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Anaphylaxis Practice Parameters Practice parameter Anaphylaxis—a 2020 practice parameter update, systematic review, and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) analysis Marcus S. Shaker, MD, MSc,a Dana V. Wallace, MD,b David B. K. Golden, MD,c John Oppenheimer, MD,d Jonathan A. Bernstein, MD,e Ronna L. Campbell, MD, PhD,f Chitra Dinakar, MD,g Anne Ellis, MD,h Matthew Greenhawt, MD, MBA, MSc,i David A. Khan, MD,j David M. Lang, MD,k Eddy S. Lang, MD,l Jay A. Lieberman, MD,m Jay Portnoy, MD,n Matthew A. Rank, MD,o David R. Stukus, MD,p and Julie Wang, MD,q Collaborators: Natalie Riblet, MD, MPH,r Aiyana M. P. Bobrownicki, MPH, MBA,r Teresa Bontrager, RN, BSN, MSNed, CPEN,s Jarrod Dusin, MS, RD, LD,s Jennifer Foley, RT(R)(N), CNMT,s Becky Frederick, PharmD,s Eyitemi Fregene, MD, MPH,r Sage Hellerstedt, MPH,r Ferdaus Hassan, PhD,s Kori Hess, PharmD,s Caroline Horner, MD,t Kelly Huntington, RN, BSN, CPN,s Poojita Kasireddy, MPH,r David Keeler, RN, BSN, CPN,s Bertha Kim, MPH,r Phil Lieberman, MD,m Erin Lindhorst, MS, RD, LD,s Fiona McEnany, MPH,r Jennifer Milbank, MPH,r Helen Murphy, BHS RRT AE-C,s Oriana Pando, MPH,r Ami K. Patel, MPH,r Nicole Ratliff, BS RT(R),s Robert Rhodes, MHA, RRT-NPS,s Kim Robertson, MBA, MT-BC,s Hope Scott, RN, CPEN,s Audrey Snell, MS, RD, CSP, LD,s Rhonda Sullivan, MS, RD, LD,s Varahi Trivedi, MPH,r and Azadeh Wickham, MS, FNP-BCs Chief Editors: Marcus S. Shaker and Dana V. Wallace Workgroup Contributors: Marcus S. Shaker, Dana V. Wallace, Jonathan A. Bernstein, Ronna L. Campbell, Chitra Dinakar, Anne Ellis, David B. K. Golden, Matthew Greenhawt, Jay A. Lieberman, Matthew A. Rank, David R. Stukus, and Julie Wang Joint Task Force on Practice Parameters Reviewers: Marcus S. Shaker, Dana V. Wallace, David B. K. Golden, Jonathan A. Bernstein, Chitra Dinakar, Anne Ellis, Matthew Greenhawt, Caroline Horner, David A. Khan, Jay A. Lieberman, John Oppenheimer, Matthew A. Rank, Marcus S. Shaker, David R. Stukus, and Julie Wang, Lebanon and Hanover, NH; Fort Lauderdale, Fla; Baltimore, Md; Morristown, NJ; Cincinnati, Cleveland, and Columbus, Ohio; Rochester, Minn; Stanford, Calif; Kingston, Ontario, and Calgary, Alberta, Canada; Denver, Colo; Dallas, Tex; Memphis, Tenn; Kansas City and St Louis, Mo; Scottsdale, Ariz; and New York, NY Anaphylaxis is an acute, potential life-threatening systemic doses of epinephrine to treat anaphylaxis are risk factors for allergic reaction that may have a wide range of clinical biphasic anaphylaxis. Antihistamines and/or glucocorticoids are manifestations. Severe anaphylaxis and/or the need for repeated not reliable interventions to prevent biphasic anaphylaxis, k a University of Texas Southwestern Medical Center, Dallas; the Department of Allergy From the Section of Allergy and Clinical Immunology, Dartmouth-Hitchcock Medical l b and Clinical Immunology, Respiratory Institute, Cleveland Clinic; the Department of Center, Geisel School of Medicine at Dartmouth, Lebanon; the Nova Southeastern m Allopathic Medical School, Fort Lauderdale; cthe Division of Allergy-Clinical Emergency Medicine, Cumming School of Medicine, University of Calgary, the d Department of Pediatrics, The University of Tennessee Health Science Center, Mem- Immunology, Johns Hopkins University, Baltimore; the Department of Internal n Medicine, Pulmonary and Allergy, University of Medicine and Dentistry of New phis; the Pediatric Allergy and Immunology, Children’s Mercy Hospital, Kansas City School of Medicine; othe Division of Allergy, Asthma, and Clinical Immunology, Jersey–Rutgers New Jersey Medical School and Pulmonary and Allergy Associates, p Morristown; ethe Department of Internal Medicine, Division of Immunology, Allergy Mayo Clinic in Arizona, Scottsdale; the Division of Allergy and Immunology, f Nationwide Children’s Hospital and The Ohio State University College of Medicine, Section, University of Cincinnati College of Medicine; the Department of Emergency q Medicine, Mayo Clinic, Rochester; gthe Allergy, Asthma, and Immunodeficiency, Columbus; the Division of Allergy and Immunology, Icahn School of Medicine at Mount Sinai, New York; rThe Dartmouth Institute for Health Policy and Clinical Division of Pulmonary, Allergy, and Critical Care Medicine, Stanford University s h Practice, Hanover; the Office of Evidence-Based Practice, Children’s Mercy Hospital, School of Medicine; the Division of Allergy and Immunology, Department of t Medicine, Queen’s University, Kingston; ithe Section of Allergy and Immunology, Kansas City; the Department of Pediatrics, Division of Allergy, Immunology, and Children’s Hospital Colorado, University of Colorado School of Medicine, Denver; Pulmonary Medicine, Washington University School of Medicine, St. Louis. jthe Department of Internal Medicine, Division of Allergy