Anaphylaxis. Choosing Wisely with Academic Detailing Conference October 21, 2017

Transcription

1 Anaphylaxis Choosing Wisely with Academic Detailing Conference October 21, 2017

2 Disclosure Natasha Rodney-Cail, Pharmacist, Drug Evaluation Unit DEU funded by the Drug Evaluation Alliance of Nova Scotia (DEANS). DEU prepares Drug Evaluation Reports for the Atlantic Common Drug Review (ACDR) Has no conflicts of interest Dr. Wade Watson No disclosures

3 Case 1 Laura C. 8 years old, 55 lbs. History of anaphylactic reaction to peanuts Anaphylactic reaction 3 years ago Generalized hives, swollen lips-tongue, SOB with wheeze Onset 15 minutes after ingestion Treated successfully with epinephrine in ED Ate a cookie at school, may have contained nuts 2 hours after ingestion: Sudden onset of cough, dizzy with flushed cheeks Carries an epinephrine auto-injector 0.15 mg not administered as uncertain of symptoms

4 Case 2 Sam S. 12 year old, brought to ED following bee sting Presents with generalized hives, low BP, SOB, and vomiting Anaphylactic reaction diagnosed and treated appropriately What next?

5 ANAPHYLAXIS Anaphylaxis is a severe, life-threatening hypersensitivity reaction It is characterized by rapidly developing, life threatening problems involving: Airway Breathing Circulation GI tract In most cases, there are associated skin and mucosal changes

6 Triggers Immunologic Non-immunologic Idiopathic

7 Symptoms Skin/cutaneous Respiratory Gastrointestinal Cardiovascular Neurological

8 Anaphylaxis is highly likely. Sudden onset of Exposure to likely allergen or trigger (2 or more of the following) Exposure to known allergen or trigger And at least one

9 Progression of a Reaction Immediate Biphasic Delayed

10 Biphasic Reactions Estimated prevalence 1% to 20% May not resemble the first phase (severity may be =, <, or >) Anne K. Ellis, and James H. Day CMAJ 2003;169:

11 Patient Factors that Contribute Age Illness Medications

12 Epinephrine First-line treatment for anaphylaxis Delays in administration associated with increased mortality

13 Give epinephrine In patients with signs or symptoms consistent with impending anaphylaxis and the clinical suspicion for anaphylaxis is high, even if formal diagnostic criteria are not met.

14

15 Dosing Recommended dosing is 0.01mg/kg up to 0.5mg IM 1mg/ml ampoules Auto-injectors: Two available doses 0.3mg 0.15mg Upsize to 0.3mg for >=25kg (55lb)

16 What next?

17 How many doses? If symptoms progress or poor response repeat dose after 5 to 15 minutes 12% - 36% may require more than one dose Usually 1 additional dose is all that is required

18 Common and Expected Side Effects Pallor Tremor Anxiety Tachycardia Headache Nausea indicate a therapeutic dose has been given!

19 Contraindications/Considerations No contraindication if treatment for anaphylaxis Caution with cardiac issues, arrhythmias, uncontrolled hypertension

20 Other therapies H1-antihistimines, H2-antihistamines, corticosteroids, and inhaled beta-2 agonists DO NOT REVERSE ANAPHYLAXIS Consider only for symptom management AFTER EPINEPHRINE

21 Observation No consensus on optimal observation period Decision based on judgement May want to consider longer duration if: Risk factors for more severe anaphylaxis (i.e. asthma) Allergens have been ingested > 1 dose epinephrine required Pharyngeal edema present Severe or prolonged symptoms Patients should have an auto-injector (fill Rx immediately) Inform of possible recurrent reaction Stay close to hospital for up to 72 hours

22 Auto-injectors

23 Anaphylaxis Management Tool kit Create emergency action plan Educate on how to avoid triggers Educate on signs & symptoms Always carry epinephrine autoinjector Know how to inject it Make sure it is in date Refer to an allergy specialist Wear identification jewelry

24 Case 1 Laura C. 8 years old, 55 lbs. History of anaphylactic reaction to peanuts Anaphylactic reaction 3 years ago Generalized hives, swollen lips-tongue, SOB with wheeze Onset 15 minutes after ingestion Treated successfully with epinephrine in ED Ate a cookie at school, may have contained nuts 2 hours after ingestion: Sudden onset of cough, dizzy with flushed cheeks Carries an epinephrine auto-injector 0.15 mg not administered as uncertain of symptoms

25 Polling Question a. Have Laura lay down and monitor for further symptoms or improvement b. Administer Laura s epinephrine auto-injector, have Mom take her to ED c. Administer Laura s epinephrine auto-injector, call 911 d. Administer epinephrine (1mg/mL ampoule) IM in arm, call 911 e. Administer epinephrine (1 mg/ml ampoule) IM in thigh, call 911

26 Case 2 Sam S. 12 year old, brought to ED following bee sting Presents with generalized hives, low BP, SOB, and vomiting Anaphylactic reaction diagnosed and treated appropriately What next?

27 Polling Question a. Send Sam home as soon as his symptoms resolve. Send with an Rx for an auto-injector and a corticosteroid. b. Observe Sam for 3 hours. If no further signs send home with an Rx for an auto-injector. c. Observe Sam for 8 hours. If no further signs send home with an Rx for an auto-injector.