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Anaphylaxis
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Anaphylaxis -
Life-threatening allergy

 

Table of Contents

What is anaphylaxis?

The doctor said it was an 'anaphylactoid reaction'. What's the difference?

What are the common causes of anaphylaxis?

How can you tell if someone is having anaphylaxis?

What happens in the body during anaphylaxis? Histamine, Antihistamines

What is the best treatment for anaphylaxis? Adrenaline (epinephrine).

Adrenaline (epinephrine) kits available

Carrying the injection kit around: special containers.

What is adrenaline (epinephrine)?

When should I inject adrenaline (epinephrine)?

What about an adrenaline (epinephrine) inhaler?
    Recent evidence (March & Oct 2000) showed they did not work.
    Consult your own specialist if this is relevant to you.

Do I need to use more than one injection of adrenaline (epinephrine)?

How long will an adrenaline (epinephrine) injection carry on working after I have injected it?

What are the side effects of adrenaline (epinephrine)?

Injecting adrenaline (epinephrine) in the wrong place can be dangerous.
A tip for doctors on treatment for accidental injection into the thumb.

Is adrenaline (epinephrine) prescribed far more often than necessary?

Other treatments for anaphylaxis Antihistamines, steroids, other.

When the immediate emergency is over. Tests to check if it was anaphylaxis. Referral to specialist.

Some medicines can make anaphylaxis worse: Beta blockers

Useful addresses & information

The Anaphylaxis Campaign

Warning bracelets and pendants

Living with Anaphylaxis: Handling the Stress. The Calgary Allergy Network, Canada, has a useful article.



What is anaphylaxis?

Anaphylaxis is the word used for serious and rapid allergic reactions usually involving more than one part of the body which, if severe enough, can kill.

The word anaphylaxis was coined when scientists tried to protect dogs against a poison by immunising them with small doses. Far from being protected, the dogs died suddenly when they got the poison again. The word used for protection by immunisation is 'prophylaxis', so the scientists coined the word 'anaphylaxis' to mean the opposite of protection. What the scientists saw in the dogs helped them to understand that the same can happen in humans. This helped us to understand asthma and other allergies too, because they work in a similar way.

Scientists now use the word 'anaphylaxis' to mean any immune reaction of this type, even if it is not serious. But most doctors use it to mean a life-threatening rapid allergic reaction.

Unfortunately this kind of 'harmful immunisation' happens to a few of us not just from injections but from ordinary foods such as nuts. Quite literally, "one man's meat is another man's poison". Our immune system, which is there to protect us from infection, goes wrong and harms or even kills us.

Injections of many kinds occasionally cause anaphylaxis. Penicillin, injected clot-busting drugs used after heart attacks, and a host of other kinds of injection can occasionally do to human beings what the experiments did to dogs. Thank goodness we now understand vastly more about anaphylaxis, though we still need research to answer important questions.

There are yet other causes of anaphylaxis. You will see more about some of those below. Anaphylaxis has become an important issue in medicine and for the increased numbers of people who have had an attack of anaphylaxis.

Why the increase? When medicines are the cause, the explanation is likely to be that we are simply using more medicines, and that newer medicines which are proteins are more likely to cause anaphylaxis. But this does not explain why foods should be causing anaphylaxis more often. For some reason all the common allergies such as hayfever, allergic asthma and food allergy have become more common. Researchers have definite ideas about why this might be so.

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The doctor said it was not anaphylaxis but an 'anaphylactoid reaction'. What's the difference?

There is not much difference to you as the sufferer. There is not much difference to the doctor who is treating you when it happens. It's serious. There is a tendency for these reactions to be less dangerous than anaphylaxis, but don't count on it.

There is a definite difference in the way it comes about. Anaphylaxis is caused by antibodies called 'immunoglobulin E', abbreviated as 'IgE'. But exactly the same end results can happen in various ways without IgE. That is called an 'anaphylactoid' reaction.

Anaphylaxis and anaphylactoid reactions differ in the things which cause them. For example nuts, fish and latex cause anaphylaxis because of IgE. Injections given before some X-rays, morphine-like drugs and some intravenous liquids given to replace blood or fluid loss cause anaphylactoid reactions without IgE.

From here on we are going to use the words anaphylactic and anaphylaxis to cover both types of reaction, since the immediate practical consequences and the immediate treatment are similar.

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What are the common causes of anaphylaxis?

Amongst the commoner causes of anaphylaxis are:

  • Foods: especially nuts, some kinds of fruit, fish and less commonly spices

  • Drugs: Especially penicillins, anaesthetic drugs, some intravenous infusion liquids, and things injected during x-rays. Aspirin and other painkillers (called NSAIDs) can produce very similar reactions.

  • Latex: mainly in rubber latex gloves, catheters, other medical products, but also in many things encountered in daily life. Sufferers are nearly always health care workers, mainly nurses, or have other occupational contact with latex. They may get anaphylaxis from bananas, avocados, kiwi fruit, figs, or other fruits and vegetables including even potatoes and tomatoes.

  • Bee or wasp (yellow jacket) stings when these cause faintness, difficulty in breathing, or rash or swelling of a part of the body which has not been stung. If you just get a very large swelling of the part of your body which was stung, you are probably not going to have anaphylaxis if stung again.

