Evaluation of Prehospital Management in a Canadian Emergency Department Anaphylaxis Cohort

Anaphylaxis—a 2020 practice parameter update, systematic review, and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) analysis

“…Clear evidence is also lacking to support a role for glucocorticoids and/or antihistamines in acute anaphylaxis, although the Cross-Canada Anaphylaxis registry recently suggested supplemental antihistamines may provide benefit when used with epinephrine. 164 In the same study, 164 supplemental use of glucocorticoids with epinephrine resulted in worse outcome.…”

“…While intravenous administration of H1 antihistamines may be used in a medical setting or by EMS, it should never be utilized in place of timely intramuscular epinephrine administration, but it may have an adjunct role in treatment after epinephrine has been administered. 164 Glucocorticoids are also frequently used as adjunctive (or sometimes primary) therapy in the treatment of anaphylaxis but also should not be administered prior to, or in place of, epinephrine. Glucocorticoids have no proven role in the treatment of an acute reaction as they work with slow onset of action by binding to the glucocorticoid receptor on cell membranes, translocating the glucocorticoid/glucocorticoid receptor complex to the nucleus, and inhibiting gene expression and production of new inflammatory mediators.…”

“…There is a scarcity of data demonstrating the efficacy of glucocorticoids in the treatment of acute anaphylaxis despite common anecdotal administration in this setting, and no studies have clearly established their benefit when combined with epinephrine and/or antihistamines. 34,164 Studies investigating the use of glucocorticoids for treatment of anaphylaxis have shown that their use is associated with reduced length of hospital stay but have not shown any benefit of preventing return visits to the ED following discharge. 165,166 Given the mechanism of action, glucocorticoids may not result in clinical improvement for 4 to 6 hours after administration, regardless of route.…”

Corticosteroids for anaphylaxis may put patients at risk

“…P atients treated with corticosteroids in the prehospital setting to manage anaphylaxis were more likely to be admitted to the ICU/hospital ward, whereas those treated with epinephrine and antihistamines needed fewer doses of epinephrine in the emergency department (ED), according to results of an observational study published in the Journal of Allergy and Clinical Immunology: In Practice. 1 "Our study shows that use of an epinephrine auto-injector in the prehospital setting has a much more significant protective effect on the clinical management of anaphylaxis than that achieved with antihistamines alone. Also, we found that corticosteroids, which are part of the treatment algorithm for anaphylaxis, can have a negative effect on patient outcomes," author Sofianne Gabrielli, MSc, from the division of pediatric allergy and clinical immunology at McGill University Health Center in Montreal, told Pharmacy Today.…”

Risk of peanut- and tree-nut–induced anaphylaxis during Halloween, Easter and other cultural holidays in Canadian children

“…To grade the severity of the anaphylactic reaction, we used a modified grading system elaborated by Muraro and colleagues. 13,14 Mild reactions were defined as generalized pruritis, flushing, urticaria, angioedema, nausea or emesis, mild abdominal pain, nasal congestion or sneezing or both, rhinorrhea, throat tightness, mild wheezing, tachycardia or anxiety. Moderate reactions were defined as crampy abdominal pain, diarrhea, recurrent vomiting, hoarseness, "barky" cough, difficulty swallowing, dyspnea, moderate wheezing or "light-headedness."…”