Risk of recurrence in anaphylaxis in children

14/01/2018

Dr Ahmad Al Shami

DISCLOSURE

I do not have any relevant financial relationship with commercial interest to disclose

Learning Objectives

Detail what best evidence says about risk of

recurrence of anaphylaxis

Background

• Anaphylaxis is an acute life threatening hypersensitivity reaction

• The incidence of anaphylaxis is 13.3/100,000 visits of PECs in Qatar and

0.2%-0.4% of ED visits in US

• Over the past few years, there has been a significant increase in the number of

anaphylaxis cases presenting to the ED

Bock SA et./ J Allergy Clin Immunol. 2007 Apr;119(4):1016-8. Epub 2007 Feb 15. Hochstadter E et./ J Allergy Clin Immunol. 2016

Jun;137(6):1888-1890.e4. doi: 10.1016/j.jaci.2016.02.016. Epub 2016 Apr 20

Background

• Studies also suggest an increase in the prevalence of food allergy, reporting an

increase of 0.6% over a 10-year period that might have stabilized in developed

countries

• Few studies have examined recurrence rates of anaphylaxis and suggest a

recurrence rate of up to 10 episodes per 100 patient-years

Ben-Shoshan M et./ Curr Allergy Asthma Rep. 2012 Aug;12(4):346-72. doi: 10.1007/s11882-012-0274-3. Vetander M et./ Clin Exp Allergy.

2012 Apr;42(4):568-77. doi: 10.1111/j.1365-2222.2011.03954.x.

Recurrence Rate of Anaphylaxis

• O’Keef A et al examined the recurrence rates of anaphylaxis in children

medically attended in an ED with anaphylaxis. The annual recurrence rate

was 17.6%

• Mullins et al evaluated a cohort of adults and children. In any 1 year, 1/12

patients who have suffered anaphylaxis will experience recurrence, and 1/50

will require hospital treatment or use adrenaline

O'Keefe A et./ J Pediatr. 2017 Jan;180:217-221. doi: 10.1016/j.jpeds.2016.09.028. Mullins R.J et./ Epub 2016 Oct 12. Clin Exp Allergy

2003;33:1033-1040

Recurrence Rate of Anaphylaxis

• Alonso MA et al examined the recurrence of anaphylaxis in a Spanish series, it

was 3.2 episodes per 100 person-years. The incidence rate for a first

recurrence of the same subtype was 2 to 6 times lower than that published

by other authors

• In other study the children with anaphylaxis are estimated to relapse at a rate

of 0.98 episodes per patient-year

Alonso MA et./ J Investig Allergol Clin Immunol. 2013;23(6):383-91. Gold MS et./ J Allergy Clin Immunol 2001;107:191-3

Trigger for Recurrent Episode

• O’Keef A et al found the food was the most common trigger for recurrent

episodes in 84.6% of cases (Tree nut 15.4%, Milk 15.4% and Peanut 6.2%)

• In Mullins et al the etiology was identified in 91.6% patients: food 61%,

stinging insects 20.4% and medication 8.3%

• Vetander et al reported that 35% of recurrent visits were due to tree nut and

peanuts combined

O'Keefe A et./ J Pediatr. 2017 Jan;180:217-221. doi: 10.1016/j.jpeds.2016.09.028. Mullins R.J et./ Epub 2016 Oct 12. Clin Exp Allergy

2003;33:1033-1040. Vetander M et./ Clin Exp Allergy. 2012 Apr;42(4):568-77. doi: 10.1111/j.1365-2222.2011.03954.x.

Trigger for Recurrent Episode

• The worst outcome is generally reserved for patients with peanut/tree nut-

induced anaphylaxis, who are most likely to suffer recurrent symptoms and

fatal outcomes

• The sensitivity to cow’s milk and egg allergy may improve with time and

exercise-associated anaphylaxis may become less frequent, those with

idiopathic anaphylaxis continue to suffer unpredictable episodes

Dibs SD et./ Pediatrics 2001. Shadick NA et./ J Allergy Clin Immunol 1999; 104:123-7

