Management Of Anaphylaxis Research Articles

Parent perspectives on food allergy management and safety during the COVID-19 pandemic.

U.S. national emergency was declared in mid-March 2020 due to the coronavirus disease 2019 (COVID-19) pandemic. Subsequently, a period of stay-at-home orders, regulatory changes, evolving medical recommendations, and food supply chain disruptions occurred. There is little published research on how such changes affected food allergy management for children with this diagnosis. The study goal was to identify parent perspectives with regard to if and/or how pandemic-related regulatory changes and evolving medical recommendations have affected food allergy management. A survey was distributed to parents of children with food allergy. An electronic Internet forms survey link was available for completion during July 2020. Data were presented as descriptive statistics, cleaned, and coded into a spreadsheet before analysis. Frequencies and percentage were calculated to describe participants' characteristics and responses. Of 377 responses, 359 met inclusion criteria. Concerns about COVID-19 exposure were expressed in 65.7% about accessing an emergency department and 73.6% had school reentry concerns; 66% had not discussed recommended anaphylaxis management algorithm changes with a provider; 85.8% had not discussed the temporary U.S. Food and Drug Administration food labeling policy with a provider. Most (62%) reported shortages of preferred safe food brands. 62% spent more time cooking safe foods from scratch. With regard to the recommendation by the U.S. Centers for Disease Control and Prevention (CDC) for classroom dining, 57.7% planned to request modifications. With regard to the CDC's recommendation to use inhalers versus nebulizers, 37.7% had not discussed the topic with a provider. Ninety-two written comments were analyzed and grouped into seven themes. New pandemic-related regulations, food supply chain disruptions, and evolving medical recommendations resulted in intensified burdens for respondents, including the increased time needed to complete food allergy management and school reentry concerns. Study results can inform clinical team members (e.g., physicians, nurses, dieticians) of effects that pandemic-related changes may have on this patient population, with subsequent consideration of patient-specific screening, education, and shared decision-making with regard to risk mitigation needs.

Anaphylaxis.

Anaphylaxis is the most severe systemic hypersensitivity reaction, and it can be life-threatening or even fatal. It involves the activation of multiple immune and non immune pathways beyond IgE, thus exhibiting different phenotypes. New symptoms of hypersensitivity caused by chemotherapy drugs, monoclonal antibodies, and biological agents have been suggested to be recognized as anaphylaxis phenotypes. No biomarker has been described that allows an unequivocal diagnosis of anaphylaxis. Moreover, more biomarkers for specific endotypes are needed to stratify severity, to predict risk, and to optimaze tretament choice in the individual patient. Food, drugs and stinging insects represent the most commly identified triggers. Idiopathic anaphylaxis is a diagnosis of exclusion and it can hide a clonal mast cell disorder. Individual risk factors and co-factors may influence the severity of anaphylaxis or its onset, and they should be identified to implement the appropriate measures to prevent recurrence. Prompt recognition and treatment are critical in anaphylaxis, adrenaline being the first-line saving therapy. Individualized anaphylaxis action plan should include avoidance measures, prescription of an adrenaline autoinjector, education, optimal management of relevant comorbidities, venom specific immunotherapy, food oral immunotherapy, and drug desensitization, when appropriate. However, the quality of acute and long-term anaphylaxis management is variable influencing the poor outcomes experienced by many patients. Clinical practice guidelines have the potential to improve outcomes, but they often prove challenging to implement in routine clinical care.

Pediatrician perspectives on symptom presentation and treatment of acute allergic reactions

BackgroundAnaphylaxis remains difficult to diagnose and epinephrine underused. ObjectiveTo better understand the thoughts of pediatricians regarding when acute allergic reactions constitute anaphylaxis and when epinephrine should be given by conducting an anonymous online survey. MethodsThe survey consisted of 8 case-based scenarios of allergic reactions with the following 2 questions on each case: (1) does this case represent anaphylaxis? and (2) if this patient immediately presented to you, would you treat the patient with epinephrine during the reaction? ResultsA total of 1001 responses were analyzed. When assessing all cases combined, there was discordance in whether a case represented anaphylaxis and administration of epinephrine was warranted in 8% of the cases. An average of 5% of all the respondents suggested that the case represented anaphylaxis but would not warrant epinephrine, whereas an average of 3% suggested that the case did not represent anaphylaxis but that epinephrine was warranted. ConclusionThe results of this survey reveal that there is discordance among pediatricians on when an allergic reaction is considered anaphylaxis and when epinephrine is warranted. These data highlight the need for continued improvement of the definition of anaphylaxis and continued need for education regarding the diagnosis and management of anaphylaxis.

