Acute Management of FPIES
There are not many measures to take except giving iv. fluids and steroids. At this regards, Sicherer wrote: "On the basis of the only partially understood pathophysiology of the immune response (T-cell–mediated) and observations of the clinical symptoms (lethargy, dehydration, shock), several suggestions can be made for emergency care that are based on response to treatments in studies reporting results of oral food challenges. If an ingestion is known to have occurred, the patient should be instructed to present to medical attention for observation. Intravenous fluid resuscitation may be needed. For patients with a history of severe reaction and onset of any symptoms, consideration should be given for administration of corticosteroids to quell a presumed T-cell–mediated reaction, and this treatment could be considered for any patient with more than minimal symptoms. From the words of Sicherer, it can be concluded that the treatment of acute episodes of FPIES is only a practice. In fact, there are no randomized studies demonstrating the usefulness of corticosteroids and, indeed, even of iv. fluids. On this topic, Powell suggested that it could be safest to place a venous access before starting an OFC, while more recently different measures were adopted. For example, Katz et al. do not place any preventive venous line and they are used to treat patients who failed OFCs with oral rehydratation. From 2008, we do not take any prophylactic measure either, as failed OFCs resolve spontaneously. We are of course always ready to take the necessary therapeutic measures, such as we did for Bridget. This less aggressive management does not produce any worst outcomes, compared to those of other Italian allergic centers that conformed to all procedures stated by Powell. On the other hand, the majority of acute FPIES episodes usually occur at home and these patients do not receive any medical assistance at all, just as Ernst experienced three times. According to the literature, and until now, FPIES did not cause any deaths. There still are many doubts about the utility of im. epinephrine, which is strongly recommended in case of anaphylaxis; we administered it only in two serious situations, one of which was Bridget's reaction. We felt that this was a useful measure, but they are only two cases. In this regard Sicherer writes: "The reaction can include symptoms of shock that may presumably respond to epinephrine, but our experience has been that iv. hydration and steroids are the only medications typically required." We think that the role of epinephrine in the treatment of acute FPIES is not clearly known: at the current state of knowledge, it is not possible to exclude it. However, we wish to emphasize that the use of epinephrine in the therapy of acute FPIES is not part of the management officially suggested.
Expert Rev Clin Immunol. 2013;9(8):707-715. © 2013 Expert Reviews Ltd.