Risks of Recurrent Episode

• Patients with a history of asthma and atopy are more likely to experience

recurrent episodes of anaphylaxis are consistent with several studies that have

identified asthma as a risk factor for anaphylaxis-related mortality

• M Adeli et al found that 55% of recurrent anaphylaxis and the comorbid

conditions including asthma in 42%,eczema in 27%

• The epinephrine auto-injectors were underused during an episode of

anaphylaxis

O'Keefe A et./ J Pediatr. 2017 Jan;180:217-221. doi: 10.1016/j.jpeds.2016.09.028. Mullins R.J et./ Epub 2016 Oct 12. Clin Exp Allergy

2003;33:1033-1040. Alonso MA et./ J Investig Allergol Clin Immunol. 2013;23(6):383-91

Anaphylaxis in Qatar

• Anaphylaxis was identified in 390/1051 files reviewed from 2011 to 2016

• Anaphylaxis affects 1/1000 Qatari pediatric population

• The mean age was three years and males 69%

• Black ant was seen in 48% among insect bites

Various triggers causing anaphylaxis

Food components as causative agents of anaphylaxis

Take Home Message

• Educational program that promotes effective avoidance strategies

• While food allergy was the commonest cause, stinging insects were also

prominent

• Physician and community awareness of anaphylaxis; its etiology, management

and comorbid diseases associated with it is highly recommended

• There is substantial underuse of epinephrine in cases of anaphylaxis

• Occasional patients develop new triggers

References• M. Adeli1,2,3, K.Alyafei, A.Alshami, S.Nisar. Etiology and Characteristics of Patients presenting with Anaphylaxis to the Pediatric Emergency Centers in Qatar

• Bock SA, Muñoz-Furlong A, Sampson HA. Further fatalities caused by anaphylactic reactions to food, 2001-2006. J Allergy Clin Immunol. 2007 Apr;119(4):1016-8.

Epub 2007 Feb 15

• Hochstadter E1, Clarke A2, De Schryver S3, LaVieille S4, Alizadehfar R5, Joseph L5, Eisman H6, Ben-Shoshan M7 Increasing visits for anaphylaxis and the benefits of

early epinephrine administration: A 4-year study at a pediatric emergency department in Montreal, Canada. J Allergy Clin Immunol. 2016 Jun;137(6):1888-

1890.e4. doi: 10.1016/j.jaci.2016.02.016. Epub 2016 Apr 20

• Ben-Shoshan M1, Turnbull E, Clarke A. Food allergy: temporal trends and determinants. Curr Allergy Asthma Rep. 2012 Aug;12(4):346-72. doi: 10.1007/s11882-012-

0274-3

• Vetander M1, Helander D, Flodström C, Ostblom E, Alfvén T, Ly DH, Hedlin G, Lilja G, Nilsson C, Wickman M Anaphylaxis and reactions to foods in children--a

population-based case study of emergency department visits. Clin Exp Allergy. 2012 Apr;42(4):568-77. doi: 10.1111/j.1365-2222.2011.03954.x.

• O'Keefe A1, Clarke A2, St Pierre Y3, Mill J3, Asai Y4, Eisman H5, La Vieille S6, Alizadehfar R3, Joseph L3, Morris J7, Gravel J8, Ben-Shoshan M9. The Risk of Recurrent

Anaphylaxis. J Pediatr. 2017 Jan;180:217-221. doi: 10.1016/j.jpeds.2016.09.028. Epub 2016 Oct 12.

• Mullins R.J. Anaphylaxis: risk factors for recurrence. Clin Exp Allergy 2003;33:1033-1040

• Alonso MA1, García MV2, Hernández JE3, Moro MM2, Ezquerra PE2, Ingelmo AR2, Albelda CV2. Recurrence of anaphylaxis in a Spanish series. J Investig Allergol Clin

Immunol. 2013;23(6):383-91

• Gold MS, Sainsbury R. First aid anaphylaxis management in children who were prescribed an adrenaline autoinjector device (Epipen). J Allergy Clin Immunol

2001;107:191-3

• Dibs SD, Baker MD. Anaphylaxis in children: a 5-year experience. Pediatrics 2001

• Shadick NA, Liang MH, Partridge AJ et al. The natural history of exercise-induced anaphylaxis: survey results from a 10-year follow up study. J Allergy Clin

Immunol 1999; 104:123-7