Anaphylaxis Management for Dentists: Knowledge and Preparedness

Background: Anaphylaxis is not common in dentistry, but poor anaphylaxis management may lead to mortality. Objective: The aim of this study was to evaluate dentists’ knowledge and preparedness to manage anaphylaxis. Materials and Methods: The study was designed as an online survey. It included questions about anaphylaxis management practices and the availability of equipment and medications in dental facilities. An online survey link was sent to members of the Turkish Dental Association (TDA). Results: A total of 952 TDA members responded to the survey. Fifty-seven point seven percent of dentists knew that adrenaline is the first choice drug to treat anaphylaxis. Fifty-two point four percent of dentists knew that intramuscular injection is the correct route of administration and 41.7% of dentists knew the correct dose to treat anaphylaxis. Only 15.3% of responding dentists answered all three questions correctly. Dentists who had previously been trained in the diagnosis and treatment of anaphylaxis performed better on questions about the first-choice drug, administration route, and dosage, when compared to untrained dentists (p<0.05). Of the responders, only 4.9% of dental facilities possessed complete medications and equipment capabilities to treat anaphylaxis. Conclusion: The majority of responding dentists did not seem to be aware of anaphylaxis management and did not have adequate equipment and medications for treatment of anaphylaxis in their dental facilities. There is an urgent need for undergraduate and postgraduate education programs to increase dentists’ ability to manage anaphylaxis. The availability of emergency anaphylaxis medication and equipment in dental facilities should be ensured.

Canadian Immunization Guide: "Anaphylaxis and other acute reactions following vaccination" chapter update.

The Canadian Immunization Guide (CIG) is a comprehensive resource on immunization for health professionals and vaccine program decision-makers. It is developed based on the evidence-based recommendations of the National Advisory Committee on Immunization (NACI). The NACI Vaccine Safety Working Group (VSWG) is comprised of NACI members, liaison members and external experts. The World Allergy Organization now recommends that antihistamines should not be used in the initial treatment of anaphylaxis. The update of the chapter was also used to provide further information and clarity to several tables in the chapter. In updating the CIG anaphylaxis guidance, VSWG conducted an environmental scan, a review of relevant literature and consulted international and Canadian experts and professional societies. The use of diphenhydramine hydrochloride as adjunctive treatment in the management of anaphylaxis in a community setting is no longer recommended. Other notable changes made to the chapter include the following: 1) retitled: "Anaphylaxis and other acute reactions following vaccination"; 2) inclusion of new tables: "Key distinguishing features of anaphylaxis and vasovagal syncope" and "Signs and symptoms of anaphylaxis"; and 3) updated tables: "Anaphylaxis management kit: recommended items" and "Dosage of intramuscular EPINEPHrine 1:1000 (1 mg/mL) solution, by age or weight". The updated CIG chapter provides healthcare providers with further clarity in recognizing and managing anaphylaxis in community settings. The updated intramuscular epinephrine dosage table will aid in optimal epinephrine administration, while the revised guidance against the use of diphenhydramine hydrochloride will prevent its unnecessary stockpiling in preparation for potential mass vaccination clinics related to the coronavirus disease 2019 pandemic.

