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• W2097471346 abstract "To the Editor:The paper “Twelve-year survey of fatal reactions to allergen injections and skin testing: 1990-2001,” by Bernstein et al,1Bernstein D.I. Wanner M. Borish L. Liss G.M. Immunotherapy Committee of the AAAAITwelve-year survey of fatal reactions to allergen injections and skin testing: 1990-2001.J Allergy Clin Immunol. 2004; 113: 1129-1136Abstract Full Text Full Text PDF PubMed Scopus (407) Google Scholar includes detailed case reports of anaphylaxis deaths in 17 patients. The information about treatment compiled in Table II of this paper includes: whether or not epinephrine was given, the time from the onset of the allergic reaction to epinephrine injection, and the epinephrine initial dose and route of administration. The importance of such careful descriptions of epinephrine use in the treatment of anaphylaxis cannot be overestimated, given the absence of prospective, randomized, controlled clinical trials of epinephrine in anaphylaxis. It appears as if 6 of the 17 patients who died either did not receive epinephrine at all (patients 2, 5, and 9), or received it 10 to >30 minutes after the reaction started (patients 1, 3, and 17). Although patient 16 received it immediately, the dose was unknown, and patient 4 received it in an unknown dose after an unknown period of time had elapsed since the onset of the reaction.1Bernstein D.I. Wanner M. Borish L. Liss G.M. Immunotherapy Committee of the AAAAITwelve-year survey of fatal reactions to allergen injections and skin testing: 1990-2001.J Allergy Clin Immunol. 2004; 113: 1129-1136Abstract Full Text Full Text PDF PubMed Scopus (407) Google ScholarThe disconcerting fact remains that 9 of the 17 patients succumbing to anaphylaxis had received the recommended dose of epinephrine 0.3-0.5 mg, either immediately or within 3 minutes of the start of their allergic reaction.1Bernstein D.I. Wanner M. Borish L. Liss G.M. Immunotherapy Committee of the AAAAITwelve-year survey of fatal reactions to allergen injections and skin testing: 1990-2001.J Allergy Clin Immunol. 2004; 113: 1129-1136Abstract Full Text Full Text PDF PubMed Scopus (407) Google Scholar Health care professionals place considerable faith in the efficacy of an initial 0.3-0.5 mg dose of epinephrine injected promptly in the treatment of anaphylaxis.2Lieberman P.L. Anaphylaxis and anaphylactoid reactions.in: Adkinson Jr., N.F. Busse W.W. Yunginger J.W. Bochner B.S. Holgate S.T. Simons F.E.R. Middleton's allergy: principles & practice. 6th ed. Elsevier, Inc, St Louis2003: 1497-1522Google Scholar Availability of a body weight measurement from within a few months of death for these 9 patients might facilitate discussion about the adequacy, or lack of adequacy, of this initial 0.3-0.5 mg epinephrine dose.In addition to the epinephrine dose injected, potential reasons for apparent lack of response to epinephrine treatment in patients with anaphylaxis from allergen injection or any other trigger include use of the subcutaneous route for epinephrine injection and the presence of asthma as a comorbidity, both of which are discussed by Bernstein et al.1Bernstein D.I. Wanner M. Borish L. Liss G.M. Immunotherapy Committee of the AAAAITwelve-year survey of fatal reactions to allergen injections and skin testing: 1990-2001.J Allergy Clin Immunol. 2004; 113: 1129-1136Abstract Full Text Full Text PDF PubMed Scopus (407) Google Scholar There are many other possible scenarios—for example, injection of epinephrine that is past the expiry date, use of a suboptimal site of injection, and such rapid progression of anaphylaxis that no treatment avails.3Simons F.E.R. First-aid treatment of anaphylaxis to food: focus on epinephrine.J Allergy Clin Immunol. 