Anaphylaxis

Johannes Ring Klinik und Poliklinik für Dermatologie und Allergologie am

BiedersteinTechnische Universität München

Munich, Bavaria, GermanyGA2LEN Center of Excellence EU frame program

Christine Kühne Center for Allergy Research and Education (CK-CARE)

XXII World Allergy Congress WAC 4 – 4 december 2011, Cancun Mexico

Anaphylaxis: definition by the World Allergy Organization

Johansson SGO et al. Revised nomenclature for allergy for global use: Report of the Nomenclature Review Committee of the World Allergy Organization, J Allergy Clin Immunol. 2004;113:832-6.

„Anaphylaxis is an (acute) severe, life-threatening

generalized or systemic hypersensitivity reaction“

(regardless of mechanism)

Increase in Incidence of Anaphylaxis

Liew WK. Anaphylaxis fatalities and admissions in Australia. J Allergy Clin Immunol 2009;123:434-42

Anaphylactic Reaction after Infusion of Dextran 60

Day 1, Unit 2a

Severity grading of anaphylactic reactions according to Ring and Meßmer (Lancet, 1977)

Grade

Symptoms observed

Skin Gastro-intestinal

Respiratory Cardio-vascular

I

Itch Flush Urticaria Angioedema

- - -

II „

(not obligatory)

Nausea Cramps

Rhinorrhoea Hoarseness Dyspnoea

Tachycardia(>20/min)RR changes(>20mmHg syst)Arrhythmia

III

„(not

obligatory) Vomitus Defecation

Laryngeal edema Bronchospasm Cyanosis

Shock

IV

„(not

obligatory)

„ Respiratory arrest

Cardiac arrest

Activators

Allergen

Auto-Ab

(IgE,FcRI)

Anaphylatoxin

Tryptase

Basic agents(Neuropeptides,

48/80,MBP)

Adenosin

Chemokines

Stem cell factor(c-kit-Ligand)

Microbial

Peptides

Mediators

Histamine

Proteoglykanes

Proteases

Other Enzymes

Cytokines

Lipid mediators

Mast Cells

I. Weichenmeier, H. Behrendt

33 jährige Patientin mit Mastozytose (ISM) seit 4 JahrenBronchialasthmaKeine frühere Allergie oder AnaphylaxieBasale Tryptase 57µg/l

Patientin wurde von Wespe in den Nacken gestochenPatientin hatte kein Notfall-Set dabeiTachykardie, Kollaps, Bewußtseinsverlust innerhalb weniger MinutenReanimation anfangs erfolgreich, aberspäter auf Intensivstation Tod durch hypoxischen Hirnschaden

Frage einer evtl. „prophylaktischen“ ASIT (Immuntherapie)

mast cell

mediator substanceseg histamine

nettle rash

dyspnoea

diarrhea, vomiting

shock

Day 1, Unit 2a

Mechanisms of anaphylaxis

Triggers of Anaphylaxis

Modif. After Hompes S et al 2009

Trigger Adults Children

Foods 16 54

Insects 55 16

Drugs 21 8

Elicitors or letal anaphylaxis

Pumphrey. Clin Exp Allergy 2000; 30:1144

Insect venoms

Foods

Drugs

Circumstances of fatal food anaphylaxisCircumstances of fatal food anaphylaxis

• Most of patients are aware of food allergy

• Mostly young asthmatics

• Several mild reactions in previous history

• Difficulties in complete avoidance

• Reactions occur mostly not at home, but in school, kindergarden , bars, restaurants, „Take-Away“, Caterer

Summation anaphylaxisSummation anaphylaxis

Nahrungsmittel

Infekte

Streß

Klima

Sport

Arzneimittel

Alkohol

Guidelines in Anaphylaxis

• 1994 Konsensuskonferenz DGAI Tryba et al Allergo-J

• 2005 Update parameter AAAAI Lieberman et al JACI

• 2006 2nd symposium NIH / FAN Sampson et al JACI

• 2007 Leitlinie Akutmaßnahmen bei Anaphylaxie Ring et al (DGAKI)Allergo-J

• 2007 Anaphylaxis in childhood (EAACI) Muraro et al Allergy

• 2008 Epinephrine – drug of choice (WAO) Kemp et al WAO Journal

• 2011 Development of Global Guidelines (WAO) Simons et al JACI

Development of „Anaphylaxis School“ by working group AGATE (AG Anaphylaxis Training and Education)

• Johannes Ring, Knut Brockow, Claudia Kugler, Martine Grosber Verena Thiebes (München TUM)

• Kirsten Beyer, Norbert Gebert (Berlin) Margitta Worm (Berlin)

• Tilo Biedermann, A Fischer (Tübingen)• Alexander Dorsch (Hohenkammer)• Ricarda Eben, B Przybilla (München

LMU)• Frank Friedrichs (Aachen)• Uwe Gieler, S Schallmayer (Gießen) • Thilo Jakob (Freiburg)• Lars Lange (Bonn)• Oliver Pfaar, Ludger Klimek (Wiesbaden)• Imke Reese (München)• Ernst Rietschel (Köln)• Sabine Schnadt (daab)• Rüdiger Szczepanski (Osnabrück)

