Comparison of international guidelines for the emergency medical management of anaphylaxis

Abstract

Background: Guideline‐based treatment approaches for managing anaphylaxis are widely believed to result in good outcomes, but the strength of evidence underpinning the recommendations made therein is unclear. Objective: To identify and compare national guidelines for the emergency medical management of anaphylaxis and to describe the extent to which the evidence base in support of key recommendations is made clear. Methods: We systematically searched key medical databases and contacted the World Allergy Organization and anaphylaxis charities in several countries to identify national guidelines. Full text copies of relevant papers were obtained and, where necessary, translated. Data were abstracted onto a customized data extraction sheet; this process was independently checked by a second reviewer. Results: Guidelines originating from Australia, Canada, Russia, UK, Ukraine and the USA were identified. While these were in agreement on the broad principles of management, there were important variations in relation to the treatments to be used and the dose and route of administration of these preparations. Most guidelines failed to make clear the strength of evidence underpinning the recommendations being made. Conclusions: There are important international differences in the recommended emergency management of anaphylaxis. It is important that an agreed core evidence‐based guideline for the management of anaphylaxis is now developed, which can then be adapted for national/local use. Clinicians need to be aware of the limitations of existing guidelines.

World Allergy Organization survey on global availability of essentials for the assessment and management of anaphylaxis by allergy-immunology specialists in health care settings

“…3,17,18 Treating and Monitoring an Acute Anaphylaxis Episode Epinephrine (adrenaline) in ampules for injection by any route was the only medication that was universally available for anaphylaxis treatment. This reflects the World Health Organization position that epinephrine is an essential medication for anaphylaxis treatment (www.who.int) and also reflects the recommendations in anaphylaxis guidelines [5][6][7][8][9][10][11][12][13][14][15][16] and previous WAO anaphylaxis publications 19 -21 that prompt injection of epinephrine (adrenaline) is the initial medication of choice in anaphylaxis.…”

“…15 Some of these guidelines were descriptive reviews that did not have the endorsement of a national allergy society, most did not make clear the strength of the evidence behind the recommendations made, and there were important differences in many of the recommendations. 15 The development of anaphylaxis guidelines is, however, a dynamic, ongoing process.…”

“…15 Some of these guidelines were descriptive reviews that did not have the endorsement of a national allergy society, most did not make clear the strength of the evidence behind the recommendations made, and there were important differences in many of the recommendations. 15 The development of anaphylaxis guidelines is, however, a dynamic, ongoing process. Since completion of the 2008 WAO survey of essentials for the assessment and management of anaphylaxis that is reported here, additional national guidelines have been developed, and additional regional guidelines have been published in indexed peer-reviewed journals.…”

“…Anaphylaxis guidelines vary in their recommendations for use of these ancillary medications. [5][6][7][8][9][10][11][12][13][14][15] Several different H 1 -antihistamines for intravenous administration are recommended in varying doses for various lengths of time. Several different glucocorticoids for intravenous administration are recommended in varying doses for various lengths of time.…”

“…H 2 -antihistamines and vasopressors in addition to epinephrine (adrenaline), such as dopamine, noradrenaline, or vasopressin, are not listed in some guidelines. 15 Nevertheless, based on decades of clinical use, consensus opinion, and systematic reviews of the literature to date, all of these medication classes are currently considered to play a role in the treatment of anaphylaxis. [5][6][7][8][9][10][11][12][13][14][15][16][17][22][23][24][25] Many of the medications in these classes were, like epinephrine, introduced for the treatment of anaphylaxis before the era of randomized controlled trials and evidence-based medicine.…”