Anaphylaxis, acute, treatment

Regarding the management of anaphylaxis, differentiation should be made between the acute treatment of an anaphylactic reaction [see chapter by Ring et al, section Treatment and Prevention, p. 201] and the management of a patient who has undergone an anaphylactic episode. 

Among the antianaphylactic drugs, epinephrine (adrenaline) is the essential substance. In the acute treatment of the anaphylaxis in addition to the classical ABC (airway, breathing, circulation) rule for cardiopulmonary resuscitation [26, 27], one can apply the AAC rule (antigen off, adrenaline, cortisone) [18], Other drugs playing a role in the treatment of anaphylaxis include antihistamines (Hi-antagonists). 

The current evidence base for the injection of epinephrine in the initial acute treatment of anaphylaxis includes clinical experience during nearly a century of use, observational studies, epidemiological studies, fatality studies, and randomized controlled trials in people at risk for anaphylaxis although not actually experiencing it at the time of the study. Moreover, the pharmacology of epinephrine has been... 

There are no new medications available for the acute treatment of anaphylaxis [17]. Epinephrine, with its multiple relevant life-saving pharmacologic actions, is likely to remain the initial drug of choice in anaphylaxis for the foreseeable future. 

For acute anaphylaxis, immediate treatment is essential, with adrenaline followed by intravenous histamine Hi receptor antagonists, glucocorticoids, fluids, and electrolytes. In view of the frequency of cardiac dysrhythmias and conduction disturbances in patients with anaphylactic shock, they should immediately be monitored (198,199). 

Although specific antisera have proven invaluable in the treatment of a variety of medical conditions (Table 13.1), they can also induce unwanted side effects. Particularly noteworthy is their ability to induce hypersensitivity reactions some such sensitivity reactions (e.g. serum sickness ) are often not acute, whereas others (e.g. anaphylaxis) can be life threatening. Because of such risks, antibody preparations derived from human donors (i.e. immunoglobulins) are usually preferred as passive immunizing agents. 

Acute anaphylaxis occurred in an 18-year-old man after the third course of intradermal injections of triamcinolone suspension ( Kenalog 10 mg per treatment) for alopecia areata (446). Subsequent rechallenge with intradermal triamcinolone 1 ml resulted in the same anaphylactic reaction as before and his serum IgE concentration was increased. 

Drugs for which concentration assays are clearly unsuited include acute therapies (i.e. not used at steady state), those with extraordinarily short half-times (e.g. injected or intranasal polypeptides) and those for which either treatment is indicated regardless (late acetaminophen/parace-tamol overdoses, see above), or when adverse events are almost automatic and should be monitored in other ways, for example CNS toxicity with salicylates (see above) or liability to bone marrow suppression with cytotoxic agents. Furthermore, the efficacy and tolerability of some drugs are known to be unrelated to circulating concentrations (e.g. penicillin anaphylaxis),... 

U. Fabry, D. Korholz, H. Jiirgens, et al. Anaphylaxis to 1-asparaginase during treatment for acute lymphoblastic leukemia in children—evidence of a complement-mediated mechanism. Pediatr. Res. 19 400 (198S). 

The use of infliximab as a biologic response modifier raises several important considerations. Both acute (fever, chills, urticaria, or even anaphylaxis) and subacute (serum sickness—like) reactions may develop after infliximab infusion. Anti—double-stranded DNA antibodies develop in 9% of patients, but a frank lupus-like syndrome occurs only rarely. Antibodies to infliximab can decrease its clinical efficacy strategies to minimize the development of these antibodies (e.g., treatment with glucocorticoids or other immunosuppressives) may be critical to preserving infliximab efficacy for either recurrent or chronic therapy. 

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