  • Unknown: A substantial proportion of sufferers have no cause found despite all efforts, even in the most expert clinics. Doctors call such unexplained attacks 'idiopathic anaphylaxis' The word 'idiopathic' in practice means we don't know the cause. Worrying as it is, death from this is very rare indeed. However, there must be a cause or causes. Some cases are bound to be simple failure to find a cause and I always regard this diagnosis as provisional, but if a recognised allergy specialist has given you this label it is unlikely that another specialist will do any better. The explanation is NOT psychological in the vast majority. So in most cases this is a disease for which medical science has not yet discovered the cause. Some top experts who have studied hundreds of patients with idiopathic anaphylaxis believe that it is a disorder of mast cells, causing them to release histamine and chemicals with similar actions too easily. There is an excellent book on this condition, quite short, and intended for doctors and patients. Title: 'Idiopathic Anaphylaxis', edited by Roy Patterson, Published by OceanSide Publications Inc, Providence, Rhode Island, 1997, ISBN 0-936587-10-5.

  • Exercise may precipitate such reactions in some ('exercise-induced anaphylaxis'), and so may exercise after food, sometimes apparently irrespective of what the food is, but in other people after specific foods. This is called 'exercise-induced food-dependent anaphylaxis'.

  • Medicines called beta blockers used for heart disease or high blood pressure can change mild reactions from another cause into severe anaphylaxis because they block the body's main defence against anaphylaxis.

  • Wrong diagnosis of anaphylaxis: a proportion (about 10%) of people sent to specialists with a diagnosis of anaphylaxis have a mistaken diagnosis and have not had anaphylaxis. If this might be true in your case, it is well worth finding this out as you may be spared unnecessary fear and wrong treatment.

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How can you tell if someone is having anaphylaxis?

Anaphylaxis usually happens quickly.

Anaphylaxis can produce:

  • An itchy nettlerash (urticaria, hives)
  • Faintness and unconsciousness due to very low blood pressure. Unlike an ordinary fainting attack, this does not improve so dramatically on lying down.
  • Swelling (angioedema)
  • Swelling in the throat, causing difficulty in swallowing or breathing
  • Asthma symptoms
  • Vomiting
  • Cramping tummy pains
  • Diarrhoea
  • A tingling feeling in the lips or mouth if the cause was a food such as nuts
  • Death due to obstruction to breathing or extreme low blood pressure (anaphylactic shock)
Faintness with a nettlerash or swelling coming on quickly is probably anaphylaxis, and if there is also difficulty in breathing the danger is greater. Faintness with difficulty in breathing alone will sometimes be due to a panic attack, but can also be due to anaphylaxis.

In the early stages it may be difficult, even for a doctor, to be sure whether the cause of symptoms is anaphylaxis or fainting or a panic attack. If there is doubt, it is sometimes best to use the treatment for anaphylaxis, but the treatment should then be reviewed with a doctor because unnecessary treatment for anaphylaxis is a bad idea. Learn the rules for knowing when to treat, to minimise the chance that you will use the treatment when you should not.

 
Fainting and Anaphylaxis: clues which may help you tell the difference
(this guide is not perfect; you need a doctor if in doubt.)
Anaphylaxis
Fainting
Colour
Pink, typically
Pale, typically
Pulse
Fast, usually
Slow, usually
Blood pressure
Can remain low lying down
Normal when lying down
Other features which may be present
Nettlerash
Swelling
Difficulty breathing
Tummy pain or diarrhoea

The person has probably fainted before.

(Some people do faint, others don't.)

 

People who are allergic to foods often notice the effect in seconds, and their life may be in jeopardy within a few minutes. Sometimes a reaction takes much longer to start, an hour or so, but can still be extremely serious. Improvement can also happen quickly, especially with the right treatment. A few people then have a second wave of anaphylaxis, so people who have had a serious anaphylactic reaction to nuts should be observed medically for about six hours or overnight.

Fortunately there is a highly effective treatment: adrenaline (epinephrine). But adrenaline (epinephrine) needs to be given as an injection, and is dangerous if used incorrectly. If you need to have adrenaline (epinephrine) available for yourself or someone in your family, it is important that you and anyone else who may have to give the adrenaline (epinephrine) should be properly trained.

It is possible for anaphylaxis to be mild and to need little or no treatment. You would not think so from most of the information you read. Of course a life-threatening attack of anaphylaxis may look mild in its early stages, so you need to go for medical help just in case, and need to have the emergency treatment immediately available in case things start to go more badly wrong. In most cases it is better to err on the side of treating anaphylaxis early rather than to leave treatment rather late. But the fact is that many people get over anaphylaxis even without treatment.

The fact that previous anaphylaxis has been mild does not guarantee that it will not be dangerous in future. Most sufferers with mild attacks do seem to have relatively mild ones if they occur again. But deaths have occurred in people who had only mild attacks before. The answer is to be prepared.

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What happens in the body during anaphylaxis?

Anaphylaxis happens when the body makes the wrong kinds of antibody, a kind called immunoglobulin E (IgE for short) to protein in our food or to something like a drug. IgE sticks to cells in our bodies (mast cells and basophils) which can release substances which have powerful effects on our blood vessels and air passages. When the same protein or drug reaches the IgE on the cells, these substances are released, causing blood vessels to relax, which makes them leaky and can cause swellings and a fall in blood pressure. At the same time they can make the breathing passages become narrow.

