How is an allergic reaction to red licorice treated?

Treatment of Allergic Reactions to Red Licorice

Intramuscular epinephrine is the first-line treatment for severe allergic reactions (anaphylaxis) to red licorice, while milder reactions can be managed with antihistamines. 1, 2

Severity Assessment and Treatment Algorithm

For Mild Allergic Reactions (isolated urticaria, mild itching, flushing)

• Administer H1 antihistamines:
  • Diphenhydramine 25-50 mg orally every 6 hours 2
  • Or non-sedating second-generation antihistamine alternative 1
• Monitor for progression of symptoms 1
• If symptoms worsen, immediately escalate to anaphylaxis treatment protocol 1

For Severe Reactions/Anaphylaxis (difficulty breathing, hypotension, swelling of lips/tongue/throat)

1. Immediate administration of epinephrine via intramuscular injection in anterolateral thigh 1, 2, 3

   • Adults and children ≥30 kg: 0.3-0.5 mg (0.3-0.5 mL)
   • Children <30 kg: 0.01 mg/kg (maximum 0.3 mg)
   • May repeat every 5-15 minutes if symptoms persist 2

2. Call for emergency assistance (911) 1

3. Place patient in recumbent position with lower extremities elevated if tolerated 1

4. Provide supplemental oxygen 1

5. Administer IV fluids for volume resuscitation 1

6. Adjunctive treatments (only after epinephrine): 1, 2

   • H1 antihistamines (diphenhydramine)
   • H2 antihistamines (ranitidine)
   • Corticosteroids
   • Albuterol for bronchospasm

7. For refractory cases: 1

   • Repeat epinephrine
   • Additional IV fluids
   • Vasopressor agents
   • Transfer to ICU

Post-Treatment Management

Observation Period

• All patients who receive epinephrine should be observed in a medical facility 1
• Minimum observation period: 4-6 hours 1, 2
• Extended observation or hospital admission for severe or refractory symptoms 1

Discharge Medications (2-3 days) 1, 2

• H1 antihistamine: diphenhydramine every 6 hours or non-sedating alternative
• H2 antihistamine: ranitidine twice daily
• Corticosteroid: prednisone daily

Patient Education and Follow-up

• Prescribe two epinephrine auto-injectors 1, 2
• Provide anaphylaxis emergency action plan 1, 2
• Educate on:
  • Complete avoidance of licorice in all forms 2
  • Early recognition of symptoms 1, 2
  • Proper use of epinephrine auto-injector 2
• Schedule follow-up with primary care provider and consider allergist referral 1

Important Clinical Considerations

Common Pitfalls to Avoid

• Never delay epinephrine administration for anaphylaxis - this is the most common and dangerous error 2
• Do not substitute antihistamines for epinephrine in severe reactions 1, 2
• Always prescribe two doses of epinephrine auto-injector 2
• Be aware that patients on beta-blockers may require glucagon (1-5 mg IV over 5 minutes) if resistant to epinephrine 1

Special Populations

Exercise caution when administering epinephrine to patients with: 1

• Cardiovascular disease
• Taking monoamine oxidase inhibitors or tricyclic antidepressants
• Using stimulant medications or cocaine
• Recent intracranial surgery, aortic aneurysm, uncontrolled hyperthyroidism, or hypertension

Despite these concerns, the benefit of epinephrine in anaphylaxis outweighs the risks, and there are no absolute contraindications to its use in a life-threatening allergic reaction 1.