The evolution of pharmacological recommendations for anaphylaxis: a comparative analysis of established textbooks

Anaphylaxis can be life-threatening-due to its rapid-progressing and often unpredictable nature. Especially in such medical emergencies, robust clinical trials regarding adjunctive therapies can be scarce and recommendations across literature may vary. Hence, the aim of this study is to investigate the evolution of recommendations for the pharmacological management of anaphylaxis in established pharmacology textbooks over time. The following German textbook series were included: Aktories, Lüllmann, and Karow. The US standard work Goodman & Gilman was reviewed for an international comparison. This study focuses on epinephrine, H₁R-antagonists, H₂R-antagonists, and GCR-agonists-analyzing their potential use in anaphylaxis via predefined criteria and contextualizing it using the current AWMF anaphylaxis guideline. Epinephrine is continuously recommended as first-line treatment in anaphylaxis across textbooks and decades-with a shift towards i.m. use. Differences prevail regarding the anaphylaxis grade at which epinephrine is indicated vs. when H₁R-antagonists are considered sufficient. Overall, H₁R-antagonists are noted as adjuncts in at least more severe anaphylaxis. H₂R-antagonists appear to lack clinical relevance and are inconsistently discussed as adjunctive add-ons. While GCR-agonists are consistently recommended as adjuncts in anaphylaxis, the included US literature deviates from the German consensus of a high-dose approach. Moreover, there are differences regarding fluid resuscitation-some textbooks merely predate the guideline's recommendation to refrain from colloids, whereas others remain at odds with it even in their latest editions. While there is general agreement on epinephrine's central role in anaphylaxis management, recommendations in literature regarding the specific roles of certain adjunctive measures vary-likely reflecting the limited evidence.