eMedicine Specialties > Pediatrics: General Medicine > Allergy & Immunology

Exercise-Induced Anaphylaxis: Treatment & Medication

Author: William B Stratbucker, MD, MS,, Assistant Professor of Pediatrics, Michigan State University; Director of Research, Pediatrics Residency Program, Helen DeVos Children's Hospital
Coauthor(s): Paul H Sammut, MBBCh, FAAP, FCCP, Medical Director of the Pediatric Intensive Care Unit, Associate Professor, Department of Pediatrics, Section of Pulmonology, University of Nebraska Medical Center
Contributor Information and Disclosures

Updated: May 8, 2009

Treatment

Medical Care

  • Discontinue exercise at the first sign of cutaneous erythema, pruritus, urticaria or malaise to prevent worsening exercise-induced anaphylaxis (EIA).
  • Subcutaneous epinephrine is the drug of choice if the symptoms progress to anaphylaxis.
  • Airway maintenance, oxygen therapy, fluid resuscitation, vasoactive drugs, and cardiopulmonary support should be used if necessary.
  • Patients can be treated with oral antihistamines (eg, diphenhydramine [Benadryl], hydroxyzine [Atarax], cetirizine [Zyrtec], loratadine [Claritin]) during exercise-induced anaphylaxis episodes and prophylactically to prevent the onset of episodes, but studies on their effectiveness are lacking.
    • Histamine2-receptor (H2) blockers, such as cimetidine (Tagamet) and the tricyclic antidepressant doxepin hydrochloride, have been tried in patients whose symptoms are not controlled on an H1 blocker alone, but the effectiveness has not been established.
    • Prophylactic sodium bicarbonate and cromolyn sodium have been suggested as preventative treatments as well but have not been used extensively.
    • Ketotifen, an H1-receptor antagonist, mast cell stabilizer, and up-regulator of beta-adrenergic receptors, has been used and found helpful in the treatment of exercise-induced anaphylaxis but is not available in the United States.
  • Prevention remains the best treatment for patients who have exercise-induced anaphylaxis. For food-dependent or drug-dependent exercise-induced anaphylaxis, avoiding the offending food or drug 12 hours prior to exercise is essential, and, if no offending food is known, avoiding the ingestion of any food 6-8 hours prior to exercise is sometimes necessary. The history of the use of aspirin or other nonsteroidal anti-inflammatory drug (NSAID) prior to the onset of an exercise-induced anaphylaxis episode is important. The avoidance of these medications prior to exercise is indicated in such a patient.
  • Patients must be instructed on the proper use of emergency injectable epinephrine, or EpiPen, and have at least one available and with them when exercising. Patients should always exercise with a partner knowledgeable about the syndrome and its emergent nature. This exercise partner should be trained in the use of an EpiPen. Patients with exercise-induced anaphylaxis should wear a medical alert bracelet with instructions for use of epinephrine.

Surgical Care

  • Patients with exercise-induced anaphylaxis require surgical intervention only if they need emergent tracheostomy or central line access.

Consultations

  • Allergist - For diagnostic workup, preventive measure, and therapy
  • Critical care specialist - During acute episode

Diet

  • If an offending food is identified, avoidance of this food for at least 12 hours prior to exercise is mandatory for the successful prevention of exercise-induced anaphylaxis episodes.
  • Patients must also monitor the amount ingested of the offending food because greater volume seems to have a direct correlation with frequency and severity of episodes.
  • If food is a trigger but no specific food is identified, then avoiding all food for 6-8 hours prior to exercise is sometimes recommended. Food avoidance strategies must be tailored to the individual patient with help from a physician.

Activity

  • Some patients with exercise-induced anaphylaxis must limit their physical activity significantly to avoid the progression of episodes.
  • Discontinuation of exercise at the earliest symptom is crucial to stop the progression of the episode.

Medication

If the syndrome has progressed to anaphylaxis, then subcutaneous epinephrine or emergency self-injectable epinephrine (eg, EpiPen) is the drug of choice (DOC). Other medications considered to be potentially helpful prophylactically and during an episode are antihistamines.

