Immunotherapy Safety for the Primary Care ... - U.S. Coast Guard

Anaphylaxis of unknown origin:
1. Aspirin/NSAID
2. Sulfites (Na/K sulfites, bisulfites, metabisulfites)
3. Exercise
4. Hormones:
A rare subset of women have cyclic anaphylaxis - often during the luteal phase of
their menstrual cycle.
• They may have positive skin tests to medroxyprogesterone, and
• They may respond favorably to ovarian suppression or oophorectomy
5. Idiopathic:
This group of patients experience recurrent anaphylaxis with no recognized cause.
• The diagnosis is based on the typical signs and symptoms, as well as
evidence of elevated urine histamine, elevated serum tryptase, and an exhaustive
search for causative factors.
• These patients all require an Ana-kit, and if anaphylaxis occurs
frequently enough may require chronic steroid therapy to control their symptoms.
• A subset of these patients even fail to respond to high-dose
corticosteroid therapy - these patients are referred to as having malignant
idiopathic anaphylaxis.
Acetylsalicylic acid (aspirin) and NSAID anaphylaxis
• Most likely mechanism is modulation of arachidonic acid metabolism by interference
with cyclooxygenase enzyme pathways. There are two consequences of this action:
1) reduction in the formation of prostaglandins, thromboxanes, and prostacyclin,
2) enhanced formation of lipoxygenase products.
• In addition to enhanced mediator release, these patients may have an increased targetorgan
sensitivity to the leukotrienes.
• Rx: aspirin avoidance, desensitization, leukotriene receptor antagonists/lipoxygenase
inhibitors.
Sulfite anaphylaxis. Should be suspected in individuals who have anaphylaxis associated with
eating, particularly if restaurants or process foods are implicated.
• These patients may have such profound bronchoconstriction that they cannot
speak and have been mistaken for a choking victim, occasionally having had the
Heimlich maneuver performed on them.
• Sulfites are frequently utilized as preservatives and antioxidants. They are added
to foods to prevent discoloration.
• Foods to which these substances are added in the highest concentrations include
• leafy salad greens (salad-bar restaurants before restrictions).
• light-colored fruits and vegetables (esp. dried fruits and instant potatoes)
• wine and beer
• fish and shellfish (particularly shrimp)
• Sulfites are also used as preservatives/antioxidants in a variety of medication.
However, when compared with the amount of sulfite in foods, most pharmaceuticals
contain small amounts of sulfite (0.25% to I %) However, the potential still exists, as
these agents are either injected directly or inhaled by the patient.