Practice Guidelines

Assessment and referral after emergency treatment of a suspected anaphylactic episode: summary of NICE guidance

BMJ 2011; 343 doi: (Published 14 December 2011) Cite this as: BMJ 2011;343:d7595
  1. M Dzingina, technical analyst (health economics)1,
  2. H Stegenga, technical analyst2,
  3. M Heath, programme manager1,
  4. D Jones, technical adviser1,
  5. G Rogers, technical adviser (health economics)1,
  6. J Kleijnen, project lead (Kleijnen Systematic Reviews)3,
  7. R Wolff, systematic reviewer (Kleijnen Systematic Reviews)4,
  8. N Armstrong, health economics lead (Kleijnen Systematic Reviews )4,
  9. P D Howdle, emeritus professor of clinical medicine5
  10. on behalf of the Guideline Development Group
  1. 1National Institute for Health and Clinical Excellence, Piccadilly Plaza, Manchester M1 4BT, UK
  2. 2National Institute for Health and Clinical Excellence, MidCity Place, London WC1V 6NA, UK
  3. 3School for Public Health and Primary Care (CAPHRI), Maastricht University, 6200 MD, Netherlands
  4. 4Kleijnen Systematic Reviews, York YO19 6FD, UK
  5. 5University of Leeds, Leeds LS2 9JT, UK
  1. Correspondence to: P D Howdle p.d.howdle{at}

Anaphylaxis is a severe, life threatening, generalised or systemic hypersensitivity reaction. It is characterised by rapidly developing, life threatening problems involving the airway (pharyngeal or laryngeal oedema) and/or breathing (bronchospasm with tachypnoea) and/or circulation (hypotension and/or tachycardia). In most cases, there are associated skin and mucosal changes.1 UK estimates suggest that about 1 in 1333 of the population in England has experienced anaphylaxis.2 A common trigger of anaphylaxis in children is food and in older people is medication.3 About 20 deaths from anaphylaxis are reported each year in the United Kingdom, of which about half are known to be iatrogenic,4 although this may be a substantial underestimate. This article summarises the most recent recommendations from the National Institute for Health and Clinical Excellence (NICE) on assessment to confirm an anaphylactic reaction and on the decision to refer a patient after emergency treatment for a suspected anaphylactic reaction.5


NICE recommendations are based on systematic reviews of the best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the Guideline Development Group’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets.

Duration of observation after suspected anaphylactic reaction

  • Observe adults and young people aged 16 years or older who have had emergency treatment for suspected anaphylaxis for 6-12 hours from the onset of symptoms, depending on their response to emergency treatment. (The main purpose of observation is to detect potential biphasic reactions and monitor response to treatment while the individual is in hospital.) In patients with reactions that are controlled promptly and easily, a shorter observation period may be considered provided that they receive appropriate care before discharge. [Based on very low quality indirect evidence from observational studies and on the experience and opinion …

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