Severity grading system for acute allergic reactions: A multidisciplinary Delphi study

Anaphylaxis—moving beyond severity…

“…àLaryngeal symptoms include stridor, vocal changes, and odynophagia. include patient perception and opinion, something that is notably absent in the methodology chosen by Dribin et al 4 Historically, the development of disease severity scores has not, in general, involved patient input. However, severity does have an impact on patients (indeed, the Consortium for Food Allergy Research severity score includes this as a determinant of severity).…”

“…However, any severity score must be fit for purpose, be informed by patient and clinician experience, and ideally be datadriven to minimize the impact of subjectivity and provide objective validation (Fig 1). 2,10 In the meantime, the severity score proposed by Dribin et al 4 highlights the inconsistencies and limitations of the NIAID criteria for anaphylaxis. Developing our understanding of the relationship between anaphylaxis definition (and indication for epinephrine treatment) and severity grading of symptoms is essential for further progress in this area.…”

“…[1][2][3] In this issue of the Journal of Allergy and Clinical Immunology, Dribin et al describe a severity grading system for acute allergic reactions that is generated by a 21-member panel through a Delphi consensus process. 4 There are a number of important principles identified and supported by the panel, including acknowledgment that severity is a continuum and that an allergic reaction can have different phases (as is the case for biphasic reactions), each with differing severities. The explanatory detail with respect to specific symptoms is also welcome.…”

“…Dribin et al 4 suggest that a severity score not dictate treatment, which is an argument that is not without merit. There is, however, a clear link between assignment of severity and diagnosis of anaphylaxis.…”

“…There is, however, a clear link between assignment of severity and diagnosis of anaphylaxis. In the proposed scoring system, gastrointestinal symptoms do not loom large as a feature of severity; therefore, one might interpret Dribin et al 4 as implying that the current inclusion of gastrointestinal symptoms in the NIAID criteria poses difficulties. The authors present an even greater paradox: that ''a patient with isolated upper airway obstruction following Hymenoptera envenomation would be categorized as having a nonanaphylactic grade 5 allergic reaction''; and yet, on the basis of the NIAID criteria, such a reaction with severe laryngeal obstruction would not constitute anaphylaxis (and arguably, therefore not warrant treatment with epinephrine).…”