conditions that predispose anaphylaxis
TRANSCRIPT
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Sandra N. González Díaz, MD, PhD
CONDITIONS THAT
PREDISPOSE ANAPHYLAXIS
December 2012
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Current President of the Latin American Society of Asthma, Allergy and Clinical Immunology (SLAAI) 2010-2012Director of the Residency Program in Allergy and Clinical Immunology, Regional Centre of Allergy and Clinical Immunology, University Hospital of Monterrey, NL since 1990
Head of Regional Centre of Allergy and Clinical Immunology, University Hospital, Monterrey, NL since 2000Professor of Regional Centre of Allergy and Clinical Immunology, UniversityHospital, Monterrey, NL since 1990Director of Fundraising Department, University Hospital since 2007
Director General, Department Fundraising at the Autonomous University of Nuevo Leon
Researcher Level 1 CONACYTPast President of the Mexican Association of Allergy and Clinical Immunology(CMICA) 2005-2007
Past President Chapter of the Latin American Society Mesoamerica Asthma, Allergy and Clinical Immunology (SLAAI) 1997-1999
Past president UNASMA (International Asthma Foundation) M2007-2011Member of CAICNL , CMICA, SLAAI, AAAAI, ACAAI, WAO, EAACI
Faculty of Medicine, U.A.N.L 1977-1983. Monterrey, NL MexicoSpecialty of Internal Medicine, University Hospital, UANL Monterrey, N.L.1986 – 1988Fellowship in Pediatric Allergy and Immunology Clíínica, UCSD, University of San Diego, California, USA, 1987-1988Subspecialty in Allergy and Clinical Immunology, University Hospital UANL , Monterrey, N. L.1988 – 1990Doctor of Medicine, Hospital Universitario UANL , Monterey, N.L.1991 - 1997
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MEDICAL TEAM CRAIC 2012
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FELLOW IN TRAINING CRAIC 2012
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+HISTORYThe first record of a case of anaphylaxis
2640 B.C.
Pharaoh Menes
Died from a bee sting
Ring J. Allergy and Clinical Immunology International 15(4): 144-148, 2003
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1889- C. Richet y Hericourt
ANAPHYLAXIS
They conducted experiments in dogs with eel serum, a powerful poison.He noted that after the second or third injection dogs were sicker than before
Term "anaphylaxis" = lack of immunityBy then Richet know the significance of their findings
Immunology's foundation: the 100-year anniversary of the Nobel Prize to Paul Ehrlich and Elie Metchnikoff. Stefan H E Kaufmann. Nature Immunology 9, 705 - 712 (2008)
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Anaphylaxis is a severe life-threatening generalized or systemic hypersensitivity reaction.
It is commonly, but not always, mediated by an allergic mechanism, usually by IgE.
Allergic (immunologic) non-IgE-mediated anaphylaxis also occurs.
Non-allergic anaphylactic reactions, formerly calledanaphylactoid or pseudo-allergic reactions, may also occur.
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+PREVALENCE OF ANAPHYLAXIS
Lifetime prevalence internationally estimated at 0.05-2%
Uncommon cause of death
Anaphylaxis fatalities often not diagnosed
Evidence base for assessment and management weak
Simons et al. WAO Anaphylaxis Guidelines.WAO Journal • February 2011
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First epidemiologic study on Anaphilaxis in Latin
America
Online questionnaire – www.slaai.org
Previously applied in Brazil
Translated into Spanish
Data filled in by allergologists
Total registered cases = 634 (Aug 2008 to Dec 2010)
http:www.slaai.org/
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Allergol Immunopathol (Madr). 2011; Nov 21. [Epub ahead of print]
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Solé et al – Clinics 2011,66:943-7
15 LA countries + Portugal – N = 634
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8,0
4,66,8
9,8
42,0
26,5
0
5
10
15
20
25
30
35
40
45
0-4 4 a 8 8 a 12 12 a 18 18 a 40 >40
Q3 – Gender?Q4 – Age?
Younger than 18 years = 191
Male44%
Female56%
Solé et al – Clinics 2011,66:943-7
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Place
No12.6%
Yes87.4%
Identification
Q6 - Place where reaction occured?Q7 – Could you identify the etiologic agent? Solé et al – Clinics 2011,66:943-7
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+Etiologic agents are differentaccording to age
Adults
Drugs (31.2%), foods (23.3%) and insect
(14.9%)
Children
Foods (26.2%), insect (25.0%) and drugs
(17.9%)
Solé et al – Clinics 2011,66:943-7
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9.8
1.9
7.8
0
47.1
1.9
27.5
3.9
11.8
25.5
3.9
17.6
3.9
0
5
10
15
20
25
30
35
40
45
50
Drugs NSAID Antib Others Food Fish/SF CM Fruits Egg Insects Bee Ant Wasp
Q8 – Type of offending agent?Solé et al – Clinics 2011,66:943-7
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6.93.4 3.4
0
31.0
10.36.9
3.46.9
44.8
13.8
27.6
3.4 3.4
0
5
10
15
20
25
30
35
40
45
50
Q8 – Type of offending agent?Solé et al – Clinics 2011,66:943-7
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23.3
14.0
9.3
14.0
2.3 2.3
4.73.4
4.7
23.3
14.0
2.3
7.0
9.3
0
5
10
15
20
25
Q8 – Type of offending agent?Solé et al – Clinics 2011,66:943-7
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31.730.6
0
12.9
6.5
0
3.21.6
11.311.3
6.5
9.3
1.6
0
5
10
15
20
25
30
35
Q8 – Type of offending agent?Solé et al – Clinics 2011,66:943-7
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33.1
27.4
4.5
23.3
14.0
0.3
4.5
1.5
12.0
6.03.8
2.3 1.5 2.30.7
0
5
10
15
20
25
30
35
Q8 – Type of offending agent?Solé et al – Clinics 2011,66:943-7
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43.5
26.2
8.96.5
23.2
13.1
1.22.9 1.8
11.3
7.1
0.63.6
1.2 0.6 1.20
5
10
15
20
25
30
35
40
45
50
Q8 – Type of offending agent?Solé et al – Clinics 2011,66:943-7
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+
RISK FACTORS FOR
ANAPHYLAXIS
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+AGE RELATED FACTORS
Simons et al. WAO Anaphylaxis Guidelines.WAO Journal • February 2011
More frequent in adults than children for some agents: radiocontrast media, plasma expanders, anesthetics – may be
function of exposure frequency.
