NSAIDs Are a Major Cause of Anaphylaxis-Related Emergency Department Visits

September 16, 2014

NSAIDs Are a Major Cause of Anaphylaxis-Related Emergency Department Visits

  1. David J. Amrol, MD

Epinephrine is first-line treatment for drug-induced anaphylaxis, but it is underutilized.

  1. David J. Amrol, MD

Anaphylaxis is a life-threatening hypersensitivity reaction that can be allergic or nonallergic. Allergic causes of drug-induced anaphylaxis generally are IgE mediated (e.g., hives and angioedema within 1 hour of penicillin administration), whereas in nonallergic anaphylaxis, inflammatory mediators are released by nonspecific immunological mechanisms (e.g., leukotrienes in aspirin-associated respiratory disease, with reactions delayed up to 2–3 hours). In this study, researchers assessed the rate of anaphylaxis among 806 patients who presented to a Brazilian emergency department with drug-induced hypersensitivity reactions.

Of 117 patients who met criteria for anaphylaxis, culprit drugs were identified in 76%. Almost 50% of reactions were caused by nonsteroidal anti-inflammatory drugs (NSAIDs), followed by latex (12%), antibiotics (4%), and neuromuscular blockers, radiocontrast agents, and midazolam (3% combined). All NSAID reactions were nonallergic, and most featured urticaria or angioedema and bronchospasm or dyspnea; reactions to antibiotics, hypnotics, neuromuscular blockers, and latex were mostly IgE mediated. IgE-mediated reactions were more severe and involved in all cases of cardiogenic shock. Only 34% of patients with moderate-to-severe anaphylaxis received epinephrine in the emergency department.

Comment

Physicians should be aware that medications can cause both allergic and nonallergic anaphylactic reactions. Although the most severe reactions involving cardiogenic shock are IgE mediated, non–IgE-mediated causes such as NSAIDs and radiocontrast still are life-threatening and actually might be more common. Epinephrine is underutilized: Regardless of cause or mechanism, it is always first-line treatment for anaphylaxis.

Editor Disclosures at Time of Publication

  • Disclosures for David J. Amrol, MD at time of publication Equity Abbott; AbbieVie; Express Scripts; Johnson and Johnson; Novartis; Pfizer; United Health Leadership positions in professional societies Allergy Society of South Carolina (Past President)

Citation(s):

Reader Comments (3)

MARSHAL SHLAFER Other Healthcare Professional, Pharmacology/Pharmacy, University of Michigan Medical School

It's sad that physicians apparently have to be "reminded" that epinephrine, not (for example) diphenhydramine, is the drug of chioce for anaphylaxis.

ASHRAF SHEHATAH Physician, Family Medicine/General Practice, odaib polyclinic

Good article

RICH HARDIN Physician, Gastroenterology

Very informative

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