Anaphylaxis

Document Overview

Document Title

Anaphylaxis

Authoring Societies

American College of Allergy, Asthma, and Immunology

American Academy of Allergy, Asthma & Immunology

Document Publication Date

Dec 17, 2023

Page Last Reviewed/Updated

May 5, 2026

Document Type

Guideline

Country of Publication

United States

Full Text Freely Available

Yes

Full Text Guideline

www.annallergy.org/article/S1081-1206(23)01304-2/fulltext

Source Citation

David B.K. Golden, Julie Wang, Susan Waserman, Cem Akin, Ronna L. Campbell, Anne K. Ellis, Matthew Greenhawt, David M. Lang, Dennis K. Ledford, Jay Lieberman, John Oppenheimer, Marcus S. Shaker, Dana V. Wallace, Elissa M. Abrams, Jonathan A. Bernstein, Derek K. Chu, Caroline C. Horner, Matthew A. Rank, David R. Stukus, Alyssa G. Burrows, Heather Cruickshank, David B.K. Golden, Julie Wang, Cem Akin, Ronna L. Campbell, Anne K. Ellis, Matthew Greenhawt, David M. Lang, Dennis K. Ledford, Jay Lieberman, John Oppenheimer, Marcus S. Shaker, Dana V. Wallace, Susan Waserman, Elissa M. Abrams, Jonathan A. Bernstein, Derek K. Chu, Anne K. Ellis, David B.K. Golden, Matthew Greenhawt, Caroline C. Horner, Dennis K. Ledford, Jay Lieberman, Matthew A. Rank, Marcus S. Shaker, David R. Stukus, Julie Wang, Anaphylaxis: A 2023 practice parameter update, Annals of Allergy, Asthma & Immunology, 2023, ISSN 1081-1206, https://doi.org/10.1016/j.anai.2023.09.015.

Supplemental Implementation Resources

• Video
• Learning Activity
• Quick-Reference Guide

Document Scope, Criteria, and Use Cases

Document Objectives

The purpose of this practice parameter is to evaluate current evidence and provide guidance to health care practitioners on the diagnosis and management of anaphylaxis. This updated practice parameter focuses on topics selected by the workgroup as described subsequently. By identifying knowledge gaps in the research literature, these guidelines may also help researchers to direct their attention to topics on which more studies are needed. This practice parameter is meant to update the selected topics and to complement our previous practice parameters on anaphylaxis but does not entirely replace or supersede those documents which may be consulted for additional background discussion on anaphylaxis and for guidance on topics not selected for review in the current update. T

Scope

Management, Prevention, Treatment

Diseases/Conditions (MeSH)

D000707 - Anaphylaxis

D000707 - Anaphylaxis

Keywords

anaphylaxis, epinephrine

Target Provider Population

allergy/immunology specialists, health care providers who care for patients with anaphylaxis

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, Operating and Recovery Room, Outpatient, School

Intended Users

Athletics/Coaching, Community Pharmacist, Law Enforcement, Nurse, Nurse Practitioner, Physician, Physician Assistant

Recommendation Development Processes & Methodology

PICO Questions

1. What is the role of serum tryptase measurements in anaphylaxis diagnosis?
2. In what settings should the clinician consider evaluation of alpha-gal allergy?
3. Is the diagnosis of anaphylaxis required for administration of epinephrine?
4. Is administration of, or response to, epinephrine necessary for the diagnosis of anaphylaxis?
5. How should anaphylaxis be diagnosed in infants and toddlers?
6. Should age of the infant/toddler experiencing anaphylaxis be used as a predictor of reaction severity?
7. Should lack of prior exposure to an allergen be used as a predictor for anaphylaxis risk?
8. Do infants and toddlers present with different signs and symptoms of anaphylaxis compared with older children and adults?
9. Should infants/toddlers be prescribed the 0.1 mg or 0.15 mg EAI?
10. What counseling and education should clinicians provide to patients to help them manage the risk of anaphylaxis in community settings?
11. : Should childcare centers and schools implement training for personnel in the management of food allergy, rather than not implementing such training?
12. Should childcare centers and schools prohibit specific foods site wide (eg, nut-free schools), rather than not implement such restrictions?
13. Should childcare centers and schools stock undesignated EAIs that can be used to treat any individual on school grounds who experiences anaphylaxis?
14. What education should clinicians provide to patients with food allergy regarding anaphylaxis in the restaurant setting?
15. Should clinicians advise use of medical identification (eg, jewelry or wallet card) for individuals at risk of anaphylaxis?
16. Should stock epinephrine in community settings be supported?
17. Should clinicians take a risk-stratified approach to EAI prescription?
18. How many EAIs should clinicians prescribe to each patient?
19. What is the optimal timing for EAI administration in relation to symptoms?
20. When should EMS be activated after EAI use?
21. What are the adverse events associated with EAI use?
22. What are the burdens of EAI prescription?
23. : What autoinjector characteristics should clinicians consider when prescribing EAIs?
24. What counseling, education, and/or training on epinephrine should clinicians provide to patients and caregivers?
25. Should BB or ACEI be discontinued or changed in patients with a history of insect sting anaphylaxis who are not yet on VIT?
26. Should VIT be recommended to patients with a history of insect sting anaphylaxis who are treated with BBs or ACEIs?
27. In patients on maintenance VIT who are treated with BBs or ACEIs, should VIT be stopped or the medication discontinued?
28. Should patients who are treated with BB or ACEI medication initiate a course of AIT?
29. In patients on maintenance AIT who are treated with BB or ACEI medication, should AIT be stopped or the medication discontinued?
30. For planned procedures where there is a risk of anaphylaxis, should BB or ACEI treatment be interrupted or continued?
31. In patients at significant risk for recurrent and unexpected anaphylaxis due to unplanned exposure or unknown cause, should BB or ACEI medication be stopped or continued?
32. What is the role of bone marrow biopsy and serum tryptase level in evaluation of patients for possible mastocytosis?
33. When should bST be measured?
34. When should patients be evaluated for mastocytosis?
35. Should patients with mastocytosis and insect sting allergy be treated with VIT?
36. Should immediate hypersensitivity skin testing or in vitro testing be performed with all potential culprit pharmacologic and nonpharmacologic agents, or should this be limited to the agents that are highly suspected?
37. Should immediate hypersensitivity skin and/or in vitro testing of suspected culprit (and alternative) agents be performed as soon as possible or delayed 4 to 6 weeks after the POA event?
38. Should challenges be performed to potential POA pharmacologic and nonpharmacologic culprits to which skin and/ or in vitro testing is negative?
39. Should patients with POA be advised to avoid repeat anesthesia?
40. Should repeat anesthesia after POA be performed with equally efficacious, structurally unrelated alternatives rather than the suspected culprit agents with negative skin and/or in vitro test results when challenge is not feasible?

Supplemental Methodology Resources

Systematic Review Document Data Supplement

Number of Source Documents

489

Includes peer/external review process?

Yes

Includes public comment process?

No

Methodologist involvement?

Yes

Patient involvement?

No

Includes multi-disciplinary group?

Yes

Includes systematic review?

Yes

Grades quality of strength of evidence?

Yes

Grades quality of strength of recommendation?

Yes

Discloses funding source?

Yes

Discloses conflicts of interest?

Yes

Includes benefits/harms analysis with recommendations?

Yes