PURPOSE OF REVIEW: This article aims to review the most relevant studies on exercise-induced anaphylaxis, published in the last year, in order to provide comprehensive and updated evidence and hopefully contribute to a better definition of its pathophysiological mechanisms and treatment strategies. RECENT FINDINGS: The search strategy was performed from 1/2/2013 to 31/1/2014 by scanning the principal electronic bibliographic database and by hand-searching the main scientific publications in Allergy and Clinical Immunology. Among the identified articles, 17 articles were selected to be part of the systematic review. Eligible studies included five experimental trials, eight case reports and four letters. SUMMARY: The overall collected evidence was of very low quality. No randomized controlled trials were identified by the searching process. Most of the data derived from reports performed in small population samples or even in individual cases. Except for one article addressing issues related to the preventive management of exercise-induced anaphylaxis, all other articles focused on prevalence rates, causative triggers and pathogenetic mechanisms. More interesting findings were related to the influence of the IL-4-C590T polymorphism on the onset of wheat-dependent exercise-induced anaphylaxis and to the usefulness of the immuno solid-phase allergen chip technique in the allergic screening of polysensityzed athletes at risk of severe reactions.

BACKGROUND: Anaphylaxis is a serious hypersensitivity reaction that is rapid in onset and may result in death. Anaphylaxis guidelines recommend glucocorticoids for the treatment of people experiencing anaphylaxis. OBJECTIVES: We sought to assess the benefits and harms of glucocorticoid treatment during episodes of anaphylaxis. SEARCH METHODS: In our previous version we searched the literature until September 2009. In this version we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 3), MEDLINE (Ovid) (1956 to September 2011), EMBASE (Ovid) (1982 to September 2011), CINAHL (EBSCOhost) (to September 2011). We also searched the UK National Research Register and websites listing ongoing trials, and contacted international experts in anaphylaxis in an attempt to locate unpublished material. SELECTION CRITERIA: We planned to include randomized and quasi-randomized controlled trials comparing glucocorticoids with any control (either placebo, adrenaline (epinephrine), an antihistamine, or any combination of these). DATA COLLECTION AND ANALYSIS: Two authors independently assessed articles for inclusion. MAIN RESULTS: We found no studies that satisfied the inclusion criteria. AUTHORS' CONCLUSIONS: We are, based on this review, unable to make any recommendations for the use of glucocorticoids in the treatment of anaphylaxis.

BACKGROUND: Anaphylaxis is a serious hypersensitivity reaction that is rapid in onset and may result in death. Anaphylaxis guidelines recommend glucocorticoids for the treatment of people experiencing anaphylaxis.  OBJECTIVES: We sought to assess the benefits and harms of glucocorticoid treatment during episodes of anaphylaxis. SEARCH METHODS: In our previous version we searched the literature until September 2009. In this version we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 3), MEDLINE (Ovid) (1956 to September 2011), EMBASE (Ovid) (1982 to September 2011), CINAHL (EBSCOhost) (to September 2011). We also searched the UK National Research Register and websites listing ongoing trials, and contacted international experts in anaphylaxis in an attempt to locate unpublished material. SELECTION CRITERIA: We planned to include randomized and quasi-randomized controlled trials comparing glucocorticoids with any control (either placebo, adrenaline (epinephrine), an antihistamine, or any combination of these). DATA COLLECTION AND ANALYSIS: Two authors independently assessed articles for inclusion. MAIN RESULTS: We found no studies that satisfied the inclusion criteria. AUTHORS' CONCLUSIONS: We are, based on this review, unable to make any recommendations for the use of glucocorticoids in the treatment of anaphylaxis.

Prompt recognition of anaphylaxis may be lifesaving. Although its presentation has been described, there are no criteria for making a rapid diagnosis. A systematic review of the literature was performed to develop objective clinical criteria aimed at improving the recognition of anaphylaxis. A MEDLINE search of the word anaphylaxis over a 1-year period identified all of the reports describing the initial manifestations. Of 160 reviewed articles, 116 contained a clinical description of anaphylaxis. Eighty-nine (77%) of these 116 articles were case reports. Hypotension (84 reports [72%]) and urticaria and/or angioedema (70 reports [60%]) were the most frequently described signs. Of the identified allergens, 73% were diagnostic or therapeutic agents. In 72 of the 80 articles in which a reaction time could be identified, the reaction occurred within 60 minutes. As a result of this analysis, we conclude that anaphylaxis recognition may be improved by the identification of one of the following criteria, which describe the presentation in 82% of the analyzed reports: (1) exposure to an allergen within 1 hour produces one or more systemic signs (hypotension, upper or lower respiratory tract compromise, or increased gastrointestinal tract motility), or (2) urticaria or angioedema accompanies at least one of these systemic signs.

