Doctors Often Fall Short in Treating Anaphylactic Allergic Attacks

Some people with allergies experience fits of sneezing, watery eyes, itchy rash and other unpleasantness. But some people experience a life-threatening reaction called anaphylactic shock, a whole-body response to an allergen that can swell the lips, tongue and throat, and threaten the ability to breathe. Anaphylaxis, which by definition involves at least two body organ systems (such as skin and lungs), must be treated quickly and appropriately to prevent death.

Two preliminary reports, however, show that many primary care and emergency physicians don’t know how to treat anaphylaxis properly, nor do they know how to prevent recurrences.

Epinephrine is the key to stopping an anaphylactic attack.

As reported on, in only 15 in 100 anaphylaxis cases did the practitioner employ all three of the major treatment recommendations-administer epinephrine within 30 minutes, prescribe auto-injectors of the drug when the patient is discharged and refer patients to an allergist or immunologist for follow-up exams and treatment.

Epinephrine, also known as adrenaline, is a hormone injected to open airways and increase respiration.

More than 300 physicians were interviewed. Not only did a significant proportion routinely fail to provide epinephrine to patients they believe are having anaphylactic reactions and fail to refer anaphylaxis patients to specialists, they believe incorrectly that some such patients should not receive epinephrine auto-injectors.

The survey, sponsored by the Asthma and Allergy Foundation of America (AAFA) reveals “likely deficiencies in physician knowledge,” said Dr. Myron Zitt at the November meeting of the American College of Allergy, Asthma, and Immunology (ACAAI).

Dr. Akhil Chouksey, another researcher, told conference attendees that anaphylaxis care in a major teaching hospital also usually failed to meet the care guidelines. A 10-year study at Case Western Reserve University in Cleveland showed that only 15 in 100 cases included all three of the major recommendations. The patients in more than 1 in 4 cases in which anaphylaxis was confirmed never received epinephrine.

A survey earlier this year sponsored by the AAFA found that about 1 in 16 people have experienced an anaphylactic response.

The physician survey involved 100 emergency room doctors, 100 allergists, 50 adult primary care physicians and 50 pediatricians. Epinephrine is supposed to be given to all patients having anaphylactic reactions, but 1 in 10 emergency room physicians and 1 in 5 primary care and pediatric physicians said they had prescribed another drug, sent the patient to a hospital or “other” action. About 97 in 100 allergists, of course, administered epinephrine.

About 6 in 10 ER docs prescribed take-home auto-injectors, but basically all the allergists did so.

It’s shocking that emergency physicians-who are most likely to see patients in anaphylactic shock-generally were deficient at all phases of follow-up care. They rarely reported ordering or referring patients for diagnostic tests to pinpoint the cause of the problem, they seldom demonstrated use of an auto-injector or explained that they have an expiration date.

Despite national guidelines that there are no absolute contraindications to epinephrine, 10 in 100 pediatric allergists and 32 in 100 of the other allergists said there were contraindications; 38 in 100 adult primary care and emergency physicians agreed.

Some physicians are reluctant to prescribe epinephrine to patients whose symptoms appear to be relatively mild; like all drugs, epinephrine can have unwelcome side effects, such as stomach problems, dizziness, headache, irregular heartbeat and breathing problems.

Still, as MedPageToday reported Zitt telling the conference, “If you’re going to sit around with a patient starting to have anaphylaxis symptoms that have one organ system involved, and wait for the other organ system to develop before you give epinephrine, you’re going to lose some patients.”

“Don’t sit on that,” he said. “Give epinephrine first, ask questions later.”

If you or a loved one shows signs of an extreme allergic reaction, seek medical care immediately. If the doctor doesn’t offer epinephrine, ask for it. Once you have a confirmed diagnosis, make sure you are prepared for future attacks. Ask about a prescription for self-injectable epinephrine (EpiPen is one such product), and carry it with you. Although it’s commonly thought that public places such as schools and restaurants stock epinephrine, often they don’t, and they are not required to do so.

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