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Anaphylaxis Rx   2011

PHARMACOLOGIC RX  OF  ANAPHYLAXIS                               REF:  eMPR 2011
Outpatient setting

First-line treatment

• EPINEPHRINE, IM auto-injector or 1:1000 solution

  • º Weight 10–25kg: 0.15mg epinephrine autoinjector, IM (anterior-lateral thigh)
  • º Weight>25kg: 0.3mg epinephrine autoinjector, IM (anterior-lateral thigh)
  • º Epinephrine (1:1000 solution) IM, 0.01mg/kg per dose; max 0.5mg per dose (anterior-lateral thigh)
  • º May need to repeat epinephrine dose every 5–15 minutes

Adjunctive treatment

• Bronchodilator (ß2-agonist): ALBUTEROL

  • º MDI (Children: 4–8 puffs; Adults: 8 puffs) or
  • º Nebulized solution (Children: 1.5mL; Adults: 3mL) every 20 minutes or continuously as needed

• H1 antihistamine: DIPHENHYDRAMINE

  • º 1–2mg/kg per dose; max 50mg IV or PO (oral liquid is more readily absorbed than tablets)
  • º Alternative dosing may be used with a less-sedating second generation antihistamine

• Supplemental oxygen therapy

• IV fluids in large volumes if patient presents with orthostasis, hypotension, or incomplete response to IM epinephrine

• Place the patient in recumbent position if tolerated, with the lower extremities elevated

         

Hospital-based setting

First-line treatment

• EPINEPHRINE IM (as above, outpatient setting), consider continuous epinephrine infusion for persistent hypotension (ideally with continuous non-invasive monitoring of blood pressure and heart rate); alternatives are endotracheal or intra-osseous epinephrine

Adjunctive treatment

• Bronchodilator (ß2-agonist): ALBUTEROL

  • º MDI (Children: 4–8 puffs; Adults: 8 puffs) or
  • º Nebulized solution (Children: 1.5mL; Adults: 3mL) every 20 minutes or continuously as needed

• H1 antihistamine: DIPHENHYDRAMINE

  • º 1–2mg/kg per dose; max 50mg IV or PO (oral liquid is more readily absorbed than tablets)
  • º Alternative dosing may be used with a less-sedating second generation antihistamine

• H2 antihistamine: RANITIDINE

  • º 1–2mg/kg per dose ; max 75–150mg PO and IV

• Corticosteroids

  • º PREDNISONE: 1mg/kg; max 60–80mg PO or
  • º METHYLPREDNISOLONE: 1mg/kg; max 60–80mg IV

• Vasopressors (other than epinephrine) for refractory hypotension, titrate to effect

• GLUCAGON for refractory hypotension, titrate to effect

  • º Children: 20–30 micrograms/kg
  • º Adults: 1–5 mg
  • º May repeat dose or followed by infusion of 5–15 micrograms/min

• ATROPINE for bradycardia, titrate to effect

• Supplemental oxygen therapy

• IV fluids in large volumes if patient presents with orthostasis, hypotension, or incomplete response to IM epinephrine

• Place the patient in recumbent position if tolerated, with the lower extremities elevated

         

Therapy at discharge

First-line treatment

• EPINEPHRINE, auto-injector prescription (2 doses) and instructions

• Education on avoidance of allergen

• Follow-up with primary care physician

• Consider referral to an allergist

Adjunctive treatment

• H1 antihistamine: DIPHENHYDRAMINE every 6 hours for 2–3 days; alternative dosing with a non-sedating second generation antihistamine

• H2 antihistamine: RANITIDINE twice daily for 2–3 days

• Corticosteroid: PREDNISONE daily for 2–3 days

NOTES

**These treatments often occur concomitantly, and are not meant to be sequential, with the exception of epinephrine as first-line treatment.

Adapted from Boyce JA, Assa'ad A, Burks AW, et al. Guidelines for the Diagnosis and Management of Food Allergy in the US: Summary of the NIAID-Sponsored Expert Panel. J Allergy Clin Immunol Dec 2010; 1105-1116.

         
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         2011