New guidelines on the management of anaphylaxis from the European Academy of Allergy and Clinical Immunology (EAACI) underscore the need to use intramuscular epinephrine as first-line treatment. The guidelines, an update from 2014, also called for simulation training for healthcare professionals to enhance anaphylaxis management. The guidelines also point to the need for pharmacokinetic data for all epinephrine autoinjector devices.
“The main difference [from the 2014 guidelines] is that we have outlined that autoinjectors should be the first-line treatment at the community level,” said Antonella Muraro, MD, PhD, head of the Food Allergy Referral Center, Department of Woman and Child Health, Padua University Hospital, Padua, Italy, in an interview with Medscape Medical News. Muraro is past president of the EAACI, EAACI chair of the anaphylaxis guidelines, and first author of the 2014 guidelines.
Another major difference in the new guidelines is that they emphasize the need for pharmacokinetic data across various injectors. “We need to have pharmacokinetic data for each brand, as they differ hugely between each other,” said Muraro. “This is paramount because the pharmacokinetics of adrenaline administered may be different [between autoinjectors]. We need to define the pharmacokinetics of each brand.”
Moreover, the new guidelines note that autoinjector devices are not interchangeable and that a patient requires training whenever there is a change in autoinjector device. “Anytime you are prescribing a device, you need to provide specific training,” she said. “It has to be considered that patients are trained to use one device, and another device may be different.”
The guidelines emphasize that antihistamines and steroids should not be initiated as first-line treatments, even though clinicians have looked to these treatments to manage acute episodes of anaphylaxis. “We could not find any evidence of the benefit of antihistamines and steroids,” said Muraro.
Another difference from the previous set of guidelines is that the new guidelines recommend that autoinjectors be considered for patients at risk for anaphylaxis who are receiving oral immunotherapy for food allergy and for patients who have cardiovascular diseases.
The guidelines also suggest simulation training as a teaching method for healthcare professionals to enhance their recognition and management of anaphylaxis in emergency cases.
Marcus S. Shaker, MD, FAAP, FACAAI, FAAAAI, professor of pediatrics and of medicine at the Dartmouth Geisel School of Medicine and a physician at the Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, commended the guideline authors for emphasizing early access to epinephrine and noted that the recommendation for early access is consistent with previous and recent anaphylaxis guidelines.
“It is a real important point for any reader [of the guidelines] to walk away with,” Shaker told Medscape Medical News. “Epinephrine is the first-line management for anaphylaxis, but sadly, many patients with anaphylaxis are still treated with antihistamines, glucocorticoids, or antiemetics before they are treated with epinephrine.”
Shaker also applauded the guideline’s emphasis on knowledge translation. “This is a key aspect to guideline implementation, and use of simulation can foster change in clinical practice,” he said. He noted the need to improve clinician readiness to appropriately institute rapid-use epinephrine in anaphylaxis management. “Changing practice styles is difficult. Patients and providers may be reluctant to use epinephrine because of fear of side effects, but simulation can help address some of these barriers,” he said.
The call in the EAACI guidelines for pharmacokinetic data for autoinjectors is a response to issues regarding dosing of epinephrine for infants, according to Shaker. “The guidelines point out that there are not great data behind pharmacokinetic dosing ranges for infants,” said Shaker. “If you have an infant who is 7.5 kg and above, these guidelines are recommending the 0.15-mg dose. That is helpful, especially across international economies where epinephrine autoinjector access continues to be limited because of what can be very high financial burdens on families.”
He also appreciated that the new EAACI guidelines continue to highlight the role of supplemental oxygen and intravenous fluids as adjunctive treatments to epinephrine for some patients.
“This document pointed out the idea that supplemental oxygen should be considered if patients are receiving epinephrine,” said Shaker. “This document also makes the point that if there is cardiovascular involvement, intravenous fluids should be considered quickly because epinephrine may not be effective without restoring circulatory volume.”
According to Shaker, the guidelines appropriately acknowledge the lack of clear benefit for antihistamines and glucocorticoids in the management of anaphylaxis. Importantly, use of these therapies should never lead to a delay in the use of epinephrine in the treatment of anaphylaxis, he said.
Muraro disclosed receiving speaker’s fees from Aimmune, DVB Technologies, Nestlè Purina, Nestlè Health Institute, Mylan-Viatris, and AlK and serving on advisory boards for Novartis, Regeneron-Sanofi, Aimmune, and DVB Technologies. Shaker has participated in research funded by DBV, is co-chair of the AAAAI/ACAAI Joint Task Force on Practice Parameters, and is an editorial board member of the Annals of Allergy, Asthma, and Immunology, and the Journal of Allergy and Clinical Immunology in Practice.
Allergy. Published online August 3, 2021. Abstract
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