Anaphylaxis School First results of a national multicenter study

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Valentine Jordan
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2 Anaphylaxis School First results of a national multicenter study J. Kupfer, S. Schallmayer, I. Fell, U. Gieler for the German study group

Anaphylaxis is an acute, potentially life-threatening hypersensitivity reaction, involving the

Anaphylaxis is defined by a number of signs and symptoms,, which occur within minutes, or up to a

Most cases are mild but any anaphylaxis has the potential to become life-threatening.

rarely, last for several days. Johansson SGO et al.

3 Anaphylaxis is an acute, potentially life-threatening hypersensitivity reaction, involving the release of mediators from mast cells, basophiles and recruited inflammatory cells. Anaphylaxis is defined by a number of signs and symptoms,, which occur within minutes, or up to a few hours, after exposure to a provoking agent. It can be mild, moderate to severe, or severe. Most cases are mild but any anaphylaxis has the potential to become life-threatening. Anaphylaxis develops rapidly, usually reaching peak severity within 5 to 30 minutes, and may, rarely, last for several days. Johansson SGO et al. Revised nomenclature for allergy for global use: Report of the Nomenclature Review Committee of the World Allergy Organization, October J Allergy Clin Immunol. 2004;113:832-6.

4 Epidemiology 3-6% of hospitalizations of patients with allergic disorders 2 to 21 cases of hospitalizated patients / year [1-8] 0.09% of all emergency admissions [2] 0.13% of all pediatric emergency situations [3] 1. Sorensen HT et al. Allergy 1989; 44: Klein JS. JACI 1995; 95: Marguet C et al.arch Pediatr 1999; 6 Suppl. 1: Moneret-Vautrin DA et al. Bull Acad Natl Med 1995; 179 : Stewart AG et al. Q J Med 1996;89: Yocum MW et al. JACI 1999; 104 : Kemp SF et al. AIM 1995; 155 : Kemp SF, Lockey EF. JACI 2002;110 : 341-8

5 Hospitalization with allergic disorders in England ( ) Gupta R et al. BMJ 2003 ; 327 : 1142

6 Symptoms and signs of Anaphylaxis The initial manifestation of anaphylaxis may be loss of consciousness. Patients often describe "a sense of doom." Gastro-intestinal: Abdominal pain. Oral: Pruritus of lips, tongue and palate, edema of lips and tongue. Respiratory: Upper airway obstruction from angioedema of the tongue. Cutaneous: Diffuse erythema, flushing, urticaria, pruritus, angioedema. Cardiovascular: Faintness, hypotension, arrhythmias Ocular: Periorbital edema, erythema, conjunctival erythema, tearing. Genito-urinary: Uterine cramps, urinary urgency or incontinence. /anaphylaxissynopsis.php

7 What doctors can do ABC mnemonic for Emergency Treatment of Anaphylaxis + pharmacolocic management A = Airway Ensure and establish a patent airway... B = Breathing Assess adequacy of ventilation and provide patient with sufficient oxygen C = Circulation Minimize or eliminate continued exposure to causative agent A = Adrenalin = epinephrine Epinephrine is the drug of choice for anaphylaxis B = Benadryl (diphenhydramine) Antihistamines are not useful for the the initial management of anaphylaxis C = Corticosteroids Corticosteroids do not benefit acute anaphylaxis but may prevent relapse or protracted anaphylaxis. /anaphylaxissynopsis.php

8 But what to do if no doctor is available? Prevention knowledge about triggers Education Program Anaphylaxis Therapy (doctor) Rescue Medication correct (self) application

9 Results from other education programs for patients with Anaphylaxis Knowledge area Vinitial Vfollow-up p Family s knowledge of how <0.001 avoid food exposure (n=53) Family s understanding < of managing reactions (n=53) Critical steps of EpiPen <0.001 Administration (n=23) Kapoor S et al. Allergy 2004; 59 :

