Anaphylaxis: Guidelines for

Diagnosis and Management

Cataract
Anaphylaxis
Philippine Society of Allergy, Asthma
and Immunology, Inc.
Unit 2504, Medical Plaza Ortigas Condominium
#25 San Miguel Avenue, Ortigas Center, Pasig City
E-mail: psaai.secretariat@yahoo.com.ph

CPM 18TH ED DIVIDERS 1.31.2017.i7 7 02/07/2017 2:10:31 PM

 Anaphylaxis

Philippine Society of Allergy, Asthma and Immunology, Inc.

Unit 2504, Medical Plaza Ortigas Condominium
#25 San Miguel Avenue, Ortigas Center, Pasig City
E-mail: psaai.secretariat@yahoo.com.ph

Officers and Members of the Board of Directors 2017-2018

President Maria Carmela Agustin-Kasala, MD

Vice-President Marysia Stella T. Recto, MD
Secretary Eden P. Macalalag, MD
Assistant Secretary Vicky W.E. Biñas, MD
Treasurer Rommel Crisenio M. Lobo, MD
Assistant Treasurer Venjilyn S. Villaver, MD
Public Relations Officer Felicia Racquel Salvador-Tayag, MD
Immediate Past President (2015-2016) Maria Carmela Agustin-Kasala, MD

Board of Trustees Eileen Alikpala-Cuajunco, MD

Vicky W.E. Biñas, MD
Ma. Fredelita Carreon-Asuncion, MD
Mary Anne R. Castor, MD
Shirley L. Kwong-Buizon, MD

Anaphylaxis Council

Chair Julia C. De Leon, MD

Members Maria Carmen Decena-Ang, MD

Julia C. de Leon, MD
Aileen Ancla-Elorde, MD
Roxanne Casis-Hao, MD

Adviser Hiyasmin Lim, MD

43
 Anaphylaxis

The Collation of Summary Statements on Anaphylaxis was adapted from the World Allergy Organization Guide-
lines for the Assessment & Management of Anaphylaxis 2011, FER Simons, et. al. Allergy Clin lmmunol 2011;127:587-93.

The Collation of Summary Statements on Anaphylaxis is a consensus of the Anaphylaxis Council of the Philippine
Society Allergy, Asthma and Immunology after taking into consideration the published evidence and clinical practice
applicability in the Philippine setting.

Anaphylaxis: Guidelines for Diagnosis Figure 2: Antibiotic triggers for anaphylaxis

and Management
Worldwide, anaphylaxis definitions commonly used are,
“a serious, life-threatening, generalized or systemic hyper­
sensitivity reaction”, and “a serious allergic reaction that
is rapid in onset and might cause death.”

Anaphylaxis has varied mechanisms and clinical present­

ations. Although prompt recognition and treatment of
anaphylaxis is imperative, both patients and healthcare
professionals often fail to recognize and diagnose early
signs and symptoms of the condition. This happens in the
Philippines as well. As of this time, unfortunately, statistics
on the actual incidence of anaphylactic episodes in our
country are unknown. International studies have shown
a lifetime prevalence of 0.5%-2.5%1.

