Biphasic anaphylaxis: A review of the literature and implications for emergency management

Pourmand, Ali; Robinson, Chelsea; Syed, Wahab; Mazer‐Amirshahi, Maryann

doi:10.1016/j.ajem.2018.05.009

Cited by 45 publications

(56 citation statements)

References 23 publications

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“…Anaphylaxis is a potentially fatal allergic reaction with an increasing incidence in the United States . A feared potential sequela is its recurrence, which may occur without any further exposure to the trigger, as in biphasic anaphylaxis, which can occur within 72 hours after resolution of initial symptoms . In addition, anaphylaxis may recur anytime afterward after a repeated exposure to the same or different trigger.…”

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confidence: 99%

“…In addition, anaphylaxis may recur anytime afterward after a repeated exposure to the same or different trigger. Food, medication, and venom allergens are triggers that have been identified as the most common inciting agents for recurrent anaphylaxis . Biphasic reactions were reported at between 1% and 21%, with the more recent studies reporting lower rates, closer to 4.5% .…”

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confidence: 99%

“…Food, medication, and venom allergens are triggers that have been identified as the most common inciting agents for recurrent anaphylaxis . Biphasic reactions were reported at between 1% and 21%, with the more recent studies reporting lower rates, closer to 4.5% . Recurrent anaphylaxis rates varied between 3% and 76%, with the larger studies reporting rates between 3% and 17.6% .…”

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confidence: 99%

“…Biphasic reactions were reported at between 1% and 21%, with the more recent studies reporting lower rates, closer to 4.5% . Recurrent anaphylaxis rates varied between 3% and 76%, with the larger studies reporting rates between 3% and 17.6% . All studies that looked at recurrent anaphylaxis rates were limited to the emergency department (ED) and did not include other patient settings, such as inpatient or outpatient.…”

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confidence: 99%

“…[1][2][3] A feared potential sequela is its recurrence, which may occur without any further exposure to the trigger, as in biphasic anaphylaxis, 4 which can occur within 72 hours after resolution of initial symptoms. 5 In addition, anaphylaxis may recur anytime afterward after a repeated exposure to the same or different trigger. Food, medication, and venom allergens are triggers that have been identified as the most common inciting agents for recurrent anaphylaxis.…”

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confidence: 99%

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Recurrent anaphylaxis in the United States: time of onset and risk factors

Chaaban

Stuart

Watley

et al. 2019

Int Forum Allergy Rhinol

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Background Studies have not yet examined the trends and risk factors of biphasic and recurrent anaphylaxis in the United States using International Classification of Diseases, tenth revision (ICD‐10) CM codes. The goal of this study is to examine the trends of biphasic and recurrent anaphylaxis in all patient care settings (inpatient, outpatient, emergency department, and observation). Methods We used the Clinformatics database from 2015 to 2017. Our main outcome measure was recurrent anaphylactic events occurring within 1 year after the initial event. We used Cox proportional hazards modeling to assess the factors associated with recurrent anaphylaxis and the Kaplan‐Meier method to estimate time to recurrence. Results There were a total of 19,039 patients with incident anaphylaxis in 2016 and, of these, 2017 had a recurrent anaphylaxis event in the 12‐month period after the index date (10.6%). The most common trigger for recurrent anaphylaxis is venom followed by food allergens. Pediatric patients aged <18 years were more likely to develop recurrent anaphylaxis compared with patients aged 18 to 64 years (hazard ratio [HR], 1.53). Patients with allergic rhinitis and asthma were more likely to develop recurrent anaphylaxis compared to those without these comorbidities (HR, 1.15 and 1.27, respectively). Conclusion This is the first national study using ICD‐10 CM codes looking at rates of biphasic and recurrent anaphylaxis in all patient care settings. Recurrent anaphylaxis is more common in the first 3 days after the initial event, in younger patients (<18 years), and in patients with allergic rhinitis and/or asthma. Physicians need to prescribe epinephrine auto‐injectors and educate their patients about the risk of recurrence.

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confidence: 99%

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confidence: 99%

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Recurrent anaphylaxis in the United States: time of onset and risk factors

Chaaban

Stuart

Watley

et al. 2019

Int Forum Allergy Rhinol

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Incidence and timing of biphasic anaphylactic reactions: a retrospective cohort study

Ichikawa

Kuriyama

Urushidani

et al. 2021

Acute Medicine & Surgery

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Aim We investigated the frequency of overall biphasic reactions, biphasic reactions that met the diagnostic criteria of anaphylaxis, and biphasic reactions that caused a severe abnormality in vital signs in patients who visited the emergency department of a tertiary hospital. Methods This retrospective cohort study included patients aged 18 years or over who presented with anaphylaxis at the emergency department of a tertiary care hospital between January 2014 and December 2016. The primary outcome was the incidence of biphasic reactions that caused a severe abnormality in vital signs and developed within 7 days. Secondary outcomes were the frequency of overall biphasic reactions and those that met the diagnostic criteria of anaphylaxis. Results In total, 437 patients aged over 18 years visited the emergency department during the study period. Among them, 202 were enrolled in this study. The proportion of patients who had overall biphasic reactions, those that met the diagnostic criteria of anaphylaxis, and those with a severe abnormality in vital signs was 8.9%, 3.0%, and 1.0%, respectively. Overall, 32.7% of patients were hospitalized, but hospitalization aided in the treatment of severe biphasic reactions at the early stage in only one patient. Conclusion We found that 8.9% of adult patients with anaphylaxis had a biphasic reaction, but biphasic reactions together with severe abnormalities in vital signs were rare.

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Comparison of the efficacy of continuous intravenous infusion versus intramuscular injection of epinephrine for initial anaphylaxis treatment

Fujizuka

Nakamura

Tamura

et al. 2022

Acute Medicine & Surgery

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Aim Continuous intravenous (CIV) infusion of epinephrine for the treatment of anaphylaxis may be required if symptoms do not improve after intramuscular (IM) injection. As CIV infusion permits precise dose adjustment, we compared treatment course and adverse events following CIV infusion and IM injection of epinephrine for the management of anaphylaxis. Methods Medical records of patients, who were treated for anaphylaxis with epinephrine, were 18 years or older, and were admitted to our department from April 2005 to March 2016, were retrospectively reviewed. The cases were categorized as CIV infusion or IM injection, and treatment course and outcomes were compared between the two groups. Results Of the 142 eligible cases, there were 78 in the CIV infusion group and 64 in the IM injection group. The CIV infusion group had lower systolic blood pressure, more respiratory symptoms, and higher Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, but required a lower total dose of epinephrine, had fewer adverse events after epinephrine administration, and showed lower incidence of biphasic reactions. In addition, compared with the IM injection group, time to administration of epinephrine was significantly longer ( P < 0.001), but time to resolution of symptoms, both from contact and epinephrine administration, was significantly shorter ( P < 0.01 and P = 0.03, respectively). Conclusion Continuous intravenous infusion of epinephrine for the treatment of anaphylaxis may be safe, has fewer adverse events, improves symptoms, and is relatively easy to administer under ready conditions. CIV infusion of epinephrine may also reduce the incidence of biphasic reactions.

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Biphasic anaphylaxis: A review of the literature and implications for emergency management

Cited by 45 publications

References 23 publications

Recurrent anaphylaxis in the United States: time of onset and risk factors

Recurrent anaphylaxis in the United States: time of onset and risk factors

Incidence and timing of biphasic anaphylactic reactions: a retrospective cohort study

Comparison of the efficacy of continuous intravenous infusion versus intramuscular injection of epinephrine for initial anaphylaxis treatment

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