Immediate Hypersensitivity Reactions Treatment & Management

Updated: Aug 11, 2020
  • Author: Becky Buelow, MD, MS; Chief Editor: Michael A Kaliner, MD  more...
  • Print
Treatment

Medical Care

Treatment may vary depending on the type of allergic reaction. Some general observations are made below, but refer to articles on the specific topics for more details about treatment (e.g., Anaphylaxis; Rhinitis, Allergic; Allergic and Environmental Asthma; Urticaria).

Anaphylaxis

Assessment of the reaction is described as follows:

  • Withdraw the offending agent if applicable (e.g., stop drug infusion).

  • Check the airway and secure if needed. Patients with respiratory compromise may need to be intubated. If laryngeal edema causes oral intubation to be difficult, a tracheostomy must be performed.

  • Assess the level of consciousness and vital signs.

Treatment is as follows:

  • Administer epinephrine immediately (see Medication). This is the most important medication and the only medication that has been shown to decrease mortality due to anaphylaxis.

  • Patient should be placed in the supine position with legs elevated. If having respiratory compromise or vomiting, then patient should be comfortable with lower extremities again elevated. Patients should not be placed upright suddenly during event or prematurely for the fear of empty ventricle syndrome. 

  • Start intravenous fluids; these should be administered rapidly and as blood pressure and overall fluid status warrant.

  • Consider other vasopressors (e.g., dopamine) if hypotension does not respond to the above measures. Norepinephrine may be used if dopamine is not effective. Importantly, isoproterenol should not be used because it is a peripheral vasodilator. Patients with beta-adrenergic blockade may be particularly difficult to treat. They have both chronotropic and inotropic cardiac suppression and may not respond to the above treatments. Glucagon has positive inotropic and chronotropic effects and is the drug of choice in these cases. Atropine can also be used but will only be effective in treating bradycardia.

  • H1- and H2-receptor blockers can be helpful in alleviating pruritus, urticaria, rhinorrhea, and other symptoms. 

  • Use albuterol nebulizers if needed.

  • Administer a corticosteroid, which is believed to help prevent or control the late-phase reaction.

  • Transfer the patient to the hospital for further observation and care.

  • Late phase reactions can occur 4-6 hours after the initial reaction and can be as severe as or worse than the original reaction. In some cases, late phase reactions can occur up to 72 hours later. Education of the patient and observation is, therefore, important.

Prevention is as follows:

  • Avoid the triggering allergen as much as possible.

  • Patients should be given a prescription for at least 2 auto-injectable epinephrine devices and instructed in their proper use (how and when to use). Importantly, patients must carry them at all times.

  • Patients must wear a Medic Alert type of bracelet to alert emergency responders to the possibility of anaphylaxis.

  • Patients should be taught what measures to take in case of a future anaphylactic reaction, i.e., immediately administer epinephrine, call emergency services (e.g., 911), or go to the nearest emergency department (even if feeling better after the epinephrine).

  • Specific allergen immunotherapy is highly effective in preventing anaphylaxis from hymenoptera stings and should always be considered for patients who have experienced a systemic reaction after an insect sting.

Allergic rhinoconjunctivitis

Avoid the offending allergen, if possible.

Oral H1-receptor blockers are helpful for controlling itchiness, rhinorrhea, and lacrimation but most have little effect on nasal congestion.

Administer an intranasal glucocorticosteroid to control nasal symptoms, including nasal congestion. These medications need to be used regularly to be effective, and patients may need to use them for a week or more before maximum effect is seen.

Other topical nasal agents include azelastine and olopatadine (H1-receptor blockers).  Nasal azelastine and olopatadine have the advantage of treating rhinorrhea, nasal itchiness, sneezing, and also congestion. Azelastine has been shown to be helpful in treating both allergic and nonallergic vasomotor rhinitis. Nasal antihistamines have a rapid onset of action and can be used on an as-needed basis.

Topical nasal decongestants can provide immediate relief of nasal congestion and can be used temporarily and as needed. Patients should be cautioned not to use them for more than a few days, however, as they can cause rebound congestion (rhinitis medicamentosa).

Topical decongestants, mast cell stabilizers, or antihistamines can be used for ocular symptoms; artificial tears or sterile saline might be helpful in mild cases, and this product can be refrigerated for an extra cooling effect. Cold compresses can also be used.  Again, use of topical decongestants should be limited to a few days, as longer use can result in rebound vasodilation.