BACKGROUND: Anaphylaxis management plans (AMPs) are increasingly advocated to improve outcomes and reduce the risk of recurrence in persons with anaphylaxis. A recent systematic review investigating their effectiveness failed to identify any randomized controlled trial evidence to guide clinical decision making. OBJECTIVES: We sought to identify and describe available AMPs, assess their acceptability and likely effectiveness, and understand potential facilitators and barriers to their use. METHODS: We performed a systematic review of published, unpublished, and ongoing epidemiologic and qualitative studies, searching 13 international databases and contacting an international panel of anaphylaxis experts. Studies were critically appraised using established international criteria and thematically synthesized. RESULTS: Nineteen of 789 potentially eligible studies identified satisfied our inclusion criteria. A number of AMPs exist, and other than agreement on the central importance of early administration of self-administered epinephrine, there is a range of perspectives on what should be included. AMPs are acceptable to patients/caregivers and might considerably reduce the risk of recurrence. This latter finding needs to be interpreted with caution given the substantial risk of bias in the limited number of intervention studies conducted. Access to specialists, problems with follow-up, and indemnity considerations relating to emergency administration of epinephrine in schools are important structural barriers to their wider use. CONCLUSIONS: There are currently no universally accepted AMPs. The available evidence to support use of self-management plans is encouraging but is, in comparison with other long-term conditions, such as asthma, extremely weak. The effectiveness and cost-effectiveness of AMPs need to be formally evaluated.

PURPOSE OF REVIEW: To review recent evidence on the effectiveness of glucocorticosteroids in the treatment and prevention of anaphylaxis. RECENT FINDINGS: Glucocorticosteroids are often used in the management of anaphylaxis in an attempt to reduce the severity of the acute reaction and decrease the risk of biphasic/protracted reactions. A recent Cochrane systematic review failed to identify any randomized controlled or quasi-randomized trials investigating the effectiveness of glucocorticosteroids in the emergency management of anaphylaxis. In contrast, randomized controlled trials have been undertaken of glucocorticosteroids, given individually or in combination with other drugs, in preventing anaphylaxis. Systematic reviews of these prophylactic approaches undertaken in patients being investigated with iodinated contrast media and treated with snake anti-venom therapy have found routine prophylaxis to be of questionable value. Trials of a combination of glucocorticosteroids and H1/H2-antihistamine premedication for preventing allergen immunotherapy-triggered anaphylaxis have yielded mixed results. SUMMARY: Glucocorticosteroids should be regarded, at best, as a second-line agent in the emergency management of anaphylaxis, and administration of epinephrine should therefore not be delayed whilst glucocorticosteroids are drawn up and administered. Routine premedication with glucocorticosteroids in patients receiving iodinated contrast media, snake anti-venom therapy or allergen immunotherapy is unlikely to confer clinical benefit.

To establish the effectiveness of interventions for the acute and long-term management of anaphylaxis, seven databases were searched for systematic reviews, randomized controlled trials, quasi-randomized controlled trials, controlled clinical trials, controlled before-after studies and interrupted time series and - only in relation to adrenaline - case series investigating the effectiveness of interventions in managing anaphylaxis. Fifty-five studies satisfied the inclusion criteria. We found no robust studies investigating the effectiveness of adrenaline (epinephrine), H1-antihistamines, systemic glucocorticosteroids or methylxanthines to manage anaphylaxis. There was evidence regarding the optimum route, site and dose of administration of adrenaline from trials studying people with a history of anaphylaxis. This suggested that administration of intramuscular adrenaline into the middle of vastus lateralis muscle is the optimum treatment. Furthermore, fatality register studies have suggested that a failure or delay in administration of adrenaline may increase the risk of death. The main long-term management interventions studied were anaphylaxis management plans and allergen-specific immunotherapy. Management plans may reduce the risk of further reactions, but these studies were at high risk of bias. Venom immunotherapy may reduce the incidence of systemic reactions in those with a history of venom-triggered anaphylaxis.

Artesunate, an artemissin derivative is a highly efficacious and relatively safe antimalarial agent. Common adverse reactions to artemissin derivatives are nausea, vomiting, anorexia and dizziness. More serious but less-frequent toxic effects of artesunate use are neutropenia, anemia, hemolysis, elevated liver enzymes and severe allergic reactions. However, anaphylactic reaction to artesunate is a rare entity. Here, we report a case of anaphylaxis to parenteral artesunate and its successful management in a female patient to whom intravenous artesunate was administered during surgery under general anesthesia.

