eg, serum tryptase) is essential (B). In the management of a patient with a previous episode of anaphylaxis, education is necessary. Emphasis on early treatment, specifically the self-administration of epinephrine, is essential (C). The patient can be instructed to wear and/or carry identification denoting the condition (eg, MedicAlert bracelet; MedicAlert Foundation of the United States, Turlock, Calif) and can also be instructed to have telephone numbers for paramedic rescue squads and ambulance services on hand. A written action plan can be helpful in this regard (C).Office management of anaphylaxisAnaphylaxis is an acute, life-threatening systemic reaction with varied mechanisms, clinical presentations, and severity that results from the sudden systemic release of mediators from mast cells and basophils. (B) The more rapidly anaphylaxis develops, the more likely the reaction is to be severe and potentially life-threatening. (C) Prompt recognition of signs and symptoms of anaphylaxis is crucial. If there is any doubt, it is generally better to administer epinephrine. (C) Epinephrine and oxygen are the most important therapeutic agents administered in anaphylaxis. Epinephrine is the drug of choice, and the appropriate dose should be administered promptly at the onset of apparent anaphylaxis. (C) Appropriate volume replacement either with colloid or crystalloids and rapid transport to the hospital are essential for patients who are unstable or refractory to initial therapy for anaphylaxis in the office setting. (B) Medical facilities should have an established plan of action to deal with anaphylaxis that is regularly practiced and the appropriate equipment to treat anaphylaxis. (B) Physicians and office staff should maintain clinical proficiency in anaphylaxis management. (D) In addition, telephone numbers for paramedical rescue squads and ambulance services might be helpful to have on hand. (C) Evaluation and management of the patient with a history of episodes of anaphylaxisThe history is the most important tool to determine whether a patient has had anaphylaxis and the cause of the episode (C). A thorough differential diagnosis should be considered, and other conditions should be ruled out (C). Laboratory tests can be helpful to confirm a diagnosis of anaphylaxis or rule out other causes. Proper timing of such tests (eg, serum tryptase) is essential (B). In the management of a patient with a previous episode of anaphylaxis, education is necessary. Emphasis on early treatment, specifically the self-administration of epinephrine, is essential (C). The patient can be instructed to wear and/or carry identification denoting the condition (eg, MedicAlert bracelet; MedicAlert Foundation of the United States, Turlock, Calif) and can also be instructed to have telephone numbers for paramedic rescue squads and ambulance services on hand. A written action plan can be helpful in this regard (C). The history is the most important tool to determine whether a patient has had anaphylaxis and the cause of the episode (C). A thorough differential diagnosis should be considered, and other conditions should be ruled out (C). Laboratory tests can be helpful to confirm a diagnosis of anaphylaxis or rule out other causes. Proper timing of such tests (eg, serum tryptase) is essential (B). In the management of a patient with a previous episode of anaphylaxis, education is necessary. Emphasis on early treatment, specifically the self-administration of epinephrine, is essential (C). The patient can be instructed to wear and/or carry identification denoting the condition (eg, MedicAlert bracelet; MedicAlert Foundation of the United States, Turlock, Calif) and can also be instructed to have telephone numbers for paramedic rescue squads and ambulance services on hand. A written action plan can be helpful in this regard (C). Office management of anaphylaxisAnaphylaxis is an acute, life-threatening systemic reaction with varied mechanisms, clinical presentations, and severity that results from the sudden systemic release of mediators from mast cells and basophils. (B) The more rapidly anaphylaxis develops, the more likely the reaction is to be severe and potentially life-threatening. (C) Prompt recognition of signs and symptoms of anaphylaxis is crucial. If there is any doubt, it is generally better to administer epinephrine. (C) Epinephrine and oxygen are the most important therapeutic agents administered in anaphylaxis. Epinephrine is the drug of choice, and the appropriate dose should be administered promptly at the onset of apparent anaphylaxis. (C) Appropriate volume replacement either with colloid or crystalloids and rapid transport to the hospital are essential for patients who are unstable or refractory to initial therapy for anaphylaxis in the office setting. (B) Medical facilities should have an established plan of action to deal with anaphylaxis that is regularly practiced and the appropriate equipment to treat anaphylaxis. (B) Physicians and office staff should maintain clinical proficiency in