Multidisciplinary Panel Develops New Grading System for Acute Allergic Reactions

Jeff Craven

August 06, 2021

A multidisciplinary panel has developed a new severity grading system they believe can help standardize how healthcare professionals and patients communicate about acute allergic reactions.

Using Delphi methodology, the panel, consisting of 21 experts in allergy and emergency care across multiple disciplines, reached consensus on the new system, which categorizes acute allergic reactions into five severity grades from mild to severe. The system is intended to be used for patients with acute allergic reactions across specialties, "regardless of whether they fulfill the NIAID/FAAN criteria for anaphylaxis," the panel wrtes in a recent article detailing the grading system. The article was published in the Journal of Allergy and Clinical Immunology.

  • Grade 1 severity includes any mild skin, gastrointestinal, or mucosal/angioedema reactions.

  • Grade 2 severity consists of two or more mild or moderate instances of grade 1 reactions.

  • Grade 3 severity includes cardiovascular, neurologic, and respiratory symptoms.

  • Grade 4 severity includes moderate cardiovascular, neurologic, or respiratory reactions or severe mucosal and/or angioedema reactions.

  • Grade 5 severity includes life-threatening severe cardiovascular, neurologic, and respiratory reactions.

The severity grading system also includes a 24-element subgrading system that covers cardiovascular, neurologic, respiratory, mucosal/angioedema, skin, and gastrointestinal symptoms.

"What we really said was, we need to have one grading system that accounts for the spectrum of severity from mild reactions to anaphylactic shock and also can be used to assess severity for different types of allergens," Timothy E. Dribin, MD, first author and a pediatrics specialist at Cincinnati Children's Hospital, in Cincinnati, Ohio, said in an interview with Medscape Medical News. Instead of having different grading systems for egg allergy, peanut allergy, anaphylaxis, and nonanaphylaxis, "let's try to have one simple one that we can use," he said.

The authors emphasize that at present, the grading system "does not dictate management decisions" for patient care. They hope the system will lead clinicians in different specialties to communicate about acute allergic reactions in the same way.

"Severity is, in a way, very subjective," Dribin said. "As a clinician, I may look at one child and my colleague may look at the same child, and we may have different assessments of how severe they are. Some of that is inherent, based on our training, based on who we are as clinicians and our experience, the number of patients we treated with anaphylaxis or other acute allergic reactions. We may just rate it differently, so there's just an inherent difference in interpretation."

Although Dribin doesn't believe the severity grading system as designed would work in a clinical setting unless it were integrated with an electronic medical record, he sees potential utility in pediatric emergency care settings. It could also be useful in prospective or retrospective studies "because it could align the terminology and the outcomes we use in both retrospective and prospective studies so that we can harmonize those outcomes," he said. "I think that would be helpful."

Dribin also sees a potential use for the severity grading system in patient-centered technology. For example, patients or their loved ones who have been taught how to recognize acute allergic reactions using the severity grading system could assess symptoms in non-healthcare settings and know how to intervene.

Stanley M. Fineman, MD, MBA, an allergist with Atlanta Allergy and Asthma, Atlanta, Georgia, who was not a member of the panel, explained in an interview that he believed the grading system would be useful in a research, but "[t]he utility in clinical practice would be more challenging," he said.

Fineman noted he was concerned about a statement by the authors about how clinicians can use the grading system to educate patients and their family members. The authors write, "Patients may be relieved to know that although their symptoms may be distressing or uncomfortable, they are not life-threatening and are mild on the spectrum of disease severity."

"I think that patients who are at risk should be prepared to treat potential anaphylaxis regardless of their prior reaction severity," Fineman said.

Dribin said the severity grading system is being validated in a prospective observational study at his center. Patient enrollment is planned for this September and October.

Development of the grading system was supported by the Division of Emergency Medicine at Cincinnati Children's Hospital. Twelve of the authors disclosed a variety of relationships with pharmaceutical companies, journals, medical startups, and other organizations in the form of funding, grant support, research support, consultancy, advisory board membership, part-time employment, stock options, an author or peer review role, membership on a task force, and/or cofounder of a company that would constitute a potential conflict of interest. The other authors and Fineman have disclosed no relevant financial relationships.

J Allergy Clin Immunol. 2021 Jul;148:173-181. Abstract

Jeff Craven is an independent journalist living in Wilmington, Delaware.

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