Sympathomimetic agents

Epinephrine, either SC or IM, is the DOC for the treatment of severe anaphylaxis in a patient with EIA. Epinephrine antagonizes the effects of the chemical mediators, including histamine and leukotrienes, on smooth muscle and blood vessels.


Epinephrine (EpiPen, EpiPen Jr)

DOC in the treatment of an anaphylactic episode in a patient with EIA. Administer epinephrine either SC, if at a medical facility, or IM with a self-injectable EpiPen. Possesses alpha-agonist effects that include increased peripheral vascular resistance, reversed peripheral vasodilatation, systemic hypotension, and vascular permeability. Beta-agonist effects of epinephrine include bronchodilatation, chronotropic cardiac activity, and positive inotropic effects.

Adult

0.3-0.5 mL (0.3-0.5 mg) of aqueous epinephrine 1:1000 concentration SC; dose may need to be repeated
EpiPen: 2 mL of epinephrine injection contained in adult EpiPen, which delivers 0.3 mg of epinephrine or 0.3 mL of 1:1000 concentration aqueous epinephrine; inject into the anterolateral aspect of the thigh, through clothing if necessary; do not inject EpiPen into the buttock or IV

Pediatric

<30 kilograms: 0.01 mL/kg (0.01 mg/kg) of aqueous epinephrine 1:1000 concentration SC; dose may need to be repeated
>30 kilograms: Administer as in adults
EpiPen: 0.15 mg of epinephrine contained in EpiPen Jr is recommended for children <30 kg; doses can be individualized by the prescribing doctor

Administration to patients on medications that may sensitize the heart to arrhythmias (eg, digitalis, mercurial diuretics, quinidine) is generally not recommended; tricyclic antidepressants or MAOIs may increase pressor response to epinephrine

No absolute contraindications in a life-threatening situation

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Accidental injection with EpiPen into the hands or feet may result in loss of blood flow to the affected area; do not inject EpiPen into the buttock or IV; use with caution in patients with heart disease; anginal pain may be induced in patients with coronary insufficiency; patients with hyperthyroidism, cardiovascular disease, hypertension, and diabetes may be theoretically at greater risk of developing adverse reactions, as well as elderly patients, pregnant women, pediatric patients <30 kg using an EpiPen, and pediatric patients <15 kg using an EpiPen Jr

Antihistamines

These agents are used to treat minor allergic reactions and anaphylaxis. They prevent histamine response in sensory nerve endings and blood vessels. These agents are more effective in preventing histamine response than in reversing it. They act by competitive inhibition of histamine at the H1 receptor. This mediates the wheal and flare reactions, bronchial constriction, mucus secretion, smooth muscle contraction, edema, hypotension, CNS depression, and cardiac arrhythmias.


Diphenhydramine (Benadryl, Benylin)

For symptomatic relief of symptoms caused by release of histamine in allergic reactions.

Adult

25-50 mg PO q6-8h prn; not to exceed 400 mg/d
10-50 mg IV/IM q6-8hprn; not to exceed 400 mg/d

Pediatric

5 mg/kg/d or 150 mg/m2/d PO/IV/IM divided tid/qid; not to exceed 300 mg/d

Potentiates effect of CNS depressants; because of alcohol content, do not administer syr dosage form to patient taking medications that can cause disulfiramlike reactions

Documented hypersensitivity; MAOIs

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

May exacerbate angle-closure glaucoma, hyperthyroidism, peptic ulcer disease, or urinary tract obstruction; xerostomia may occur

More on Exercise-Induced Anaphylaxis

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

  1. Maulitz RM, Pratt DS, Schocket AL. Exercise-induced anaphylactic reaction to shellfish. J Allergy Clin Immunol. Jun 1979;63(6):433-4. [Medline].

  2. Lee JY, Yoon S, Ye YM, Hur GY, Kim S, Park HS. Gliadin-specific IgE in wheat-dependent exercise-induced anaphylaxis. Allergy Asthma Proc. Nov-Dec 2008;29(6):614-21. [Medline].

