eMedicine Specialties > Allergy and Immunology > Major Allergic Diseases

Anaphylaxis: Follow-up

Author: Stephen F Kemp, MD, FACP, Professor of Medicine, Associate Professor of Pediatrics, Director of Allergy and Immunology Fellowship Program, Departments of Medicine and Pediatrics, Associate Director of Division of Clinical Immunology and Allergy, Department of Medicine, University of Mississippi Medical Center; Consultant in Allergy and Immunology, Medical Service, G V (Sonny) Montgomery Veterans Affairs Medical Center
Coauthor(s): G William Palmer, MD, Consulting Staff, Shoreline Allergy and Asthma Associates
Contributor Information and Disclosures

Updated: Apr 29, 2009

Follow-up

Further Inpatient Care

  • Because of the potential for biphasic reactions, the patient should be observed for as long as 24 hours after a severe episode of anaphylaxis.35
  • In milder episodes, a 2-hour observation period after the symptoms have subsided is usually adequate.
  • Indications for hospital admission include initial phases of anaphylaxis characterized by hypotension, poorly controlled asthma, respiratory failure or hypoxemia, a biphasic reaction or prior history of biphasic anaphylaxis, and secondary complications such as arrhythmias or myocardial ischemia.
  • Hypotension should be treated aggressively with intravenous fluids and vasopressors (epinephrine and dopamine) in an intensive care unit setting with invasive monitoring as required.
  • Persistent bronchospasm should be treated by continuing albuterol and intravenous steroid administration.
  • Biphasic reactions should be treated by continuing steroids and directing therapy at the specific manifestations of the late-phase response.

Further Outpatient Care

  • At discharge, all patients should be provided an epinephrine autoinjector and receive proper instruction on how to self-administer it in case of a subsequent episode.34 They should also carry diphenhydramine and take this in conjunction with use of the epinephrine autoinjector. Furthermore, they should be instructed to keep an epinephrine autoinjector with them at all times, to keep the device from extremes of heat, and to replace any such device prior to its expiration date.
  • Patients should be instructed to have ready and prompt access to emergency medical services for transportation to the closest emergency department for treatment.
  • Patients should also be instructed that if an epinephrine autoinjector is used, they should immediately seek emergency care because epinephrine is very short acting and biphasic reactions can occur.
  • Therapy with antihistamines and oral glucocorticoids should probably continue at home for another 2-3 days to prevent recurrence.
  • The most important aspect of outpatient follow-up is evaluation by an allergist-immunologist.
    • Skin testing and/or in vitro IgE tests for foods, stinging insects, medications, or latex should be performed as directed by the patient's history. Documented hypersensitivity to latex is an indication for evaluation of possible allergy cross-reacting foods (eg, banana, kiwi, avocado).
    • If the patient's history and skin test or in vitro IgE tests results confirm Hymenoptera sensitivity as the probable cause of anaphylaxis, venom-specific immunotherapy should be initiated to prevent future episodes.
    • Future avoidance of culprit foods, medications, latex, or radiocontrast media (RCM) must be emphasized.
    • If a culprit medication is required in the future and no other alternatives are available, a desensitization procedure should be performed by the allergist/immunologist, usually in an intensive care unit setting.
    • If RCM is required in the future, a pretreatment protocol may be used (see Prophylaxis for intravenous RCM).
    • The patient must be provided a prescription for an epinephrine autoinjector (EpiPen, EpiPen Jr, or Twinject) and instructed in its proper use.

