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Guideline (S2k) on Acute Therapy and Management of Anaphylaxis: 2021 Update

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Guideline (S2k) on Acute Therapy and Management of Anaphylaxis: 2021 Update guidelines Allergo J Int (2021) 30:1–25 https://doi.org/10.1007/s40629-020-00158-y Guideline (S2k) on acute therapy and management of anaphylaxis: 2021 update S2k-Guideline of the German Society for Allergology and Clinical Immunology (DGAKI), the Medical Association of German Allergologists (AeDA), the Society of Pediatric Allergology and Environmental Medicine (GPA), the German Academy of Allergology and Environmental Medicine (DAAU), the German Professional Association of Pediatricians (BVKJ), the Society for Neonatology and Pediatric Intensive Care (GNPI), the German Society of Dermatology (DDG), the Austrian Society for Allergology and Immunology (ÖGAI), the Swiss Society for Allergy and Immunology (SGAI), the German Society of Anaesthesiology and Intensive Care Medicine (DGAI), the German Society of Pharmacology (DGP), the German Respiratory Society (DGP), the patient organization German Allergy and Asthma Association (DAAB), the German Working Group of Anaphylaxis Training and Education (AGATE) Johannes Ring · Kirsten Beyer · Tilo Biedermann · Andreas Bircher · Matthias Fischer · Thomas Fuchs · Axel Heller · Florian Hoffmann · Isidor Huttegger · Thilo Jakob · Ludger Klimek · Matthias V. Kopp · Claudia Kugler · Lars Lange · Oliver Pfaar · Ernst Rietschel · Franziska Rueff · Sabine Schnadt · Roland Seifert · Britta Stöcker · Regina Treudler · Christian Vogelberg · Thomas Werfel · Margitta Worm · Helmut Sitter · Knut Brockow Published online: 28 January 2021 © The Author(s) 2021 Keywords Anaphylaxis · Food allergy · Drug LT Leukotriene allergy · Adrenalin · Emergency management · NSAID Non-steroidal anti-inflammatory drugs Pharmacotherapy · Group education · Auto-injector · PAF Platelet-activating factor COVID-19 · Vaccination s.c. Subcutaneous Abbreviations Background ACE Angiotensin converting enzyme AGATE German Working Group of Anaphylaxis Train- Anaphylaxis is an acute systemic reaction involving ing and Education symptoms of an immediate-type allergic reaction that CD Cluster of differentiation can comprise the whole organism and potentially be DAAB Patient organization German Allergy and fatal [1–3]. Asthma Association Although anaphylaxis is a highly acute process in EIA Exercise-induced anaphylaxis terms of its symptoms, there is a chronic immunolog- FDEIA Food-dependent exercise-induced anaphy- ical imbalance underlying this condition that leads to laxis immediate reactions as soon as contact with the elic- FiO2 Inspired oxygen fraction itor occurs. This chronic condition may have severe ICD International Statistical Classification of Dis- effects of both a psychological and an organizational eases and Related Health Problems nature on the everyday life of affected individuals. IgE Immunoglobulin E The definition of anaphylaxis is not internationally i.m. Intramuscular standardized. Also, a number of different classifica- i.v. Intravenous tion systems are in use. The most commonly used K Guideline (S2k) on acute therapy and management of anaphylaxis: 2021 update 1 guidelines classification in German-speaking countries is used not provide evidence-based information on whether in this guideline. specific treatments have been effective. Anaphylactic reactions are among the most severe, It is well known that patients, e.g., after successfully potentially life-threatening, and dramatic events in al- treated anaphylaxis due to an insect sting, are not op- lergology. Acute treatment is carried out according timally followed-up [9–11]. These problems in basic to international guidelines and recommendations in management underline the need for further research, textbooks. This guideline is an update of earlier ver- as well as the importance of the guideline presented sions from 1994, 2007, and 2014 [4–8] and takes in- here. ternational guidelines [3, 7] into consideration (see This guideline is intended for all physicians, as well Addendum). as other individuals active in health care, involved in Anaphylactic reactions may spontaneously cease the acute treatment, diagnostics, and management of at any stage of symptoms, but may also progress patients with anaphylaxis. in severity despite adequate treatment. This unpre- dictability makes it difficult to evaluate the efficacy of Epidemiology of anaphylaxis therapeutic procedures. Single-case observations do In recent years, a number of studies on the world- wide prevalence of anaphylactic reactions have been Prof.Dr.Dr.J.Ring( ) · T. Biedermann · C. Kugler · published [12–21]. Due to the varying definitions, as K. Brockow Department Dermatology and Allergology Biederstein, well as the fact that anaphylaxis with fatal outcome is Technical University Munich, Biedersteiner