Skin: Itch, reddening, swelling, nettle rash

Gastrointestinal tract: Itchy palate, nausea, vomiting, abdominal cramps, diarrhea

Respiratory tract: Cold, narrow throat, stridor, cough, dyspnoea

Cardiovascular: Vertigo, disorientation, tachycardiahypotension, collapse, unconsciousness shock

Symptoms of anaphylaxis

Day 1, Unit 2a

AGATE

Interdisciplinary Group:

• Dermatologist• Emergency Physician• ENT• Pneumologist• Nutritionist • Pediatrician• Psychologist• Patient organisation

Struktured educational programs („Schools“) in allergy

• Asthma Arbeitsgemeinschaft Asthma-Schulung (AGAS)

• Neurodermitis Arbeitsgemeinschaft Neurodermitis-Schulung (AGNES)

• Anaphylaxie Arbeitsgemeinschaft Anaphylaxie – Training und Edukation (AGATE)

General measures

Adrenaline

Volume

Basics of Treatment of AnaphylaxisBasics of Treatment of Anaphylaxis

Antihistamine Glucocorticoids

„„Emergency Set“ for self-medicationEmergency Set“ for self-medication

• Adrenaline, Antihistamine, Cortisone• Application galenics for easy swallowing • Adrenaline as Autoinjector

+ +

Objectives of AGATE

• Basic knowledge anaphylaxis (symptoms, medication)

• Coping with anaphylactic reactions

• Practical training in use of self medication

• Avoiding triggers

• Coping with fear

• Exchange of experiences with other patients

Who is educated?

• Patients and relatives

• Patients to whom an epinephrine autoinjector was prescribed (anaphylaxis, adults with mastocytosis)

• Train the Trainer Seminars: Physicians (Allergists), Psychologists, Nutritionists

Structure of Programmme

• Outpatient education

• 2 Meetings with 4 units of 45 minutes

• Interdisciplinary approach

• Standardised programme with manual

• Groups of 6 adults or 12 parents of 6 children

• Opportunities and limits of educational programs (1 TU)

• Basics of organization and management of patient education schools (3 TU)

• Psychosocial aspects (6 TU)

• Pedagogic basics (8 TU)

• Medical aspects of anaphylaxis (10 TU)

Qualification for „Anaphylaxis Trainer“according to the AGATE curriculum: Contents

TU =teaching unit á 45 minutes

• Methodic/didactic opportunities for all age groups

• Adequate didactic tools and gadgets for working with children, parents and adults or kindergarden personel

• Group dynamics• Group structuring, processes, intervention

methods• Relaxation and body perception• Role performance games illustrating initiation

and solution of problems under everyday conditions

Qualification for „Anaphylaxis Trainer“according to the AGATE curriculum:

Pedagogic content

• Basics of anaphylaxis– Symptoms, early warning signs – Triggers– Diagnosis and differential diagnoses – Individual risk and influencing factors

• Survey of treatment options– Trigger avoidance– Allergen-specific immunotherapy (ASIT)– Outlook to future approaches

• Practical management in case of emergency– Emergency set: medications– Application of emergency medication– Adrenaline autoinjector training

Anaphylaxis School: Contents 1st Day

Day 1, Unit 1 b

• What to do in case of emergency? (repetition)– Anaphylaxis

– Recognition– Remembering – Counteracting– Taking serious

• Elicitor-specific modules for:– Foods - Drugs– Insect venoms - Latex

• Everyday survival strategies • Anaphylaxis and social environment

Day 2, Unit 1b

Anaphylaxis School: Contents 2nd Day

Qualification for „Anaphylaxis Trainer“according to the AGATE curriculum

• Medical: Allergist or equivalent experience

• Psychological: Psychology, Psychosomatic medicine, Psychotherapy, pedagogics plus > 1 year experience in behavioural therapy with chronic diseases

• Nutrition: ecotrophology, dietary assistance with special experience in food allergy (membership in WG)

• Nurse/children‘s nurse: optional

• Hospitation (observer) in anaphylaxis school

• Train-the-Trainer seminar

• Supervision

• Certificate

Qualification for „Anaphylaxis Trainer“according to the AGATE curriculum: Program

Prevention

avoid triggers

knowalternatives

immunotherapy for Insect venom allergy

take emergency drugs always along

train application ofemergency drugs

inform social environment

individualemergency plan

knowsymptoms

remember

Day 1, Unit 3

Conclusions

• Anaphylaxis is not rare• Main elicitors are drugs, insects and foods• Adrenaline is the main drug in acute treatment• It is important to find causal elicitor by allergy

diagnostics• If possible, allergen-specific immunotherapy• Research regarding „summation“ factors is

necessary• Strict avoidance of elicitor is best prevention• The „anaphylaxis school“ program is helpful in

acute management and avoidance of elicitors thus facilitating patient‘s life

Thanks to:K. Brockow

C. Kugler

U. Darsow

M. Grosber

V. Thiebes