Antigen-injection immunotherapy is very effective in treating inhalant allergies and can be considered in patients whose symptoms do not respond well to medications or in patients who cannot avoid the allergen in question (e.g., cat owner allergic to cats). The mechanism of action of immunotherapy is not yet fully elucidated. Immunotherapy causes antigen-specific immunoglobulin G4 to be formed  and these have been shown to block the effects of antigen-specific IgE binding to effector cells. Immunotherapy is thought to dampen the TH2 response and some feel it also tips the balance of TH2 and TH1 towards a TH1 phenotype. Importantly, regulatory T cells play an important role through the production of suppressive cytokines IL-10 and TGF-β. [35, 8]   [78]

An alternative to antigen-injection immunotherapy, aka, subcutaneous immunotherapy (SCIT), is sublingual immunotherapy (SLIT), which is used in Europe and has been approved by the FDA in the United States. The SLIT formulations approved for use in the US are Ragwitek, Grastek, Oralair and Odactra. The first dose of each tablet needs to be supervised by an allergist. Each patient should be prescribed and taught how and when to use auto-injectable epinephrine.

  • Grastek is timothy grass allergen extract approved for patients 5-65 years old who have allergic rhinitis with or without allergic conjunctivitis and positive testing to grass pollen. One tablet is taken sublingually daily for 12 weeks prior to grass pollen season and throughout the season as well. [36]

  • Ragwitek is short ragweed allergen extract approved for patients 18-65 years old who have allergic rhinitis with or without allergic conjunctivitis and positive testing to short ragweed. One tablet is taken sublingually daily for 12 weeks prior to short ragweed season and throughout the season. [37]

  • Oralair is a mixture of five grass allergen extracts. It is approved for patients 5-65 years old who have allergic rhinitis with or without allergic conjunctivitis and positive testing to grass pollen. One tablet is taken sublingually for 16 weeks prior to grass pollen season and throughout the season. [38]

  • Odactra is a mixture of two house dust mite allergen extracts. It is approved for patients 18-65 years old who have allergic rhinitis with or without allergic conjunctivitis and positive testing to dust mite. One tablet is taken sublingually daily. [77]

Asthma

Avoid the offending allergen, if possible.

A key factor in controlling allergic asthma is controlling allergic rhinitis symptoms.

Therapy depends on the severity of disease as well as age of patient. In 2007, the National Asthma Education and Prevention Program (NAEPP) Expert Panel from the National Heart, Lung, and Blood Institute (NHLBI) released guidelines on the diagnosis and management of asthma. These guidelines use a stepwise treatment approach based on age and severity of the asthmatic treated. [31]

  • All asthmatics are classified as intermittent, mild persistent, moderate persistent or severe persistent based on risk and impairment (see History for asthma for details).

  • Age of the patient, along with symptoms, will also help guide treatment options. Step 1 treatment is for intermittent asthmatics while Steps 2-6 listed below are the preferred daily medications for persistent asthmatics from the guidelines. [31] Alternative treatment options are listed in the guidelines. [31]

 

Table. (Open Table in a new window)

Age

Step 1

Step 2

Step 3

Step 4

Step 5

Step 6

0-4 years

SABA PRN

Low-dose ICS

Medium-dose ICS

Medium-dose ICS plus LABA or montelukast

High-dose ICS plus LABA or montelukast

High-dose ICS plus LABA or montelukast and oral corticosteroids

5-11 years

SABA PRN

Low-dose ICS

Low-dose ICS plus LABA or LTRA or theophylline

Medium-dose ICS plus LABA

High-dose ICS plus LABA

High-dose ICS plus LABA plus oral corticosteroids

12 years or older

SABA PRN

Low-dose ICS

Low-dose ICS plus LABA or medium-dose ICS

Medium-dose ICS plus LABA

High-dose ICS plus LABA

High-dose ICS plus LABA plus oral corticosteroids

 

Symptoms and SABA use should be reassessed after starting treatment. If patients are well-controlled for 3 months, step down therapy may be employed. Conversely, if a patient’s symptoms are not well-controlled, step up therapy is warranted.

All patients with asthma should have an albuterol metered-dose inhaler (MDI) (or nebulizers for young children) to use as needed for acute symptoms but the newest GINA guidelines state ICS-LABA (LABA=formoterol) can be used in adolescents and adults for the as needed medication (please see overview of GINA guidelines below).

Patients with exercise-induced bronchospasm (EIB) should receive short-acting beta2-agonist treatment 15-20 minutes prior to exercise and/or montelukast at least 2 hours prior to exercise. 

