Epinephrine Recommended, Even If Anaphylaxis Unconfirmed

Diana Phillips

August 10, 2015

UPDATED August 19, 2015 // Do not hesitate to use epinephrine for possible anaphylaxis, even in the absence of proof that patients' symptoms are the result of an allergic reaction, experts agree.

"Epinephrine in appropriate doses is safe, and there are no absolute contraindications for its use in treating anaphylaxis," according to a consensus statement prepared by an expert panel of emergency physicians and allergists.

"Delay in administration of epinephrine may lead to more severe and treatment resistant anaphylaxis," the authors report in an article published online August 6 in the Annals of Allergy, Asthma and Immunology.

"It is not necessary for the [National Institute of Allergy and Infectious Disease and the Food Allergy and Anaphylaxis Network] criteria to be met to administer epinephrine," they stress.

The panel was convened in 2014 to discuss the limitations of current knowledge and barriers to emergency management of anaphylaxis, focusing specifically on three primary barriers to improved care: the complexity of diagnosing anaphylaxis, the underuse of epinephrine, and inadequate postdischarge follow-up.

In addition to patients with anaphylaxis, those identified as being at risk for anaphylaxis are candidates for epinephrine administration, Stanley M. Fineman, MD, from Emory University School of Medicine and Atlanta Allergy and Asthma Clinic, Atlanta, Georgia, and colleagues report. At-risk patients include those with a history of previous severe reaction, as well as those who have had a known or suspected exposure to their allergic trigger, with or without the development of symptoms.

Antihistamines and glucocorticoids do not work fast enough to be an appropriate first-line treatment for a severe reaction, but they may be administered after epinephrine at the discretion of the treating physicians, the authors write.

The panel also recommends providing a prescription for epinephrine autoinjectors to patients treated for anaphylaxis or for severe allergic reactions in emergency settings, and to those considered at risk for a future event. It is imperative that these individuals also be provided with an action plan for autoinjector use before discharge, they write.

Postdischarge protocol should also include referral to an allergist "to assist with diagnosis confirmation, trigger identification, and continued outpatient management," the authors write.

Breaking down barriers to optimal emergency management of anaphylaxis "should be a joint effort of all who have a stake in improving anaphylaxis care, including emergency physicians, emergency medical services practitioners, allergists, and patient advocacy groups," the authors write, noting the need for widespread education efforts for emergency medical services practitioners and emergency department clinicians to improve the diagnosis and management of anaphylaxis.

In addition, "allergists should be proactive in seeking collaborations with emergency practitioners in their community," the authors conclude.

"I think this is an excellent statement, especially since harm is unlikely and benefit significant," Tim Craig, DO, professor of medicine and pediatrics, Division of Pulmonary, Allergy and Critical Care, Penn State University, College of Medicine in Hershey, told Medscape Medical News. "The risk benefit ratio of not treating is high but the inverse is very low.... If in doubt, treat."

This research was supported by an educational grant from Mylan Specialty LP. The authors and Dr Craig have disclosed no relevant financial relationships.

Ann Allergy Asthma Immunol. Published online August 6, 2015. Abstract

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