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Ketotifen: A Role in the Treatment of Idiopathic Anaphylaxis
Abstracts AB205
J ALLERGY CLIN IMMUNOL VOLUME 135, NUMBER 2
Pre-Hospital Use of Epinephrine for Treatment of Anaphylaxis in Children and Adolescents Melissa Lee, DO, David R. Stukus, MD, FAAAAI; Nationwide Children’s Hospital, Columbus, OH. RATIONALE: Epinephrine is the most effective and first line treatment for anaphylaxis but is underutilized by patients and medical personnel. METHODS: We performed a retrospective review of the electronic medical record for all patients ages 0-25 with ICD-9 codes 995.0,995.6x, who presented to the Emergency Department(ED) or Urgent Care(UC) at a tertiary care pediatric academic referral center during the time period 2009-2013. RESULTS: Four-hundred-and-eight patients(mean age57.25 years,62% male) were identified. Thirty-six percent (N5148) received epinephrine prior to arrival at ED/UC, 65% (N5264) had a prior history of anaphylaxis, and 47% (N5191) had a prior epinephrine auto-injector prescription. Peanuts (N5149,37%) and tree nuts (N585,21%) were the most common causes identified. Symptoms included: skin/mucosal (N5378,93%), respiratory (N5305, 75%), and gastrointestinal (N5147,36%). Of all patients, 42% (N5175) were discharged to home, but only 13% (N555) had a follow up appointment scheduled with an Allergist/Immunologist. Hospitalization occurred for 33% (N5134), with 2.7% (N511) requiring intensive care. Patients who received epinephrine prior to arrival at ED/UC differed in the following characteristics: history of prior anaphylaxis (N5 264,65%; OR54.267, p<0.0001), reaction at school (N549,12%; OR5 2.636, p50.0021), disposition to home (N5175, 42%; OR51.786, p50.0073), and age 13-17 years (N591,22%; OR51.802, p50.0194). Patients who did not receive epinephrine prior to arrival at ED/UC differed in the following characteristics: required transfer to another medical facility (N588,22%; OR57.70, p<0.0001), reaction at home (N5 120,29%; OR5 1.758, p50.0178), epinephrine auto-injector available at time of reaction(N552, 13%;OR52.327, p50.0206),and involvement of two or more organ systems (N5335,82%; OR51.986, p50.0106). CONCLUSIONS: Despite being established as the most effective and first line treatment of anaphylaxis, the majority of children and adolescents did not receive epinephrine prior to arrival at the ED/UC. Increased education for patients and emergency responders is paramount to improving treatment for this life-threatening condition.
663
Ketotifen: A Role in the Treatment of Idiopathic Anaphylaxis Zhenhong Li, MD, PhD, Jocelyn Celestin, MD, FAAAAI; Albany Medical College, Albany, NY. RATIONALE: Idiopathic anaphylaxis is a life-threatening disease characterized by acute and recurrent episodes of urticaria, angioedema, airway compromise, gastrointestinal symptoms and shock. It is diagnosed when a patient has signs and symptoms of anaphylaxis without any apparent triggers. The treatment consists of anti-histamines and oral steroids. However, long term prednisone therapy has a variety of known debilitating side effects. Ketotifen is an oral anti- allergic drug which also inhibits the release of mast cell and basophil mediators. It has been shown to be effective for treating chronic urticaria and idiopathic anaphylaxis. METHODS: We describe 6 patients with corticosteroid dependent idiopathic anaphylaxis who were successfully treated with ketotifen. Detailed history, physical examination and extensive laboratory evaluation failed to indicate any specific trigger of their anaphylaxis. RESULTS: The duration of symptoms prior to treatment ranges from one month to 13 years. All patients had angioedema, urticaria or both. Some patients had various concomitant medical conditions but none of them was shown to be casually related with their anaphylactic episodes. Some of them were on long term prednisone treatment. All patients were placed on 2-4 mg ketotifen orally twice daily. Among the 6 patients, one had an episode of recurrence requiring increased dose of ketotifen. Five of the 6 patients were able to come off prednisone without recurrence of symptoms. CONCLUSIONS: Our clinical experience suggests that ketotifen is effective in inducing remission of corticosteroid dependent idiopathic anaphylaxis. More studies are needed to determine the role of Ketotifen in the treatment of idiopathic anaphylaxis.
