Risk Factors For Severe Anaphylaxis Research Articles

Characteristics of anaphylaxis from tertiary-care hospital in lower northern Thailand: A ten-year retrospective cross-sectional study.

The prevalence and etiology of anaphylaxis vary based on geographic regions, study design, and definition used. Anaphylaxis leading to emergency department visits and hospitalizations has increased worldwide. The prevalence and etiology of anaphylaxis vary based on geographic regions, study design, and definition used. Anaphylaxis leading to emergency department visits and hospitalizations has increased worldwide. A cross-sectional retrospective analysis of medical records from patients with ICD-10 confirmed anaphylaxis was performed at Naresuan University Hospital between March 2011 and February 2021. We identified 439 anaphylaxis episodes in 381 patients within 10 years. The average annual occurrence rates of anaphylactic episodes were 25.0 per 100,000 outpatient and emergency department visits and 11.2 per 100,000 inpatient visits. Both pediatric and adult anaphylaxis events increased annually, from 13.3 (children: 20.5, adults: 12.4) in 2012 to 46.6 (children: 52.6, adults: 46.1) episodes per 100,000 visits in 2021. Peak incidence was observed in adolescents and young adults. Food was the most common trigger, with shrimp and fried insects being predominant. Risk factors for severe anaphylaxis were underlying cardiovascular diseases, drug triggers, and wheezing. Epinephrine was administered in 98.4% of all episodes. Although, there were no fatalities, only 11.4% of patients received prescriptions for self-injectable epinephrine. The study underscores an increasing trend of anaphylaxis affecting both children and adults in lower northern Thailand, with shrimp and fried insects as common triggers.

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

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. 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. 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. 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. 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.

Evaluation of the triggers and the treatment models of anaphylaxis in pediatric patients.

Anaphylaxis is an acute, life-threatening systemic hypersensitivity reaction. We aimed to evaluate the demographic and clinical characteristics of patients presenting with anaphylaxis, as well as triggers and risk factors, and to determine the rate of adrenaline auto-injector (AAI) usage. The study was planned in the pediatric allergy outpatient clinic over a 1-year period. The data of children diagnosed with anaphylaxis were evaluated retrospectively; demographic characteristics, causes of anaphylaxis, and treatment modalities were recorded in the created study form. Eighty children (29 females) with a median age of 6.5 years (range: 1 month-17 years) were evaluated. The most common triggers were foods under 2 years of age (73%), and drugs (70%) above 2 years of age. Nearly half of the anaphylaxis episodes (n=41, 51.3%) occurred at home. Cutaneous and respiratory symptoms were the most commonly reported complaints (98.8%). The median age of the patients at the first attack with severe anaphylaxis (n=29, 36.3%) was significantly higher than the rest (p:0.007). The age at onset of the reaction (p:0.006) and occurrence of the reaction in hospital conditions (p<0.001) were determined to be significant risk factors for severe anaphylaxis. Most of them received antihistamines (95.7%) and corticosteroids (91.3%), while 78.3% received adrenaline. Only 9.5% of patients with recurrent episodes of anaphylaxis used AAIs. Foods in infants and drugs in older children were the leading causative allergens of anaphylaxis. The most common clinical manifestations were respiratory and cutaneous symptoms. The older age at onset of the reaction and the occurrence of the reaction in hospital conditions were determined to be significant risk factors for severe anaphylaxis. It was determined that the frequency of AAI use was low among patients and their families.

Anaphylaxis in Risky Populations.