Digital technology for anaphylaxis management impact on patient behaviour: A randomized clinical trial

Epinephrine is the first-line treatment for anaphylaxis. Patients at risk should always carry an epinephrine autoinjector (EAI). Several EAI gaps have been identified. We sought to evaluate satisfaction using a medical device (digital technology comprising an EAI smart case connected to a mobile APP) with functions that overcome most of the EAI limitations and to determine whether patient behaviour and anaphylaxis management improve with its use. This was a randomized, open-label, crossover clinical trial in a tertiary hospital involving patients with history of anaphylaxis carrying an EAI. The study was conducted in two three-month periods, one with and one without the medical device. The primary endpoint was satisfaction with the medical device. Usability, adherence, anxiety and anaphylaxis episodes were evaluated as secondary endpoints. A total of 100 patients were included (mean age 38.1years, 74% female), and 95 completed the trial. The satisfaction visual analogue scale (VAS) after using the medical device was higher than before its use (89.1 [95% CI, 60.2-99.1] vs 56.3 [95% CI, 48.1-81.4]; P<.0001). The adherence VAS improved from 59.7 (95% CI, 54.0-65.3) to 88.6 (95% CI, 84.2-92.9) (P<.0001). Overall, 90% patients found the medical device easy to use. Patients' anxiety decreased from 52.2% to 29.3% (P<.001). Seven episodes of anaphylaxis occurred during the study, all in patients without the medical device (P=.025). Eighty-eight per cent of patients felt more involved in the management of anaphylaxis when using the medical device. This is the first clinical trial evaluating digital technology for EAIs, showing a change of behaviour in patients at risk of anaphylaxis, increasing satisfaction, improving adherence, and reducing anxiety, with good usability.

Criteria positive and criteria negative anaphylaxis, with a focus on undifferentiated somatoform idiopathic anaphylaxis: A review and case series.

Background: Undifferentiated somatoform (US) idiopathic anaphylaxis (IA) is considered a psychogenic disorder characterized by a lack of observable physical findings and poor response to treatment. Although failure to diagnose true anaphylaxis can have disastrous consequences, identification of US-IA is crucial to limit unnecessary expenses and use of health care resources. Objective: To better define the presentation and understand the potential relationship between US-IA and underlying psychiatric comorbidities. Methods: We retrospectively reviewed 110 visits by 107 patients to our institution for evaluation and management of anaphylaxis over a 1-year period. The patients were classified as having either criteria positive (CP) or criteria negative (CN) anaphylaxis based on whether they met Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network Symposium criteria for the clinical diagnosis of anaphylaxis. Patient characteristics, including objective and subjective signs and symptoms, and the presence of psychiatric diagnoses were collected and analyzed. Statistical significance was assessed by using the Fisher exact test. A literature review of US-IA and other psychogenic forms of anaphylaxis was performed. Results: Patients with CP anaphylaxis were more likely to present with hypotension, wheezing, urticaria, and vomiting than were patients with CN anaphylaxis. The patients with CN anaphylaxis were more likely to present with subjective symptoms of sensory throat tightness or swelling compared with patients with CP anaphylaxis. No significant difference was detected in the prevalence of psychiatric conditions between the two groups. Conclusion: Patients who met previously established diagnostic criteria for anaphylaxis were more likely to present with objective physical findings than those who did not meet criteria for true anaphylaxis. CN patients who presented for treatment of anaphylaxis were more likely to present with subjective symptoms. Formal diagnostic criteria should be used by clinicians when evaluating patients with suspected anaphylaxis.

A050 THE IMPACT OF COVID-19 AND DISEASE CONTROL MEASURES ON PEDIATRIC FOOD ALLERGY PARENTS/CAREGIVERS AND PATIENTS

COVID-19 affects the daily lives of many food allergy (FA) patients. To characterize its impact, a national survey was administered to parents/caregivers of food-allergic children. Surveys were administered to parents/caregivers from 1)FARE’s patient registry, 2)the multi-site FORWARD clinical cohort study of Black and White food-allergic children, and 3)Stanford clinical FA patient database. Visual analogue scales from 0(much less)—5(equivalent)—10(much greater) quantified FA-related psychosocial burden relative to 2019. COVID-19 Exposure and Family Impact Surveys (CEFIS) were also administered. Responses were obtained through FARE (N=488), FORWARD (N=118), and Stanford (N=65) between 5/15-7/7. While a greater proportion of FARE and Stanford respondents were high-SES and reported White race/ethnicity relative to FORWARD participants, CEFIS scores were similar (M=6.9-7.6)--indicative of similar levels of COVID-19 exposure/impact. Compared to 2019, FARE respondents reported slightly elevated levels of concern (M=5.4;SD=2.5) about accidental ingestion, anaphylaxis management self-efficacy (M=5.2;SD=1.99); FA-related worry/anxiety/stress (M=5.7;SD=2.2-2.3); their child’s nutrition (M=5.4;SD=2.2), and risk of severe (M=6.4;SD=2.3) and fatal (M=6.0;SD=2.1) FA outcomes. Greater parental concern was reported regarding ability to obtain safe foods (M=6.5;SD=2.4); worry about cross-contact among prepared/delivered foods (M=6.4;SD=2.3); activation of EMS (M=7.0;SD=2.3 or going to the ED (M=7.8;SD=2.1) for anaphylaxis treatment. Comparing parental self- vs child-proxy-report responses suggested children were less burdened. However, parent self- and child-proxy-report among FORWARD and Stanford patients indicated less concern relative to 2019 (M<5) for most of the aforementioned domains except for activating EMS (M=6.0-6.7;SD=2.8-2.3) or receiving FA treatment in the ED (M=6.9-7.3;SD=2.7-2.2). The impact of COVID-19 on FA patients and their parents/caregivers is substantial, but heterogenous.

