Last updated November 8, 2022

Anaphylaxis

Diagnosis

The Joint Task Force suggests that a clinician incorporate severity of anaphylaxis presentation and/or the administration of >1 dose of epinephrine for the treatment of initial anaphylaxis as a guide to determining a patient’s risk for developing biphasic anaphylaxis. (C, VL)
620

The Joint Task Force suggests extended clinical observation in a setting capable of managing anaphylaxis (to detect a biphasic reaction) for patients with resolved severe anaphylaxis and/or those who need >1 dose of epinephrine. (C, VL)
620

Treatment

The Joint Task Force suggests against administering glucocorticoids or antihistamines as an intervention to prevent biphasic anaphylaxis. (C, VL)
620
The Joint Task Force suggests in favor of administering glucocorticoids and/or antihistamines to prevent anaphylaxis or infusion-related reactions when indicated for specific agents in chemotherapy protocols. (C, VL)
620
The Joint Task Force suggests against routinely administering glucocorticoids and/or antihistamines to prevent anaphylaxis in patients with prior radiocontrast hypersensitivity reactions (HSRs) when readministration of a low- or iso-osmolar, nonionic RCM agent is required. (C, VL)
620
The Joint Task Force suggests in favor administering of glucocorticoids and/or antihistamines as an intervention to prevent anaphylaxis in patients undergoing aeroallergen rush immunotherapy (RIT). (C, VL)
620
Good Practice Statements
Administer epinephrine as the first-line pharmacotherapy for uniphasic and/or biphasic anaphylaxis. (, )
620
Do not delay the administration of epinephrine for anaphylaxis, since doing so may be associated with higher morbidity and mortality. (, )
620
After diagnosis and treatment of anaphylaxis, all patients should be kept under observation in a setting capable of managing anaphylaxis until symptoms have fully resolved. (, )
620
All patients with anaphylaxis should receive education on anaphylaxis, including avoidance of identified triggers, presenting signs and symptoms, biphasic anaphylaxis, treatment with epinephrine, and the use of epinephrine auto-injectors, and they should be referred to an allergist. Of note, there may be some circumstances where self-injectable epinephrine is deferred (ie, resolved anaphylaxis and drug trigger with high likelihood of successful avoidance), and shared decision making may play a role in some circumstances. (, )
620
Suggested Key Clinical Advice
Severe anaphylaxis and/or the need for >1 dose of epinephrine to treat anaphylaxis are risk factors for biphasic anaphylaxis. Additional risk factors include wide pulse pressure, unknown anaphylaxis trigger, cutaneous signs and symptoms, and drug trigger in children. Extended observation is suggested for patients with resolved severe anaphylaxis and/or those with need for >1 dose of epinephrine.
Antihistamines and/or glucocorticoids are not reliable interventions to prevent biphasic anaphylaxis but may be considered as secondary treatment.
Evidence supports a role for antihistamine and/or glucocorticoid premedication in specific chemotherapy protocols and rush aeroallergen immunotherapy.
Evidence is lacking to support the routine use of antihistamines and/or glucocorticoid premedication in patients receiving low- or iso-osmolar contrast material to prevent recurrent radiocontrast media (RCM) anaphylaxis.
Administer epinephrine as the first-line pharmacotherapy for uniphasic and/or biphasic anaphylaxis.
Do not delay the administration of epinephrine for anaphylaxis.
After diagnosis and treatment of anaphylaxis, all patients should be kept under observation until symptoms have fully resolved.
All patients with anaphylaxis should receive education about anaphylaxis, risk of recurrence, trigger avoidance, self-injectable epinephrine, and thresholds for further care, and they should be referred to an allergist for follow-up evaluation.

Recommendation Grading

Overview

Title

Anaphylaxis

Authoring Organizations

Publication Month/Year

April 1, 2020

Supplemental Implementation Tools

Podcast, Quick-Reference Guide, Patient Information, Video

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Male, Female, Adolescent, Adult, Child, Older adult

Health Care Settings

Ambulatory, Childcare center, Correctional facility, Emergency care, Home health, Hospital, Long term care, Medical transportation, Outpatient, School, Operating and recovery room

Intended Users

Athletics coaching, law enforcement, nurse, nurse practitioner, community pharmacist, physician, physician assistant

Scope

Treatment, Management, Prevention

Diseases/Conditions (MeSH)

D000707 - Anaphylaxis

Keywords

anaphylaxis, epinephrine

Supplemental Methodology Resources

Systematic Review Document