Considerations for At-Home Management of Food-Induced Anaphylaxis
Guidance for Allergists/Immunologists from the CSACI
Current as of August 14, 2023 and based on available evidence to date
Authors: Elissa M Abrams MD MPH, Anne K Ellis MD MSc, Tim Vander Leek MD, Waleed Alqurashi MD MSc, Philippe Begin MD PhD, Edmond S Chan MD, Amelie Gauthier MD, Harold Kim MD, Douglas Mack MD MSc, Jennifer LP Protudjer PhD, Julia Upton MD MPH, Moshe Ben Shoshan MD MSc
Home management of food-induced anaphylaxis with epinephrine use but without emergency medical services (EMS) activation may be appropriate in certain circumstances. Guidance from the United States in conjunction with Food Allergy Research and Education (FARE) during the COVID-19 pandemic first proposed this approach to reduce healthcare burden and decrease the risk of infection as a result of the pandemic.1 As we move past the COVID-19 pandemic, however, this guidance can still apply. A recent perspective article in Annals of Allergy, Asthma and Immunology advocated retiring routine EMS activation.2
Historically, transfer to a healthcare facility for anaphylaxis management and observation has long been a part of international anaphylaxis guidance. This recommendation has been in place to allow for additional intervention if subsequent management of anaphylaxis is needed both for the acute event and in the event of a biphasic reaction, which has been historically estimated to occur in 5- 20% of patients. However, the risk of severe or clinically significant biphasic reaction is likely much lower than that.3,4 The Canadian Pediatric Society (CPS) currently recommends a period of observation of at least 4-6 hours in the Emergency Department (ED) following the onset of allergic symptoms to assess the need for further resuscitative measures for persistent or refractory reactions and to monitor for a biphasic reaction.3 Similarly, Translating Emergency Knowledge for Kids (TREKK) currently recommends monitoring for 2-6 hours or overnight based on reaction severity and individual risk factors.5
- The mandatory requirement to activate EMS may lead to an association of the use of epinephrine with EMS activation, and so result in non-use or delayed use of intramuscular epinephrine6,7
- Fatality in anaphylaxis is an exceptionally rare outcome, with an overall prevalence of 0.47-0.69 per million persons an stable case fatality rates at 0.1% of all ED visits.8,9
- Severe biphasic anaphylaxis is less common than previously reported, and biphasicanaphylaxis fatality is exceptionally rare (0.5 to 1 death per million person- years)1,10,11
- Biphasic anaphylaxis and other severe anaphylaxis outcomes (including admission to the intensive care unit/hospital ward) are most effectively prevented by early epinephrine administration12
- The high safety profile of intramuscular epinephrine does not require any ED monitoring and can be safely managed at home13
- Adjunct therapies provided in the ED such as antihistamines and steroids have not been demonstrated to reduce the risk of a biphasic reaction nor of fatality4,14
- Routine activation of EMS for resolved anaphylaxis after epinephrine therapy is a low value practice an associated with a significant healthcare cost ($142 million US dollars per life-year saved and $1.4 billion US dollars to prevent one death)15
- There remains significant healthcare utilization issues in the EDs as well as increased risk of infection transmission, not just from COVID-19 but from other respiratory viruses as well.16–19
In considering this guidance, at-home management of anaphylaxis could apply under a stringent set of circumstances in a shared decision-making approach between patient and clinician that include the following factors:
- Patient/caregiver comfort level with the recognition and management of anaphylaxis, in particular the prompt and correct use of epinephrine auto-injector
- Immediate access to at least two, in date, weight-appropriate dose of epinephrine autoinjectors
- Absence of risk factors for a biphasic reaction: a prior biphasic reaction, a moderate-to- severe reaction, delayed use of epinephrine (>60 minutes) or requirement of more than one dose of epinephrine4,14,20
- Absence of risk factors for severe anaphylaxis outcomes: cardiovascular disease, asthma (especially active or poorly controlled), mastocytosis1,4,11,21
- Symptom resolution with one dose of epinephrine administration
- Patient/caregiver preference
In all other circumstances EMS should continue to be activated.
Acknowledgements: The authors would like the acknowledge the CSACI board members L Connors, M Hanna, K Hildebrand, V Kim, S Lohrenz, A O’Keefe, L Rosenfield and H Vliagoftis for their assistance.
- Casale TB, Wang J, Nowak-Wegrzyn A. Acute At Home Management of Anaphylaxis During the Covid-19 Pandemic. J Allergy Clin Immunol Pr. 2020;8:1795–7.
- Greenhawt M, Lieberman JA, Dribin TE, Shaker MS, Spergel J. Retire the advice to send patients to the emergency department after epinephrine use for observation. Ann Allergy Asthma Immunol. 2023;130:697–8.