Histamine is one of these substances released from the cells. Antihistamines are medicines which stop histamine from working. So you might think that they would be good for nut allergy, and so they can be when the reaction is mild. But as tablets they take about an hour to get into the bloodstream properly, and this is far too slow to save lives in serious reactions.

Antihistamines also don't prevent all the effects of histamine, for example effects of histamine on the heart, in serious reactions.

Older antihistamines made people drowsy, which is dangerous if you have to drive. So it could add to your danger if you take one and then drive to get medical help. Insist on a modern antihistamine which does not make you drowsy.

More importantly, histamine is not the only dangerous substance released during anaphylaxis. The same cells with IgE antibody on their surface release many other substances which can be just as dangerous. Antihistamines do not protect you against these other substances. This is another reason why antihistamines used alone will not save life in some really serious attacks of anaphylaxis.

Fortunately, adrenaline (epinephrine), the standard treatment for life-threatening anaphylaxis, works against all the most dangerous aspects of anaphylaxis, not just those caused by histamine.

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What is the best treatment for anaphylaxis?

Although there are several important treatments, by far the most important is:

Adrenaline (epinephrine)

There is one drug which will work against all the effects of all the dangerous substances released in anaphylaxis. It is adrenaline (epinephrine). For serious attacks, it is a vital treatment. You need to inject it; inhalers may no longer be an option.

There are special syringe kits to make injection easy:

Name of injection kit

Country

(incomplete list)

Dose

Source

Comment

EpipenUSA, EuropeAdult 0.3 mg
Child 0.15 mg
Dey Laboratories (USA)
ALK (Eur)
Long-established
AnapenUKAdult 0.3 mg
Child 0.15 mg
Lincoln Medical Limited, UKIdentical drug & dose to Epipen. Easy to use.
AnaKitUSA2 doses of 0.3 mg: other doses possibleBayerLong-established. Red box also contains antihistamine tablets and flimsy tourniquet (for bee or wasp sting).
AnaguardUSA, also available elsewhere.As AnaKitBayerSyringe as AnaKit , pen-like container is compact and strong, no tablets or tourniquet.
Min-I-JetUK1 mg, other doses possibleIMS, UKSeems designed more for hospital use.

The Epipen Jr, which delivers 0.15 mg adrenaline (epinephrine). Supplier in USA: Dey Laboratories, 2751 Napa Valley Corporate Drive, Napa, CA 94558, Tel. 800-755-5560

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A note for UK users: (personal view)
The Epipen and the Anapen are available on ordinary prescription in Britain. The Min-I-Jet was, we guess, developed for use in hospitals and clinics rather than by lay people. The Anapen is perhaps the most intuitive to use, and may be least likely to malfunction if not used quite correctly.

An adrenaline (epinephrine) inhaler which was available in the UK and many other countries, the Medihaler Epi, was withdrawn by the manufacturer (3M) because of stability problems, though it had been proved to work. Other inhalers are avaiable in the USA but evidence presented in March 2000 showed them to be ineffective when tested on volunteers. New adrenaline (epinephrine) inhalers may be introduced in the future..

All these devices with adrenaline (epinephrine) are only reliable if you follow the instructions. They can be dangerous if used the wrong way. If you need them it is important that someone teaches you how to use them properly. If you cannot get such teaching (and you should be able to), then make sure you read the instructions with great care.

Adrenaline (epinephrine) cannot help you if you do not have it with you.

Keep the adrenaline (epinephrine) in a clearly marked robust pouch or case so that it is easy to keep with you. Protect it from light and from high temperatures. In hot climates, keep the container out of direct sunlight and overheated locations such as parked cars. For example in a bag of beach things you can keep it wrapped in several layers of clothing, but still rapidly retrievable by tying one end of a cord to the container and the other end to the handle of the beach bag.

 

How long will the epinephrine (adrenaline) keep?      Info based on FE Simons, 2000, in press.

Not forever. Make sure that you check the expiry date on the syringe and make sure that you have a replacement by the time this date comes. It really can lose a lot of its effectiveness if you let it go out of date.

Some manufacturers will let you know when the time comes to replace the kit. But you have to fill in a coupon and send it to them when you get your kit. Otherwise they obviously can't give you this service.

Be sure to follow the storage instructions. The Epipen must not be kept in a refrigerator, and no epinephrine injection device must be allowed to freeze (replace if this happens accidentally, e.g. in a car left in freezing conditions long enough).

Often the adrenaline (epinephrine) solution goes yellow or brown when it is becoming useless, but you can't rely on this. It can also become useless without changing colour. So do take care to follow the manufacturer's storage instructions.

 

Carrying the injection kit around: special containers

Special pouches for injection kits and inhalers are available from the the Allergypack website, at www.allergypack.com.

The protective tube for the Epipen is flimsy and disintegrates if carried about. Robust tubes are available from the Protectube website, at http://www.Protectube.com/. I've had a look at one of these and it's certainly a vast improvement. The price is reasonable and shipping charges are the same outside North America as in Canada & USA. They are made of polycarbonate. Recommended.

