eMedicine Specialties > Allergy and Immunology > Allergy Pathogenesis

Hypersensitivity Reactions, Immediate: Follow-up

Author: Miriam K Anand, MD, Consulting Staff, Department of Allergy/Immunology, Allergy Associates and Lab, Ltd
Coauthor(s): John M Routes, MD, Professor of Pediatrics, Medical College of Wisconsin; Chief, Section of Allergy and Clinical Immunology, Department of Pediatrics, Children's Hospital of Wisconsin
Contributor Information and Disclosures

Updated: Jun 16, 2009

Follow-up

Deterrence/Prevention

  • Avoidance of the allergen is the best method of prevention, but this is not always possible (eg, avoiding insect stings). For this reason, patients should always have their rescue medications with them (eg, EpiPen, albuterol MDI).

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • If an inciting agent is established, discussing the importance of antigen avoidance and possible outcomes in the event of reexposure is important.
  • Patients with latex allergies must avoid all products containing latex (eg, gloves, balloons, condoms, elastic). Nonlatex gloves should be available at their place of employment (if applicable). If such a patient requires surgery, a latex-free operating room must be provided.
  • If the patient reports a history of hives, angioedema, or anaphylaxis with any previous medication, medications from an alternative class should be used, if needed. If this is not possible, the patient should be referred to an allergist for desensitization to the medication. Administering a test dose of the medication without further evaluation is not safe.
  • Patients with a history of anaphylaxis should be given a prescription for at least 2 doses of autoinjectable epinephrine (eg, 2 EpiPens or 1 Twinject) and instructed in their use. Importantly, they should carry these devices at all times. Prescribing multiple pens can be helpful so that patients can keep them readily available (eg, at work, at home, in purse/pocket). They also should be aware of the expiration dates of the pens so that new ones can be issued if needed. Liquid diphenhydramine should also be kept on hand and used in the event of a reaction. Patients should be cautioned against driving or operating heavy machinery, as diphenhydramine can cause drowsiness.
  • Patients with a history of anaphylactic reactions to certain medications should get a Medi-Alert bracelet that indicates which drugs cause the reactions. This may also be helpful for patients with anaphylactic reactions to foods.

Special Concerns

  • Pregnancy
    • Patients may experience improvement, worsening, or no change in the frequency and severity of allergic reactions during pregnancy.
    • No human studies have been performed with antihistamines. Currently, the first-generation sedating antihistamines (eg, chlorpheniramine, diphenhydramine [category B], cyproheptadine) are used in pregnancy if needed. Chlorpheniramine is available in a time-release formula (ie, bid dosing) and may cause less drowsiness than some of the others. Most of the nonsedating antihistamines are category C and should be avoided. However, cetirizine and loratadine are category B drugs, as is the leukotriene antagonist montelukast.
    • Systemic corticosteroids can be administered after the first trimester if necessary. Inhaled budesonide for the treatment of asthma is a category B drug. In addition, nasal and inhaled cromolyn and inhaled nedocromil are minimally absorbed and are considered safe. Both are category B. Terbutaline, but not albuterol, is also a category B drug.
  • Elderly patients
    • Antihistamines can have adverse anticholinergic effects and therefore must be used with caution in elderly patients.
    • Adverse corticosteroid effects can be especially problematic for elderly patients because these patients are at greater risk for having or developing osteoporosis, cataracts, or GI ulcers.
 


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References
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Further Reading

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Keywords

type I hypersensitivity reactions, allergic reactions, IgE-mediated reactions, immunoglobulin E-mediated reactions, atopy, immunopathology, immediate hypersensitivity reactions, cytotoxic hypersensitivity reactions, delayed hypersensitivity reactions, anaphylaxis, allergic asthma, urticaria, angioedema, allergic rhinitis, drug reaction, atopic dermatitis, inactivation antibody reactions, activation antibody reactions, cytotoxic antibody reactions, cytolytic antibody reactions, immune-complex reactions, T-cell cytotoxic reactions, granulomatous reactions

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Contributor Information and Disclosures

Author

Miriam K Anand, MD, Consulting Staff, Department of Allergy/Immunology, Allergy Associates and Lab, Ltd
Miriam K Anand, 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-American Society of Internal Medicine, and American Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

John M Routes, MD, Professor of Pediatrics, Medical College of Wisconsin; Chief, Section of Allergy and Clinical Immunology, Department of Pediatrics, Children's Hospital of Wisconsin
John M Routes, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Allergy Asthma and Immunology, American Association of Immunologists, American College of Allergy, Asthma and Immunology, American Society for Microbiology, American Society for Virology, Clinical Immunology Society, and Federation of American Societies for Experimental Biology
Disclosure: Nothing to disclose.

Medical Editor

Stephen Rosenfeld, MD, Professor Emeritus, Department of Medicine, Allergy, Immunology and Rheumatology Unit, University of Rochester School of Medicine and Dentistry
Stephen Rosenfeld, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association of Immunologists, American Federation for Clinical Research, Clinical Immunology Society, and Medical Society of the State of New York
Disclosure: Elan Ownership interest None; Invitrogen Ownership interest None; Merck Ownership interest None; Pfizer Ownership interest None; Medco Health Ownership interest None; Millipore Ownership interest None

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Michael R Simon, MD, MA, Clinical Professor Emeritus, Departments of Internal Medicine and Pediatrics, Wayne State University School of Medicine; Adjunct Staff, Division of Allergy and Immunology, Department of Internal Medicine, William Beaumont Hospital
Michael R Simon, MD, MA 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, Michigan Allergy and Asthma Society, Michigan State Medical Society, Royal College of Physicians and Surgeons of Canada, and Society for Experimental Biology and Medicine
Disclosure: Secretory IgA, Inc. Ownership interest Board membership

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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