What are the treatment options for severe allergies?

Treatment Options for Severe Allergies

Epinephrine is the first-line treatment for severe allergic reactions (anaphylaxis) and should be administered immediately upon recognition of symptoms to prevent morbidity and mortality. 1

Emergency Management of Anaphylaxis

First-Line Treatment

• Epinephrine administration:
  • Intramuscular (IM) injection is the preferred route 2
  • Administer in the anterolateral thigh (vastus lateralis muscle) 2
  • Dosing based on weight:
    • 0.15 mg for children weighing less than 25 kg
    • 0.3 mg for children over 25 kg and adults
    • Alternative dosing: 0.01 mg/kg of 1:1,000 solution (maximum 0.5 mg) 2, 1
  • May repeat dose every 5-15 minutes if symptoms persist 2

Adjunctive Treatments

These should not replace epinephrine but can be used in conjunction:

1. Antihistamines:

   • H1 antihistamines (e.g., diphenhydramine 25-50 mg orally/IV) for itching and urticaria 2
   • Second-generation H1 antihistamines (e.g., cetirizine 10 mg) may be preferred due to less sedation 2, 1
   • H2 antihistamines have minimal supporting evidence but are sometimes used concurrently 2

2. Bronchodilators:

   • Albuterol via nebulizer or metered-dose inhaler for bronchospasm 2
   • Should be considered adjunctive to epinephrine, not a replacement 2

3. Corticosteroids:

   • Not helpful for acute anaphylaxis due to slow onset (4-6 hours) 2
   • May help prevent biphasic or protracted reactions 2
   • Treatment typically for 2-3 days 2

4. Fluid resuscitation:

   • IV crystalloid fluids for hypotension 1
   • Rapid bolus of 500-1000 mL, repeated as needed 1

5. Oxygen:

   • Supplemental oxygen as needed 1

Long-Term Management for Severe Allergies

Allergen Avoidance

• Complete avoidance of identified trigger allergens 2
• Education on reading food labels for those with food allergies 2
• Avoidance of products with precautionary labeling (e.g., "may contain") 2

Prescription of Emergency Medications

• All patients with severe allergies should be prescribed:
  • Two epinephrine autoinjectors 1, 3
  • Antihistamines for mild symptoms 2
  • Clear instructions on when to use each medication 2

Allergen Immunotherapy

• Consider for specific allergies (e.g., insect venom, environmental allergens) 2
• Conventional immunotherapy schedules involve gradually increasing doses over 14-28 weeks 2
• Accelerated schedules (rush or cluster) achieve therapeutic dose faster but may have increased risk of systemic reactions 2
• Must be administered in settings equipped to manage potential reactions 2

Patient Education and Follow-up

Education Requirements

• Training on proper use of epinephrine autoinjectors 4
• Repeated instruction improves proper technique (only 5.6% of patients demonstrate perfect technique after initial training) 4
• Written emergency action plan 1
• Recognition of anaphylaxis symptoms 1

Monitoring

• All patients who receive epinephrine should be monitored for 4-6 hours 1
• Observation for biphasic reactions, which can occur up to 72 hours later 1
• Follow-up with allergist for comprehensive evaluation 1

Common Pitfalls in Anaphylaxis Management

1. Underuse of epinephrine:

   • Only 27.1% of anaphylaxis patients treated by health professionals receive epinephrine 5
   • Common reasons for not using epinephrine include perception that reaction isn't severe enough, use of other medications first, and fear of using autoinjectors 6

2. Delayed administration:

   • Delayed epinephrine administration is associated with increased morbidity and mortality 3, 7
   • Epinephrine should be administered promptly once anaphylaxis is suspected 3

3. Improper route of administration:

   • Subcutaneous administration is less effective than intramuscular 2
   • IV epinephrine should be reserved for patients who don't respond to IM injection and fluid resuscitation 2

4. Overreliance on antihistamines:

   • H1 antihistamines only relieve itching and urticaria, not respiratory or cardiovascular symptoms 2
   • Should never be substituted for epinephrine in anaphylaxis 2

5. Failure to carry autoinjectors:

   • Only 46% of patients bring their device to follow-up visits 4
   • 22.4% of untreated cases had a device available but didn't use it 5

By following these evidence-based guidelines for the management of severe allergies, healthcare providers can significantly reduce morbidity and mortality associated with anaphylaxis while improving patients' quality of life.