World Allergy Organization Anaphylaxis Guidelines: 2013 Update of the Evidence Base

Abstract

The World Allergy Organization (WAO) Guidelines for the assessment and management of anaphylaxis are a widely disseminated and used resource for information about anaphylaxis. They focus on patients at risk, triggers, clinical diagnosis, treatment in health care settings, self-treatment in the community, and prevention of recurrences. Their unique strengths include a global perspective informed by prior research on the global availability of essentials for anaphylaxis assessment and management and a global agenda for anaphylaxis research. Additionally, detailed colored illustrations are linked to key concepts in the text [Simons et al.: J Allergy Clin Immunol 2011;127:593.e1-e22]. The recommendations in the original WAO Anaphylaxis Guidelines for management of anaphylaxis in health care settings and community settings were based on evidence published in peer-reviewed, indexed medical journals to the end of 2010. These recommendations remain unchanged and clinically relevant. An update of the evidence base was published in 2012 [Simons et al.: Curr Opin Allergy Clin Immunol 2012;12:389-399]. In 2012 and early 2013, major advances were reported in the following areas: further characterization of patient phenotypes; development of in vitro tests (for some allergens) that help distinguish clinical risk of anaphylaxis from asymptomatic sensitization; epinephrine (adrenaline) research, including studies of a new epinephrine auto-injector for use in community settings, and randomized controlled trials of immunotherapy to prevent food-induced anaphylaxis. Despite these advances, the need for additional prospective studies, including randomized controlled trials of interventions in anaphylaxis is increasingly apparent. This 2013 Update highlights publications from 2012 and 2013 that further contribute to the evidence base for the recommendations made in the original WAO Anaphylaxis Guidelines. Ideally, it should be used in conjunction with these Guidelines and with the 2012 Guidelines Update.

Suspected anaphylaxis from intravenous cefazolin during general anaesthesia in a dog

“…For example, hypotension is a common side effect of anaesthetic drugs and tachycardia often reflects a nociceptive response (Harper et al 2009). Treatment of anaphylaxis is based on the ABC ("airway", "breathing", "circulation") principles of Volume resuscitation is recommended during initial management of anaphylaxis (Perel et al 2013, Simons et al 2011, Simons et al 2013. Fluids were provided in this case as part of the anaesthetic management plan, but additional boluses could have been given as supportive therapy during the periods of hypotension.…”

“…Antihistamine and corticosteroid administration should not replace epinephrine as neither relieve the life-threatening symptoms of anaphylaxis (Simons et al 2013). The administration of antihistamines is not supported by high-quality evidence: they have a relatively slow onset of action (compared with epinephrine), do not relieve hypotension or bronchoconstriction and may cause sedation (Simons et al 2013).…”

“…The administration of antihistamines is not supported by high-quality evidence: they have a relatively slow onset of action (compared with epinephrine), do not relieve hypotension or bronchoconstriction and may cause sedation (Simons et al 2013). Similarly, there is a significant absence of evidence supporting the use of glucocorticoids in the primary management of anaphylaxis, except for a potential role in preventing biphasic anaphylaxis (Choo et al 2012, Tole andLieberman 2007).…”

“…Treatment is based on addressing cardiovascular collapse, impaired ventilation and oxygenation, relative hypovolaemia, and removing potential causative agents (Dewachter et al 2009, Harper et al 2009, Simons et al 2011, Simons et al 2013. However, despite well-established evidence-based guidelines for treating anaphylaxis with epinephrine as a first line therapy, compliance is poor (Choo et al 2012, Grabenhenrich et al 2012.…”

Triggers, risk factors and clinico‐pathological features of urticaria in dogs – a prospective observational study of 24 cases

“…In contrast to veterinary medicine, the clinical criteria for diagnosing and grading anaphylaxis are well established in human medicine, but still under continuous debate. 11,22 As mentioned above, this is largely due to the huge number of possible differential diagnoses, especially when skin signs are lacking. In this latter situation, anaphylaxis should be differentiated from all other causes of acute diarrhoea or vomiting, respiratory distress, collapse, heart failure or sudden death.…”