In the University of the Philippines – Philippine General

Hospital in 2010-2014, the numbers ranged from 12-28
reported cases per year. The adult patients (aged 18
to above 60) comprised 52% of the cases and majority
(96%) are females.
The top triggers were chemotherapeutic drugs, antibiotics
and radiocontrast media (Figure 1).
Figure 1: Anaphylaxis triggers (2010-2014), UP-PGH
Others 9
Food 3
Sedatives 2
NSAIDs 8
Blood products 12
Chemo drugs 48
Vitamin K 7
RCM 18
Anti-Kochs 6
Antibiotic 20
Among the chemotherapeutic drugs, anaphylaxis second-
ary to taxanes in adults was seen while etoposide was
the main culprit for pediatric patients. Of the antibiotics,
penicillin still remains to be the most commonly impli-
cated drug for both the adult and pediatric population
(Figure 2).
Despite the diagnosis of anaphylaxis, more than half
(54%) of the patients were not given epinephrine during
the anaphylactic episode2.
The guidelines written by the World Allergy Organization
were created to answer the need for global guidelines
for anaphylaxis. They were developed after documenting
PJAAI, July - December 2015, Vol. 18, No. 2, pp. 3-6.
44
that essential medications, supplies and equipment for
assessment and management are not universally avail-
able worldwide, including in our own local setting. They
were also created with the awareness that ANY health
care practitioner might, at some time, have to assess and
manage anaphylaxis in a low-resource environment.
The beauty of this document is that in order to cross
language barriers, the important aspects or principles
of assessment and management have been adequately
summarized in 5 comprehensive illustrations and they
incorporate contributions from more than 100 allergy/
immunology specialists on 6 continents received through
the WAO member societies and the WAO Board of
Directors.
It is in this regard that the Anaphylaxis Council of the
Philip­pine Society of Allergy, Asthma and Immunology
sees it fit to adapt the WAO guidelines for use in our
local setting.
The guidelines are organized into 3 main sections:
assess­ment of patients with anaphylaxis, management
of anaphylaxis in a health care setting, and management
of anaphylaxis at time of discharge from a health care
setting. The succeeding portion highlights the important
points from the guideline.
ASSESSMENT OF PATIENTS WITH ANAPHYLAXIS
In this guideline, the diagnosis of anaphylaxis remains
to be based on clinical findings and a detailed history
is key. Laboratory tests such as serum tryptase are not
specific for anaphylaxis and may even be normal for some
patients. Pattern recognition of the temporal relation of
exposure to triggers and sudden onset of symptoms is
essential. Typically, symptoms occur in 2 organ systems:
skin and mucous membrane, upper and lower respiratory
tract, gastrointestinal tract, cardiovascular system and
central nervous system. Anaphylaxis may be diagnosed
using the WAO guidelines. (Table 1).