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+GENDER
Reportedly more frequent in females for latex, aspirin, and muscle relaxants
May be more frequent in males for Hymenoptera stings, perhaps a function of exposure
An age-related effect has been shown with males affected more frequently under age 15 years, and females affected more frequently after age 15
Simons et al. WAO Anaphylaxis Guidelines.WAO Journal • February 2011
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+CONCOMITANT DISEASES
Simons et al. WAO Anaphylaxis Guidelines.WAO Journal • February 2011
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+CURRENT MEDICATIONS/DRUGS
Medications
Antibiotics (B lactam)
NSAIDs
Recently: biological (infliximab 3%)
Simons et al. WAO Anaphylaxis Guidelines.WAO Journal • February 2011
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+FOOD
Walnuts have often been involved, with the peanut, the most common in USA.
Also shellfish, fish, milk and egg
Wheat and rice may be the most common cause in Asia
Middle East: sesame
In children, milk, egg
Simons et al. WAO Anaphylaxis Guidelines.WAO Journal • February 2011
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+CO-FACTORS
Exercise
Some cofactors for submission:Dependent foods: tomatoes, seafood, wheat, peanuts, corn.
NSAIDs, alcohol, menstruation, exposure to pollen,
Simons et al. WAO Anaphylaxis Guidelines.WAO Journal • February 2011
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+INSECT BITE
Hymenoptera: bees, vespid, ants
Very studied in Europe, North
Species vary from region to region
Systemic reactions:Adults: 3%
Children: 1%
Mosquitoes, ticks, little studied
Simons et al. WAO Anaphylaxis Guidelines.WAO Journal • February 2011
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OTHER RISK FACTORS IN ANAPHYLAXISPancake Syndrome (Oral Mite Anaphylaxis)WAO Journal , Mayo 2009 pag. 91-96 Mario Sanchez-Borges,MD et all.
History of atopic disease
Sensitivity Mites
Cutaneous hypersensitivity to NSAIDs
Ingestion of Pancakes / Breaded or food contaminated with mites
Ingestion of more than 1mg of mite allergen (> 500 mites / g. Flour)
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+OTHER POSSIBLE RISK FACTORS
Elevated baseline levels of tryptase
Histamine
Bradykinin (because of low serum ACE activity)
Platelet-activating factor (PAF) (because of low serum PAF acetylhydrolase activity)
Simons et al. WAO Anaphylaxis Guidelines.WAO Journal • February 2011
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+SUMARY
The incidence of anaphylaxis is increasing
Anaphylaxis is underdiagnosed and underreported
Risk factors for death include the presence of asthma, and deaths occur relatively more
frequently in teenagers and in the elderly with other medical problems
Patients subject to recurrent anaphylactic episodes should try to avoid drugs which
complicate therapy or potentially may increase the severity of a reaction
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+ MEASURES TO REDUCE THE INCIDENCE OF ANAPHYLAXIS AND ANAPHYLACTIC DEATHS
General Obtain thorough history for drug allergy.
Avoid drugs that have immunologic or biochemical cross-reactivity with any agents to which the patient is sensitive.
Administer drugs orally rather than parenterally when possible.
Check all drugs for proper labeling. Keep patients in the office 20 to 30 minutes after injections.
Adkinson: Middleton's Allergy: Principles and Practice, 7th ed.Chapter 59 – Anaphylaxis . Phillip L. Lieberman
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Have patient wear and carry warning identification tags.
Teach self-injection of epinephrine and caution patients to keep an epinephrine auto-injector with them.
Discontinue beta-adrenergic blocking agents, angiotensin-converting enzyme (ACE) inhibitors, ACE blockers, monoamine oxidase inhibitors, and certain tricyclic antidepressants when possible.
Use preventive techniques when patients are required to undergo a procedure or take an agent that places them at risk. Such techniques include pretreatment, provocative challenge, and desensitization.
MEASURES TO REDUCE THE INCIDENCE OF ANAPHYLAXIS AND ANAPHYLACTIC DEATHS
Adkinson: Middleton's Allergy: Principles and Practice, 7th ed.Chapter 59 – Anaphylaxis . Phillip L. Lieberman
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+ GRACIAS.