A Proposal from the Montpellier World Health Organization Collaborating Centre for Better Management and Prevention of Anaphylaxis

Since the first description of anaphylaxis in 1902, its clinical importance as an emergency condition has been recognized worldwide. Anaphylaxis is a severe, potentially life-threatening systemic hypersensitivity reaction characterized by rapid onset and the potential to endanger life through respiratory or circulatory compromise. It is usually, although not always, associated with skin and mucosal changes. Although the academic/scientific communities have advocated to promote greater awareness and protocols for the management of anaphylaxis based on best evidence, there are few efforts documenting feedback as to the success of these efforts. In this article, we review the key unmet needs related to the diagnosis and management of anaphylaxis, and propose a public health initiative for prevention measures and a timetable action plan that intends to strengthen the collaboration among health professionals and especially primary care physicians dealing with anaphylaxis, which can encourage enhanced quality of care of patients with anaphylaxis. More than calling for a harmonized action for the best management of anaphylaxis to prevent undue morbidity and mortality, the Montpellier World Health Organization Collaborating Centre here proposes an action plan as a baseline for a global initiative against anaphylaxis. We strongly believe that these collaborative efforts are a strong public health and societal priority that is consistent with the overarching goals of providing optimal care of allergic patients and best practices of allergology.

World Allergy Organization Anaphylaxis Guidance 2020

Anaphylaxis is the most severe clinical presentation of acute systemic allergic reactions. The occurrence of anaphylaxis has increased in recent years, and subsequently, there is a need to continue disseminating knowledge on the diagnosis and management, so every healthcare professional is prepared to deal with such emergencies. The rationale of this updated position document is the need to keep guidance aligned with the current state of the art of knowledge in anaphylaxis management. The World Allergy Organization (WAO) anaphylaxis guidelines were published in 2011, and the current guidance adopts their major indications, incorporating some novel changes. Intramuscular epinephrine (adrenaline) continues to be the first-line treatment for anaphylaxis. Nevertheless, its use remains suboptimal. After an anaphylaxis occurrence, patients should be referred to a specialist to assess the potential cause and to be educated on prevention of recurrences and self-management. The limited availability of epinephrine auto-injectors remains a major problem in many countries, as well as their affordability for some patients.

Diagnosing, managing and preventing anaphylaxis: Systematic review.

This systematic review used the GRADE approach to compile evidence to inform the European Academy of Allergy and Clinical Immunology's (EAACI) anaphylaxis guideline. We searched five bibliographic databases from 1946 to 20 April 2020 for studies about the diagnosis, management and prevention of anaphylaxis. We included 50 studies with 18 449 participants: 29 randomized controlled trials, seven controlled clinical trials, seven consecutive case series and seven case-control studies. Findings were summarized narratively because studies were too heterogeneous to conduct meta-analysis. It is unclear whether the NIAID/FAAN criteria or Brighton case definition are valid for immediately diagnosing anaphylaxis due to the very low certainty of evidence. There was also insufficient evidence about the impact of most anaphylaxis management and prevention strategies. Adrenaline is regularly used for first-line emergency management of anaphylaxis but little robust research has assessed its effectiveness. Newer models of adrenaline autoinjectors may slightly increase the proportion of people correctly using the devices and reduce time to administration. Face-to-face training for laypeople may slightly improve anaphylaxis knowledge and competence in using autoinjectors. We searched for but found little or no comparative effectiveness evidence about strategies such as fluid replacement, oxygen, glucocorticosteroids, methylxanthines, bronchodilators, management plans, food labels, drug labels and similar. Anaphylaxis is a potentially life-threatening condition but, due to practical and ethical challenges, there is a paucity of robust evidence about how to diagnose and manage it.

