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DGDispatch
Anaphylaxis May Require More Than 1 or Even 2 Doses of Epinephrine: Presented at ACAAI
By Crystal Phend
ANAHEIM, CA -- November 14, 2005 -- Physicians who treat patients with severe allergies -- especially those who have had a prior anaphylactic episode or are receiving immunotherapy -- need to be prepared to treat anaphylaxis with more than 1 dose of epinephrine.
The recommendation was made during a presentation here on November 7th at the American College of Allergy, Asthma and Immunology (ACAAI).
According to Phillip E. Korenblat, MD, professor of clinical medicine, Washington University, St. Louis, Missouri, at least 20% of patients who have an anaphylactic reaction require more than 1 shot of epinephrine.
He reviewed the research and presented a strategy for treatment for allergists, who may be faced with anaphylactic shock in the office, particularly when administering immunotherapy.
The first step -- assessment -- needs to be done rapidly based on symptoms, including nausea, vomiting, abdominal pain, throat or chest tightness, breathlessness, wheeze, collapse, and the skin symptoms of erythema, hives, or angioedema.
Reviews of deaths associated with anaphylaxis have shown that changing to a more upright position can cause loss of consciousness or death, so the patient should remain lying down, Dr. Korenblat said.
Physicians should check for vital signs and the need for airway ventilation, and should administer oxygen and/or an inhaled beta2 agonist for bronchospasm, if needed.
Epinephrine is the drug of choice, Dr. Korenblat said, although additional medications may include antihistamines, corticosteroids, glucagons, and vasopressors.
Dr. Korenblat was one of the first to study multiple doses of epinephrine. He first published results in Allergy and Asthma Proceedings (1999; vol. 20, 6; 383-386) of a chart review of patients receiving immunotherapy or in a clinical trial in which they received an insect sting challenge.
He found that 35.5% of 88 patients needed more than 1 injection of epinephrine and patients with higher grade reactions were more likely to need more than 1 shot -- 72% of patients with grade 3 compared with 42% of patients with grade 2 and 20% of patients with grade 1 reactions.
"Patients at risk and their caregivers need to recognize that more than 1 dose of epinephrine may be required and should be available for prevention of progression from acute allergic reaction to anaphylaxis as well as the treatment of anaphylaxis," Dr. Korenblat said.
More recently, a report from the Wilford Hall Medical Center at the Lackland Air Force Base, in Texas, indicated that 21% of patients who had an anaphylaxis reaction while receiving immunotherapy required more than 1 dose, with 6% requiring more than 2 doses.
If patients do have a serious reaction that does not respond well to 1 or more doses of epinephrine, Dr. Korenblat suggested calling emergency services and asking for the rescue squad.
Dr. Korenblat is a speaker for and on the advisory board of Verus Pharmaceutical.
[Presentation title: Clinical Challenges in Recognizing, Diagnosing and Treating Anaphylaxis: Treatment of Episode.]
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