Anaphylaxis: A review and update

Jennifer Tupper; Shaun Visser

Compose eLetter

Title *

Author Information

Contributors
First Name and Middle Initial * First or given name, e.g. 'Peter'. Last Name * Your last, or family, name, e.g. 'MacMoody'. Email Address * Your email address, e.g. higgs-boson@gmail.com Occupation * Your role and/or occupation, e.g. 'Orthopedic Surgeon'. Affiliation * Your organization or institution (if applicable), e.g. 'Royal Free Hospital'.

Statement of Competing Interests

Competing interests? *

Yes

Please describe the competing interests

CAPTCHA

This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.

What code is in the image? *

Enter the characters shown in the image.

Vertical Tabs

Jump to comment:

Re:some questions
john vu

Published on: 16 May 2013
Anaphylaxis
Nabil Saieed

Published on: 01 December 2010
Good Topic, Disappointingly Referenced
Aaron Orkin

Published on: 14 November 2010
question
fenar mansoor

Published on: 08 November 2010
some questions
Biljana kostovic

Published on: 31 October 2010
Thanks
Alison Martel

Published on: 31 October 2010
Good Review
Edward St. Godard

Published on: 28 October 2010
Clarification
Helen Ostro-Brown

Published on: 27 October 2010
Epinephrine and BB's - is glucagon helpful?
Donella Anderson

Published on: 27 October 2010
Dose of adrenalin in anaphylaxsis
David J May

Published on: 27 October 2010
Question . . .
Carly A Thompson

Published on: 27 October 2010
Clarification
Howard S Seiden

Published on: 16 October 2010

Published on: (16 May 2013)
Page navigation anchor for Re:some questions
Re:some questions
john vu, md
Interesting to know that only epinephrine (and airway protection) is the only effective first line. Review from a WHO publication seems also to indicate that lorantadine (rather than benadryl) might be a better alternative with less anticholinergic and sedation side effect. A well studied protocol for rebound prophylaxis would be also helpful.
Conflict of Interest:
None declare...
Show More

Interesting to know that only epinephrine (and airway protection) is the only effective first line. Review from a WHO publication seems also to indicate that lorantadine (rather than benadryl) might be a better alternative with less anticholinergic and sedation side effect. A well studied protocol for rebound prophylaxis would be also helpful.
Conflict of Interest:
None declared
Show Less

Competing Interests: None declared.
Published on: (1 December 2010)
Page navigation anchor for Anaphylaxis
Anaphylaxis
Nabil Saieed, Family Physician
The impact of reading this article is to remember that with anaphylaxis it is not necessary to find cutaneous manifestations - antihistaminics and cortisone need time to work so they don't have a role in emergency treatment of anaphylaxis.

Competing Interests: None declared.
Published on: (14 November 2010)
Page navigation anchor for Good Topic, Disappointingly Referenced
Good Topic, Disappointingly Referenced
Aaron Orkin, Family Physician
Dear Editors,
Drs. Tupper and Visser have taken on an important topic with their review of anaphylaxis.
My concerns with this review are directed primarily to the CFP editors and reviewers who brought this piece to publication. Tupper and Visser's article places heavy and repeated emphasis on UpToDate as a primary source for a wide range of assertions. An article from UpToDate serves as Tupper and...
Show More

Dear Editors,
Drs. Tupper and Visser have taken on an important topic with their review of anaphylaxis.
My concerns with this review are directed primarily to the CFP editors and reviewers who brought this piece to publication. Tupper and Visser's article places heavy and repeated emphasis on UpToDate as a primary source for a wide range of assertions. An article from UpToDate serves as Tupper and Visser's only reference on key facts concerning mortality in anaphylaxis, fluid resuscitation in anaphylaxis, the role of H1 and H2 blockers in treating anaphylaxis, the role of steroids in treating anaphylaxis, and features of biphasic anaphylactic reactions.
Tupper and Visser's article has been published as a 'review and update', and although there is no assertion that the piece qualifies as a systematic review, it is disappointing that it should rely so heavily on UpToDate. Written by expert authorities conducting manual unsystematic reviews of the literature, UpToDate itself does not qualify as a systematic review. Tupper and Visser also reference eMedicine for a key fact on the pathophysiology of anaphylaxis.
This 'review and update' constitutes the republication of information drawn from another unsystematic synthesis of sources and expert opinions. Tupper and Visser's reference list show little evidence of having perused the numerous high-quality and current Conchrane reviews on topics related to anaphylaxis [1],[2],[3], although many of these sources are referenced by the UpToDate article that Tupper and Visser have repeatedly cited. Reviewers and editors should expect authors to read and cite the high quality sources directly.
A published 'review and update' should show some evidence of a more thorough examination of the literature than an UpToDate article could provide. Should CFP be printing summaries of UpToDate articles?
[1] Sheikh, A, Ten Broek, V, Brown, SGA, Simons, FER. H1- antihistamines for the treatment of anaphylaxis: Cochrane systematic review. Allergy 2007;62:830.
[2]Sheikh A, Shehata YA, Brown SGA, Simons FER. Adrenaline for the treatment of anaphylaxis: Cochrane systematic review. Allergy 2009;64:204.
[3]Choo, KJ, Simons, FE, Sheikh, A. Glucocorticoids for the treatment of anaphylaxis. Cochrane Database Syst Rev 2010; 3:CD007596.
Show Less

Competing Interests: None declared.
Published on: (8 November 2010)
Page navigation anchor for question
question
fenar mansoor, MD
I reviewed other rapid responses to this article. I am wondering if we give antihistamine IM or it is not indicated. Is there any evidence for it?