Inpatient & Outpatient Medications

  • Inpatient medications are those listed in Medication.
  • Outpatient medications are the oral forms of antihistamines and corticosteroids that should be continued for a short time (a few days) following an episode. The benefit of these drugs is more theoretical because no studies exist that prove their benefit in this setting.
    • See Medication for the oral doses of diphenhydramine and ranitidine.
    • A convenient oral corticosteroid is prednisone. No proven best dose exists. In adults, a dose of 1 mg/kg/d in divided doses is probably adequate; in children, a dose of 0.5-1 mg/kg twice daily is appropriate. Tapering is not necessary unless the patient has been taking steroids chronically.
  • Patients with frequent idiopathic anaphylaxis may benefit from daily antihistamine therapy (both H1 antagonists and H2 antagonists) or, in rare circumstances, daily corticosteroid therapy. For daily therapy, diphenhydramine or hydroxyzine is often used first. Second-generation less-sedating antihistamines may be preferable because of decreased adverse effects. In their adult doses, these include fexofenadine (Allegra) at 180 mg/d, loratadine (Claritin) at 10 mg/d, cetirizine (Zyrtec) at 10 mg/d, desloratadine (Clarinex) at 5 mg/d, and levocetirizine (Xyzal) at 5mg/d. However, none has been specifically evaluated in anaphylaxis prevention. Some specialists prescribe extra doses of antihistamines as needed and as tolerated to control symptoms.
  • The most important medication following an episode of anaphylaxis is an epinephrine automatic injector, which the patient should always have immediately available in case of recurrence. Epinephrine is sensitive to both light and temperature; it should not be stored in a refrigerator or in the glove compartment of a motor vehicle, for example.
    • An EpiPen (Dey Laboratories, Napa, CA) autoinjector for adults is available with a single 0.3-mg (1:1,000 v/v) dose. Similarly, an EpiPen Jr., with a 0.15-mg (1:2,000 v/v) dose, is available for children who weigh less than 30 kg. The Twinject (Verus Pharmaceuticals, San Diego, CA) is a pen-sized device containing two doses of epinephrine available either as a 0.15 or a 0.3 mg formulation. The first of the two doses in both cases is delivered by autoinjector, while the second is injected manually. For more information, see EpiPen.com or Twinject.com.
    • Placebo syringes are recommended as educational tools. Live demonstrations of injections might be considered on a case by case basis when the patient or parent expresses a fear of injection.34
    • The patient should be instructed to obtain emergent medical care immediately after injecting the epinephrine because the effect is short lived (<15 min) and additional doses of epinephrine and other therapy may be required.

Transfer

  • The physician's office should be prepared to initiate therapy for anaphylaxis, and patients who receive treatment should be monitored continuously to facilitate prompt detection of new clinical findings or treatment complications.
  • A patient should be transferred to an emergency facility depending on the clinical severity of the reaction, response to treatment, and the likelihood that other complications will occur.

Deterrence/Prevention

  • Some anaphylactic reactions are so severe that treatment is unsuccessful and death occurs. This underscores the critical importance of education, avoidance, and prevention. An allergist-immunologist can provide comprehensive professional advice on these matters.36
  • Prophylactic treatment with antihistamines may give sufficient protection in some patients, but this is variable.
  • Avoidance is the only form of prevention for most inciting agents.36 Insect sting anaphylaxis can be prevented with allergen immunotherapy, which is highly effective. IgE-independent anaphylactic reactions to radiocontrast media (RCM) can be prevented with pretreatment and use of low osmolar agents. Anti-IgE may be a good prophylactic agent for severe food allergy, but the one study published to date was with TNX-901, which is not being marketed. A phase II multicenter study with omalizumab (Xolair) in peanut allergy was discontinued prematurely because of safety concerns in some study subjects. Obtained data were insufficient to draw any conclusions, but a slight trend existed toward greater tolerability of peanuts in subjects treated with omalizumab compared to placebo.
  • Patients at risk for recurrent anaphylaxis should wear a MedicAlert bracelet (see MedicAlert Foundation).36 They should also avoid the use of beta-blockers, tricyclic antidepressants, and monoamine oxidase inhibitors because of potential drug interactions with necessary therapies. Angiotensin-converting enzyme inhibitors may also be a potential problem.
  • Patients at risk for recurrent anaphylaxis might benefit from a written Action Plan (see Patient Education).36 The use and benefit of such plans has yet to be formally evaluated.37,38

Complications

  • Death from anaphylaxis occurs, but it is uncommon (see Mortality/Morbidity).
  • Complications are also unusual, with most patients recovering completely.
  • Respiratory failure from severe bronchospasm or laryngeal edema can cause hypoxia, which could lead to brain injury if prolonged.
  • Hypotension and hypoxia may lead to cardiac ischemia or arrhythmias.

