Anaphylaxis is an acute serious allergic reaction, with multi-organ system manifestations
caused by the release of chemical mediators . It requires immediate recognition and
intervention.
The estimated rate of anaphylaxis in children was 10.5 per 100,000 persons-years .
Although the Rochester Epidemiology Project showed a rate of 75.1 per 100,000
person-years in children aged 9 years and 65.2 per 100,000 person-years in children aged
10-19-years old.
In the state of Qatar with approximately 280,000 visits annually to Pediatric Emergency
Center (PEC), there were 171 cases of anaphylaxis seen at the facility from September
2015 to September 2016.
Anaphylaxis is a clinical diagnosis based on typical systemic manifestations, due to
exposure to a causative agent. There are many possible triggers, including food,
medication, insect venoms, rubber latex and vaccines . In some individuals, anaphylaxis
is idiopathic. Both IgE and non-IgE activation of mast cells and basophils that results
in the release and production of several inflammatory and vasoactive substances, these
substances most commonly involve the skin, respiratory, cardiovascular, and
gastrointestinal systems. As a result, urticarial, angioedema, bronchospasm,
laryngospasm, increased vascular permeability and decreased vascular tone.
Anaphylaxis involves a range of signs and symptoms from hives, wheezing and angioedema to
cardiovascular collapse and death [9,10]. More than 80% of the patients will present with
flushing, itching, hives, angioedema, or other skin or mucosal symptoms. Generally up to
70%, at least 2 organ systems (skin, respiratory, cardiovascular, gastrointestinal
systems) are involved; however, only 10-45% have cardiovascular symptoms, including chest
pain, hypotension, or shock . Between 5% and 14% of patients may experience a recurrence
of anaphlactoid reaction 8-12 hours after the initial presentation, called Biphasic
(late-phase) . Most of these reactions are mild or moderate . Risk factors for biphasic
reactions include a severe initial reaction; presence of laryngeal edema or hypotension;
delay in the administration of adrenaline (epinephrine); too small a dose of adrenaline;
and a history of a previous biphasic reaction . Delayed symptoms can develop despite
treatment .
The mainstay of treatment for children experiencing anaphylaxis remains adrenaline 1:1000
intramuscularly (IM) . H1-antihistamines are also commonly administered in anaphylaxis.
The combination of H1 and H2 antihistamines appears to be more effective, especially for
cutaneous symptoms . The onset of activity of these agents is slower than epinephrine and
is considered next-in-line treatment.
International guidelines consider antihistamines and glucocorticoids as second-line .
Corticosteroids are not life-saving and do not have an immediate effect on the symptoms
of anaphylaxis, since it takes 4-6 hours to work.
Glucocorticoids are administered to 50% of individuals with anaphylaxis, despite a lack
of compelling evidence supporting their use.
Recent retrospective study in emergency department, evaluated the association between
glucocorticoids administration and prolonged length of stay. In 4years retrospective
chart review study on anaphylaxis patient, 70% of study patients received glucocorticoids
as part of their treatment. Glucocorticoids were not found to reduce follow up revisit in
the three days post discharge. And it didn't decrease the likelihood of extra epinephrine
need for flare of symptoms, and only found to decrease length of stay in severe
anaphylaxis.
The existing evidence for the use of glucocorticoids appears to consist mainly of
retrospective studies, case reports, and other descriptive literature. The need exists,
however, for a prospective study on the use of glucocorticoids in the treatment of
anaphylaxis and its effectiveness in prevention of biphasic reaction. The objective of
the current study, therefore, is to complement the current research on anaphylaxis and to
investigate if glucocorticoids are effective in the treatment of anaphylaxis and if it
can prevent or limit biphasic reaction.
This will be the first randomized controlled trial to look at steroid use in anaphylaxis
and its impact on anaphylaxis treatment on a prospective fashion which will be used to
help standardize care in the use of steroid for this common condition.
