Pre-Hospital Epinephrine More Common in Anaphylaxis Cases Treated at Home

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A new investigation comparing anaphylaxis management between at-home and emergency department (ED) care settings in children receiving milk oral immunotherapy (OIT) revealed pre-hospital epinephrine use was significantly higher in reactions managed at home.¹

Canadian medical guidelines currently mandate the transfer of an individual to the ED for further assessment after anaphylaxis.² On the other hand, recent US-based guidelines recommend against routine transfer to the ED in all anaphylaxis cases, instead advising for case-by-case evaluation based on patient factors and circumstances.³

“With the shift in guidelines in some regions retiring the advice to transfer all patients to the ED post-epinephrine administration, our study provides timely evidence that supports the safety and efficacy of at-home management of certain anaphylactic reactions,” wrote the investigative team, led by Roy Khalaf, faculty of medicine, McGill University.¹

In this analysis, Khalaf and colleagues explored the distinction in anaphylaxis management and patient characteristics between those who presented to the ED after an anaphylactic episode and those who did not. Participants in the retrospective cohort study were children with challenge-confirmed diagnoses of milk allergy receiving milk OIT at 3 children’s hospitals in Canada from 2014 to 2023.

Adverse reactions matching the National Institute of Allergy and Infectious Disease’s definition of anaphylaxis were included for analysis. Investigators grouped the participants according to response post-allergic reaction into those who visited the ED and those who managed the reaction entirely at home.

Ultimately, 27 children receiving cow’s milk OIT were included for analysis—51.9% were male and the median age was 12 at the start of OIT. A total of 60 anaphylactic reactions were reported during the study period, with 63.3% leading to a visit to the ED and 8.3% classified as severe.

Upon analysis, 22 anaphylactic reactions were managed at home, compared with 38 in the ED. Antihistamines were the most commonly used treatment for both home management (63.6%) and ED management (31.6%). Respiratory manifestations were the most prevalent (83.3%) among all reactions, followed by dermatologic (71.7%) and gastrointestinal (45.0%).

However, Khalaf and colleagues identified no notable difference in the degree of severity of reaction between those managed at home and those in the ED. All patients, whether treated in the ED or at home, received ≥1 intramuscular epinephrine dose for anaphylaxis. A total of 95.5% of reactions managed at home required ≥1 dose of intramuscular epinephrine, compared with 78.9% of reactions in the ED.

Meanwhile, in the pre-hospital setting, 68.4% of reactions managed in the ED previously received a single-dose epinephrine. On the other hand, pre-hospital epinephrine was significantly higher in reactions managed at home (100%; P =.01).

As epinephrine administration was notably higher among patients managed at home, Khalaf and colleagues questioned the current recommendations for mandatory transfer to the ED. However, they admitted the study’s limitations included potential selection bias, as patients were undergoing OIT and presumably were health literate with access to care.

“...Early epinephrine use intervention at home can potentially successfully treat reactions without the need for further treatment in a hospital setting, especially if prompt administration is sufficient to control symptoms,” they wrote.

References

1. _{Buyansky D, Khalaf R, Gabrielli S, et al. Anaphylaxis Management in Paediatric Patients Undergoing Milk Oral Immunotherapy. Clin Exp Allergy. Published online October 9, 2024. doi:10.1111/cea.14582}
2. _{Cheng A. Emergency treatment of anaphylaxis in infants and children. Paediatr Child Health. 2011;16(1):35-40.}
3. _{Greenhawt M, Lieberman JA, Dribin TE, Shaker MS, Spergel J. Retire the advice to send patients to the emergency department after epinephrine use for observation. Ann Allergy Asthma Immunol. 2023;130(6):697-698. doi:10.1016/j.anai.2023.01.015}