2004; 113: 837-844Abstract Full Text Full Text PDF PubMed Scopus (183) Google Scholar To the Editor: The paper “Twelve-year survey of fatal reactions to allergen injections and skin testing: 1990-2001,” by Bernstein et al,1Bernstein D.I. Wanner M. Borish L. Liss G.M. Immunotherapy Committee of the AAAAITwelve-year survey of fatal reactions to allergen injections and skin testing: 1990-2001.J Allergy Clin Immunol. 2004; 113: 1129-1136Abstract Full Text Full Text PDF PubMed Scopus (407) Google Scholar includes detailed case reports of anaphylaxis deaths in 17 patients. The information about treatment compiled in Table II of this paper includes: whether or not epinephrine was given, the time from the onset of the allergic reaction to epinephrine injection, and the epinephrine initial dose and route of administration. The importance of such careful descriptions of epinephrine use in the treatment of anaphylaxis cannot be overestimated, given the absence of prospective, randomized, controlled clinical trials of epinephrine in anaphylaxis. It appears as if 6 of the 17 patients who died either did not receive epinephrine at all (patients 2, 5, and 9), or received it 10 to >30 minutes after the reaction started (patients 1, 3, and 17). Although patient 16 received it immediately, the dose was unknown, and patient 4 received it in an unknown dose after an unknown period of time had elapsed since the onset of the reaction.1Bernstein D.I. Wanner M. Borish L. Liss G.M. Immunotherapy Committee of the AAAAITwelve-year survey of fatal reactions to allergen injections and skin testing: 1990-2001.J Allergy Clin Immunol. 2004; 113: 1129-1136Abstract Full Text Full Text PDF PubMed Scopus (407) Google Scholar The disconcerting fact remains that 9 of the 17 patients succumbing to anaphylaxis had received the recommended dose of epinephrine 0.3-0.5 mg, either immediately or within 3 minutes of the start of their allergic reaction.1Bernstein D.I. Wanner M. Borish L. Liss G.M. Immunotherapy Committee of the AAAAITwelve-year survey of fatal reactions to allergen injections and skin testing: 1990-2001.J Allergy Clin Immunol. 2004; 113: 1129-1136Abstract Full Text Full Text PDF PubMed Scopus (407) Google Scholar Health care professionals place considerable faith in the efficacy of an initial 0.3-0.5 mg dose of epinephrine injected promptly in the treatment of anaphylaxis.2Lieberman P.L. Anaphylaxis and anaphylactoid reactions.in: Adkinson Jr., N.F. Busse W.W. Yunginger J.W. Bochner B.S. Holgate S.T. Simons F.E.R. Middleton's allergy: principles & practice. 6th ed. Elsevier, Inc, St Louis2003: 1497-1522Google Scholar Availability of a body weight measurement from within a few months of death for these 9 patients might facilitate discussion about the adequacy, or lack of adequacy, of this initial 0.3-0.5 mg epinephrine dose. In addition to the epinephrine dose injected, potential reasons for apparent lack of response to epinephrine treatment in patients with anaphylaxis from allergen injection or any other trigger include use of the subcutaneous route for epinephrine injection and the presence of asthma as a comorbidity, both of which are discussed by Bernstein et al.1Bernstein D.I. Wanner M. Borish L. Liss G.M. Immunotherapy Committee of the AAAAITwelve-year survey of fatal reactions to allergen injections and skin testing: 1990-2001.J Allergy Clin Immunol. 2004; 113: 1129-1136Abstract Full Text Full Text PDF PubMed Scopus (407) Google Scholar There are many other possible scenarios—for example, injection of epinephrine that is past the expiry date, use of a suboptimal site of injection, and such rapid progression of anaphylaxis that no treatment avails.3Simons F.E.R. First-aid treatment of anaphylaxis to food: focus on epinephrine.J Allergy Clin Immunol. 2004; 113: 837-844Abstract Full Text Full Text PDF PubMed Scopus (183) Google Scholar ReplyJournal of Allergy and Clinical ImmunologyVol. 115Issue 3PreviewTo the Editor: Full-Text PDF" @default.
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