Pharmacologic Management of Anaphylaxis
| PHARMACOLOGIC MANAGEMENT OF ANAPHYLAXIS |
|---|
| Outpatient setting |
|
First-line treatment • EPINEPHRINE, IM; auto-injector or 1:1000 solution º Weight 10–25kg: 0.15mg epinephrine autoinjector, IM (anterior-lateral thigh) º Weight>25kg: 0.3mg epinephrine autoinjector, IM (anterior-lateral thigh) º Epinephrine (1:1000 solution) IM, 0.01mg/kg per dose; max 0.5mg per dose (anterior-lateral thigh) º May need to repeat epinephrine dose every 5–15 minutes Adjunctive treatment • Bronchodilator (β2-agonist): ALBUTEROL º MDI (Children: 4–8 puffs; Adults: 8 puffs) or º Nebulized solution (Children: 1.5mL; Adults: 3mL) every 20 minutes or continuously as needed • H1 antihistamine: DIPHENHYDRAMINE º 1–2mg/kg per dose; max 50mg IV or PO (oral liquid is more readily absorbed than tablets) º Alternative dosing may be used with a less-sedating second generation antihistamine • Supplemental oxygen therapy • IV fluids in large volumes if patient presents with orthostasis, hypotension, or incomplete response to IM epinephrine • Place the patient in recumbent position if tolerated, with the lower extremities elevated |
| Hospital-based setting |
|
First-line treatment • EPINEPHRINE IM (as above, outpatient setting), consider continuous epinephrine infusion for persistent hypotension (ideally with continuous non-invasive monitoring of blood pressure and heart rate); alternatives are endotracheal or intra-osseous epinephrine Adjunctive treatment • Bronchodilator (β2-agonist): ALBUTEROL º MDI (Children: 4–8 puffs; Adults: 8 puffs) or º Nebulized solution (Children: 1.5mL; Adults: 3mL) every 20 minutes or continuously as needed • H1 antihistamine: DIPHENHYDRAMINE º 1–2mg/kg per dose; max 50mg IV or PO (oral liquid is more readily absorbed than tablets) º Alternative dosing may be used with a less-sedating second generation antihistamine • H2 antihistamine: RANITIDINE º 1–2mg/kg per dose; max 75–150mg PO and IV • Corticosteroids º PREDNISONE: 1mg/kg; max 60–80mg PO or º METHYLPREDNISOLONE: 1mg/kg; max 60–80mg IV • Vasopressors (other than epinephrine) for refractory hypotension, titrate to effect • GLUCAGON for refractory hypotension, titrate to effect º Children: 20–30 micrograms/kg º Adults: 1–5 mg º May repeat dose or followed by infusion of 5–15 micrograms/min • ATROPINE for bradycardia, titrate to effect • Supplemental oxygen therapy • IV fluids in large volumes if patient presents with orthostasis, hypotension, or incomplete response to IM epinephrine • Place the patient in recumbent position if tolerated, with the lower extremities elevated |
| Therapy at discharge |
|
First-line treatment • EPINEPHRINE, auto-injector prescription (2 doses) and instructions • Education on avoidance of allergen • Follow-up with primary care physician • Consider referral to an allergist Adjunctive treatment • H1 antihistamine: DIPHENHYDRAMINE every 6 hours for 2–3 days; alternative dosing with a non-sedating second generation antihistamine • H2 antihistamine: RANITIDINE twice daily for 2–3 days • Corticosteroid: PREDNISONE daily for 2–3 days |
| NOTES |
|
**These treatments often occur concomitantly, and are not meant to be sequential, with the exception of epinephrine as first-line treatment. Adapted from Boyce JA, Assa'ad A, Burks AW, et al. Guidelines for the Diagnosis and Management of Food Allergy in the United States: Summary of the NIAID-Sponsored Expert Panel Report. J Allergy Clin Immunol 2010; 126(6):1105–18. (Rev. 7/2012) |
