Anaphylaxis
Publication Date: April 1, 2020
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)
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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)
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Treatment
The Joint Task Force suggests against administering glucocorticoids or antihistamines as an intervention to prevent biphasic anaphylaxis. (C, VL)
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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)
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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)
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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)
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Good Practice Statements
Administer epinephrine as the first-line pharmacotherapy for uniphasic and/or biphasic anaphylaxis. (, )
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Do not delay the administration of epinephrine for anaphylaxis, since doing so may be associated with higher morbidity and mortality. (, )
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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. (, )
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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. (, )
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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
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Overview
Title
Anaphylaxis
Authoring Organizations
American College of Allergy, Asthma, and Immunology
American Academy of Allergy, Asthma & Immunology
Publication Month/Year
April 1, 2020
Supplemental Implementation Tools
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