Straße 29, 80802 Munich, Germany O. Pfaar [email protected] Section of Rhinology and Allergy, Department of K. Beyer Otorhinolaryngology, Head and Neck Surgery, University Department of Pediatrics, Division of Pulmonology, Hospital Marburg, Philipps-University Marburg, Marburg, Immunology and Critical Care Medicine, Germany Charité—University Hospital Berlin, Berlin, Germany E. Rietschel A. Bircher Department of Pediatrics, University Hospital Cologne, Department of Dermatology, University Hospital of Basel, Cologne, Germany Basel, Switzerland F.Rueff M. Fischer Department of Dermatology and Allergology, Hospital of the Clinic for Anaesthesiology, Intensive Care Medicine, Ludwig Maximilians University, Munich, Germany Emergency Medicine and Pain Therapy, ALB FILS Hospitals Göppingen, Göppingen, Germany S. Schnadt German Allergy and Asthma Association, T. Fuchs Mönchengladbach, Germany Department of Dermatology, University Hospital Göttingen, Göttingen, Germany R. Seifert Institute of Pharmacology, Hannover Medical School, A. Heller Hannover, Germany Department of Anesthesiology and Operative Intensive Care Medicine, Medical Faculty, University of Augsburg, B. Stöcker Augsburg, Germany Medical practice for pediatrics and youth medicine, Poppelsdorfer Allee, Bonn, Germany F.Hoffmann Dr. von Hauner Children’s Hospital, Ludwig Maximilians R. Treudler University, Munich, Germany Department of Dermatology, Venereology, and Allergology, Leipzig Interdisciplinary Allergy Center, University Hospital I. Huttegger Leipzig, Leipzig, Germany Department of Pediatrics, University Hospital Salzburg, Salzburg, Austria C. Vogelberg Department of Pediatric Pneumology and Allergology, T. Jakob University Hospital Carl Gustav Carus, Technical University Department of Dermatology and Allergology, University of Dresden, Dresden, Germany Medical Center Gießen (UKGM), Justus-Liebig-University Gießen, Gießen, Germany T. Werfel Immunodermatology and Experimental Allergology Unit, L. Klimek Department of Dermatology, Allergology, and Venereology, Center of Rhinology and Allergology, Wiesbaden, Germany Medical University Hannover, Hannover, Germany M. V. Kopp M. Worm Pediatric Respiratory Medicine, Department of Pediatrics, Department of Dermatology, Venereology, and Allergology, Inselspital, Bern University Hospital, University of Bern, Charité—University Hospital Berlin, Berlin, Germany Bern, Switzerland H. Sitter L. Lange Institute for Surgical Research, Philipps-University Marburg, St. Marien-Hospital Bonn, Bonn, Germany Marburg, Germany 2 Guideline (S2k) on acute therapy and management of anaphylaxis: 2021 update K guidelines Table 1 Common elicitors of severe anaphylactic reac- Pathophysiology tions in children and adults (data from the anaphylaxis reg- istry March 2017, n= 8046 [28, 29]) Anaphylaxis is usually caused by an immunologi- Elicitors Children Adults cal reaction—most frequently an immunoglobulin E (in %) (in %) (IgE)-mediated allergy. IgE activates mast cells and Foods 60 16 basophils via cross-linking of high-affinity IgE re- Insect venoms 22 52 ceptors, leading to increased expression of surface Drugs 7 22 markers (CD63, CD203c), as indirectly measurable Others 5 3 on basophils. The symptoms of anaphylactic reac- Unknown 7 6 tions are mediated by a variety of substances released from mast cells and basophil granulocytes such as histamine, prostaglandins, leukotrienes (LTB 4, LTC 4, not always diagnosed, one needs to assume a certain and LTD 4), tryptase, platelet-activating factor (PAF), number of unreported cases. heparin, proteases, serotonin, and cytokines [30–34]. A limitation with regard to data on the epidemiol- The relative importance of these mediators in humans ogy of anaphylaxis arises due to the variable coding cannot easily be estimated for methodological reasons of anaphylaxis according to ICD-10. There are several and is a matter of discussion. There is consensus that ICD-10 codes that can include anaphylaxis. The new histamine is involved in anaphylactic reactions [30]. ICD-11 will be introduced in 2022, possibly with a new Thus, the intravenous application of histamine can classification of anaphylaxis [22–24]. There is a par- elicit anaphylactic symptoms in healthy individu- ticular need for classification regarding whether re- als [35, 36]. Furthermore, there is discussion as to peated cutaneous reactions in manifest type I allergy whether, in addition to IgE in rare cases (e.g., dex- can already be regarded as anaphylaxis, whether, by tran 4,5), other antibody classes can also elicit similar definition, involvement of at least two organ systems symptoms to, or aggravate, an IgE-mediated reaction; is required, or whether involvement of only the res- the complement split products, C3a, C4a, and C5a piratory and/or cardiovascular system can represent (anaphylatoxins), are the most important mediators
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