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Table 3 World Allergy Organization subcutaneous systemic reaction grading system

From: Sublingual immunotherapy: World Allergy Organization position paper 2013 update

Grade 1 Grade 2 Grade 3 Grade 4 Grade 5
Symptoms(s)/sign(s) of one organ system present:* Symptoms(s)/sign(s) of more than one organ system present: Lower respiratory Lower or upper respiratory Death
Asthma (eg, 40% PEF or FEV1 drop, NOT responding to an inhaled bronchodilator) Respiratory failure with or without loss of consciousness
Generalized pruritis, urticaria, flushing, or sensation of heat or warmth**
or or or or
Angioedema (not laryngeal, tongue, or uvular) Lower respiratory Upper respiratory Cardiovascular
or Asthma: cough, wheezing, shortness of breath (eg, <40% PEF or FEV1 drop, responding to an inhaled bronchodilator) Laryngeal, uvula, or tongue edema with or without stridor Hypotension with or without loss of consciousness
Upper respiratory
Rhinitis (eg, sneezing, rhinorrhea, nasal pruritis, and/or nasal congestion)
or or
Throat-clearing (itchy throat)  
or Gastrointestinal
Cough perceived to come from the upper airway, not the lung, larynx, or trachea Abdominal cramps, vomiting, or diarrhea
or or
Conjunctival erythema, pruritus, or tearing Other
  Uterine cramps
Nausea, metallic taste, or headache
Patients may also have a feeling of impending doom, especially in grades 2, 3, or 4.
Note: children with anaphylaxis seldom convey a sense of impending doom and their behavior changes may be a sign of anaphylaxis, eg, becoming very quiet or irritable and cranky.
Scoring includes a suffix that denotes if and when epinephrine is administered in relationship to symptom(s)/sign(s) of the SR: a, ≤5 minutes; b, >5 minutes to ≤10 minutes; c, >10 to ≤20 minutes; d, >20 minutes; z, epinephrine not administered.
The final grade of the reaction will not be determined until the event is over, regardless of the medication administered. The final report should include the first symptom(s)/sign(s) and the time of onset after the subcutaneous allergen immunotherapy injection and a suffix reflecting if and when epinephrine was administered, eg, Grade 2a; rhinitis: 10 minutes.
Final report: Grade, a-d or z ________________First symptom ________________ Time of onset of first symptom ________________
Comments ††
  1. *Each Grade is based on organ system involved and severity. Organ systems are defined as: cutaneous, conjunctival, upper respiratory, lower respiratory, gastrointestinal, cardiovascular, and other. A reaction from a single organ system such as cutaneous, conjunctival, or upper respiratory, but not asthma, gastrointestinal, or cardiovascular is classified as a Grade 1. Symptom(s)/sign(s) from more than one organ system or asthma, gastrointestinal, or cardiovascular are classified as Grades 2 or 3. Respiratory failure or hypotension, with or without loss of consciousness, defines Grade 4 and death Grade 5. The grade is determined by the physician’s clinical judgment.
  2. **This constellation of symptoms may rapidly progress to a more severe reaction.
  3. Symptoms occurring within the first minutes after the injection may be a sign of severe anaphylaxis. Mild symptoms may progress rapidly to severe anaphylaxis and death.
  4. ††If signs or symptoms are not included in the Table or the differentiation between an systemic response and vasovagal (vasodepressor) reaction, which may occur with any medical intervention, is difficult, please include comment, as appropriate.
  5. Adapted from [73]. Reprinted with permission from Elsevier Publishers.