Adrenaline (epinephrine) must be protected from light and the original flimsy brown container helps with this. If you use the Protectube you must provide separate light protection for your Epipen, e.g. by keeping the whole thing in a lightproof container or wrapping the barrel in kitchen foil, making sure that it is still readily identifiable as your emergency kit.

Protectube


 

What is adrenaline (epinephrine)?

Adrenaline (epinephrine) is a quick-acting hormone. Our body produces it from two glands sitting just above each kidney. This happens when we meet an emergency; the adrenaline (epinephrine) makes our heart pump faster, widens the air passages in the lungs, and tightens up our blood vessels. We get the well-known feeling of alertness and the feeling of a rapid heartbeat and tremor which comes from suddenly being in an emergency. Not only does adrenaline (epinephrine) ready the body and the mind for 'fight or flight', but adrenaline (epinephrine) also works against all the effects of anaphylaxis.

So adrenaline (epinephrine) is the body's own natural quick-acting hormone for emergencies. When we inject it from a syringe, we can give more than the body can produce quickly.

This means you get more benefit, but also more side-effects and some dangers. In most people adrenaline (epinephrine) is very safe if you use the right dose in the right way, but it is important to understand what you are being asked to use.

When should I inject adrenaline (epinephrine)?

Some specialists say you should inject adrenaline (epinephrine) for any reaction. We don't agree.

Our recommendation is the

'3D' RULE

  1. Definite reaction: evidence of a reaction should be obvious.

  2.     Deterioration: the aim is to inject BEFORE life is in immediate danger. If the reaction is improving by the time you get the adrenaline (epinephrine), just keep the adrenaline (epinephrine) handy for six hours in case it gets worse again.

  3.         Death seems any sort of possibility if the deterioration continues another 5 to 10 minutes.

     


    Only two things cause death: the '2D' RULE

    1. Difficult breathing whether due to swelling in the throat or to asthma. If it really seems to be just asthma, an asthma inhaler may work. But adrenaline (epinephrine) will help in both asthma and throat swelling.

    2.     Deteriorating consciousness: once the child or adult patient is unconscious, life is in danger, if only from inhaling vomit, quite likely in a food allergy reaction. Make sure you know the 'recovery position' known to every competent first-aider. But give adrenaline (epinephrine) to prevent unconsciousness if that seems increasingly possible.

     


    Finally, the '1D' RULE

    • Do give adrenaline (epinephrine) if in doubt! If you think there may be any risk to life because of difficulty in breathing or because it seems possible the patient is beginning to feel faint or 'pass out', then the earlier you give the adrenaline (epinephrine), the better it will work.

 

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What about an adrenaline (epinephrine) inhaler?

Adrenaline (epinephrine) inhalers seemed a good option in the past. There was good evidence that they could work, but the inhaler to which this applied has been withdrawn.

In March 2000 Dr. F. E. Simons of Winnipeg, Canada, presented clear evidence at the American Academy of Allergy, Asthma and Immunology (AAAAI) conference in the USA that the current ones do not work, and in October 2000 she backed this up with further detail. Since right now we are only aware of adrenaline (epinephrine) inhalers from one manufacturer, whose products were the ones used in this research, we believe that currently available adrenaline (epinephrine) inhalers do not work and that at best you must never rely on them. We do not currently issue such inhalers to our patients and do not renew the prescriptions of patients who have such inhalers which go out of date.

If you have such an inhaler, we urge you to consult your allergy specialist about it. Please remember that throughout these web pages what we write is not intended as individual medical advice but as information of possible interest to you, and that your treatment should be determined by your own doctor or properly qualified health professional.

In any case, even if they are capable of working, inhalers will only help if you use them correctly. A nurse or doctor should make sure you have got the technique right. Obviously an inhaler won't work if you can't breathe well enough because of your reaction. If your reactions look as if they might be life-threatening then an inhaler alone not adequate; you need an injection kit.

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Do I need to use more than one injection of adrenaline (epinephrine)?

Sometimes, in really bad anaphylaxis, someone may need more than one adrenaline (epinephrine) injection, but nearly always one injection is enough to save life. Too many injections of adrenaline (epinephrine) can definitely be dangerous. For example a young man who gave himself five injections probably died from the injections and not from the anaphylaxis. So your doctor's advice is vital; you may be able to stand more or less adrenaline (epinephrine) than the next patient, and your doctor can give you advice which is right for you.

Some doctors recommend carrying more than one injection dose, and others do not. Some of the injection kits can give more than one dose, but the spring-loaded automatic injectors can only give one dose.

The dose of adrenaline (epinephrine) in the injection kits is usually 0.3 mg for an adult, which is rather low for a really dangerous reaction in a full-sized adult. The reason for this is safety. We know that this dose works in the vast majority of people, but that a few people would get bad side effects from a higher dose. So we recommend this smallish dose because it is the safest overall. But your doctor may be able to give advice more appropriate for you. Hospital doctors would often give 0.5 mg, nearly twice as much. Some would give 1.0 mg, but our opinion is that this is an uncomfortably large dose even for most young adults to give all at once unless the situation is much more desperate than it usually is.

We recommend that the decision on whether you need one or two injection kits is one for which you need your doctor's advice.

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How long will an adrenaline (epinephrine) injection carry on working after I have injected it?