ANTECEDENTES: La anafilaxia es una grave reacción de hipersensibilidad de aparición rápida y que puede causar la muerte. La adrenalina se recomienda como el tratamiento de elección inicial para la anafilaxia. OBJETIVOS: Evaluar los beneficios y los daños de la adrenalina (epinefrina) en el tratamiento de la anafilaxia. ESTRATEGIA DE BÚSQUEDA: Se hicieron búsquedas en el Registro Cochrane Central de Ensayos Controlados (Cochrane Central Register of Controlled Trials, CENTRAL) ( 2007, número 1), MEDLINE (1966 hasta marzo 2007), EMBASE (1966 hasta marzo 2007), CINAHL (1982 hasta marzo 2007), BIOSIS (hasta marzo 2007), ISI Web of Knowledge (hasta marzo 2007) y en LILACS (hasta marzo2007). También se realizaron búsquedas en las listas de ensayos en curso en los sitios web. http://clinicaltrials.gov/, http://www.controlledtrials.com y http://www.actr.org.au/; también se estableció contacto con las compañías farmacéuticas y expertos internacionales en anafilaxia con el objeto de localizar el material no publicado. CRITERIOS DE SELECCIÓN: Se eligieron para la inclusión los ensayos controlados aleatorios y cuasialeatorios que compararon la adrenalina con ninguna intervención, placebo u otros agonistas adrenérgicos. RECOPILACIÓN Y ANÁLISIS DE DATOS: Dos autores, de forma independiente, evaluaron los artículos para la inclusión. RESULTADOS PRINCIPALES: No se encontraron estudios que cumplieran los criterios de inclusión. CONCLUSIONES DE LOS AUTORES: En base a esta revisión, no se pudo plantear ninguna nueva recomendación sobre el uso de la adrenalina para el tratamiento de la anafilaxia. Aunque se necesitan ensayos clínicos aleatorios, doble ciegos, controlados con placebo, de calidad metodológica alta, para definir el grado real de los beneficios de la administración de adrenalina en la anafilaxia, tales ensayos tienen poca probabilidad de realizarse en los individuos con anafilaxia. En efecto, pueden ser poco éticos porque se considera que el tratamiento rápido con adrenalina es sumamente importante para la supervivencia en la anafilaxia. Además, tales estudios serían difíciles de realizar porque los episodios anafilácticos ocurren generalmente sin advertencia, frecuentemente en un contexto no médico, y la gravedad es diferente tanto entre los individuos, como de un episodio a otro en el mismo individuo. En consecuencia, puede ser difícil o imposible de obtener las mediciones al inicio y las mediciones cronometradas frecuentes. A falta de ensayos apropiados se recomienda, aunque sobre la base de pruebas menos óptimas, que la administración de adrenalina por una inyección intramuscular (i.m.) debe considerarse todavía como el tratamiento de primera línea de la anafilaxia.

ANTECEDENTES: La anafilaxia es una reacción alérgica sistémica aguda, que puede ser potencialmente mortal. Los antihistamínicos H1 se usan con frecuencia como un tratamiento adyuvante al tratamiento de la anafilaxia. OBJETIVOS: Evaluar los beneficios y daños de los antihistamínicos H1 en el tratamiento de la anafilaxia. ESTRATEGIA DE BÚSQUEDA: Se hicieron búsquedas en el Registro Cochrane Central de Ensayos Controlados (Cochrane Central Register of Controlled Trials)(CENTRAL), (), MEDLINE (1966 hasta junio 2006);EMBASE (1966 hasta junio 2006); CINAHL (1982 hasta junio 2006) y en ISI Web of Science (1945 hasta junio 2006). También se estableció contacto con compañías farmacéuticas y expertos internacionales en anafilaxia con el objeto de localizar el material no publicado. CRITERIOS DE SELECCIÓN: Ensayos controlados aleatorios y cuasialeatorios que comparaban antihistamínicos H1 con placebo y ninguna intervención. RECOPILACIÓN Y ANÁLISIS DE DATOS: Dos autores evaluaron de forma independiente los artículos para la inclusión. RESULTADOS PRINCIPALES: No se encontraron estudios que cumplieran los criterios de inclusión. CONCLUSIONES DE LOS AUTORES: En base a esta revisión, no se pueden hacer recomendaciones para la práctica clínica. Se necesitan ensayos controlados aleatorios, aunque es probable que sea difícil diseñarlos y ejecutarlos.