Underuse of epinephrine for the treatment of anaphylaxis: missed opportunities

Prince, Benjamin; Mikhail, Irene; Stukus, David R.

doi:10.2147/jaa.s159400

Cited by 94 publications

(75 citation statements)

References 59 publications

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“…3,7,16 The underuse of epinephrine by healthcare professionals can be explained by the complexity involved in establishing the diagnosis of anaphylaxis, lack of knowledge of how to administer epinephrine and use epinephrine auto-injectors, and misconceptions about epinephrine safety. 15,25 To help improving the appropriate use of epinephrine in patients diagnosed with anaphylaxis within the emergency setting, physician training programs should be implemented.…”

Section: Discussionmentioning

confidence: 99%

Tree Nuts Anaphylaxis in Preschool Age Children

Matias

Gáspár

Соколова

et al. 2020

Eur Ann Allergy Clin Immunol

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Introduction: The incidence of food-induced anaphylaxis (FIA) is increasing in young children. Although the commonest culprits are cow's milk and egg, FIA to tree nuts (TNs) have been increasing. Objective: Characterization of children referred to our allergy department due to TNs-induced anaphylaxis (TNs-FIA) during preschool age. Materials and Methods: We have retrospectively included 25 children with clinical history of preschool TNs-FIA, proven by allergological work-up. TNs sensitization was assessed by skin prick tests and/or specific IgE. Results: The mean age of the first anaphylactic episode was 3.1±1.2 years. The majority (92%) had an allergic disease (52% asthma). The implicated TNs were cashew (11 children), walnut (8), pine nut (5), hazelnut (2) and almond (1). The reaction occurred after the first known ingestion in 68%. In 92%, symptoms appeared within 30 minutes after exposure. The most frequent clinical symptoms were mucocutaneous (96%), respiratory (80%) and gastrointestinal (52%). Twenty-one children were admitted to the emergency department, although only 48% were treated with epinephrine. An underneath IgE-mediated mechanism was proven in all cases. Immunologic cross-reactivity with other TNs was identified in 84%, and with peanut in 36%. Overall, in our center, TNs-FIA represents 18% of all causes of FIA. Conclusions: In preschool age children with TNs-FIA, cashew and walnut were the commonest implicated nuts. Most reactions occurred briefly after exposure to minimal amounts of TNs, demonstrating the high potency of these allergens. About one-third also had peanut sensitization. Potentially life-threatening TNs allergy can occur early in childhood and adequate management should be undertaken.

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Section: Discussionmentioning

confidence: 99%

Tree Nuts Anaphylaxis in Preschool Age Children

Matias

Gáspár

Соколова

et al. 2020

Eur Ann Allergy Clin Immunol

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“…22 Epinephrine is the cornerstone of anaphylaxis management but continues to be underutilized. [23][24][25] As a nonselective adrenergic agonist, epinephrine works rapidly to increase peripheral vascular resistance through vasoconstriction, to increase cardiac output, to reverse bronchoconstriction and mucosal edema, and to stabilize mast cells and basophils. 26,27 Despite underuse of rapidly acting epinephrine as first-line treatment, fatal anaphylaxis is a rare outcome, with population prevalence rates between 0.47 and 0.69 per million persons (0.25%-0.33% of anaphylaxis hospitalizations or ED visits).…”

Section: Executive Summarymentioning

confidence: 99%

“…At an anaphylaxis PEER of 12.9%, chemotherapy premedication is associated with a decreased risk of anaphylaxis. The NNT is 16 (range, [13][14][15][16][17][18][19][20][21][22][23][24][25].…”

Section: Policy Level Nomentioning

confidence: 99%

Anaphylaxis—a 2020 practice parameter update, systematic review, and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) analysis

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2020

Journal of Allergy and Clinical Immunology

489

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“…There are several reasons physicians may be reluctant to administer epinephrine. Potential reasons include uncertain diagnosis, fear of side effects, and fear of misusing the auto‐injector . In a survey of 207 ED providers in the US, only 9% used the agreed‐upon criteria established by the National Institute of Allergy and Infectious Diseases (NIAID) for diagnosis of anaphylaxis .…”

Section: Discussionmentioning

confidence: 99%

“…Potential reasons include uncertain diagnosis, fear of side effects, and fear of misusing the auto-injector. 25 In a survey of 207 ED providers in the US, only 9% used the agreedupon criteria established by the National Institute of Allergy and Infectious Diseases (NIAID) for diagnosis of anaphylaxis. 26 The low positive predictive value (68%) of these criteria makes it a challenge for ED providers given the need to have a broad differential diagnosis.…”

Section: Discussionmentioning

confidence: 99%

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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Underuse of epinephrine for the treatment of anaphylaxis: missed opportunities

Cited by 94 publications

References 59 publications

Tree Nuts Anaphylaxis in Preschool Age Children

Tree Nuts Anaphylaxis in Preschool Age Children

Anaphylaxis—a 2020 practice parameter update, systematic review, and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) analysis

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

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