Many doctors say that the adrenaline (epinephrine) will wear off in 15 to 20 minutes. This would often mean you might not get to a hospital in time, e.g. if you reacted whilst on holiday. The published evidence suggests that adrenaline (epinephrine) injected under the skin (subcutaneously) works for much longer than this, perhaps longer than the 150 minutes for which one set of research workers carried on measuring adrenaline (epinephrine) in the blood of their volunteers. Our feeling is that the same would be true for injections in to the muscle at the side of the thigh (intramuscular).

The bottom line is that single doses from the widely used injectors have an excellent record for patient survival. So in practice one injection does seem to do the job and enable people to get any extra help they need under nearly all circumstances.

But if you are in a remote area, you should carry more than one dose.

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What are the side effects of adrenaline (epinephrine)?

In the doses we recommend, trembling, palpitations (feeling your heart beating fast), and a feeling of tension or anxiousness. These are normal effects of the adrenaline (epinephrine) and soon wear off. Higher doses cause an extremely unpleasant feeling and may be dangerous to the heart.

If you have high blood pressure, or an abnormal heart rhythm, or narrowing of the coronary arteries, or if you are treated for depression with an unusual medicine called a monoamine oxidase inhibitor, special caution is needed with adrenaline (epinephrine), and a specialist should advise you.

  • Injecting adrenaline (epinephrine) in the wrong place can be dangerous.
    People have accidentally injected adrenaline (epinephrine) into their thumb when trying to figure out how the syringe worked or when trying to check why it did not work (probably because they did not apply it to the skin at right angles, jamming the mechanism). This is dangerous. Adrenaline (epinephrine) can shut off the whole blood supply by constricting the blood vessels at the base of the finger or thumb. The result is likely to be gangrene.
    For a report on treatment of this emergency, see our page for doctors.
    Injecting other places can be dangerous too. Inject adrenaline (epinephrine) into the muscle of the side of the thigh, nowhere else, unless you are a doctor and know exactly what you are doing.

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For debate:

Is adrenaline (epinephrine) being prescribed far more often than necessary?

Deaths of young children from anaphylaxis are very rare. Yet huge numbers of children now go around with adrenaline (epinephrine) injection kits. All medical treatments have side effects and dangers. Although adrenaline (epinephrine) injections given correctly are remarkably safe, they may be more dangerous than the disease if the risk to life from the disease is small enough.

A group of paediatricians in the UK suspects that the dangers of adrenaline do indeed outweigh the benefits. They are planning to find out how many children with food allergies under the age of 16 years actually die or nearly die from anaphylaxis per year. Their aim is to find better rules for deciding whether a child's life is in danger, so that far fewer children with allergies will need adrenaline kits.

If such research succeeds, vast numbers of parents would be able to heave a sigh of relief. Their families and their children's teachers and carers would be spared unnecessary fear and the burden of keeping and using adrenaline.

It is amazing but true that we don't have even remotely reliable figures for the number of deaths and near-deaths from food allergy. This is because of the way death certificates are filled in and turned into statistics, and to some extent because of the low importance given to allergy in the training of doctors. Without this knowledge we can't tell parents how the risk without treatment balances up against the risk of treatment. Widespread prescription of adrenaline is recent and we don't know the risks as well as we would like. What we are doing now is the best we can manage with inadequate information. Better information offers a definite hope of better treatment, which, according to the research group, could mean much less treatment.

Why do we prescribe adrenaline (epinephrine) for so many children ?

A few years ago it was a real rarity for a child in the UK to have adrenaline (epinephrine) to use for anaphylaxis. Now hundreds of children in Leicestershire alone have adrenaline (epinephrine), and the same is true in other parts of the UK and world-wide. Almost every school in Leicestershire now has at least one child with adrenaline (epinephrine) for food allergy, and most schools have more than one.

In Leicestershire there seem to have been three children who have died from nut allergy in the last five years, and we found out about each these through newspaper reports or by chance. So there may well have been other deaths we do not know about.

Parents with nut-allergic children tell me that they would happily see tens or hundreds of thousands of children given adrenaline (epinephrine) to save one child's life. So even just taking our local experience, it looks as if we are doing what parents want.

Since we know that national statistics on deaths from food allergy are very unreliable, they may be a big underestimate, so the risk may be greater than we know.

People who have died from nut allergy have often not had particularly life-threatening reactions before. This means that we have to regard almost all nut allergy as life-threatening. We knowingly prescribe adrenaline (epinephrine) for children in whom we are perfectly aware that the risk is very low. We say so to their parents. We prescribe adrenaline because this is what parents in general want and on balance it is what we feel we would want for our own children if we faced the same problem.

Not infrequently we find ourselves under pressure from a parent to prescribe adrenaline when we feel that the risk really is far too low to justify that; these discussions are difficult because of the great uncertainties.

Personally, I regard the prescribing of an adrenaline kit as an evil, but the lesser of two evils in an inadequately understood situation. If there were a safe way of prescribing less, I would welcome that with great relief.

What are the disadvantages of adrenaline (epinephrine)?

Risks
The usual side effects of adrenaline (epinephrine) are well-known, and given in a separate section (click here). They are normally not serious if you use the right dose in the right way. But for some people with other medical conditions or treatments there are special risks, which an expert doctor will have to take into account when considering a prescription for adrenaline. These special risks are especially rare in children.

