Anaphylaxis in elderly people

Abstract

Purpose of reviewAnaphylaxis is common in old-age adults but is insufficiently understood by physicians, and may be underdiagnosed. This review discusses the specificities of anaphylaxis in this age group and stresses the importance of adrenaline in its management.Recent findingsData from the European Anaphylaxis Registry on elderly patients is a major finding. Other findings include the prevention of possible anaphylactic reactions in coronavirus disease 2019 vaccination as well as some new epidemiologic data.SummaryThe most common risk factors are hymenoptera venom and food and drug allergy. Cardiovascular symptoms are the most important ones to reverse in old-age adults, especially due to the multiple comorbidities. Anaphylaxis in old-age adults has a more severe outcome than in younger ones. Polypharmacy is a specific factor to be considered. The Airway, Breathing, Circulation, Disability, Exposure (ABCDE) algorithm is applicable in all clinical emergencies for immediate assessment and treatment, and should be considered for all patients. Adrenaline is the mainstay of the management of the condition. There are no absolute contraindications to the prescription of self-injectable adrenaline in elderly individuals at risk of anaphylaxis.

Clinical outcomes of AIT in the elderly population

“…It is possible that the use of epinephrine in elderly patients, particularly those with cardiovascular disease, may place patients at greater risk for drug side effects. However, the data suggest that these complications may be manageable [ 36 ▪ , 37 ].…”

Changing patterns in the epidemiology of drug allergy

“…16,17,19 Females over 55 years of age exposed to multiple medications are overrepresented. 9,18 The incidence of Stevens-Johnson syndrome (SJS)/Toxic epidermal necrolysis (TEN) is 1.4 to 6 per million individuals per year, 24 drug rash with eosinophilia and systemic symptoms syndrome (DRESS) is 10 cases per million and acute generalized exanthematous pustulosis (AGEP) one to five cases per million per year with an overall SCAR mortality of 10%, which increases up to 50% or higher for SJS/TEN in the elderly and immunocompromised hosts. [25][26][27][28][29] Antibiotics represent 14.8% of all anaphylactic reactions reported to FDA (U.S. Food & Drug Administration) from 1999 to 2019 and monoclonal antibodies (mAbs) hypersensitivity reaction (HSR) rate has increased from 2% in 1999 to 17.4% in 2019.…”

“…Drug exposures are different across the globe due to costs and supply chain 8 . Patients with cystic fibrosis, cancer, and chronic inflammatory conditions have chronic and multiple drug exposure patterns as opposed to the general population, who is exposed to drugs intermittently 8,9 …”

“…Urticaria and maculopapular rashes are the main presentation 19 in children and adults 23 and the main causes of DA‐related hospitalizations include anaphylaxis and delayed reactions such as severe cutaneous adverse reactions (SCARs) 16,17,19 . Females over 55 years of age exposed to multiple medications are overrepresented 9,18 . The incidence of Stevens–Johnson syndrome (SJS)/Toxic epidermal necrolysis (TEN) is 1.4 to 6 per million individuals per year, 24 drug rash with eosinophilia and systemic symptoms syndrome (DRESS) is 10 cases per million and acute generalized exanthematous pustulosis (AGEP) one to five cases per million per year with an overall SCAR mortality of 10%, which increases up to 50% or higher for SJS/TEN in the elderly and immunocompromised hosts 25–29 …”

“…8 Patients with cystic fibrosis, cancer, and chronic inflammatory conditions have chronic and multiple drug exposure patterns as opposed to the general population, who is exposed to drugs intermittently. 8,9 A DA label is typically acquired in childhood and never challenged until an urgent need arises in adulthood, when delabeling may have time constraints and be deemed unsafe. The lack of harmonized strategies to record DA hampers collection of comparable epidemiological data.…”