Competing Interests: None declared.
Published on: (31 October 2010)
Page navigation anchor for some questions
some questions
Biljana kostovic, MD
I was wondering about the incidence of complications if overtreating with epi. Also, can you use epidrip for anaphylaxis? Thank you.

Competing Interests: None declared.
Published on: (31 October 2010)
Page navigation anchor for Thanks
Thanks
Alison Martel, physician
Great summary and very straight forward. Very beneficial to know that 20% of people with anaphylaxis don't have a rash.

Competing Interests: None declared.
Published on: (28 October 2010)
Page navigation anchor for Good Review
Good Review
Edward St. Godard, WRHA
Thank you for the succinct review. Nice to know that one needs to remember only one drug necessary, and to realized that beta-blockade necessitates dose reduction.

Competing Interests: None declared.
Published on: (27 October 2010)
Page navigation anchor for Clarification
Clarification
Helen Ostro-Brown, physician
Your statement regarding patients on beta blockers appears contradictory at first glance because you mention that the beta blockers may decrease the response to epinephrine. This would imply that one may use a higher dose. However, you also state that there will be unopposed alpha activity, implying that one would then use a lower dose. Please clarify this.

Competing Interests: None declared.
Published on: (27 October 2010)
Page navigation anchor for Epinephrine and BB's - is glucagon helpful?
Epinephrine and BB's - is glucagon helpful?
Donella Anderson, Family Physician
In your article you suggest cutting the epinephrine dose in half for those patients on beta blockers. You did not mention the use of glucagon in this scenario. Is there evidence to support the use of glucagon? If so, please elaborate on how and when to use it. Thank-you.

Competing Interests: None declared.
Published on: (27 October 2010)
Page navigation anchor for Dose of adrenalin in anaphylaxsis
Dose of adrenalin in anaphylaxsis
David J May, GP
I learned and have used an initial IM dose of 1mg adrenalin in patients with anaphylaxis (ie one 1cc amp of 1:1000). This article suggests that I may be using more than three times the recommended dose. I realise that a study on the correct dose might be difficult, but what evidence is there as to the numbers needed to treat (and harm) for various doses? Or are these recommendations (like the ones I am currently using) b...
Show More

I learned and have used an initial IM dose of 1mg adrenalin in patients with anaphylaxis (ie one 1cc amp of 1:1000). This article suggests that I may be using more than three times the recommended dose. I realise that a study on the correct dose might be difficult, but what evidence is there as to the numbers needed to treat (and harm) for various doses? Or are these recommendations (like the ones I am currently using) based on "specialist opinion".
Show Less

Competing Interests: None declared.
Published on: (27 October 2010)
Page navigation anchor for Question . . .
Question . . .
Carly A Thompson, Physician
Hello,
Quick question . . . if you see a patient with a severe allergic reaction, but it does not meet the criteria for anaphylaxis, do you give them a prescription for an Epipen? (For example, a patient who was stung by yellow jackets repetitively over the period of a week so that he developed at the final sting facial swelling (as he was bitten on the face). However, there were NO respiratory symptoms,...
Show More

Hello,
Quick question . . . if you see a patient with a severe allergic reaction, but it does not meet the criteria for anaphylaxis, do you give them a prescription for an Epipen? (For example, a patient who was stung by yellow jackets repetitively over the period of a week so that he developed at the final sting facial swelling (as he was bitten on the face). However, there were NO respiratory symptoms, no hives, just edema, no oral involvement and he presented late?) My bias is yes, especially if you notice a worsening of each reaction to an allergen.
Thank you! Carly Thompson
Show Less

Competing Interests: None declared.
Published on: (16 October 2010)
Page navigation anchor for Clarification
Clarification
Howard S Seiden, Physician - FCFP
Hundreds of thousands of people will be receiving influenza immunization in the coming weeks. We normally package adrenalin and diphenhydramine in our 'emergency' kits for nurses administering the shots in occupational or public clinics. Your article suggests that there is no role for antihistamines. Is the evidence such that we can defensibly no longer provide it to our nurses? Is there any role for antihistamine...
Show More

Hundreds of thousands of people will be receiving influenza immunization in the coming weeks. We normally package adrenalin and diphenhydramine in our 'emergency' kits for nurses administering the shots in occupational or public clinics. Your article suggests that there is no role for antihistamines. Is the evidence such that we can defensibly no longer provide it to our nurses? Is there any role for antihistamines in the treatment of Type I hypersensitivity reactions? If as you suggest there is no role, at what point would you administer adrenalin when signs of anaphylaxis, minus respiratory distress, are present? I notice that although you've indicated that corticosteroids are likewise ineffective the patient in the case you presented received them. I think you need to clarify what role if any, remains for steriods and antihistamines in anaphylactoid reactions.
Show Less

Competing Interests: None declared.