  3. Gangemi S, Mistrello G, Roncarolo D, Amato S, Minciullo PL. Pomegranate-dependent exercise-induced anaphylaxis. J Investig Allergol Clin Immunol. 2008;18(6):491-2. [Medline].

  4. Orhan F, Karakas T. Food-dependent exercise-induced anaphylaxis to lentil and anaphylaxis to chickpea in a 17-year-old boy. J Investig Allergol Clin Immunol. 2008;18(6):465-8. [Medline].

  5. Adachi A, Horikawa T, Shimizu H, et al. Soybean beta-conglycinin as the main allergen in a patient with food-dependent exercise-induced anaphylaxis by tofu: food processing alters pepsin resistance. Clin Exp Allergy. Jan 2009;39(1):167-73. [Medline].

  6. Sheffer AL, Austen KF. Exercise-induced anaphylaxis. J Allergy Clin Immunol. Aug 1980;66(2):106-11. [Medline].

  7. Soyer OU, Sekerel BE. Food dependent exercise induced anaphylaxis or exercise induced anaphylaxis?. Allergol Immunopathol (Madr). Jul-Aug 2008;36(4):242-3. [Medline].

  8. Kjaer BN, Laursen LC. [Food-dependent exercise-induced anaphylaxis]. Ugeskr Laeger. Dec 1 2008;170(49):4058. [Medline].

  9. Gani F, Selvaggi L, Roagna D. [Exercise-induced anaphylaxis]. Recenti Prog Med. Jul-Aug 2008;99(7-8):395-400. [Medline].

  10. Castells MC, Horan RF, Sheffer AL. Exercise-induced anaphylaxis (EIA). Clin Rev Allergy Immunol. Winter 1999;17(4):413-24. [Medline].

  11. Castells MC, Horan RF, Sheffer AL. Exercise-induced Anaphylaxis. Curr Allergy Asthma Rep. Jan 2003;3(1):15-21. [Medline].

  12. Dice JP. Physical urticaria. Immunol Allergy Clin North Am. May 2004;24(2):225-46, vi. [Medline].

  13. Gonzalez-Quintela A, Vidal C, Gude F. Alcohol, IgE and allergy. Addict Biol. Sep-Dec 2004;9(3-4):195-204. [Medline].

  14. Hosey RG, Carek PJ, Goo A. Exercise-induced anaphylaxis and urticaria. Am Fam Physician. Oct 15 2001;64(8):1367-72. [Medline].

  15. Ii M, Sayama K, Tohyama M, Hashimoto K. A case of cold-dependent exercise-induced anaphylaxis. Br J Dermatol. Aug 2002;147(2):368-70. [Medline].

  16. Joint Task Force on Practice Parameters. The diagnosis and management of anaphylaxis: an updated practice parameter. J Allergy Clin Immunol. Mar 2005;115(3 Suppl 2):S483-523. [Medline].

  17. Kutting B, Brehler R. Exercise-induced anaphylaxis. Allergy. Jun 2000;55(6):585-6. [Medline].

  18. Lashley M, Klein N. Exercise-induced anaphylaxis in a 4-year-old boy. Ann Allergy. Apr 1990;64(4):381-2. [Medline].

  19. Longo G, Barbi E, Puppin F. Exercise-induced anaphylaxis to snails. Allergy. May 2000;55(5):513-4. [Medline].

  20. Matsuo H, Morimoto K, Akaki T, et al. Exercise and aspirin increase levels of circulating gliadin peptides in patients with wheat-dependent exercise-induced anaphylaxis. Clin Exp Allergy. Apr 2005;35(4):461-6. [Medline].

  21. Morimoto K, Hara T, Hide M. Food-dependent exercise-induced anaphylaxis due to ingestion of apple. J Dermatol. Jan 2005;32(1):62-3. [Medline].

  22. Morimoto K, Tanaka T, Sugita Y, Hide M. Food-dependent exercise-induced anaphylaxis due to ingestion of orange. Acta Derm Venereol. 2004;84(2):152-3. [Medline].