But there are more disadvantages. Firstly it is a fact that not every adrenaline kit prescribed will be used correctly. People are simply not infallible. Although we must do everything we can to minimise this risk, it is no good ignoring it. Even in our own clinic, where we lay tremendous stress on training the adults in charge of a child repeatedly and where we are lucky to have facilities for this which most clinics don't have, it is a fact that distressingly many people make serious mistakes when we test their knowledge a couple of months later.

People have injected adrenaline into their thumbs (dangerous), have used the training dummy injectors on the wrong parts of the body, or have failed to give an injection because they didn't do what we had taught them. Elsewhere, there have been deaths because people gave too high a dose, either by giving too many injections or by giving too big an injection (impossible with the present UK kits). Doctors have mistakenly injected adrenaline into a vein at a strength which is only safe when injected into muscle or skin.

The risks from these mistakes are part of the risks of using adrenaline, and we must weigh them in the balance when we prescribe it.

Other disadvantages
Having to keep adrenaline kits at home, at school and when out and about is a serious nuisance. Having to remember to take it wherever you go is another burden on your life.

The fact that you have been told you need the adrenaline is a constant reminder of the risk of death. If that risk is in fact vanishingly small (for example much smaller than the risks from accidents, infections, or drug abuse), then the very fact that you have the adrenaline may harm you and your family by imposing another stress on your life on top of the others which you may face.

The cost of repeated and duplicated prescriptions and the time of your specialist and family doctor and nurses at clinics and at school is not trivial. These funds could otherwise be spent on other health care.

For all these reasons we should not take the view that we may as well prescribe adrenaline just because 'at least it can't do any harm'. It can and it does.

But if the risk of not having adrenaline is bigger than the risk from having it then we should offer adrenaline. We should then not be swayed by prejudice against the treatment, perhaps based on the fact that 'we never did it before' (when there was not so much nut allergy) or on under-reporting of the dangers of nut allergy because the medical statistics are unreliable.

What are the flaws in the argument that adrenaline is prescribed far more often than necessary?
There seem to be flaws in the argument and research plan as we have seen it in print. This may be because the authors were asked to be brief.

The job of doctors and experts is to establish the facts as well as possible, to explain these clearly, to make recommendations where we feel that known facts justify these, but to make final decisions after letting parents tell us what their priorities are. The reason for this is that such decisions are never a question of fact alone, but necessarily involve value judgements. Experts may be no better than lay people when it comes to these. Parents and patients have a right to have their views taken into account.

The authors seem overconfident that we can count the number of deaths from anaphylaxis accurately. Our information is that Death Certificate information is not accurate for this, and that not all deaths will become known to paediatricians. Over-busy paediatricians may not be as reliable at reporting incidents as the researchers hope. Standards of expertise and practice vary so much that treatment is an inadequate indicator of severity.

Most important of all is this question. How many children is it worth issuing with adrenaline kits to save the life of one child? I have debated this with groups of parents of nut-allergic children. Always they have come up with figures which astonish me, typically in the region of 100,000 children issued with kits to save one life.

Of course these parents would change their minds if it became clear that the risk of death from adrenaline was greater than the risk of death from the allergy. But this argument is likely to be difficult, because both figures should be very low.

People will reject the argument that deaths are unimportant because they are few if safe and acceptable measures can prevent them. Society provides other examples of public insistence on safety measures which seem hard to justify on quantitative grounds.

When it comes to judging the psychological disadvantages of having adrenaline around, doctors really cannot make the decision without serious discussion with parents, and even with the children.

Our verdict
The arguments against adrenaline kits are serious ones, which need to be explored and debated. My feeling is that we will become more restrictive about adrenaline prescription as we learn more.

The most important reason why there is an argument is that we do not know as much as we need to know. Research to establish the facts is necessary.

Doctors must recognise the value judgements involved, and the right of parents in making those value judgements. As in the case of other difficult medical decisions, this will not be simple because both doctors and parents vary in their personal qualities and judgements. There will always remain instances of disagreement. But exercising humanity and good sense does not mean that a doctor must always give way to a parent.

Debate fuelled by careful research is necessary and healthy.

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Other treatments for anaphylaxis

Remember that this or any web page cannot give reliable individual advice. Your own expert medical adviser will be able to give you better individual advice. You may however find the page useful for discussion.

Before adrenaline (epinephrine). (But do not delay adrenaline / epinephrine).
  • Lie the patient down if there is faintness or low blood pressure, or unconsciousness But if there is swelling in the throat with difficulty in breathing and there is not a serious problem with faintness, it is better to sit the patient up to avoid making the throat swelling worse. What if you have faintess and throat swelling? Decide which is most life-threatening. Get help quickly.

  • Ensure the patient does not choke or inhale vomit. Vomiting is especially likely if food allergy was the cause of anaphylaxis. Put the patient in the recovery position'. If you don't know what that is, ask a doctor or nurse, or a well-trained first-aider.

After giving adrenaline (epinephrine),
OR some of the following may be appropriate if adrenaline (epinephrine) is clearly unnecessary but you are nevertheless concerned.
  • Get prompt medical help. In Britain, the ideal is often a paramedic ambulance to rush the patient to the nearest hospital which has an Accident and Emergency Department.

