A regional approach to unmet needs in anaphylaxis

Allergic diseases are under-diagnosed and undertreated despite their wide prevalence, and particularly anaphylaxis is often under-estimated. Evidence-based anaphylaxis guidelines developed by principal allergy organizations agree on increased prevalence of anaphylaxis, especially in patients younger than 18 years (18-27,30): this trend highlights the need for actions on anaphylaxis management and prevention (3,4). Lack of prompt connection between emergency department and allergy unit after discharge, and of a dedicated ICD-9th identification code (18-26), can delay diagnosis and treatment of anaphylaxis (28,29). Also in the experience of our Allergy Unit, patients reach the allergist office after several attacks treated in ED (17), without a previous evaluation and risk assessment. Keeping in mind unmet needs in anaphylaxis (4), we focused on regional approaches to health care delivery. The key point of our project was to establish an active collaboration between allergist clinicians and their counterparts in emergency medicine, with a system of quick filing report of patients discharged from ED with the suspect of anaphylactic reaction, directed to a central allergy unit, acting in a hub and spoke model with the Ligurian allergy network (31). Aim of the project was to improve epidemiological data collection via direct connection among ED and allergy network; moreover, we tried to provide a quick and proper evaluation of all reported patients, identifying, when possible, the agent responsible for anaphylaxis, to provide instructions on how to minimize future exposure; as all individuals at risk for anaphylaxis should carry and know how to self-administer epinephrine, we managed to provide auto injector and proper training when appropriate. A follow up on readmissions was carried out during the study and four months later. In a 20 months observation period (2013/2014), 205 patients were reported: it was possible to reach a diagnosis and risk assessment in 64.3%. Anaphylaxis diagnosis was considered likely if any 1 of 3 criteria is satisfied within minutes to hours: acute onset of illness with involvement of skin, mucosal surface, or both, and at least 1 of the following: respiratory compromise, hypotension, or end-organ dysfunction; 2 or more of the following occur rapidly after exposure to a likely allergen: involvement of skin or mucosal surface, respiratory compromise, hypotension, or persistent gastrointestinal symptoms; hypotension develops after exposure to a known allergen for that patient: age-specific low blood pressure or decreased systolic blood pressure more than 30% compared with baseline. Of 205 patients reported, 132 were classified as severe anaphylaxis; other 73 cases reported were 12 drugs related angioedema (mostly NSAID related), 9 ACEi related angioedema, 3 ereditary C1inh deficiency angioedema, 24 istaminergic idiopatic angioedema, 14 urticaria angioedema, 6 severe asthma, 2 latex reactions; in three patients a proper diagnosis was not achieved due to refuse / impossibility to perform diagnostic workout. Hymenoptera venom and food proved to be the main triggers, followed by drugs. 100% patients at risk of anaphylaxis received self-injectable adrenaline, pertinent education and individual action plan. In the same period, even though short, there were only two readmissions to ED. First result seems to confirm the usefulness of our approach to address some of unmet needs in anaphylaxis management, as recently pointed out by ICON guidelines (4).