Systemic corticosteroid bursts may need to be used for exacerbations of severe cases.

Patients with allergic asthma may respond well to specific allergen immunotherapy. This is recommended from Steps 2-4 in patients 5 years or older. [31]

In patients 12 years or older refractory to the usual medications (Steps 5 and 6) who have antigen-specific IgE to perennial environmental aeroallergens, may benefit from therapy with omalizumab (Xolair), a humanized monoclonal antibody that prevents binding of IgE to high-affinity IgE receptors on mast cells and basophils. [39, 40, 41, 31]

Global Initiative for Asthma (GINA) recently changed asthma guidelines to recommend adolescents and adults with mild asthma not be treated with as needed SABA monotherapy for two reasons: the usage of SABA doesn't protect against severe exaacerbation and frequent use of the SABA actually increases the risk of exacerbation. GINA now recommends symptom-driven or daily low dose inhaled corticosteroids to reduce the risk of serious exacerbations. The new controller options include:

--For intermittent asthma, as needed low dose ICS-formoterol or low dose ICS taken whenever SABA is taken

-OR-

--Regular ICS or ICS-LABA every day, plus as needed SABA

-OR-

--Maintenance and reliever treatment with ICS-formoterol, with the reliever being low-dose budesonide-formoterol

Please see the published GINA guidelines for more details.  [98]

Urticaria/angioedema

Avoid the offending allergen if known.

A second-generation H1-receptor blocker should be added for monotherapy (i.e., cetirizine 10 mg daily). [42]

If symptoms are not controlled with this alone, the dose of the second generation H1 antagonist can be increased up to four times the recommended dose (i.e., cetirizine 20 mg BID). Alternatively, another second generation H1 antagonist (i.e., fexofenadine) or a first generation H1 antagonist (i.e., hydroxyzine at bedtime) can be added. Other possible treatments with H2 antagonists or leukotriene modifiers can also be added. [42]

If symptoms continue to occur, increasing the first generation H1 antagonist may be helpful. [42]

Omalizumab (Xolair) has been found to be useful in patients with chronic urticaria refractory to high dose treatment with H1 antihistamines (ref60) and is FDA approved for refractory chronic urticaria in patients 12 years and older. In addition, other medications such as cyclosporine may be used to treat recalcitrant chronic urticaria. [42]

Atopic dermatitis

Avoid the offending allergen if possible, and properly hydrate and care for the skin.

Topical glucocorticosteroids and topical immunomodulators (e.g., tacrolimus) can be used. [43, 44]

Dupilumab (Dupixent) is a monoclonal antibody antagonist which binds to the IL-4 receptor alpha antagonist. It is FDA approved for the treatment of moderate to severe atopic dermatitis in patients age 6 and older whose atopic dermatitis is not well controlled on topical prescription medications.  [80]

 

Next:

Consultations

Consultation with an allergist, pulmonologist, and/or critical care medicine specialist may be necessary for protracted anaphylactic shock or severe asthma exacerbations.

Consult an allergist or immunologist for the following conditions:

  • Allergic rhinoconjunctivitis not easily controlled with medications

  • Nonallergic, vasomotor rhinitis

  • Asthma: Of patients with asthma, at least 50% of adults have allergies as factors causing or contributing to their asthmatic inflammation. More than 90% of children with asthma are allergic.

  • Allergy evaluation prior to the initiation of Xolair

  • Chronic urticaria or angioedema (>6 weeks), or severe intermittent urticaria or angioedema, even if individual attacks last < 6 weeks

  • History of anaphylaxis from insect bite or sting

  • History of anaphylaxis with unknown cause

  • Possible drug desensitization (if known allergy to drug for which no good alternatives are available)

  • Atopic dermatitis, moderate to severe

  • Sinusitis before proceeding to surgery; nasal polyposis

  • Food allergy 

  • Eosinophilic esophagitis or gastritis

  • Suspicion of congenital or acquired immune abnormalities

  • Diagnosis and treatment of acquired immunoglobulin deficiencies

  • Persistent pruritus

Previous
Next:

Diet

Patients should avoid foods to which they are allergic.

Certain food proteins can cross-react with other proteins (e.g., latex with avocado, banana, kiwi, chestnut, pineapple, passion fruit, apricot, and grape; ragweed with watermelon, cantaloupe, and honeydew melon; tree fruits with birch pollen).

Patients must be counseled about these possible cross-reactivities and should avoid the food if it causes symptoms.

 

Previous