  • Antihistamine tablets or syrups are helpful for really mild anaphylaxis but unlikely to save someone's life in serious anaphylaxis. Firstly, they get into the bloodstream too slowly. Secondly they don't protect against all the things which happen in anaphylaxis.

  • Antihistamine injection: probably helps, but there is no need to carry one about; carry adrenaline (epinephrine) instead.

  • Steroid injection: Usually given by doctors for severe anaphylaxis treated in the surgery or in hospital. Probably makes no difference to saving life, but may prevent other symptoms once the emergency is over. They take four to eight hours to start doing anything noticeable.

  • Intravenous fluids: regularly used in hospital for treating the low blood pressure and bad circulation in anaphylaxis, and very important as part of the treatment.

  • Oxygen may be given by ambulance crew or doctors.

  • There are other treatments which doctors know about. There is no substitute for prompt medical care, preferably in an Accident and Emergency Department (Casualty, Emergency Room) or Children's emergency department. Often, of course, the nearest family doctor will be the only doctor you can get quickly enough.

  • Six to twelve hours observation in hospital. A small proportion of people who have anaphylaxis will have a second attack after the first one has passed. These second or 'late' reactions can on occasion be dangerous. Just how often such reactions happen is controversial, but experts on anaphylaxis recommend that the patient should be kept under observation overnight or for at least six hours. It is surely sufficient to spend this time in a waiting area where the patient will never be left unobserved; provided the patient is reasonably well there is no need to occupy an expensive hospital bed for this.

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When the immediate emergency is over

Sometimes it is not certain that the patient had anaphylaxis. There may be other explanations if the features were not typical. There are at least two useful tests which can be done during the hours after the emergency. One is to take a clotted blood sample (the doctor will know what this means) and test for sormething called 'mast cell tryptase'. The other is to collect urine for a few hours (the exact timing is not always regarded as all that important, but emptying the bladder immediately after the reaction and then collecting for 2 or 4 hours is fine) and test this to measure something called 'methylhistamine' (this is what histamine turns into when your body inactivates it).

Referral to a specialist is necessary if the cause of your anaphylaxis is not known and you have not seen a specialist. Whether or not the cause is known, a specialist will be able to help you to guard against future attacks.

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Some medicines can make anaphylaxis worse: Beta blockers

Beta blockers are medicines used to treat high blood pressure, some heart rhythm problems, and some other conditions. Unfortunately they can make asthma worse, even when they are only used in the form of eye drops for an eye problem called glaucoma (increased pressure in the eye).

Anaphylaxis can also be made worse by beta blockers, and beta blockers will make treatment with drugs like adrenaline (epinephrine) less effective. In fact some patients who have only urticaria or angioedema (angiedema, angioneurotic edema) when off beta blockers will collapse with a drop in blood pressure when they are on beta blockers. So beta blockers can turn bearable skin reactions into dangerous reactions with shock.

Here are some references to the medical literature on this:

  1. Don't get stung with the adrenergic blockers (beta or alpha). Watson A. Aust Fam Physician. 1995 Oct; 24(10): 1879.
  2. Anaphylactoid and anaphylactic reactions. Hazards of beta blockers. Lang DM. Drug Saf. 1995 May; 12(5): 299 304.
  3. Assessment of patients who have experienced anaphylaxis: a 3 year survey. Yocum MW; Khan DA. Mayo Clin Proc. 1994 Jan; 69(1): 16 23.
  4. Elevated risk of anaphylactoid reaction from radiographic contrast media is associated with both beta blocker exposure and cardiovascular disorders [erratum in Arch Intern Med 1993 Nov 8;153(21):2412]. Lang DM; Alpern MB; Visintainer PF; Smith ST. Arch Intern Med. 1993 Sep 13; 153(17): 2033 40.
  5. [Severe anaphylactic shock with heart arrest caused by coffee and gum arabic, potentiated by beta blocking eyedrops]. Moneret Vautrin DA; Kanny G; Faller JP; Levan D; Kohler C. Rev Med Interne. 1993 Feb; 14(2): 107 11.
 

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Useful addresses & information

  • The Anaphylaxis Campaign, a national UK charity and self-help organisation. Join it. Its Newsletter and meetings will be invaluable to you.

    Address:   (since November 1997)

    The Ridges
    2 Clockhouse Rd
    Farnborough
    Hampshire
    GU14 7QY
    UK

    Telephone: 01252 542 029
    Fax: 01252 377 140

    Website: http://www.anaphylaxis.org.uk/whom.html

     

    NEW
    The Anaphylaxis Network of Canada site is also of interest even if you don't live in Canada.


  • A BOOK ON ANAPHYLAXIS FOR PATIENTS AND PARENTS

    Title: "Life-threatening Allergic Reactions. Understanding & Coping with Anaphylaxis"

    Authors: Dr Deryk Williams, Anna Williams, Laura Croker.
    Publisher: Piatkus, UK.
    Year of publication: 1997
    ISBN: 0-7499-1700-8
    Paperback. £ 7.99

    Co-written by a General Practitioner, a psychologist and a writer specialising in health matters, this book can be read in an evening and is full of useful information, anecdotes and ideas. There are a few errors. As with all such sources of information, including the web page you are reading now, check matters of importance with the doctor who is advising you locally. Covers the range of common causes of anaphylaxis, for example not only nut allergy but also latex allergy. Rather extensive discussion of the psychological impact. Whilst this is a real enough problem, I would personally recommend contact with a self-help group such as the Anaphylaxis Campaign rather than professional psychological help for the vast majority. It is also important that professionals including doctors and nurses do not needlessly heighten your anxiety. With anxiety as with other things, prevention is better than cure. According to its front cover this book is recommended by the Anaphylaxis Campaign.