Management of pediatric allergic reaction: Practice patterns of Canadian pediatric emergency physicians

Anaphylaxis is a severe allergic reaction that can be life-threatening. The literature indicates that the incidence of anaphylaxis is increasing and that there are deficiencies in both recognition and management. We aimed to examine the magnitude of these gaps in Canadian pediatric emergency medicine (PEM). We conducted a self-administered survey of the Pediatric Emergency Research Canada (PERC) physician database. The survey tool was developed through a literature review to identify recurring themes of gaps in anaphylaxis diagnosis and management. The final tool contained four scenarios; three scenarios featured each of the National Institute of Allergy and Infectious Diseases (NIAID) anaphylaxis criteria, separately, and a fourth case of non-anaphylactic allergy. Multiple-choice questions associated with each scenario addressed diagnosis, management, and disposition. Additional questions focused on epinephrine prescribing, observation durations, and respondent demographics. Of the 214 members invited to participate in the survey, 152 (71%) responded. Anaphylaxis was accurately recognized 93%, 82%, and 99% of the time for the NIAID criteria one through three, respectively. When anaphylaxis was recognized, epinephrine was prescribed for each case 96%, 95%, and 72% of the time, respectively. Of all respondents, 115 (76%) accurately diagnosed all three cases of anaphylaxis and 82 (54%) treated anaphylaxis with epinephrine each time it was indicated. Most respondents recognized cases of anaphylaxis; however, a substantial number demonstrated gaps in management that may adversely impact this vulnerable population. The recognition of anaphylaxis without urticaria or pulmonary findings and treatment of anaphylaxis with epinephrine, where indicated, were the main gaps identified.

Diagnosis and management of anaphylaxis.

Anaphylaxis is a serious allergic reaction that is rapid in onset and may be life threatening. An informal review of the literature was performed in a nonsystematic way for this article. Key published work was identified and included. The incidence and prevalence of anaphylaxis have increased over time. Anaphylaxis is unpredictable and can be the result of various allergic triggers, including food, insect venom, and medication. In children, the most frequent trigger is food. The diagnosis is based on clinical criteria. After confirmation of the relevant allergen trigger, prevention occurs through strict avoidance of the allergen and optimal management of existing comorbidities. Patients with anaphylaxis require immediate assessment and treatment. The management of a patient with anaphylaxis should start with the removal of exposure to the known or suspected trigger, followed by the assessment of the patient's circulation, airway patency, breathing, and mental status. The administration of epinephrine at a dose of 0.01 mg/kg (1:1000) intramuscularly is the first-line treatment for anaphylaxis, and there are no absolute contraindications to this treatment. The maximum single dose of epinephrine is 0.5 mg and may be repeated after 5-10 minutes if needed. After administration of epinephrine, patients with anaphylaxis should be placed supine with their lower limbs elevated. They should not be placed in the upright position. Studies of fatal and near-fatal allergic reactions identified potential risk factors for fatalities such as asthma, peanuts and/or tree nuts, and delayed epinephrine use, and provided important information that may help minimize the future risk. Patients and their families need to be well educated on how to manage potential anaphylactic reactions with training in the use of epinephrine autoinjectors and personalized emergency management plans. Health care professionals must be familiar with this clinical emergency and able to respond to anaphylaxis in a timely and appropriate manner.

