Anaphylaxis update focuses on seven areas with new evidence and recommendations

An updated practice parameter on anaphylaxis focuses on seven areas in which new evidence has emerged and in which recommendations may differ from the previouspractice parameter published in 2015. The 53-page update was developed by the Joint Task Force on Practice Parameters (JTFPP) of the American Academy of Allergy, Asthma & Immunology (AAAAI) and the American College of Allergy, Asthma, & Immunology (ACAAI). The Joint Task Force included experts in anaphylaxis management from the United States and Canada.Summary of changes and differences 1. Diagnostic criteria for anaphylaxis have been revised, and patterns of anaphylaxis are defined. Clinical criteria for diagnosing persistent, refractory and biphasic anaphylaxis are summarized in a table. An anaphylaxis consensus severity grading system is presented in a separate figure. Measurement of serum tryptase is important for diagnosis of anaphylaxis and to identify underlying mast cell disorders. 2. Infants and toddlers In infants and toddlers, age-specific anaphylaxis symptoms may differ from older children and adults. Patient age is not correlated with reaction severity, and anaphylaxis is unlikely to be the initial reaction to an allergen on first exposure. 3. Community settings Anaphylaxis is most difficult to recognize and treat outside of healthcare facilities. Different community settings for anaphylaxis (e.g., home, school, work, dining out, travelling) require specific measures for prevention and treatment of anaphylaxis. 4. Epinephrine autoinjectors Optimal prescribing and use of epinephrine autoinjectors requires specific counselling and training of patients and caregivers, including when and how to administer the epinephrine autoinjector and whether and when to call 911. If epinephrine is used promptly, immediate activation of emergency medical services may not be required if the patient experiences a prompt, complete and durable response. Emergency medical services should be activated if anaphylaxis is severe, fails to resolve promptly, fails to resolve completely or nearly completely, or returns or worsens after the first dose of epinephrine.5. Beta-blockers (BBs) and angiotensin-converting enzyme inhibitors (ACEIs) Both BBs and ACEIs were previously considered to be contraindicated in patients at high risk for anaphylaxis, because of increased risk of severe anaphylaxis. However, for most medical indications, the risk of stopping or changing BB or ACEI medication may exceed the risk of more severe anaphylaxis if the medication is continued, especially in patients with insect sting anaphylaxis. Venom immunotherapy may be considered for patients receiving BBs/ACEIs, with shared decision-making regarding the balance of benefits and harms. Patients receiving maintenance-dose allergen immunotherapy (AIT) have minimal increased absolute risk of severe anaphylactic reaction when receiving BBs/ACEIs and may consider continuing AIT and medications based on shared decision-making.6. Mastocytosis An estimated 40%–50% of adults with mastocytosis are at risk for anaphylaxis. Evaluation for mastocytosis, including a bone marrow biopsy, should be considered for adults with severe insect sting anaphylaxis or recurrent idiopathic anaphylaxis. 7. Perioperative anaphylaxis After perioperative anaphylaxis, repeat anesthesia may proceed in the context of shared decision-making and based on the history and results of diagnostic evaluation with skin tests or in vitro tests when available, and supervised challenge when necessary.The update includes detailed discussion on the seven topics described above, as well as 48 recommendations related to these topics. Other useful features in the update:A table offering expert opinion-based strategies and considerations for safe dining to discuss with patients who have a food allergyA table summarizing key points for clinicians on anaphylaxis in community settingsA table outlining risk factors and cofactors potentially associated with severe or fatal anaphylaxisGeneral guidance for activation of emergency medical services and administration of a second dose of epinephrine A table reviewing considerations for and against home management of anaphylaxis A summary framework for evaluation of the benefits and risks of BB or ACEI medication in patients at risk for anaphylaxisA review of the knowledge gaps related to use of BB or ACEI medication in patients at risk for anaphylaxis.Reference1. Golden DBK, Wang J, Waserman S, et al. Anaphylaxis: a 2023 practice parameter update. Ann Allergy Asthma Immunol 2023; (in press) published online December 17, 2023. (accessed January 11, 2024).

Anaphylaxis update focuses on seven areas with new evidence and recommendations

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