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

S514 Lieberman et al
J ALLERGY CLIN IMMUNOL
MARCH 2005
Jogging is a common activity precipitating attacks, but
brisk walking, bicycling, racquet sports, skiing, and
aerobic exercise might also be associated with such
anaphylactic reactions. 170-172 In some patients exerciseinduced
anaphylaxis will only occur after ingestion of
a specific food or medication, such as aspirin or other
nonsteroidal anti-inflammatory agents. Ingestion of these
medications before exercise has been reported by 13% of
affected individuals, 173 and their elimination might enable
the patient to tolerate exercise. Exercise-induced anaphylaxis
in the postprandial state, without identification of
a specific food, occurred in 54% of the respondents in
the same survey. Exercise-induced anaphylaxis has also
been reported when a certain food is ingested after, as
well as before, exercise (see food allergy parameter). In
some patients specific foods have been shown to trigger
these reactions. Elimination of these foods might allow
the patient to exercise without anaphylaxis development.
113,173-176 These patients might ingest these foods
without anaphylaxis development if they do not exercise
for 4 to 6 hours after eating them. Provocation of exerciseinduced
anaphylaxis with a latency period after food
consumption of 24 hours has been reported. 113 For this
reason, it is prudent to individualize this management
recommendation, particularly for individuals with postparandial
(nonfood specific) exercise-induced anaphylaxis.
It should also be clear that these foods might be
ingested in the absence of exercise without difficulty. Thus
both exercise and food ingestion are necessary to produce
the reaction. Individuals who have exercise-induced
anaphylaxis might have a higher incidence of a personal
and/or family history of atopy. 170
Exercise-induced anaphylaxis should be distinguished
from other exercise-associated medical conditions.
Arrhythmias or other isolated cardiovascular events related
to exercise can be first seen with vascular collapse
but are not associated with pruritus, erythema, urticariaangioedema,
or upper respiratory obstruction. Patients
who have exercise-induced anaphylaxis usually have
wheezing in association with other symptoms of anaphylaxis,
whereas patients who have exercise-induced bronchospasm
have symptoms referable only to the lower
respiratory tract.
Cholinergic urticaria is a physical allergy characterized
by the development of punctate (1-3 mm diameter),
intensely pruritic wheals with erythematous flaring after
an increase in core body temperature or stress. A minority
of individuals with exercise-induced anaphylaxis have
cutaneous lesions consistent with cholinergic urticaria.
Classic cholinergic urticaria elicited by means of
exercise, as noted above, is characteristically associated
with an increase in the core body temperature without
vascular collapse. However, in 2 of 16 patients who did
not have punctate urticaria with increase of core body
temperature, a syndrome resembling exercise-induced
anaphylaxis was seen with punctate urticaria progressing
to collapse. 171 Unlike cholinergic urticaria, simply
increasing the core body temperature does not necessarily
produce symptoms of exercise-induced anaphylaxis.
In addition, these syndromes might rarely appear
concurrently.
A detailed history of symptoms associated with the first
episode, as well as previous attacks, should be obtained.
The history should include details concerning activities
and ingestants that might precipitate an episode of
anaphylaxis. Particular attention should be given to the
antecedent use of aspirin or other nonsteroidal antiinflammatory
agents, as well as any seasonality to the
attacks.
Prophylactic use of H 1 and H 2 antihistamines has
generally not been effective in preventing exercise-induced
anaphylaxis. 172 This is not without controversy,
however, because reports have demonstrated in selected
patients that antihistamine prophylaxis might help reduce
the frequency and/or intensity of attacks. 177,178
Early recognition of the prodromal manifestations of
exercise-induced anaphylaxis is extremely important, with
discontinuation of exercise at the earliest symptom.
Modification of the exercise program by means of reduction
in intensity or duration might be helpful in
reducing episodes of exercise-induced anaphylaxis.
Avoidance of exercise for 4 to 6 hours after eating is
important in those individuals with documented exerciseinduced
anaphylaxis after food ingestion.
The emergency management of exercise-induced anaphylaxis
is the same as that of anaphylaxis of other causes.
The early administration of epinephrine is essential.
Intravenous volume replacement, adequate oxygenation,
and vigilance for upper airway compromise, with possible
endotracheal intubation or tracheostomy, might also be
required. H 1 blocking agents might be helpful but should
not be relied on to abort the attack.
Affected individuals should discontinue exercise at
the earliest symptom consistent with exercise-induced
anaphylaxis, usually pruritus and cutaneous warmth or
erythema (flushing). Such individuals should be accompanied
during exercise by a companion aware of their
condition and capable of providing emergency assistance.
Patients with exercise-induced anaphylaxis should
have injectable epinephrine available at all times of
exercise for self-administration in the event of symptoms.
Any patient who has a history consistent with
food-dependent exercise-induced anaphylaxis should be
told not to exercise for 4 to 6 hours after eating. There is
controversy as to whether all patients should similarly
be told not to exercise postprandially, and the decision
to do so in such instances remains a clinical decision for
the physician.
IDIOPATHIC ANAPHYLAXIS
Summary Statements
51. The symptoms of idiopathic anaphylaxis are identical
to those of episodes related to known causes. C
52. Patients with idiopathic anaphylaxis should receive
an intensive evaluation, including a meticulous
history to rule out a definite cause of the events. C