Anaphylaxis should be clinically diagnosed with immediate recognition, whereas, despite advances in the field of allergy, the symptoms of anaphylaxis remain to be under-recognized, diagnosis is often missed, and treatment is often delayed. Anaphylaxis presents with symptoms in a spectrum of severity, ranging from mild objective breathing problems to circulatory shock and/or collapse. Indeed, anaphylaxis management frequently relies on a 'one-size-fits-all approach' rather than a precision medicine care model, despite the evidence that anaphylaxis is a heterogeneous condition with differences in causative agents, clinical presentation, and host susceptibility. The key important risk factors for severe anaphylaxis and mortality are certain age groups or certain stages of life (infants, elderly and pregnant women), augmenting factors (physical exercise, alcohol consumption, menstruation, acute infections), concurrent use of some medications (beta-adrenergic blockers (β-blockers) and angiotensin-converting enzyme (ACE) inhibitors, non-steroidal anti-inflammatory drugs (NSAIDs), and proton pump inhibitors (PPIs), and concomitant diseases (i.e. asthma, cardiovascular disease, mastocytosis). The present review aims to collectively address the patient groups who are at high risk of having anaphylaxis, those who have a more severe course, those that are difficult to diagnose, and require a special approach in treatment. Therefore, the risky populations like the elderly, pregnant women, patients receiving β- blockers or ACE inhibitors, those with concomitant cardiovascular diseases, asthma, and mastocytosis, or those having higher baseline serum tryptase levels are discussed, including their clinical presentations and treatment strategies. Additionally, anaphylaxis during the perioperative period is addressed.

Anaphylaxis: Advances in the Past 10 Years

In the past ten years, anaphylaxis has grown into its own special area of study within Allergy-Immunology, both at the bench and at the bedside. This review focuses on some of the most clinically relevant advances over the past decade. These include simplified and more inclusive diagnostic criteria for adults and children, uniform definition of biphasic anaphylaxis, and improved systems for objective severity grading. Studies reported in the past decade have led to improved understanding of normal and abnormal regulation of mast cell function, translating into better diagnostic and therapeutic approaches to patients with anaphylaxis. Research has provided improved recognition and treatment of mast cell disorders, and has identified a new condition, hereditary alpha tryptasemia, that may impact anaphylactic syndromes. We have learned to recognize new causes (alpha-gal), new pathways (MRGPRX2), and many risk factors for severe anaphylaxis. The stability of epinephrine in autoinjectors was reported to be very good for several years after the labeled expiry date, and it can tolerate freezing and thawing. Repeated and prolonged exposure to excessive heat leads to degradation of epinephrine activity. New treatments to prevent severe anaphylaxis have been described, utilizing new ways to block the IgE receptor or modulate intracellular signaling pathways.

Risk Factors for Severe Anaphylaxis in Children

To understand factors that would help identify patients who are at an increased risk of developing severe anaphylaxis.In this study, the researchers included 453 emergency department (ED) visits identified with anaphylaxis in a 2-year time period (May 2016 to April 2018) in 7 pediatric EDs in Spain.This was a prospective multicenter study in 7 pediatric EDs in which researchers had ED staff recruit patients to participate at the time of anaphylaxis diagnosis. The ED provider completed a data questionnaire at the time of discharge from the hospital or admission to the hospital. The questionnaire and the treatment of each patient were then reviewed, with a significant focus on the 61 visits of patients diagnosed with severe anaphylaxis that met ≥1 of the following criteria: ≥2 doses of epinephrine, clinically important biphasic reaction, endotracheal intubation, intensive care admission, and/or death.With the use of multivariable regression, 5 independent risk factors were found for severe anaphylaxis including (1) a history of asthma, (2) an onset of symptoms <5 minutes after allergen exposure, (3) a nonwell appearance, (4) tachycardia, and (5) hypotension. Furthermore, the risk of severe anaphylaxis increased with each additional risk factor.In this study, the researchers identified 5 factors that increased the risk of severe anaphylaxis. These should be considered in the management of anaphylaxis cases in the ED, such as planning for inpatient observation versus outpatient management.The significant limitations of this study include that∼20% of anaphylaxis ED cases were not recruited for the study, and the baseline asthma control was not assessed, thus they were unable to identify if the link between asthma and severe anaphylaxis is more an association with uncontrolled asthma at baseline rather than simply an asthma diagnosis. Regardless of these limitations, the prospective nature of this study out of the ED allowed them to include nearly all patients who come to the ED for anaphylaxis evaluation. This is significant when compared with prospective reviews completed from allergy clinic follow-up as a number patients with anaphylaxis who are treated in the ED do not have proper follow-up. Finally, this study identified factors that may increase the risk of complications from anaphylaxis that would be helpful to consider when deciding between inpatient monitoring versus outpatient management.

