Rebecca A. Gruchalla, MD

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Rebecca A. Gruchalla, MD
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Treatment IssuesFood dependent, Exercise
TriggeredAnaphylaxis

• Rebecca S. Gruchalla, M.D., Ph.D.
• Professor of Internal Medicine and Pediatrics
• Director, Division of Allergy and Immunology
• UT Southwestern Medical Center

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Frequency of Signs/Symptoms of Anaphylaxis
Anaphylaxis An updated practice parameter. J
Allergy Clin Immunol 115S483-523, 2005
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Frequency of Signs/Symptoms of Anaphylaxis
(cont.)
Anaphylaxis An updated practice parameter. J
Allergy Clin Immunol 115S483-523, 2005
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Exercise-Induced Anaphylaxis Syndromes
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Anaphylactoid Reactions Non- IgE-Mediated

• Direct release of mediators from mast cells and
  basophils
• Drugs
• Idiopathic
• Physical factors (cold, heat, exercise)
• Disturbances in arachidonic acid metabolism
• Aspirin
• Nonsteroidal anti-inflammatory drugs
• Activation of contact and complement systems

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The Culprit
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Mast Cell/Basophil Mediators
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Mast Cell/Basophil Mediators
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Schematic Representation of Anaphylaxis
Severity of Symptoms
Antigen exposure
Time - Hours
Slide courtesy of Hugh Sampson, M.D.
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Anaphylaxis Prevention

• For Food allergy
• Identify the correct food(s)
• Avoid accidental ingestion
• Wear/carry appropriate identification
• Carry self-injectable epinephrine
• Maintain education of everyone around the
  individual

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Anaphylaxis Exercise-Induced SyndromePrevention

• Avoid exercise in proximity to eating meals, if
  reaction is food-dependent (no sooner than 4-6
  hours after eating)
• Exercise with a buddy
• Carry self-injectable epinephrine
• Carry a cell phone(no trail running where there
  is no easy access for emergency personnel)

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Management of Anaphylaxis

• Assess the adequacy of oxygenation, cardiac
  output and tissue perfusion
• In the field
• Injectable epinephrine (dependent on history and
  symptoms)
• lt10 kg epinephrine (11000) 0.01 mg/kg/dose
• 10-20 kg EpiPen Jr (0.15 mg epinephrine)
• 20-28 kg Epipen Jr or EpiPen dependent on
  history
• gt28 kg EpiPen (0.3 mg epinephrine)
• Oral liquid diphenhydramine 1-1.5 mg/kg up to 75
  mg
• Transport to emergency facility

Sampson Pediatrics 1111601-8, 2003
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Management of Anaphylaxis

• In the emergency medical facility
• Supplemental oxygen and airway management
• IM epinephrine (IV for severe hypotension)
• IV fluid expansion
• H1 antagonist (diphenhydramine) oral, IM or IV
• Corticosteroids oral prednisone (1-2 mg/kg up
  to 75 mg) or IV solumedrol (1-2 mg/kg up to 125
  mg)
• Nebulized albuterol every 20 minutes or
  continuous
• H2 antagonist (ranitidine 1-2 mg/kg up to 150
  mg)
• Glucagon for refractory hypotension
• Discharge therapy antihistamine and prednisone
  (1 mg/kg up to 75 mg) daily for 3 days referral
  to an allergy specialist

Sampson Pediatrics 1111601-8, 2003
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EpiPen Jr vs EpiPen in Young Children Weighing
15-30 Kg at Risk for Anaphylaxis

• 10 children studied
• 5 used the EpiPen Jr (mean age 5.4 0.4 yrs
  mean weight 18 0.6 kg)
• 5 used the EpiPen (mean age 6.6 0.5 yrs mean
  weight 25.4 1.5 kg)
• Peak plasma epinephrine concentrations were
  promptly achieved

Simons et al. J Allergy Clin Immunol 109171-5,
2002