Patients with the following should be prescribed an epinephrine autoinjector: a previous systemic allergic reaction; food allergy and asthma; or a known food allergy to peanut, tree nuts, fish, or crustacean shellfish. In addition, some consideration should be given to prescribing an epinephrine autoinjector for all patients with food allergy who have IgE-mediated reactions, because it is impossible to predict the severity of subsequent reactions.
Patients should be verbally instructed on the proper use of epinephrine autoinjectors. They should also receive an instructional video, if available, and a written anaphylaxis emergency action plan. Patients should be instructed on the value of medical identification jewelry for easy recognition of their potential for anaphylaxis and food-allergen triggers. Patients should be told the importance of carrying epinephrine at all times and of making sure that family and friends are aware of the risks of anaphylaxis, the patient's triggers, and how to administer epinephrine. If allowed by state law, students should be advised to carry their epinephrine autoinjector at school and at all school-related events.
Patients and family members should be advised to regularly check the epinephrine autoinjector expiration dates (which expire after 1 year) and to verify that the liquid remains clear. Ideally, the prescribing physician's office should see patients annually or notify patients (or their parents or guardians) by telephone or mail that their autoinjector will soon reach its expiration date. Patients can be encouraged to register for automated pharmacy reminders for epinephrine renewal. Epinephrine autoinjectors are temperature sensitive and should be stored at room temperature to prevent degradation of the medication.
Treatment of Acute, Life-Threatening, Food-Induced Allergic Reactions
For food-induced anaphylaxis, prompt and rapid treatment with epinephrine is paramount. Delayed administration of epinephrine has been implicated in contributing to fatalities.10,11,16,62
Initial management of anaphylaxis should include elimination of the allergen and intramuscular injection of epinephrine (). Autoinjector dosing for epinephrine is 0.15 mg for children who weigh 10 to 25 kg and 0.3 mg for those who weigh >25 kg. These steps should be followed by a call for an emergency medical team, placement of the patient in a recumbent position with lower extremities elevated (if tolerated), and adjunctive therapy (). If a patient responds poorly to the initial dose of epinephrine or has ongoing or progressive symptoms, repeated dosing may be required after 5 to 15 minutes.
Pharmacologic Management of Anaphylaxis
Given their anti-inflammatory properties, systemic corticosteroids are often recommended for preventing biphasic or protracted food-induced allergic reactions, but evidence to support their use is lacking.65
Observation Period After Food-Induced Anaphylaxis
There is no consensus in the literature regarding the optimal time duration for observing a patient who has been successfully treated for anaphylaxis before discharge. All patients who receive epinephrine for food-induced anaphylaxis should proceed to an emergency facility for observation and possibly additional treatment. A reasonable length of time for observation of most patients who have experienced anaphylaxis is 4 to 6 hours; a prolonged observation time or hospital admission is reasonable for patients with severe or refractory symptoms.51,61
Discharge Plan After Treatment for Food-Induced Anaphylaxis
All patients who have experienced anaphylaxis should be sent home with (1) an anaphylaxis emergency action plan, (2) an epinephrine autoinjector (2 doses), (3) a plan for monitoring autoinjector expiration dates, (4) a plan for arranging further evaluation, and (5) printed information about anaphylaxis and its treatment66
(). Advice should be provided to the patient regarding follow-up with his or her primary health care professional within 1 to 2 weeks after a food-induced anaphylaxis event. The patient may be referred to a specialist such as an allergist or immunologist for further evaluation.
Management of Milder Acute Food-Induced Allergic Reactions in Health Care Settings
Milder forms of allergic reactions, such as flushing, urticaria, isolated mild angioedema, and symptoms of oral allergy syndrome, can be treated with H1
When antihistamines alone are given, ongoing observation and monitoring are warranted to ensure a lack of progression to more significant symptoms of anaphylaxis. If progression or increased severity is noted, epinephrine should be administered immediately. If there is history of a previous severe allergic reaction, epinephrine should be administered promptly and earlier in the course of treatment (eg, at the onset of even mild symptoms).