Basal Tryptase High Levels Associated with a History of Arterial Hypertension and Hypercholesterolemia Represent Risk Factors for Severe Anaphylaxis in Hymenoptera Venom-Allergic Subjects over 50 Years Old

Introduction: Allergy to Hymenoptera venom (HV) may lead to life-threatening anaphylaxis. Some of the factors influencing the symptom’s severity are still undetermined. The aim of this study was to identify the clinical aspects associated with the most severe reactions in a population with HV allergy, by comparing clinical and immunochemical biomarkers between patients with previous local large reactions (LLRs) and systemic reactions (SRs). Methods: We selected adult patients with a history of HV allergy, with positive diagnostic tests and a correlation with one single Hymenoptera species. Age, gender, atopy, serum basal tryptase (sBT) value, total IgE, venom-specific IgE, history of hypertension, cardiovascular diseases, and hypercholesterolemia were compared between patients with previous LLRs and SRs. Results: 460 adult patients (381 SRs, 79 LLRs) were included. Age (p = 0.0097), male gender (p < 0.0001), arterial hypertension (p = 0.046), hypercholesterolemia (p = 0.009), and higher sBT levels (p = 0.0004) were significantly associated with severe reactions as independent variables. Moreover, considering the previous variables as risk factors, there was a significant and progressive increase in the odds of being Mueller III + IV as the number of positive variables increased. Patients with sBT ≥6.4 ng/mL adjusted for any of the positive variables had increased the risk of Mueller grade IV reaction (p < 0.0001). Conclusion: According to our results, older age, male gender, arterial hypertension, hypercholesterolemia, and increased levels of sBT ≥6.4 ng/mL are risk factors for severe anaphylaxis to HV in adults. Atopy and allergic asthma do not increase the risk of HV-induced SRs.

Natural history and long-term follow-up of Hymenoptera allergy.

Information on the natural history of hypersensitivity reactions is helpful for deciding which patient urgently needs a venom immunotherapy (VIT). The frequency of self-reported systemic allergic reactions (SAR) to Hymenoptera stings is approximately 3-7% in the Northern Hemisphere. About 25% of SAR are severe (anaphylactic shock). Fatal sting reactions are very rare. The most important risk factor for severe insect sting anaphylaxis is mast cell disease. Other risk factors are higher age, vespid venom allergy (in contrast to honeybee venom allergy), repeated stings, male sex, and treatment with ACE inhibitors. Preceding large local reactions seem not to play a risk factor for subsequent SAR. The majority of risk factors for severe anaphylaxis are not modifiable. For patients presenting with well defined risk factors for a very severe or even fatal anaphylaxis, VIT is of utmost importance, and they should be performed for the rest of their life. Sting challenge tests are required to identify patients in whom treatment was ineffective. Those patients, who did not receive VIT although presenting with a firm indication, or in whom VIT was stopped, require yearly monitoring to teach preventive measures and to renew the emergency kit.

Risk Factors for Severe Anaphylaxis in Children

To identify risk factors associated with severe anaphylaxis in children. We carried out a multicenter prospective observational study including children less than 18years old diagnosed with anaphylaxis in 7 Spanish pediatric emergency departments (EDs) between May 2016 and April 2018. Children were considered to have severe anaphylaxis if they met one or more of the following criteria: requirement for 2 or more doses of epinephrine, clinically important biphasic reaction, endotracheal intubation, intensive care unit admission, and/or death. We included 453 episodes of anaphylaxis. Of these, 61 were classified as severe anaphylaxis (13.5%, 95% CI [10.6-16.9]): 53 (11.7%) required more than 1 dose of epinephrine, and there were 14 (3.1%) cases of clinically important biphasic reactions, 2 (0.4%) intubations in the ED, and 6 (1.3%) admissions to the intensive care unit. No patients died. In the multivariable regression, we identified 5 independent risk factors for severe anaphylaxis: history of asthma (P=.002; OR 2.705, 95% CI [1.431-5.113]), onset of the symptoms less than 5minutes after the allergen exposure (P=.002; OR 2.619, 95% CI [1.410-4.866]), non-well appearance (P=.005; OR 2.973, 95% CI [1.380-6.405]), tachycardia (P=.014; OR 2.339, 95% CI [1.191-4.959]), and hypotension (P=.036; OR 3.725, 95% CI [1.087-12.762]). Childhood anaphylaxis is usually well controlled in the ED. Children with a history of asthma, rapid onset of the symptoms, who are non-well appearing, or have tachycardia or hypotension upon arrival to the ED are more likely to have severe episodes.