10 Aims: AGATE-patient education program Basics: Definition of anaphylaxis, diagnosis, symptoms Master emergency (self)treatment Avoid triggers Support and exchange of experience Master anxiety and conflict situations

11 Contents of the course day 1 Experiences, expectations of participants Basics: Definition of anaphylaxis, diagnosis, symptoms Anxiety reactions; identify and differ Prevention, coping with the disease, treatment options Acute therapy, emergency kit: drugs meet (time until effect occurs, correct order when taken) Acute therapy, emergency management: emergency action plan (practical exercise / role play) Acute therapy with autoinjector: training and confidence in dealing with autoinjector

12 Contents of the course day 2 Repeat: acute treatment and contents of the 1 st day Trigger-related prevention activities: food, drugs, insect stings, latex, mastocytosis Everyday strategies: tools for dealing with anaphylaxis in everyday life, strengthening safety in the social environment (role playing) Questions, final discussion

13 AGATE-patient education program For patients and parents of children who wear a Adrenalininjektor Outpatient Program: 2 meetings each 4 x 45 minutes Interdisciplinary approach (allergist, nutritionist, psychologist, nurse) Standardized program with manual Group size between 6 (adults) and 12 (parents)

14 Hypotheses Primary efficacy variables (1) Education participants have a greater increase in knowledge than the control group (2) Education participants achieve a greater increase in the total score of the behavioral trial than the control group

15 Hypotheses Secondary efficacy variables (1) Education participants have a greater increase in quality of life than the control group (2) Education participants achieve greater reduction of anxiety and depression than the control group

16 Evaluationstudy Patients with Indikation for Autoinjector in 12 clinics N =160 (80 parents, 80 adults) Randomisation Drop-out 20% Education participants Outcome-Variables: Knowledge about Anaphylaxis Emergency procedures QoL Anxiety, Depression (HADS) Waiting control group Follow-up 3 month

17 adults parents N = 195 n = 100 n = 95 Age / 5 Gender m = 30, f = 70 m=12, f=81/ children m=65, f=30 Marital status 67% 84% Anaphylaxis bees/ vasps (Mastocytosis) nuts (41%), milk (16%) Comorbidity 38% (asthma) 68% (asthma, atopic dermatitis) Medication prescribed 95% (93% picked up) 97% (94% picked up) Satisfaction with clinician 82% very satisfied 86% very satisfied

18 Anaphylaxis specific knowledge (adults) education participants (n=52) p<.05 control group (n=44)

19 Behaviour test of an emergency situation (adults) education participants (n=54) p <.001 control group (n=41)

20 Quality of life; anxiety, depression (adults) Scale: everyday and professional life: significant differences between T0-T2 in training group (p < 0,05) No significant changes over the time for the scales: Satisfaction with social life Physical complaints Mental condition Treatment of allergy Satisfaction Anxiety and Depression

21 Anaphylaxis specific knowledge (parents) education participants (n=49) p <.01 control group (n=46)

22 Behaviour test of emergency sitution (parents) education participants (n=49) p <.001 control group (n=44)

23 Anxiety HADS (parents) education participants (n=46) p <.05 control group (n=44)

24 Quality of life, depression (parents) No significant changes over the time: Emotional Impact Food Anxiety Social and Dietary Limitations Depression

Discussion Patients with anaphylaxis show the following changes after the training program: - Knowledge enhancement - A better application of

25 Discussion Patients with anaphylaxis show the following changes after the training program: - Knowledge enhancement - A better application of antiallergic drugs in the behavioral test - A slightly improved quality of life An expansion of the program to several clinics will be sought

26 Thank you for your attention

Myth: Prior Episodes Predict Future Reactions REALITY: No predictable pattern Severity depends on: Sensitivity of the individual Dose of the allergen

Myth: Prior Episodes Predict Future Reactions REALITY: No predictable pattern Severity depends on: Sensitivity of the individual Dose of the allergen Anaphylaxis Fatalities Estimated 500 1000 deaths annually