  23. Novembre E, Cianferoni A, Bernardini R, et al. Anaphylaxis in children: clinical and allergologic features. Pediatrics. Apr 1998;101(4):E8. [Medline]. [Full Text].

  24. Perez-Calderon R, Gonzalo-Garijo MA, Fernandez de Soria R. Exercise-induced anaphylaxis to onion. Allergy. Aug 2002;57(8):752-3. [Medline].

  25. Perkins DN, Keith PK. Food- and exercise-induced anaphylaxis: importance of history in diagnosis. Ann Allergy Asthma Immunol. Jul 2002;89(1):15-23. [Medline].

  26. Senna G, Mistrello G, Roncarolo D, et al. Exercise-induced anaphylaxis to grape. Allergy. Dec 2001;56(12):1235-6. [Medline].

  27. Shadick NA, Liang MH, Partridge AJ, et al. The natural history of exercise-induced anaphylaxis: survey results from a 10-year follow-up study. J Allergy Clin Immunol. Jul 1999;104(1):123-7. [Medline].

  28. Tilles S, Schocket A, Milgrom H. Exercise-induced anaphylaxis related to specific foods. J Pediatr. Oct 1995;127(4):587-9. [Medline].

  29. Volcheck GW, Li JT. Exercise-induced urticaria and anaphylaxis. Mayo Clin Proc. Feb 1997;72(2):140-7. [Medline].

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Keywords

exercise-induced anaphylaxis, EIA, food-dependent exercise-induced anaphylaxis, drug-dependent exercise-induced anaphylaxis, medicine-dependent exercise-induced anaphylaxis, physical urticaria, pruritus, NSAIDs, shock, hypotension, anaphylaxis syndrome, nausea, cramping, diarrhea, vomiting, tinnitus, vertigo, pruritus, difficulty breathing, chest tightness, treatment, diagnosis

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Contributor Information and Disclosures

Author

William B Stratbucker, MD, MS,, Assistant Professor of Pediatrics, Michigan State University; Director of Research, Pediatrics Residency Program, Helen DeVos Children's Hospital
William B Stratbucker, MD, MS, is a member of the following medical societies: American Academy of Pediatrics and Wilderness Medical Society
Disclosure: Nothing to disclose.

Coauthor(s)

Paul H Sammut, MBBCh, FAAP, FCCP, Medical Director of the Pediatric Intensive Care Unit, Associate Professor, Department of Pediatrics, Section of Pulmonology, University of Nebraska Medical Center
Paul H Sammut, MBBCh, FAAP, FCCP is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Lung Association, American Thoracic Society, and International Society for Heart and Lung Transplantation
Disclosure: Nothing to disclose.

Medical Editor

C Lucy Park, MD, Head, Division of Allergy, Immunology, and Pulmonology, Associate Professor, Department of Pediatrics, University of Illinois at Chicago
C Lucy Park, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Medical Association, Chicago Medical Society, Clinical Immunology Society, and Illinois State Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

John Wilson Georgitis, MD, Consulting Staff, Lafayette Allergy Services
John Wilson Georgitis, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Academy of Pediatrics, American Association for the Advancement of Science, American College of Chest Physicians, American Lung Association, American Medical Writers Association, and American Thoracic Society
Disclosure: Nothing to disclose.

CME Editor

David Pallares, MD, Clinical Assistant Professor, Department of Pediatrics, Division of Allergy and Immunology, University of Louisville
David Pallares, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology
Disclosure: Nothing to disclose.

Chief Editor

Harumi Jyonouchi, MD, Associate Professor, Division of Pulmonary Allergy/Immunology and Infectious Diseases, Department of Pediatrics, UMDNJ-New Jersey Medical School
Harumi Jyonouchi, MD is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Academy of Pediatrics, American Association of Immunologists, American Medical Association, Clinical Immunology Society, New York Academy of Sciences, Society for Experimental Biology and Medicine, Society for Mucosal Immunology, and Society for Pediatric Research
Disclosure: Nothing to disclose.

 
 
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