Risk Factors and Cofactors for Severe Anaphylaxis

Severe anaphylaxis is a generalized reaction in which cardiovascular and respiratory involvement lead to a fatal or near-fatal outcome. Triggers of severe anaphylaxis differ from one age group to another and are mostly represented by drugs and hymenoptera stings in adults and food in children. Several risk factors and cofactors can increase the odds of severe anaphylaxis by different and still undefined mechanisms. Major risk factors for severe anaphylaxis include old age, male sex, and preexisting medical conditions such as mast cell disorders, cardiovascular diseases, and uncontrolled asthma. Antihypertensive drugs appear to increase the severity of anaphylaxis probably by impairing compensatory mechanism to support blood pressure during the reaction. Severe reactions are also associated with transient cofactors such as exercise following specific allergen exposure, treatment with nonsteroidal anti-inflammatory drugs, and alcohol consumption. Identification of risk factors and potential concurrent cofactors for each individual patient is mandatory to prevent severe anaphylaxis. Risk stratification is crucial to develop personalized prevention strategies and action plans to avoid potentially life-threatening reactions.

Risk factors for severe anaphylaxis in the United States

BackgroundAnaphylaxis is an acute systemic allergic reaction and may be life-threatening. ObjectiveTo assess risk factors associated with severe and near-fatal anaphylaxis in a large observational cohort study. MethodsWe analyzed administrative claims data from Medicare Advantage and privately insured enrollees in the United States from 2005 to 2014. Severe anaphylaxis was defined as anaphylaxis resulting in hospital or intensive care unit (ICU) admission, requiring endotracheal intubation, or meeting criteria for near-fatal anaphylaxis. ResultsOf 38,695 patients seen in the emergency department for anaphylaxis during the study period, 4,431 (11.5%) required hospitalization, 2,057 (5.3%) were admitted to the ICU, 567 (1.5%) required endotracheal intubation, and 174 (0.45%) were classified as having a near-fatal episode. Multivariable analysis revealed that medication-related anaphylaxis (odds ratio [OR], 1.50; 95% confidence interval [CI], 1.38–1.63; P < .001), age of 65 years or older (OR, 3.15; 95% CI, 2.88–3.44; P < .001), and the presence of cardiac disease (OR, 1.56; 95% CI, 1.50–1.63; P < .001) or lung disease (OR, 1.23; 95% CI, 1.16–1.30; P < .001) were associated with increased odds of severe anaphylaxis requiring any hospital admission, ICU admission, or intubation or being a near-fatal reaction. ConclusionIn this large contemporary cohort study, 11.6% of patients had severe anaphylaxis. Age of 65 years or older, medication as a trigger, and presence of comorbid conditions (specifically cardiac and lung disease) were associated with significantly higher odds of severe anaphylaxis. Additional studies examining risk factors for severe anaphylaxis are needed to define risk assessment strategies and establish a framework for management.

Different clinical features of anaphylaxis according to cause and risk factors for severe reactions

