Managing Anaphylaxis – Epinephrine, Antihistamines, and Corticosteroids: Over 10 years of C-CARE Registry Data

Colli LD, Ali AA, Gabrielli S, Colli MD et al. Ann Allergy Asthma Immunol. 2023 Sep 7:S1081-1206(23)01214-0. doi: 10.1016/j.anai.2023.08.606.

Abstract

Background

Epinephrine is the first-line treatment for anaphylaxis but is often replaced with antihistamines or corticosteroids. Delayed epinephrine administration is a risk factor for fatal anaphylaxis. Convincing data on the role of antihistamines and corticosteroids in anaphylaxis management is sparse.

Objective

To establish the impact of prehospital treatment with epinephrine, antihistamines, and/or corticosteroids in anaphylaxis management.

Methods

Patients presenting with anaphylaxis were recruited prospectively and retrospectively in 10 Canadian and one Israeli emergency departments (ED) between April 2011 and August 2022, as part of the Cross-Canada Anaphylaxis Registry. Data on anaphylaxis cases were collected using a standardized form. 

Primary outcomes were uncontrolled reactions (>2 doses of epinephrine in ED), no prehospital epinephrine use, use of intravenous (IV) fluids in ED, and hospital admission. Multivariate regression was used to identify factors associated with primary outcomes.

Results

Among 5364 reactions recorded, median age was 8.8 (IQR, 3.78,16.9) years, 54.9% were males, and 52.5% had a known food allergy. In the prehospital setting, 37.9% received epinephrine, 44.3% received antihistamines, and 3.15% received corticosteroids. Uncontrolled reactions happened in 250 reactions. Patients treated with prehospital epinephrine were less likely to have uncontrolled reactions [aOR 0.955 (95%CI 0.943, 0.967)], receive IV fluids in ED [aOR 0.976 (95%CI 0.959, 0.992)], and to be admitted following the reaction [aOR 0.964 (95%CI 0.949, 0.980)]. Patients treated with prehospital antihistamines were less likely to have uncontrolled reactions [aOR 0.978 (95%CI 0.967, 0.989)], and to be admitted following the reaction [aOR 0.963 (95%CI 0.949, 0.977)]. Patients who received prehospital corticosteroids were more likely to require IV fluids in ED [aOR 1.059 (95%CI 1.013, 1.107)] and be admitted [aOR 1.232 (95%CI 1.181, 1.286)].

Conclusion

Our findings in this predominantly pediatric population support the early use of epinephrine and suggest a beneficial effect of antihistamines. Corticosteroids use in anaphylaxis should be revisited.

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