Managing anaphylaxis: risk management and clear communication
Updates and Controversies in Anaphylaxis
Symposium presented Friday, February 24, 2023
Moderator
Vivian P. Hernandez-Trujillo, MD
Director, Division of Allergy and Immunology, Miami Children’s Hospital
Presenters
Marcus Shaker, MD, MS
Professor of Pediatrics and Medicine, Dartmouth Geisel School of Medicine
Anaphylaxis Controversies: Integrating Value With Patient Safety
Karla E. Adams, MD
Associate Professor of Pediatrics, Uniformed Services University
Venom Anaphylaxis and Immunotherapy
Gerald Volcheck, MD
Professor of Medicine, Mayo Clinic
Perioperative Anaphylaxis
Speakers consider controversial aspects of biphasic anaphylaxis, offer perspectives on venom immunotherapy, and discuss prevention of perioperative anaphylaxis.
Clinical issues in anaphylaxis range from the nuances of managing biphasic anaphylaxis and venom immunotherapy to strategies for preventing perioperative anaphylaxis.
Biphasic anaphylaxis: integrate value with safety
Diagnostic criteria for anaphylaxis are imperfect, said Marcus Shaker, MD, but, “importantly, fulfilling diagnostic criteria is not required to administer epinephrine to treat this acute, potentially life-threatening systemic, allergic reaction.” Dr. Shaker is professor of pediatrics and medicine at Dartmouth Geisel School of Medicine.
Biphasic allergic reactions, or recurrences of allergic reactions hours or days later, can increase risk of anaphylaxis. Factors contributing to biphasic reactions include insufficient treatment of initial anaphylaxis, the short half-life of medications used for initial treatment, secondary absorption of antigen, and late-phase response from immunoglobulin E-mediated mechanisms.
Beta-blockers and angiotensin-converting enzyme (ACE) inhibitors, common treatments for other conditions, may inhibit compensatory responses to anaphylaxis and have been shown to increase anaphylaxis severity. However, said Dr. Shaker, “there is risk on both sides, and the greater risk to patients may be in stopping these medications. Balancing use of beta-blockers and ACE inhibitors in patients at risk for anaphylaxis is complex and requires shared decision-making.”
Epinephrine is the first line of pharmacotherapy for uniphasic and biphasic anaphylaxis. However, severe anaphylaxis and multiple epinephrine doses increase biphasic risk. While commonly administered for allergic reactions, antihistamines and/or glucocorticoids to prevent anaphylaxis are generally not very effective, as established in several studies.
There have been several updates to anaphylaxis guidelines. A 2021 study by Dribin et al developed a consensus severity grading system for acute allergic reactions, including anaphylactic and nonanaphylactic reactions, which is awaiting international validation. An anaphylaxis practice parameter update published in 2020, Grading of Recommendations, Assessment, Development and Evaluation (GRADE), identified risk factors for biphasic anaphylaxis. This guideline concluded that glucocorticoids and/or antihistamines were not helpful for anaphylaxis prevention. A new anaphylaxis practice parameter will be released later this year.
Venom anaphylaxis and immunotherapy
Venom as a trigger for anaphylaxis-related hospital emergency room visits has increased 58% over the last 8 to 9 years, said Karla E. Adams, MD, associate professor of pediatrics, Uniformed Services University, but the case-fatality rate has remained essentially unchanged for decades. The fatality rate is higher in individuals with mastocytosis, and certain outdoor occupations may be associated with a higher risk for Hymenoptera venom allergy (HVA).
Venom-induced anaphylaxis often involves cardiovascular symptoms. Further, cardiovascular disease is more common in HVA and associated with a higher risk of severity; patients with underlying cardiovascular disease have a 3 to 5 times greater risk of anaphylaxis than those without cardiovascular disease. Dr. Adams noted, however, that a recent study by Sturm et al suggested that patients taking ACE inhibitors and/or beta blockers had no higher risk of severe sting reactions or adverse events during venom immunotherapy than patients not taking these medications.
Dr. Adams said that her approach to immunotherapy involves creating a risk profile for the patient that will inform the immunotherapy process. The profile consists of patient factors such as occupation and hobbies, sting history, and biomarkers. “These factors guide how fast to build things up, what safety nets I need to put in place, and what the duration will be,” she said.
Perioperative anaphylaxis: risk awareness and communication
Perioperative anaphylaxis is most commonly associated with anesthesia administration, noted Gerald W. Volcheck, MD, professor of medicine, Mayo Clinic. An analysis of near-fatal and fatal perioperative anaphylaxis showed that of 35 million surgeries, 5,458 perioperative anaphylaxis cases were identified. Of these, 7% were near fatal or fatal.
Risk factors for perioperative anaphylaxis within the first 30 minutes of anesthesia are most often due to antibiotics, neuromuscular blocking agents, and hypnotic-inducing agents. Symptoms after 30 minutes of anesthesia can be due to latex reaction, chlorhexidine, protamine, supravital dyes, plasma expanders, blood products, sugammadex, and excipients.
“Prevention of perioperative anaphylaxis requires close communication among the anesthesiologist, allergist, emergency room, and patient,” said Dr. Volcheck. He further noted that while the US medical system unfortunately does not focus on perioperative anaphylaxis, the United Kingdom has an excellent resource (NAP6, or National Audit Projects) with templated letters to use for more effective communication, including from the anesthesiologist to the patient and to the allergist, and from the allergist to the anesthesiologist, patient, and primary care provider.
Selected references
Dribin TE, Schnadower D, Spergel JM, et al. Severity grading system for acute allergic reactions: a multidisciplinary Delphi study. J Allergy Clin Immunol 2021;148(1):173-181. doi: 10.1016/j.jaci.2021.01.003
Garvey LH, Ebo DG, Mertes PM, et al. An EAACI position paper on the investigation of perioperative immediate hypersensitivity reactions. Allergy 2019;74(10):1872-1884. doi: 10.1111/all.13820
Gonzalez-Estrada A, Campbell RL, Carrillo-Martin I, Renew JR, Rank MA, Volcheck GW. Incidence and risk factors for near-fatal and fatal outcomes after perioperative and periprocedural anaphylaxis in the USA, 2005-2014. Br J Anaesth 2021;127(6):890-896. doi: 10.1016/j.bja.2021.06.036
International Suspected Perioperative Allergic Reaction (ISPAR) Group
https://perioperativeallergy.com/
Shaker MS, Wallace DV, Golden DBK, et al. Anaphylaxis--a 2020 practice parameter update, systematic review, and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) analysis. J Allergy Clin Immunol 2020 Apr;145(4):1082-1123. doi: 10.1016/j.jaci.2020.01.017.
Sturm GJ, Herzog SA, Aberer W, et al. β-blockers and ACE inhibitors are not a risk factor for severe systemic sting reactions and adverse events during venom immunotherapy. Allergy 2021;76(7):2166-2176. doi: 10.1111/all.14785
Volcheck GW, Melchiors BB, Farooque S, et al. Perioperative hypersensitivity evaluation and management: a practical approach. J Allergy Clin Immunol Pract 2023;11(2):382-392. doi: 10.1016/j.jaip.2022.11.012
Disclosures
There were no relevant faculty disclosures.