Prognosis

  • The Olmsted County study detected a total of 154 episodes involving 133 people in a 5-year period.10 Most patients (116) had only 1 episode in those 5 years. Thirteen people had 2 episodes, and 4 people had 3 episodes.
  • In contrast, in the Memphis study, 48% of patients had 3 or more anaphylactic episodes.11 Of the 112 patients who responded to survey, however, 38 patients (34%) reported a recurrence of symptoms and the remaining 74 patients (66%) reported remission of symptoms. Overall, 85% of patients were either in remission or reported diminished symptom severity in a subsequent episode or episodes. The Memphis study evaluated a referral population and also deliberately excluded patients with anaphylaxis due to insect stings or SCIT.11

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Failure to consider anaphylaxis in a patient presenting with syncope or hypotension
  • Failure to prescribe an epinephrine automatic injector and to document patient education regarding storage and use
  • Failure to diagnose the cause of anaphylaxis where a means of prevention can be identified
  • Failure to avoid prescribing a drug to which the patient is known to be sensitive or a similar, cross-reacting drug
  • Failure to administer epinephrine expediently instead of less-effective medications
  • Desensitizing a patient to a specific drug without documenting the need for the drug, failure to obtain informed consent, and a lack of adequate training
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Stephen C Dreskin, MD, PhD, to the development and writing of this article.



More on Anaphylaxis

Overview: Anaphylaxis
Differential Diagnoses & Workup: Anaphylaxis
Treatment & Medication: Anaphylaxis
Follow-up: Anaphylaxis
References
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Further Reading

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Keywords

anaphylaxis, systemic allergic reaction, anaphylactic reaction, anaphylactoid reaction, allergic reaction, allergies, peanut allergy, latex allergy, shellfish allergy, hypersensitivity reaction, food allergy, insect sting, Hymenoptera venom, wasp sting, bee sting, yellow jacket sting, hornet sting, penicillin allergy, radiocontrast hypersensitivity, cardiovascular collapse, laryngeal edema, atopy, atopic disease, fire ant sting, immunotherapy, platelet activating factor, PAF, anaphylactic shock, EpiPen, epipen, food allergies, bee allergy, bee sting allergy

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Contributor Information and Disclosures

Author

Stephen F Kemp, MD, FACP, Professor of Medicine, Associate Professor of Pediatrics, Director of Allergy and Immunology Fellowship Program, Departments of Medicine and Pediatrics, Associate Director of Division of Clinical Immunology and Allergy, Department of Medicine, University of Mississippi Medical Center; Consultant in Allergy and Immunology, Medical Service, G V (Sonny) Montgomery Veterans Affairs Medical Center
Stephen F Kemp, MD, FACP is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Allergy, Asthma and Immunology, American College of Physicians, American Federation for Medical Research, American Medical Association, Association of Subspecialty Professors, Joint Council of Allergy, Asthma and Immunology, Mississippi State Medical Association, and Southern Society for Clinical Investigation
Disclosure: Dey LP Honoraria Speaking and teaching; Verus Pharmaceuticals Consulting fee Consulting; Pfizer Consulting fee Endpoint Committee; Intelliject None Consulting

Coauthor(s)

G William Palmer, MD, Consulting Staff, Shoreline Allergy and Asthma Associates
G William Palmer, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology
Disclosure: Nothing to disclose.

Medical Editor

Stephen C Dreskin, MD, PhD, Director of Allergy, Asthma, and Immunology Practice, Professor of Medicine, Departments of Internal Medicine and Immunology, University of Colorado Health Sciences Center
Stephen C Dreskin, MD, PhD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association for the Advancement of Science, American Association of Immunologists, American Association of Neuropathologists, American Association of Ophthalmic Pathologists, American Association of Oral and Maxillofacial Surgeons, American College of Allergy, Asthma and Immunology, Clinical Immunology Society, and Joint Council of Allergy, Asthma and Immunology
Disclosure: Genentech Consulting fee Consulting

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Samuel R Marney, Jr, MD, Director, Associate Professor, Department of Internal Medicine, Division of Allergy and Immunology, Vanderbilt University School of Medicine
Samuel R Marney, Jr, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Allergy, Asthma and Immunology, American College of Physicians, and Tennessee Medical Association
Disclosure: Nothing to disclose.

CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint Louis University School of Medicine
Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians
Disclosure: Nothing to disclose.

Chief Editor

Michael A Kaliner, MD, Clinical Professor of Medicine, George Washington University School of Medicine; Chief, Section of Allergy and Immunology, Washington Hospital Center; Medical Director, Institute for Asthma and Allergy
Michael A Kaliner, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association of Immunologists, American College of Allergy, Asthma and Immunology, American Society for Clinical Investigation, American Thoracic Society, and Association of American Physicians
Disclosure: Abbott Consulting fee Consulting; Alcon Consulting fee Consulting; Glaxo Consulting fee Consulting; Greer Consulting fee Consulting; Sanofi Consulting fee Consulting; Schering Consulting fee Consulting; Teva  Consulting; Meda Honoraria Speaking and teaching

 
 
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