A survey of anesthetists’ experience and perspectives of perioperative anaphylaxis at an Australian tertiary hospital

Background : Anaphylaxis is a life-threatening emergency that requires prompt recognition and institution of life-saving therapy. Perioperative Anaphylaxis Management Guidelines have been developed by the Australian and New Zealand College of Anaesthetists and Australian and New Zealand Anaesthetic Allergy Group and anesthetic societies worldwide to facilitate diagnosis and management of this rare, but severe complication. Objectives : To perform a cross-sectional survey of the anesthetists’ experience of perioperative anaphylaxis at a single centre and its effect on their practice. Design : Survey questionnaire constructed in Survey Monkey® and sent via e-mail link to all anesthetists. This questionnaire included qualitative and quantitative questions. Setting : Royal Brisbane and Women’s Hospital, a tertiary referral hospital in Queensland. Methods : Anesthetic specialists and provisional fellows at The Royal Brisbane and Women’s Hospital were surveyed using an online platform regarding their experiences of managing anaphylaxis, referral for testing, formal incident reporting and knowledge of existing departmental protocol. We also asked if their experience of anaphylaxis modified their clinical practice. Results : Forty-five out of 102 (44%) of the specialists and provisional fellows surveyed responded. Of these, 17 (38%) had been involved as primary anesthetist and 20 (44.5%) indirectly in at least one suspected case of perioperative anaphylaxis in the past 12-months. Most anesthetists were aware of the resources available in this crisis and appropriate referral for testing had occurred. There was poor local and national reporting of anaphylaxis as a critical incident. Conclusion : A large percentage of the anesthetists surveyed had seen a case of perioperative anaphylaxis in the past year. Managing this life-threatening event has led to practice change for many anesthetists. There is a requirement for further education around incident reporting.

Winning the war against anaphylaxis requires continued professional patient manegement till discharge

Anaphylaxis and anaphylactic shock are not alien to the anesthesiologists. Many anesthetic and even non-enesthetic drugs used in the hospitals may teigger it. Successful management extends even beyond the initial recovery. The aim of this study was to determine the current knowledge of the doctors of different specialities concerning the management of anaphylaxis after diagnosis till discharge of the patient.

Anaphylaxis: knowledge among oral and maxillofacial surgeons

The aim of the present study was to evaluate knowledge regarding the conduct and adequate management of anaphylaxis on the part of oral-maxillofacial surgeons. A quantitative evaluation was performed through a cognitive survey on the subject. The sample was composed of 104 specialists and who participated in the Brazilian Oral-Maxillofacial Surgery and Traumatology Conference. A total of 31.7% of the interviewees were unaware of any protocol for anaphylaxis. Among those with information on the subject, the majority (78.8%) reported that adrenaline is the main drug for the treatment of anaphylaxis, but 50% of these individuals did not know the correct dosage and only 35.6% reported that intramuscular administration was the proper route. Only 12.5% reported having witnessed a case of anaphylaxis and all such cases were resolved with a favorable outcome. A considerable number of surgeons (34.6%) reported not having any drug for emergency care in their offices, but the majority (71.2%) reported being capable of administering such drugs. The present findings revealed a lack of knowledge on the part of many oral-maxillofacial surgeons regarding anaphylactic reactions and treatment.

An audit on schools’ policy regarding emergency adrenaline auto-injector use and provision of spare pens in the East and North Hertfordshire region of the UK

With the increase in the incidence of food allergies and recent adrenaline auto-injector (AAI) shortage in the UK, it is important that schools remain updated about the policy on the emergency use of AAI in schools for children at risk of anaphylaxis. The purpose of this audit is to review current practice in schools in a UK region covered by the Paediatric Allergy Service at the East and North Hertfordshire NHS Trust. We were then able to identify whether schools are aware of and following the national Department of Health guidance regarding emergency AAI use, including provision of spare pens. An online questionnaire was developed to gather information on the schools’ respective policies regarding emergency AAI use, and their awareness and engagement with the recent “Spare Pens” policy. This was sent to all 230 schools within the districts of East and North Hertfordshire, Stevenage and Welwyn Hatfield, covering 78,450 students. Out of 230 schools, 180 completed the questionnaire, covering 62,695 children aged 3-18 years. Of this cohort, 814 children are diagnosed to be at risk of anaphylaxis and prescribed with AAIs. 649 (79.7%) have allergy action plans in school. 179 (99.4%) schools train their staff regarding management of anaphylaxis, with 138 (77.1%) training every year or less. Although 136 (75.6%) were aware of the Spare Pen policy, only 32 (17.8%) stock their own AAIs. 164 (91.1%) schools keep children’s own AAIs on site, (159/164) 97% of which have them within 5 minutes’ reach, and (118/164) 72.0% store them appropriately. Majority of the respondent schools are compliant with current guidance and are aware of the “Spare pen” policy. However, there remains a need to ensure that children at risk of anaphylaxis are provided with their own action plans and AAIs that are readily accessible, because only a minority of school’s stock spare pens.

