Anaphylaxis treatment

Ongoing epinephrine research relevant to human anaphylaxis is critically important. In its absence, the use of epinephrine in anaphylaxis treatment in the 21st century will continue to be based mostly on clinical experience, or worse, on expedience, instead of on clinical science. 

Epinephrine—a naturally occurring hormone, also called adrenaline, which increases the speed and force of heartbeats and thereby the work that can be done by the heart. It remains the drug of choice for anaphylaxis treatment. 

Acute myocardial ischemia Adrenaline administration is the gold standard for anaphylaxis treatment but it may cause acute myocardial ischemia. This pathophysiology is a different entity from Kounis syndrome [19 ]. 

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. 

Fisher MMD Clinical observations on the pathophysiology and treatment of anaphylactic cardiovascular collapse. Anesth Intensive Care 1986 17 17-21. Galli S (ed) Anaphylaxis. Novartis Foundation Symposium 157. Chichester, Wiley, 2004. Gronemeyer W Noradrenalin statt Adrenalin beim anaphylaktischen Schock. Dtsch Med Wochenschr 1980 102 101. 

Wiggins CA, Dykowicz MS, Patterson R Idiopathic anaphylaxis. Classification, evaluation and treatment of 123 patients. J Allergy Clin Immunol 1988 82 849-855. 

Simons FE, Peterson S, Black CD Epinephrine dispensing for the out-of-hospital treatment of anaphylaxis in infants and children a population-based study. Ann Allergy Asthma Immunol 2001 86 622-626. 

Shapiro GG, Metcalfe DD Omalizumab for the treatment of unprovoked anaphylaxis in patients with systemic mastocytosis. J Allergy Clin Immunol 2007 119 1550-1551. 

Contraindications are the same as for immunotherapy for inhalant allergy, but are relative in nature because of the life-saving potential of venom immunotherapy. Elderly patients, especially with preexisting cardiovascular disease, are at a high risk to develop severe or even fatal anaphylaxis [26]. Therefore, venom immunotherapy is often recommended in patients over 50-60 years of age. Since (3-blocker treatment is associated with a significantly increased survival rate in patients with coronary heart... 

The well-known adverse reaction formerly often observed after intramuscular injection of clemizol penicilUn in the treatment of syphilis with anaphylaxis-like symptoms plus CNS involvement in the absence of immimological sensitization to penicillin was called the Hoigne syndrome or embolic-toxic reaction, and might be explained by intravasal appUcation of LA with subsequent toxic effects [8]. 

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). 

Hj-antagonists alone, such as cimetidine or ranitidine, have a modest effect on cutaneous flush reaction and maybe also on the heart [14, 52]. However, when applied they should be given together with Hj-antagonists. There are some studies showing a beneficial effect of combined H - and Hj-antagonist treatment or pretreatment in anaphylaxis [46, 53]. 

Tables. Technical supplies required for adequate treatment of anaphylaxis... 

Gu X, Simons KJ, Simons FER Administration by sublingual tablet feasible for the first aid treatment of anaphylaxis A proof-of-concept study. Diophar Drug Dispos 2002 23 213-216. 

Brown SG, Blackman KE, Stenlake V, Heddle RJ Insect sting anaphylaxis prospective evaluation of treatment with intravenous adrenaline and volume resuscitation. Emerg Med J 2004 21 149-154. Lieberman P Use of epinephrine in the treatment of anaphylaxis. Curr Opin Allergy Clin Immunol 2003 3 313-318. 

Simons FE First-aid treatment of anaphylaxis to food focus on epinephrine. J Allergy Clin Immunol 2004 113 837-844. 

In this review, we will describe the pharmacologic activity of epinephrine in anaphylaxis, the evidence base for its use, epinephrine dosing and routes of administration, epinephrine autoinjector use in first-aid treatment, reasons for failure to inject epinephrine promptly, reasons for occasional apparent lack of response, and future directions in epinephrine research. 

Strength of recommendation for use as initial treatment of first choice in anaphylaxis ... 

With regard to epinephrines potential adverse cardiac effects, it is important to remember that in anaphylaxis, the heart is a target organ. Mast cells located between myocardial fibers, in perivascular tissue, and in the arterial intima are activated through IgE and other mechanisms to release chemical mediators of inflammation, including histamine, leukotriene C4, and prostaglandin D2. Coronary artery spasm, myocardial injury, and cardiac dysrhythmias have been documented in some patients before epinephrine has been injected for treatment of anaphylaxis, as well as in patients with anaphylaxis who have not been treated with epinephrine [11, 12]. 

Serious adverse effects of epinephrine potentially occur when it is given in an excessive dose, or too rapidly, for example, as an intravenous bolus or a rapid intravenous infusion. These include ventricular dysrhythmias, angina, myocardial infarction, pulmonary edema, sudden sharp increase in blood pressure, and cerebral hemorrhage. The risk of epinephrine adverse effects is also potentially increased in patients with hypertension or ischemic heart disease, and in those using (3-blockers (due to unopposed epinephrine action on vascular Ui-adrenergic receptors), monoamine oxidase inhibitors, tricyclic antidepressants, or cocaine. Even in these patients, there is no absolute contraindication for the use of epinephrine in the treatment of anaphylaxis [1,5,6]. 

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... 

Optimal use of epinephrine autoinjectors for first-aid treatment of anaphylaxis in community settings is hampered by several issues. In most countries, these include the availability of only two pre-measured epinephrine doses and only a few different needle lengths, and the need to replace outdated autoinjectors at 12- to 18-month intervals due to degradation of the epinephrine solution they contain. 

Physicians face a dilemma with regard to prescribing an optimal epinephrine dose in an autoinjector for first-aid treatment of people at risk for anaphylaxis in a community setting, because only two pre-measured epinephrine doses, 0.15 and 0.3 mg, are... 

Lack of appropriate dose options and needle length options should not deter physicians from prescribing epinephrine autoinjectors for the first-aid out-of-hospital treatment of anaphylaxis. 

Up to 20% of anaphylaxis episodes in adults, and up to 6% of episodes in children, are biphasic or protracted, and involve recurrent or persistent symptoms without any ongoing or additional exposure to the anaphylaxis trigger. Administering too little epinephrine too late during treatment of the initial symptoms of an anaphylaxis episode is one of the factors reported to increase the risk of biphasic or protracted anaphylaxis [27]. 

Although epinephrine autoinjectors are widely dispensed for first-aid treatment of anaphylaxis in some countries, they are neither available nor affordable in many others [33]. In these situations, physicians sometimes equip patients at risk for anaphylaxis in the community with an epinephrine ampule and a disposable 1-ml syringe. Some physicians also recommend this approach for infants, for whom, as noted previously, no appropriate epinephrine dose is available in an autoinjector formulation. 

Preparedness for first-aid treatment of anaphylaxis in the community involves not only a prescription for epinephrine autoinjectors, but also an Anaphylaxis Emergency Action Plan, appropriate medical identification, and anaphylaxis education. 

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