  • TheNational Jewish Center for Immunology and Respiratory Medicine in Denver, Colorado, USA, has a web page on anaphylaxis in its extensive website on asthma and allergy. Have a look to compare advice. Note that there are always differences between countries in the treatments available and the opinions of doctors.

  • Lincoln Medical Limited, the company which produces and sells the Anapen self-injection device for adrenaline. They have a video and leaflets and can answer queries about the Anapen.
    Email:

 

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Warning bracelets and pendants

  • SOS Talisman® : Pendants containing a strip of paper on which essential medical and personal details can be written. Easily identified by medical emergency staff. Obtainable through jewellers in Britain. No fee beyond purchase of talisman.

  • Life Alert ® Life Alert is a high quality medical identification bracelet or pendant suited to people with serious allergies. With room for over 600 characters of information, the EMT or other responder can be directed to a carried Epi-Pen or medication, and can have a wide variety of other information available instantly. As with the SOS Talisman in the UK, no telephone calls are needed in an emergency, and there is no annual fee.

  • Medic Alert International ® is a non-profit Registered Charity which sells bracelets or pendants with a clear symbol, on the reverse of which medical conditions can be engraved or stamped. A telephone number on the item gives access to a computer database with essential details about you. UK prices in 2001 range from 19.95 to 185 pounds sterling, with an annual subscription of 10 pounds sterling.

    Address in British Isles & Ireland:

             Medic Alert British Isles & Ireland
    1 Bridge Wharf
    156 Caledonian Road
    London
    N1 9UU
    UK

    Telephone: 0207 833 3034
    FAX: 0207-278-0647

    International code for UK is 44. From outside UK dial + 44-207 833 3034

    Data entered 28 Dec 1997, amended 11 Apr 2001. Consult Medic Alert International site for up-to-date info.

    To contact Medic Alert in:

    Telephone

    FAX

    Australia South61-9-334-122261-88-271-4844
    Australia West61-9-334-122261-9-334-1231
    Canada416-696-0142416-696-8524
    Cyprus357-2-315-113357-2-49-2216
    Fiji 679-665-133679-662-468
    Greece30-1-363-145430-1-934-3716
    Iceland354-561-3122354-561-5122
    Malaysia60-3-750-281660-3-756-2253
    New Zealand64-4-528-8218679-662-468
    South Africa27-21-461-732827-21-461-6654
    USA1-800-825-3785
    ZambiaNone260-2-227059
    Zimbabwe263-4-759-512263-4-759-510
     

     

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This page contains some important information which we hope you will find useful. We welcome e-mail with questions and tips to help us make the page more useful.


This page is maintained by Dr. Martin Stern
Updates (incomplete list): 6 Nov 1997 Withdrawal of adrenaline inhaler. 5 Dec 1997 Accidental injection of adrenaline into finger. 29 Dec 1997 Link to Medic Alert International, 11 Feb 1998, 18 Feb 1998 Changes in '3D' rule, adrenaline inhalers. 20 March 98 New EpiPen supplier & 2 other changes, 21 April 98 adrenaline inhalers, 24 to 28 April 98 Is adrenaline being prescribed far more often than necessary? 17 May 1998 Easier to find Anaphylaxis Campaign.   EpiPen Alert 22 May 1998. 10 June 1998 Changes to number of deaths in Leicestershire, and number of children we should treat. 21 June & 20 July 1998 Epipen Alert amended. 20 Sept 1998 Item on stress , CAN website. 27 Sept 1998; change to Epipen alert. 10 Oct 98 additional link to Anaphylaxis Campaign. 25 Oct 98 idiopathic anaphylaxis text expanded following email request. 31 Dec 98 Removal of information on import of adrenaline inhaler at the request of the importer. 14 Mar 99 revised text on arguments against adrenaline. 14 Jun 99 link to Life Alert. 11 Sep 99 Ana-Kit and Ana-Guard Alert. 14 & 20 Oct 1999 Allergypack pouches and Protectube. 27 Jul 00 Protectube image. Adrenaline (epinephrine) inhalers thought ineffective; text amended and largely removed. Outdated ref to faulty injection kits removed. 29 Nov 00 adrenaline actions, epinephrine widely added in brackets as a result of international name change. 7 Dec 2000 minor changes & adrenaline (epinephrine) stability. 26 Jan 2001 adrenaline (epinephrine) inhaler major edit, clarification of other treatments. 11 & 16 Apr 2001 anaphylactoid reactions, idiopathic anaphylaxis, Medic Alert & SOS Talisman update. 27 Apr 2001 ACN. 9-7-01 Anapen supplier. Dec 2002 Outdated product warning removed. Anapen update, AnaHelp removed. 4 May 03 warning on freezing injection kits.

Copyright © 1998, 1999, 2000, 2001, 2002, 2003 Dr. Martin Stern