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Table 9 Recommendations at Time of Discharge From the Healthcare Setting

From: World Allergy Organization Guidelines for the Assessment and Management of Anaphylaxis

   Epinephrine/adrenaline auto-injectora
   Epinephrine from an ampule/syringeb or prefilled syringec (alternative but not preferred formulations)
Other aspects of discharge management
   Anaphylaxis emergency action plan (personalized, written)
   Medical identification (eg, bracelet, wallet card)
   Medical record electronic flag (or chart sticker)
   Emphasize the importance of follow-up, preferably with an allergy/immunology specialist
Assessment of sensitization to allergen
   Before discharge, consider assessing sensitization to allergens suggested in the history of the acute episode, by measuring serum IgE levels to relevant allergen(s), if the test is availabled
   3-4 weeks after the episode, confirm allergen sensitization using skin testse
   Challenge/provocation tests might be needed in some patients, for example, with food or medication allergy, in order to assess risk of future anaphylactic episodes furtherf
Long-term risk reduction: avoidance and/or immunomodulation
   Food-triggered anaphylaxis: avoidance of relevant food(s)
   Stinging insect-triggered anaphylaxis: avoidance of stinging insects; subcutaneous venom immunotherapy (protects up to 80-90% of adults and 98% of children)
   Medication-triggered anaphylaxis: avoidance of relevant medications; if indicated, medically supervised desensitization in a healthcare setting according to published protocols
   Idiopathic anaphylaxis: for frequent episodes, consider glucocorticoid and H1-antihistamine prophylaxis for 2-3 months
Optimal management of asthma and other concomitant diseases
  1. aSome formulation of injectable epinephrine should be carried at all times by patients at risk of recurrence; only 3 fixed doses are available in auto-injectors (0.1 mg, 0.3 mg, and 0.5); more than one epinephrine injection is needed in up to 23% of adults receiving an epinephrine injection for anaphylaxis; therefore, consider prescribing more than one epinephrine auto-injector.
  2. bRecommended for use in community settings if epinephrine (adrenaline) auto-injectors are not available or affordable; even when training and written instructions are provided, people without a medical background find it hard to draw up an epinephrine dose accurately and rapidly from an ampule by using a 1 mL syringe.
  3. cRecommend only if epinephrine (adrenaline) auto-injectors are not available or affordable; unsealed, prefilled syringes containing epinephrine should be replaced regularly every 3-4 months because epinephrine degrades rapidly on exposure to air.
  4. dIf allergen-specific IgE levels are measured in a blood sample obtained during or shortly after the episode, neutralization or consumption of serum IgE may have occurred; also in patients who have received intravenous fluid resuscitation, levels can be falsely low or absent/undetectable due to the dilutional effect on circulating IgE.
  5. eSkin prick tests should be performed to assess sensitization to foods, venoms, and medications; intradermal tests are useful in venom and medication allergy, but are generally contraindicated in food allergy.
  6. fShould be conducted only in appropriately equipped healthcare facilities staffed by professionals who are trained and experienced in patient selection, performing challenges according to protocol, and diagnosing and treating anaphylaxis. Before a challenge is performed, the potential risk versus the potential benefit should be discussed with the patient and documented in the medical record. In many countries, written informed consent is obtained before challenge/provocation tests.
  7. Adapted from references [2, 2225, 32, 59, 68, 69, 72, 73, 87, 96, 97, 99, 132139].