Anaphylaxis in primary care: Systematic review to support quality of management and optimization of health-care pathways

Anaphylaxis is a severe, life-threatening systemic hypersensitivity reaction characterized by rapid onset and the potential to endanger life. Most of cases of anaphylaxis are first seen by general practitioners (GPs) or emergency doctors. This systematic review is intended to provide evidence-based decision support tools to GPs confronted with anaphylactic patients. We searched MEDLINE, EMBASE, Cochrane Controlled Register of Trials, Lilacs databases from inception from 1988, for manuscripts concerning anaphylaxis and primary care, without language restrictions. We screened studies, extracted data, and assessed risk of bias independently in duplicate. The manual review was performed by two independent ratters. The degree of inter-rater agreement was assessed using Cohen’s kappa. Main outcomes included clinical history, clinical examination, treatment, use of epinephrine and timing to refer the patient to the specialist. We selected 56 studies, comprising 37 original articles, 15 reviews and 4 guidelines. Twenty-three (41%) were focused on specific aetiology: food-induced anaphylaxis (FA) (52%), drug allergy (DA) (35%) and venom allergy (VA) (13%). With a kappa value of 0.67, there was a high agreement on the classification procedures between the two raters. Data showed that in the presence of respiratory and/or cardiovascular symptoms, patients should be promptly treated and sent to the emergency room. Structured clinical history was reported as being mandatory for the diagnosis of anaphylaxis, mainly based on 5 key points: type of manifestations, type of trigger, chronology between reaction and suspected allergen, reproducibility and risk factors. Most documents (44%) covered food-induced anaphylaxis occurring in childhood, with suspected IgE-mediated reaction. Most anaphylaxis in adults were related to DA or VA (48%). Data still stress lack of the recognition of manifestations (48%), treatment with anti-histamines and systemic corticosteroids (26%), delayed application of epinephrine (35%) and highlight the need of decision aids to support diagnosis and anaphylaxis by GPs (38%). GPs should advise an emergency plan and prescribe adrenaline auto-injectors. Reasons for referring to specialists based on the literature are: to investigate aetiology, to undergo specific treatment, such as allergen immunotherapy, severe cases or in suspicion of underlying condition, such as mastocytosis. Evidence presented supports the construction of a decision tree in order to improve management of anaphylaxis. This intends to optimize the life-time of these patients across the health care pathways and prevent avoidable deaths. It is intended that the resultant decision support tool will undergo field-testing for validation.

Achieving equitable management of allergic disorders and primary immunodeficiency in a Black, Asian and Minority Ethnic population

Achieving equitable management of allergic disorders and primary immunodeficiency in a Black, Asian and Minority Ethnic population

Novel Approaches to Food Allergy Management During COVID-19 Inspire Long-Term Change

The SARS-CoV2 pandemic has prompted a re-evaluation of our current practice of medicine. The seemingly abrupt worldwide spread of this disease resulted in immediate changes and a reduction in many allergy-focussed services and procedures. The reality of the long-term circulation of this virus in our communities requires us to evolve as a specialty. In this article, we outline current and future challenges in the management of food allergy in light of coronavirus disease 2019 (COVID-19). We focus on infant food allergy prevention, management of anaphylaxis, accurate diagnosis with oral food challenges, and active management of food allergy with oral immunotherapy. This article identifies the challenges of conflicting guidelines, shortcomings of acute management approaches, and inherent system deficiencies. We offer perspectives and strategies that can be implemented now, including an evaluation of virtual care and telemedicine for the management of food allergy. The use of a shared decision-making model results in novel approaches that can benefit our patients and our specialty for years to come. COVID-19 has forced us to re-evaluate our current way of thinking about food allergy management to better treat our patients.