- CPS Position Statement: Emergency treatment of anaphylaxis in infants and children [Internet]. Available from: https://cps.ca/documents/position/emergency-treatment-anaphylaxis
- Shaker MS, Wallace D V, Golden DBK, Oppenheimer J, Bernstein JA, Campbell RL, et al. Anaphylaxis-a 2020 practice parameter update, systematic review, and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) analysis. J Allergy Clin Immunol. 2020;145:1082–123.
- TREKK: Bottom Line Recommendations: Anaphylaxis [Internet]. Available from: https://trekk.ca/system/assets/assets/attachments/554/original/2021-05-27_Anaphylaxis_v_2.1.pdf?1622566873
- Gabrielli S, Protudjer JLP, Gooding G, Gerdts J, Ben-Shoshan M. Anaphylaxis-related knowledge and concerns in Canadian families during the coronavirus disease 2019 pandemic. Vol. 127, Annals of allergy, asthma & immunology : official publication of the American College of Allergy, Asthma, & Immunology. United States; 2021. p. 496–7.
- Glassberg B, Nowak-Wegrzyn A, Wang J. Factors contributing to underuse of epinephrine autoinjectors in pediatric patients with food allergy. Ann allergy, asthma Immunol Off Publ Am Coll Allergy, Asthma, Immunol. 2021;126:175-179.e3.
- Xu YS, Kastner M, Harada L, Xu A, Salter J, Waserman S. Anaphylaxis-related deaths in Ontario: a retrospective review of cases from 1986 to 2011. Allergy Asthma Clin Immunol. 2014;10:38.
- Lee JK, Vadas P. Anaphylaxis: mechanisms and management. Clin Exp allergy J Br Soc Allergy Clin Immunol. 2011;41:923–38.
- Ichikawa M, Kuriyama A, Urushidani S, Ikegami T. Incidence and timing of biphasic anaphylactic reactions: a retrospective cohort study. Acute Med Surg. 2021;8:e689.
- Turner PJ, Jerschow E, Umasunthar T, Lin R, Campbell DE, Boyle RJ. Fatal Anaphylaxis: Mortality Rate and Risk Factors. J Allergy Clin Immunol Pr. 2017;5:1169–78.
- Gabrielli S, Clarke A, Morris J, Eisman H, Gravel J, Enarson P, et al. Evaluation of Prehospital Management in a Canadian Emergency Department Anaphylaxis Cohort. J Allergy Clin Immunol Pr. 2019;7:2232-2238.e3.
- Cardona V, Ferré-Ybarz L, Guilarte M, Moreno-Pérez N, Gómez-Galán C, Alcoceba-Borràs E, et al. Safety of Adrenaline Use in Anaphylaxis: A Multicentre Register. Int Arch Allergy Immunol. 2017;173:171–7.
- Alqurashi W, Ellis AK. Do Corticosteroids Prevent Biphasic Anaphylaxis? J allergy Clin Immunol Pract. 2017;5:1194–205.
- Shaker M, Kanaoka T, Feenan L, Greenhawt M. An economic evaluation of immediate vs non-immediate activation of emergency medical services after epinephrine use for peanut-induced anaphylaxis. Ann Allergy Asthma Immunol. 2019;122:79–85.
- Quach C, McArthur M, McGeer A, Li L, Simor A, Dionne M, et al. Risk of infection following a visit to the emergency department: a cohort study. C Can Med Assoc J = J l’Association medicale Can. 2012;184:E232-9.
- Shaw D. The hidden risks of the waiting room: confidentiality and cross-infection. Br J Gen Pract J R Coll Gen Pract. 2019;69:299.
- Gross TK, Lane NE, Timm NL. Crowding in the Emergency Department: Challenges and Recommendations for the Care of Children. Pediatrics. 2023;151.
- CIHI: NACRS emergency department visits and lengths of stay [Internet]. [cited 2023 Aug 10]. Available from: https://www.cihi.ca/en/nacrs-emergency-department-visits-and-lengths-of-stay
- Pourmand A, Robinson C, Syed W, Mazer-Amirshahi M. Biphasic anaphylaxis: A review of the literature and implications for emergency management. Am J Emerg Med. 2018;36:1480–5.
- Pouessel G, Turner PJ, Worm M, Cardona V, Deschildre A, Beaudouin E, et al. Food-induced fatal anaphylaxis: From epidemiological data to general prevention strategies. Clin Exp allergy J Br Soc Allergy Clin Immunol. 2018;48:1584–93.
- Miles LM, Ratnarajah K, Gabrielli S, Abrams EM, Protudjer JLP, Bégin P, et al. Community Use of Epinephrine for the Treatment of Anaphylaxis: A Review and Meta-Analysis. J allergy Clin Immunol Pract. 2021;
- Simons FER. Anaphylaxis. J Allergy Clin Immunol. 2010;125:S161-81.