Intended for healthcare professionals

Rapid response to:

Clinical Review Lesson of the week

Adrenaline given outside the context of life threatening allergic reactions

BMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7389.589 (Published 15 March 2003) Cite this as: BMJ 2003;326:589

Rapid Response:

Careful before withdrawing self-administered adrenaline!

The lesson of the week by Johnston et al (1) has given us some
concern. Although we do agree that the misuse of adrenaline, as in the two
cases reported, may be life threatening itself, I wouldn’t like to see an
increase in the incidence of life threatining anaphylaxis due to the
underuse of the drug after the publication of the article. It is, in fact,
well established that adrenaline administration is critical during the
course of acute anaphylaxis: the earlier is given, the better is the
outcome.

Some points need to be addressed.

1. Anaphylaxis is not rare. Two studies have estimated that the prevalence
of anaphylaxis varies from 1:3333 (USA) to 1:3400 (Australia) inhabitants
and that foods, drugs and insects account for up to 73% cases (2, 3). The
true prevalence may be even higher as several cases go unreported or
misdiagnosed.

2. Anaphylaxis and self-administered adrenaline (EpiPen). As underlined
recently by Simons (4) at the Annual Meeting of American Academy of
Allergy, Asthma, Immunology (AAAAI), anaphylaxis occurs more frequently in
a community setting than in a hospital or other healthcare setting. In the
former setting foods, insects and drugs play a major role, whereas in the
latter radiocontrast agents, latex, allergen-specific immunotherapy and
drugs are more probably involved. Adrenaline dispensing rates for out-of-
hospital use (EpiPen) in the youngest population (<_17 years="years" of="of" age="age" can="can" be="be" as="as" high="high" _1.4="_1.4" _5="_5" indicating="indicating" that="that" indeed="indeed" the="the" prevalence="prevalence" may="may" that.="that." p="p"/>In conclusion, be aware that anaphylaxis, although rarely a fatal event as
pointed out by Johnston et al (1), may be around the corner when less you
expect to see it. Johnston et al did a "good job" in warning us about the
misuse of adrenaline, but they should have also stressed how important is
to try and identify the cause of any anaphylactic or anaphylactoid (non-
IgE-mediated) or even minor allergic reactions (urticaria and non life
threatening angioedema), as prevention is the best treatment: avoidance
for foods and drugs, immunotherapy for insects. It’s every allergist's
experience that a minor reaction today does not necessarily mean a minor
reaction to-morrow. In other words, before withdrawing an EpiPen
particularly in children and adolescents, any attempt should be made to
positively identify the etiology of the reaction: careful history taking
with attention to timing of the reaction, allergy skin or laboratory
tests, C1-inhibitor deficiency evaluation, double-blind-placebo-controlled
-food-challenge are all available tools for this purpose.

References

1. Johnston SL, Unsworth J, Gompels MM. Adrenaline given outside the
context of life threatening allergic reactions. BMJ 2003;326:589-90.

2. Yocum MW, Butterfield JH, Klein JS et al. J Allergy Clin Immunol
1999;104:452-6.

3. Brown AFT, McKinnon D, Chu K. J Allergy Clin Immunol 2001;108:861-6.

4. Simons FER. Anaphylaxis. Annual Meeting of the American Academy of
Allergy, Asthma, Immunology, March 7-12, 2003,Denver, CO.

5. Simons FER, Peterson S, Black CD. Epinephrine dispensing patterns for
an out-of-hospital population: a novel approach to studying the
epidemiology of anaphylaxis. J Allergy Clin Immunol 2002;110:647-51.

Competing interests:  
None declared

Competing interests: No competing interests

14 March 2003
Daniela Zauli
Associate Professor of Allergy and Clinical Immunology
Sara Zucchini, Alberto Grassi, Giorgio Ballardini, Francesco B. Bianchi
Dept. of Internal Medicine, Cardioangiology, Hepatology, University of Bologna. 40138 Bologna, Italy