BackgroundAnaphylaxis is a life-threatening allergic reaction. Several studies reported different anaphylactic reactions according to the causative substances. However, a comparison of anaphylaxis for each cause has not been done. This study was conducted to identify common causes of anaphylaxis, characteristics of anaphylactic reaction for each cause and to analyze the factors related to the severity of the reaction. MethodsMedical records of patients who visited the emergency room of Ewha Womans University Mokdong Hospital from March 2003 to April 2016 and diagnosed with anaphylactic shock were retrospectively reviewed. We compared the clinical features of anaphylaxis according to the cause. In addition, the severity of anaphylaxis was analyzed and contributing factors for severe anaphylaxis were reviewed. ResultsA total of 199 patients with anaphylaxis were analyzed. Food was the most common cause (49.7%), followed by drug reaction (36.2%), bee venom (10.1%), and unknown cause (4.0%). Cardiovascular symptoms of syncope and hypotension were more common in drug-induced anaphylaxis. The incidence of severe anaphylaxis was the highest in anaphylaxis due to drugs (54.2%). Urticaria and other skin symptoms were significantly more common in food-induced anaphylaxis. Risk factors for severe anaphylaxis included older age, male, and drug-induced one. Epinephrine treatment of anaphylaxis was done for 69.7% and 56.9% of patients with food-induced and drug-induced anaphylaxis, respectively. ConclusionsMore severe anaphylaxis developed with drug treatment and in males. Low rate of epinephrine prescription was also observed. Male patients with drug induced anaphylaxis should be paid more attention.

Risk factors for severe anaphylaxis in patients receiving anaphylaxis treatment in US emergency departments and hospitals

Although reported risk factors for severe anaphylaxis include older age, presence of comorbid medical conditions, and concomitant medications, previous studies have used varying definitions for anaphylaxis and heterogeneous methodology. To describe risk factors for severe anaphylaxis among US patients treated in emergency departments (EDs) or hospitals for anaphylaxis. Individuals with an ED visit/hospitalization for anaphylaxis were identified from 2 MarketScan Research Databases using an expanded International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code algorithm. Eligibility for the current study required continuous medical and prescription coverage for at least 1 year before and after the index date. Severe anaphylaxis was defined as a reaction requiring hospital admission. Among 11,972 individuals, 2,622 (22%) had severe anaphylaxis. Unadjusted analysis showed that severe anaphylaxis was associated with older age and higher comorbidity burden. These patients were also less likely to have filled an epinephrine autoinjector (EAI) prescription or visited an allergist/immunologist, but more likely to have had an ED visit/hospitalization (any cause). On multivariable analysis, filling an EAI prescription (odds ratio [OR], 0.64; 95% CI, 0.53-0.78) or visiting an allergist/immunologist (OR, 0.78; 95% CI, 0.63-0.95) before the index event was associated with a lower risk of severe anaphylaxis, while any previous ED visit (OR, 1.18; 95% CI, 1.07-1.30) or hospitalization (OR, 1.55; 95% CI, 1.36-1.75) was associated with a higher risk of severe anaphylaxis. In this large cohort with an ED visit or hospitalization for anaphylaxis, 22% had severe anaphylaxis. Pre-index preventive anaphylaxis care (ie, EAI prescription fill and allergist/immunologist visit) was associated with a significantly lower risk, supporting the benefits of preventive anaphylaxis care in real-world practice.

Over- and underestimated parameters in severe Hymenoptera venom–induced anaphylaxis: Cardiovascular medication and absence of urticaria/angioedema

Severe anaphylaxis in Hymenoptera venom allergy has been associated with a number of risk factors including elevation of baseline serum tryptase (BST), older age, concomitant diseases, and concurrent medication. The aim of this study was to evaluate indicators and risk factors for severe anaphylaxis due to Hymenoptera field stings with an emphasis on details related to the sting reaction and concurrent medication. In this single-center observational cohort study, we included 657 consecutive patients fulfilling the criteria for venom immunotherapy. Severity of sting-induced anaphylaxis was analyzed in relation to patient-specific risk factors (age and sex, preexisting cardiopulmonary conditions, cardiovascular medication) and details related to the sting reaction (culprit insect, localization of the sting, time interval to onset of symptoms, and presence or absence of cutaneous involvement). BST was determined in a subgroup of patients with moderate to severe anaphylaxis. Four significant indicators and risk factors of severe anaphylaxis were identified (P< .001): (1) elevation of BST, (2) absence of urticaria or angioedema during anaphylaxis, (3) time interval of less than 5 minutes from sting to onset of symptoms, and (4) senior age. The absence of urticaria/angioedema is significantly related to BST elevation (P= .02). No relationship could be established between the severity of anaphylaxis and comorbidities or concurrent cardiovascular medication. Absence of urticaria/angioedema is an indicator of severe anaphylaxis and possibly mastocytosis, requiring determination of BST. Study data do not provide evidence for an aggravation of sting-induced anaphylaxis by concurrent beta-blockade or angiotensin-converting enzyme inhibition.