04 CPM 18th ed Anaphylaxis 2015 44 44 02/03/2017 1:29:56 PM


Table 1. WAO Criteria for the Diagnosis of Anaphylaxis
Anaphylaxis is highly likely when any of the three
criteria is fulfilled:
1. Acute onset of an illness (minutes to several hours)
with involvement of the skin, mucosal tissue, or
both (e.g., generalized urticaria, itching or flushing,
swollen lips tongue uvula)
AND AT LEAST ONE OF THE FOLLOWING:
A) Respiratory compromise
B) Reduced blood pressure or associated symp-
toms of end organ dysfunction OR
2. Two or more of the following that occur rapidly after
exposure to a likely allergen for that patient (minutes
to several hours)
A) Involvement of the skin-mucosal tissue
B) Respiratory compromise
C) Reduced blood pressure
D) Persistent gastrointestinal symptoms OR
3. Reduced blood pressure after exposure to a known
allergen for that patient
A) Infants and children: low systolic blood pressure
(age-specific) or greater than 30% decrease in
systolic blood pressure
B) Adults: systolic blood pressure of less than 90
mmHg or greater than 30% decrease from the
person’s baseline
The risk factors for severe or fatal anaphylaxis include ex-
tremes of age, concomitant diseases (e.g., asthma, cardio­
vascular diseases, mast cell disorders and severe atopic
disease) and medications (beta blockers and ACE inhibitors)
Likely triggers also seem to differ per age group. Food is
the most common trigger for children, teens and young
adults while insect stings and medications are more
common in the older age groups.
Middle and elderly patients were also considered to be
vulnerable patients because they may present as acute
coronary syndrome. Infants are also included since they
are unable to voice out their symptoms and may have
signs not typical of the ones mentioned. Infants may
present with flushing and dysphonia upon crying, spitting
up after feeding and incontinence. Prompt treatment of
pregnant patients is also warranted as the mother and
baby are at risk for hypoxic/ischemic encephalopathy.
MANAGEMENT OF ANAPHYLAXIS IN A HEALTH-
CARE SETTING
Having a written emergency protocol for anaphylaxis is
espoused by the guideline. Once a diagnosis of anaphy-
laxis has been determined, the following steps should
be made: remove possible triggers, assess circula-
tion, airway, breathing, skin, mental status and weight,
simulta­neously call for help and inject epinephrine
intra­muscularly in the mid-anterolateral thigh, position
the patient on his/her back or in a position of comfort. If
needed, the patient may be given supplemental oxygen,
inserted with intravenous catheter for IV infusion and fluid
resuscitation and started on chest compressions.
Epinephrine is still the first line of treatment for anaphy-
laxis. This is given at a dose of 0.01 mg/kg of 1:1,000 (1
04 CPM 18th ed Anaphylaxis 2015 45 45
Anaphylaxis
mg/mL) solution with a maximum dose of 0.5 mg in adults
and 0.3 mg in children given intramuscularly at the mid
anterolateral thigh. Through this route, peak plasma and
tissue concentrations are achieved rapidly. Epinephrine
is still recommended over antihistamines or glucocorti­
coids as it is able to prevent and relieve hypotension
and shock, decreases inflammatory mediator release,
addresses airway obstruction due to mucosal edema
and has bronchodilator and vasoconstrictive effects. Its
onset of action is also much faster than glucocorticoids.
Useful second-line interventions include removing the
trigger where possible, calling for help, correct position-
ing of the patient, high-flow oxygen, intravenous fluids,
inhaled short-acting bronchodilators, and nebulized
beta-2 agonists.
In the Philippines, epinephrine autoinjectors are not yet
available, but despite that, epinephrine still remains the
drug and treatment of choice for anaphylaxis. We recom-
mend giving the appropriate dose, extracting the proper
volume (0.01 mg/kg of 1:1,000 (1 mg/mL) solution with a
maximum dose of 0.5 mg in adults and 0.3 mg in children
into a tuberculin syringe and administering it intramuscu-
larly (deltoid or mid-anterolateral thigh).
MANAGEMENT OF ANAPHYLAXIS AT TIME OF
DISCHARGE FROM A HEALTHCARE SETTING
Patient education about possible recurrence of symptoms
and what to do in case it does recur is part of the discharge
plans. They should be prepared and be adept at self-
treatment with epinephrine. Possible triggers should be
investigated and may be done through allergy skin testing.
No optimal time after an anaphylactic episode has been
established by studies but, generally, after 3-4 weeks
the testing may be done. lf there is resounding history
of anaphylaxis but the skin testing turns out negative,
a retesting may be done after a few weeks or months.
Immunomodulation in the form of immunotherapy and
provocation tests may also be looked into.
Locally, the Council finds that there is still a need to train
clinicians (medical students and hospital staff) in recog-
nizing and managing anaphylactic episodes. There are
issues regarding under-diagnosing and under-reporting of
cases as well as a lack of a registry for these cases.
SUMMARY/CLOSING STATEMENT:
Anaphylaxis is a potentially life-threatening condition
whose clinical diagnosis is based on recognition of
presenting features. First-line treatment for anaphylaxis
is intramuscular epinephrine, locally administered via
syringe instead of an auto-injector. Discharge plans should
involve an assessment of the risk of further reactions, a
management plan, and, where appropriate, prescribing
epinephrine. If epinephrine is prescribed, education on
when and how to use it should be provided. Consult with
an allergist is essential to investigate possible triggers,
to perform a comprehensive risk assessment, and to
prevent future episodes by developing personalized
risk reduction strategies including, where possible,
commencing allergen immunotherapy. Teaching and
equipping the patient and all caregivers is key.3
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02/03/2017 1:29:56 PM
 Anaphylaxis
REFERENCES

1. Lieberman P, Camargo Cajr, Bohlke K, Jick H, Miller RL, Sheikh A, et

al. Epidemiology of anaphylaxis: findings of American College of Allergy,
Asthma and Immunology Epidemiology of Anaphylaxis Working Group.
Ann Allergy Asthma lmmunol 2006;97:596-602.
2. Section of Allergy and lmmunology, UP-PGH. Census from 2010-2014.
Unpublished.
3. Muraro A, Roberts G, Worm M. Bilo_ MB, Brockow K. Fern_andez Rivas
M. et. al., on behalf of the EAACl Food Allergy and Anaphylaxis Guidelines
Group. Anaphylaxis: guidelines from the European Academy of Allergy
and Clinical immunology Allergy 2014:69:1026-1045.

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