Many Patients with Anaphylaxis Do Not Receive First-Line Adrenaline Treatment

A recent study showed many participants did not receive adrenaline, the guideline-compliant first-line therapy for anaphylaxis.1

“The literature published to date and the data presented here suggest that there is some uncertainty among prehospital health care professionals about how to recognize and treat anaphylactic reactions,” wrote investigators, led by Theresa Lüdke, from Technische Universität Dresden in Germany.1

Since anaphylactic reactions can be life-threatening, guidelines emphasized a rapid diagnosis and therapy for anaphylaxis. In cases of severe anaphylaxis, many guidelines recommend immediate treatment with intramuscular adrenaline. After all, adrenaline is the fastest onset of action of all anaphylaxis medications and can reduce the risk of biphasic reactions. However, research from the US and Switzerland has shown that allergists do not always follow the guidelines for anaphylaxis therapy.2,3

A chart review study of 21 emergency departments in the US found that only 18% of patients who experienced a food allergic reaction came to the emergency department by ambulance.2 At the hospital, 72% of patients received antihistamines, 48% received systemic corticosteroids, 16% received epinephrine, and 33% received respiratory treatments such as inhaled albuterol.

Lüdke and colleagues conducted a 5-year analysis to assess anaphylaxis emergency treatment and its outcome in children and adults.1 The team collected demographic data, triggers, symptoms, and hospitalization rates of anaphylaxis, leveraged from 2012 – 2016 Emergency Medical Services of Dresden/Germany. Air rescue data was not collected.

Investigators analyzed anaphylaxis severity, therapy, further monitoring, and the treatment outcome among 1131 adults (mean age: 50.5 years; 61.8% males) and 223 children (mean age: 7.4 years; 58.3% males) with anaphylactic reactions (Grade I-IV). In total, 591 adults and 102 children experienced severe anaphylaxis, commonly triggered by medication (33%) and food (61%), respectively. The average time between the alert and the arrival of the Emergency Medical Services was 6 minutes (range: 1 – 47 minutes) for children and 7 minutes (range: 1 – 60 minutes) for adults.1

The retrospective review found 7% of adults and 8% of children with ≥ Grade II anaphylactic reactions received adrenaline. Investigators saw a significant correlation between adrenaline therapy and improved condition in adults (P < .001) and children (P = .016).1

More than half of children (61.4%) received immediate therapy, either glucocorticoids (50.7%), H1-receptor-antagonists (45.3%), H2-receptor-antagonists (24.2%), and adrenaline (4.2%) for any anaphylactic reaction. Among children, 54.3% had Grade I reactions (59.5% treated with medicine; 2.5% with adrenaline), 38.6% had Grade II reactions (61.6% treated with medication; 5.8% with adrenaline), and 7.1% had Grade III reactions (75% treated with medication; 18.8% treated with adrenaline).1

Moreover, 75.2% of adults received emergency medication: glucocorticoids (68.3%), H1-receptor antagonists (69.2%), H2-receptor antagonists (57.4%), and adrenaline (4.5%). Among adults, 47.7% had Grade I reactions (70.2% treated with immediate medication; 1.9% with adrenaline), 40.5% had Grade II reactions (79.7% treated with medication; 4.4% with adrenaline), and 11.8% had Grade III reactions (80.5% treated with medication; 15.8% with adrenaline).1

In the sample, 66% of adults and 83% of children with severe anaphylaxis were hospitalized, and 21% of adults and 13% of children did not receive further medical observation despite having a severe reaction. The study found a nonsignificant correlation between symptom severity and hospitalization (P = .179) for children but a significant correlation for adults (P < .001).1

“Further studies could help to close the existing medical care gap,” investigators wrote.1 “However, in the case of emergency treatment of anaphylaxis, double-blind, placebo-controlled, randomized trials are hardly feasible, even though they are needed.”

References

1. Lüdke T, Günther S, Cuevas M, Haacke W, Frank M. Treatment and Outcome of Anaphylactic Reactions in Emergency Medical Services of Dresden/Germany: A 5-Year Analysis. Prehosp Disaster Med. 2025 Feb;40(1):12-20. doi: 10.1017/S1049023X25000184. Epub 2025 Mar 20. PMID: 40109094.

2. Clark S, Bock SA, Gaeta TJ, Brenner BE, Cydulka RK, Camargo CA; Multicenter Airway Research Collaboration-8 Investigators. Multicenter study of emergency department visits for food allergies. J Allergy Clin Immunol. 2004 Feb;113(2):347-52. doi: 10.1016/j.jaci.2003.10.053. PMID: 14767453.Helbling, A, Fricker, M, Bircher, A, et al. Notfallbehandlung beim allergischen Schock. Swiss Med Forum – Schweiz Med-Forum. 2011. https://doi.emh.ch/smf.2011.07462. Accessed March 25, 2025.