and Immunology, 1082 J ALLERGY CLIN IMMUNOL SHAKER ET AL 1083 VOLUME 145, NUMBER 4 although evidence supports a role for antihistamine and/or radiocontrast media anaphylaxis. Epinephrine is the first-line glucocorticoid premedication in specific chemotherapy pharmacotherapy for uniphasic and/or biphasic anaphylaxis. protocols and rush aeroallergen immunotherapy. Evidence is After diagnosis and treatment of anaphylaxis, all patients lacking to support the role of antihistamines and/or should be kept under observation until symptoms have fully glucocorticoid routine premedication in patients receiving low- resolved. All patients with anaphylaxis should receive education or iso-osmolar contrast material to prevent recurrent on anaphylaxis and risk of recurrence, trigger avoidance, Disclosure of potential conflict of interest: The JTFPP members and work group Milwaukee, WI 53202. E-mail: pfl[email protected]); [email protected]. members’ conflict of interest disclosure forms can be found at www.allergyparameters. Previously published practice parameters of the Joint Task Force on Practice Parameters org. Jonathan Bernstein has received financial support from Sanofi, Regeneron, Astra- for Allergy & Immunology are also available at http://www.allergyparameters.org, Zeneca, Merck, Optinose, Takeda, CSL Behring, Biocryst, Pharming, the National In- http://www.AAAAI.org, and http://www.ACAAI.org. stitutes of Health, Taylor Francis, INEOS; is Editor in Chief of the Journal of Asthma, The Joint Task Force on Practice Parameters (JTFPP) is committed to ensuring that the INEOS Medical Immunosurveillance Director, Vice Chair and Lectureship Chair of practice parameters are based on the best scientific evidence at the time of publication, the American Academy of Allergy, Asthma & Immunology (AAAAI) Foundation, and that such evidence is free of commercial bias to the greatest extent possible. The Chairman of Allergists for Israel, American College of Asthma, Allergy, and Immu- JTFPP recognizes that experts in a field are likely to have interests that could come into nology (ACAAI) Asthma Chair, Scientific Chair, and Young Investigator Award Chair; conflict with the development of a completely unbiased and objective practice and serves of the Board of Directors and Scientific Committee of Interasma. Ronna parameter. To take advantage of their expertise, a process has been developed to Campbell has served as a peer reviewer for EB Medicine and an author for UpToDate. acknowledge potential conflicts of interest (COI) and attempt to prevent them from Chitra Dinakar has received financial support from Propeller Health, ACAAI (stipend influencing the final document in a negative way. To preserve the greatest transparency for Editorial Board of AllergyWatch), the American Association of Allergists of Indian regarding potential COI, all members of the JTFPP and the practice parameters work Origin; serves on the Board of Directors of the AAAAI and on the Medical Advisory groups will complete a standard potential COI disclosure form prior to the Board of Food Equity Initiative; is Assistant Editor of AllergyWatch. Anne Ellis has development of each document, which will be available for external review by the received financial support from ALK-Abello, AstraZeneca, Green Cross, Merck, No- sponsoring organization and any other interested individual. In addition, before vartis, Nuvo, Pediapharm, Pfizer, Kaleo, Novartis, Sanofi, Regeneron; serves on the confirming the selection of the work group chairperson and members, the JTFPP will Board of Directors of the Canadian Allergy Society of Allergy and Clinical Immu- discuss and resolve all relevant potential COI associated with this selection. Finally, all nology. David Golden has received financial support from Aquestive, Sandoz, ALK- members of parameter work groups will be provided a written statement regarding the Abello, Sandoz, Genentech, Stallergenes-Greer, and UpToDate. Matthew Greenhawt importance of ensuring that the parameter development process is free of commercial has received financial support from Aquestive, Merck, Allergenis, Allergy Therapeu- bias. During the review process there are additional measures to avoid bias. At the tics, Sanofi Genzyme, Genentech, Aravax, Prota, Before Brands, the Institute for Clin- workgroup level, all the sections are reviewed by all work group members to ensure ical and Economic Review, ACAAI, DBV, Intrommune; is supported by the Agency of that content is appropriate and without apparent bias. If a section is deemed to have Healthcare Research and Quality; has served on the advisory board of International apparent bias, it will be appropriately revised without the section author’s involvement, Food Protein-Induced Enterocolitis Syndrome Association, the Asthma
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