Épidémiologie de l’asthme et des allergies alimentaires

In the course of the “atopic march”, sensitization to food allergens appears earliest, followed by sensitization to inhalant allergens, which is a factor favoring the subsequent development of asthma. While the sequence atopic dermatitis and/or food sensitization (allergy)–asthma–allergic rhinitis is usually the case, exceptions to this schema are relatively frequent. Asthma and food allergy, conditions occurring more and more often, are closely linked, especially in children. Note that bronchospasm can be a symptom of food allergy. Note also that asthmatic disease is one of the principal risk factors for severe anaphylaxis and death associated with food allergy, with recognized under-utilization of auto-injectable adrenalin. Conversely, because of the “intrinsic” severity of asthma, food allergy represents an important risk factor for severe acute asthma, being able to put the life, especially that of young children, adolescents and young adults, in danger. In practice, one must: (I) look for a history of asthma or existing asthma in all patients suspected of having food allergy, (II) be assured of optimal control of asthma diagnosed during the course of a food allergy workup, and (III) in all cases, refer the patient to an allergy specialist, because experience proves that one food allergic patient out of two does not benefit from such a consultation and the resulting special recommendations.

Use of multiple doses of epinephrine in food-induced anaphylaxis in children

Food allergy is the most common cause of anaphylaxis outside the hospital setting. We sought to determine the rate, circumstances, and risk factors for repeated doses of epinephrine in the treatment of food-induced anaphylaxis in children. Anonymous questionnaires were distributed to families of children with food allergies during allergy outpatient visits to a food allergy referral center. Demographic information, allergy and reaction history, and details regarding the last 2 anaphylactic reactions requiring epinephrine were collected. A total of 413 questionnaires were analyzed. Seventy-eight children (median, 4.5 years of age; range, 0.5-17.5 years) reported 95 reactions for which epinephrine was administered. Two doses were administered in 12 (13%) and 3 doses in an additional 6 (6%) reactions treated with epinephrine. Peanut, tree nuts, and cow's milk were responsible for >75% of reactions requiring epinephrine. Patients receiving multiple doses of epinephrine more often had asthma (P = .027) than children receiving a single dose. The amount of food ingested or a delay in the initial administration of epinephrine were not risk factors for receiving multiple doses. The second dose of epinephrine was administered by a health care professional in 94% of reactions. In this referral population of children and adolescents with multiple food allergies, 19% of food-induced anaphylactic reactions were treated with more than 1 dose of epinephrine. Prospective studies are necessary to identify risk factors for severe anaphylaxis and to establish rational guidelines for prescribing multiple epinephrine autoinjectors for children with food allergy.

Adult food allergy

Adult food allergy is estimated at approximately 3.2% worldwide. The persistence of childhood food allergy is unusual, peanut allergies excepted. Once established in adults, food allergy is rarely cured. Factors favoring the acquisition of allergy could be sensitization to pollens, occupational sensitization by inhalation, drugs (such as tacrolimus), and sudden dietary changes. Severe anaphylaxis and oral allergy syndrome are frequent. The fatality risk is estimated at 1% in severe anaphylaxis. Risk factors for severe anaphylaxis are agents causing increased intestinal permeability, such as alcohol and aspirin. b-blockers, angiotensin-converting enzyme (ACE) inhibitors, and exercise are other factors. Gastrointestinal food allergy remains, to a large extent, undiagnosed in adults. Food allergens are mainly fruit and vegetable, related to pollen sensitizations, or to latex allergy. Wheat flour allergy is increasing. The diagnosis relies on prick skin tests, detection of specific IgEs, and standardized oral challenges. Strict avoidance diets are necessary. Specific immunotherapy to pollens may be efficient for cross-reactive food allergies.