What should I prescribe for a patient with suspected anaphylaxis due to a cherry allergy?

From the Guidelines

For suspected anaphylaxis due to a cherry allergy, immediately administer epinephrine via an auto-injector (such as EpiPen or Auvi-Q) at a dose of 0.3mg for adults or 0.15mg for children, injected into the mid-outer thigh, as recommended by the most recent guidelines 1. This should be followed by calling emergency services (911) for transport to the hospital for monitoring and further treatment. After epinephrine administration, give an H1-antihistamine such as diphenhydramine (Benadryl) 25-50mg for adults or 1mg/kg for children, and consider adding an H2-blocker like famotidine 20mg for adults. For ongoing management, prescribe a second epinephrine auto-injector for the patient to carry at all times, and provide a written anaphylaxis action plan. Patient education should include strict avoidance of cherries and potentially related fruits in the Rosaceae family, careful label reading, and wearing medical alert identification. Epinephrine is the first-line treatment because it rapidly reverses the life-threatening cardiovascular and respiratory effects of anaphylaxis by constricting blood vessels, relaxing airway muscles, and reducing inflammation and hives, as supported by the latest practice parameter update 1. Key considerations in anaphylaxis management include:

• Prompt administration of epinephrine without delay, as emphasized in recent guidelines 1
• Observation in a setting capable of managing anaphylaxis until symptoms have fully resolved, as recommended by good practice statements 1
• Education on anaphylaxis, including avoidance of identified triggers, presenting signs and symptoms, biphasic anaphylaxis, treatment with epinephrine, and the use of epinephrine auto-injectors, as outlined in the latest practice parameter update 1.

From the FDA Drug Label

Adrenalin® is a non-selective alpha and beta adrenergic agonist indicated for: Emergency treatment of allergic reactions (Type 1), including anaphylaxis Adults and Children 30 kg (66 lbs) or more: 0.3 to 0.5 mg (0.3 to 0.5 mL) intramuscularly or subcutaneously into anterolateral aspect of the thigh every 5 to 10 minutes as necessary Children 30 kg (66 lbs) or less: 0.01 mg/kg (0.01 mL/kg), up to 0.3 mg (0.3 mL), intramuscularly or subcutaneously into anterolateral aspect of the thigh every 5 to 10 minutes as necessary

You should prescribe epinephrine (IM) for a patient with suspected anaphylaxis due to a cherry allergy. The dosage is:

• 0.3 to 0.5 mg for adults and children over 30 kg, administered intramuscularly or subcutaneously every 5 to 10 minutes as necessary.
• 0.01 mg/kg (up to 0.3 mg) for children under 30 kg, administered intramuscularly or subcutaneously every 5 to 10 minutes as necessary 2.

From the Research

Anaphylaxis Treatment

To address a patient with suspected anaphylaxis due to a cherry allergy, consider the following steps:

• Remove the trigger: immediately remove the patient from exposure to the allergen (cherry) to prevent further reaction 3.
• Administer epinephrine: give intramuscular epinephrine as the first-line treatment for anaphylaxis, as it is the most effective way to relieve symptoms and prevent fatal outcomes 3, 4, 5, 6.
• Provide supportive care: ensure the patient's airway, breathing, and circulation are stable, and provide oxygen if necessary 3, 4.
• Consider adjunct medications: after epinephrine administration, consider using histamine H1 and H2 antagonists, corticosteroids, beta2 agonists, and glucagon as adjunct treatments, but only if necessary and under close monitoring 3, 7, 5.

Medication Considerations

When deciding on medications to prescribe:

• Epinephrine is the primary treatment and should be administered promptly 3, 4, 5, 6.
• Antihistamines may be used as adjunct therapy, but they do not replace epinephrine and may not relieve all symptoms of anaphylaxis 7, 5, 6.
• Corticosteroids may be beneficial in reducing the length of hospital stay, but their use in emergency treatment of anaphylaxis is not universally recommended, and some studies suggest revisiting their use 7, 5.

Patient Monitoring and Follow-up

After initial treatment:

• Monitor the patient for a biphasic reaction, which can occur within 4 to 12 hours after the initial reaction 3.
• Develop an emergency action plan and refer the patient to an allergist for further evaluation and management 3.
• Educate the patient on avoiding triggers and the proper use of an epinephrine auto-injector 3.