A joint task force of the American College of Allergy, Asthma and Immunology (ACAAI) and the American Academy of Allergy, Asthma and Immunology (AAAAI) has issued new recommendations to healthcare providers who treat anaphylaxis and atopic dermatitis (eczema). The document, entitled “Anaphylaxis: A 2023 practice parameter update” was published Sunday in the journal Annals of Allergy, Asthma & Immunology.
Dr Jay Lieberman, allergist and co-chair of the Joint Task Force for Practice Parameters, gives the following rationale for the update:
Both anaphylaxis and atopic dermatitis are allergic conditions that affect millions of people – in the United States and around the world. We regularly update our practice parameters to make sure allergists and other healthcare practitioners are aware of best practices when diagnosing and managing these disorders. When physicians and their staffs are aware of updated guidance, it means patients are getting the best, most appropriate care.
While the document covers a wide range of practice parameters, of particular interest to food allergy sufferers and their caregivers are the recommendations regarding when to administer epinephrine and whether it is necessary to call emergency medical services (EMS, i.e. 911 in the US and Canada) afterward.
Prior to this update, it was widely accepted that when anaphylaxis was suspected, epinephrine was to be administered immediately and EMS called. The new practice recommendations add some nuance.
Recommendation 25 [conditional with very low certainty of evidence] suggests patients be counseled that an epinephrine auto-injector (EAI) should be administered at the first sign of suspected anaphylaxis but that, in general, epinephrine should not be administered to a patient who is asymptomatic.
The authors note:
There is no evidence that preemptive use of epinephrine in asymptomatic patients prevents anaphylaxis. A 2018 analysis used Markov modeling to evaluate the cost-effectiveness of preemptive epinephrine use in cases when a patient has a known ingestion to an allergen without symptoms. The absolute protective effect of preemptive epinephrine use in the absence of symptoms was low and not cost-effective. However, the authors note that advice regarding preemptive epinephrine use may be patient preference sensitive. For example, although there is a lack of evidence on the benefits of preemptive epinephrine use, it is possible that a more proactive approach might be appropriate for patients with a history of rapidly progressive near-fatal anaphylaxis or underlying mastocytosis. Clinicians should engage patients in shared decision-making that considers individual risk factors, values, and preferences.
As for whether EMS should be called after the administration of an epinephrine auto-injector, Recommendation 26 [conditional with very low certainty of evidence] provides the following guidance:
We suggest that clinicians counsel patients that immediate activation of EMS may not be required if the patient experiences prompt, complete, and durable response to treatment with epinephrine, provided that additional epinephrine and medical care are readily available, if needed. We suggest that clinicians counsel patients to always activate EMS after epinephrine use if anaphylaxis is severe, fails to resolve promptly, fails to resolve completely or nearly completely, or returns or worsens after a first dose of epinephrine.
They suggest the following pragmatic approach:
- Observe at home if signs and symptoms that had emerged before epinephrine administration resolve within minutes of epinephrine administration, without recurrence, or if the patient is asymptomatic. Patients with scattered residual hives or other rash (including erythema), even those with newly emerging but isolated hives or erythema without other symptoms occurring after epinephrine administration, may be observed at home provided no additional new symptoms develop.
- Consider EMS activation and possibly a second dose of epinephrine, or may continue to observe at home if comfortable, if signs and symptoms that had emerged before administration of the first dose of epinephrine are improving or resolving within minutes of epinephrine administration. For example, persistence of a mild sensation of globus, nausea, coughing, or stomachache may be closely observed at home provided symptoms are improving (not worsening and are perceived to be getting better) and do not persist for longer than 10 to 20 minutes without observing additional signs of improvement. Multiple contextual factors (Table 19 below) may influence a patient or caregiver’s decision whether to administer a second dose of epinephrine and contact EMS or continue observing without further intervention.
- Activate EMS immediately and consider a second dose of epinephrine (do not observe at home) if signs and symptoms that had emerged before epinephrine administration are not resolving or are worsening. Particularly concerning symptoms would include respiratory distress, stridor, altered consciousness, cardiovascular instability, cyanosis, or incontinence not typical for their age. This would also include non-skin symptoms that fail to resolve or worsen, including but not limited to repeated (>2 total) episodes of vomiting, persistent hoarseness, cough, dysphagia, wheezing, or lightheadedness.
Here is the table referred to above:
Table 19: Considerations for and Against Home Management of Anaphylaxis
|Considerations for home management
|Considerations against home management
|• Patients/caregivers engaged in shared decision process
|• Patients/caregivers not comfortable with managing anaphylaxis without activating EMS/ED
|• Immediate access to at least 2 EAIs
|• No availability of EAIs or only 1 EAI
|• Immediate access to person(s) who can provide help if needed
|• Being alone, without immediate access to person(s) who can provide help if needed
|• Clear understanding of the symptoms warranting the immediate use of EAI, availability of the anaphylaxis treatment plan
|• Being unaware of the allergic symptoms that warrant the use of EAI
|• Familiarity with the EAI device administration technique
|• Lack of technical proficiency with administration of EAI
• Hesitance about the intramuscular injection (needle phobia)
|• Clear understanding of the benefits of early epinephrine treatment in anaphylaxis
|• Concerns about the potential epinephrine adverse effects
|• Good adherence to previous treatment recommendations, for example, use EAI for anaphylaxis in the past or use of controller medications for chronic conditions
|• Poor adherence to previous treatment recommendations, for example, not administering EAI for anaphylaxis in the past or not using controller medications for chronic conditions
|• History of severe/near-fatal anaphylaxis treated with more than 2 doses of epinephrine, hospitalization, intubation
This is a significant change from prior recommendations provided here for your information. Again, please be sure to discuss the new guidance with your allergist before making any changes to your anaphylaxis emergency action procedures.