664
Delayed Urticarial and Anaphylactic Reactions to Red Meat: Age of Onset, Severity, and Immunology Among 353 Cases and 140 Controls Scott P. Commins, MD, PhD1, Alexander J. Schuyler, BS, BA2, Lisa J. Workman, BA3, Luis A. Matos, MD, MBA, FAAAAI4, Saju S. Eapen, MD4, Charles J. Lane, MD5, Theo Rispens, PhD6, Peter W. Heymann, MD7, Timothy F. Platts-Mills, MD, MSc8, Thomas A. E. Platts-Mills, MD, PhD, FAAAAI, FRS1; 1Division of Asthma, Allergy and Immunology, University of Virginia Health System, Charlottesville, VA, 2Department of Medicine, Division of Asthma, Allergy and Immunology, University of Virginia, Charlottesville, VA, 3University of Virginia, Charlottesville, VA, 4Asthma and Allergy Center, Roanoke, VA, 5 Allergy Partners, Lynchburg, VA, 6Sanquin Research, Amsterdam, Netherlands, 7Division of Asthma, Allergy & Immunology, University of Virginia Health System, Charlottesville, VA, 8Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC. RATIONALE: Patients with IgE to galactose-alpha-1,3,-galactose report delayed reactions, which vary from itching or gastrointestinal distress to frank anaphylaxis. METHODS: Patients who presented to allergy clinics in Virginia with histories compatible with delayed reactions to red meat (n5353) or with recurrent urticarial or anaphylactic reactions of other types (n5140), many of which appeared to be idiopathic, completed a questionnaire. Sera were assayed for IgE antibodies, total IgE, and alpha-gal specific IgG. RESULTS: IgE was measured to alpha-gal and mammalian allergens, to six inhalant allergens, to five foods, and to two venoms. Results for IgE and IgG to alpha-gal were analyzed in relation to symptoms and related to evidence of preexisting atopy. The presence of IgE antibodies to inhalant allergens was not correlated with sensitization to alpha-gal. Severity of reactions (urticaria, n587 or anaphylaxis, n5249) was not associated with the titer of IgE antibodies to alpha-gal. In addition, neither the ratio of alpha-gal IgE to total IgE nor IgG antibodies to alpha-gal were correlated to reaction severity. Of those with anaphylaxis, 45% reported their first food reaction after age 40, and in 85% of cases the reactions started 2 hours or more after eating meat. The severity of reactions was not related to age of onset or delay before reactions. CONCLUSIONS: Patients with delayed anaphylaxis to red meat present a novel disease with late onset, delayed expression, no immediate symptoms of food allergy, and a very high incidence of previous exposure to ticks. Atopy was not a predictor of IgE responses or food reactions.
MONDAY
662
J ALLERGY CLIN IMMUNOL VOLUME 135, NUMBER 2
Pre-Hospital Use of Epinephrine for Treatment of Anaphylaxis in Children and Adolescents Melissa Lee, DO, David R. Stukus, MD, FAAAAI; Nationwide Children’s Hospital, Columbus, OH. RATIONALE: Epinephrine is the most effective and first line treatment for anaphylaxis but is underutilized by patients and medical personnel. METHODS: We performed a retrospective review of the electronic medical record for all patients ages 0-25 with ICD-9 codes 995.0,995.6x, who presented to the Emergency Department(ED) or Urgent Care(UC) at a tertiary care pediatric academic referral center during the time period 2009-2013. RESULTS: Four-hundred-and-eight patients(mean age57.25 years,62% male) were identified. Thirty-six percent (N5148) received epinephrine prior to arrival at ED/UC, 65% (N5264) had a prior history of anaphylaxis, and 47% (N5191) had a prior epinephrine auto-injector prescription. Peanuts (N5149,37%) and tree nuts (N585,21%) were the most common causes identified. Symptoms included: skin/mucosal (N5378,93%), respiratory (N5305, 75%), and gastrointestinal (N5147,36%). Of all patients, 42% (N5175) were discharged to home, but only 13% (N555) had a follow up appointment scheduled with an Allergist/Immunologist. Hospitalization occurred for 33% (N5134), with 2.7% (N511) requiring intensive care. Patients who received epinephrine prior to arrival at ED/UC differed in the following characteristics: history of prior anaphylaxis (N5 264,65%; OR54.267, p<0.0001), reaction at school (N549,12%; OR5 2.636, p50.0021), disposition to home (N5175, 42%; OR51.786, p50.0073), and age 13-17 years (N591,22%; OR51.802, p50.0194). Patients who did not receive epinephrine prior to arrival at ED/UC differed in the following characteristics: required transfer to another medical facility (N588,22%; OR57.70, p<0.0001), reaction at home (N5 120,29%; OR5 1.758, p50.0178), epinephrine auto-injector available at time of reaction(N552, 13%;OR52.327, p50.0206),and involvement of two or more organ systems (N5335,82%; OR51.986, p50.0106). CONCLUSIONS: Despite being established as the most effective and first line treatment of anaphylaxis, the majority of children and adolescents did not receive epinephrine prior to arrival at the ED/UC. Increased education for patients and emergency responders is paramount to improving treatment for this life-threatening condition.
663
Ketotifen: A Role in the Treatment of Idiopathic Anaphylaxis Zhenhong Li, MD, PhD, Jocelyn Celestin, MD, FAAAAI; Albany Medical College, Albany, NY. RATIONALE: Idiopathic anaphylaxis is a life-threatening disease characterized by acute and recurrent episodes of urticaria, angioedema, airway compromise, gastrointestinal symptoms and shock. It is diagnosed when a patient has signs and symptoms of anaphylaxis without any apparent triggers. The treatment consists of anti-histamines and oral steroids. However, long term prednisone therapy has a variety of known debilitating side effects. Ketotifen is an oral anti- allergic drug which also inhibits the release of mast cell and basophil mediators. It has been shown to be effective for treating chronic urticaria and idiopathic anaphylaxis. METHODS: We describe 6 patients with corticosteroid dependent idiopathic anaphylaxis who were successfully treated with ketotifen. Detailed history, physical examination and extensive laboratory evaluation failed to indicate any specific trigger of their anaphylaxis. RESULTS: The duration of symptoms prior to treatment ranges from one month to 13 years. All patients had angioedema, urticaria or both. Some patients had various concomitant medical conditions but none of them was shown to be casually related with their anaphylactic episodes. Some of them were on long term prednisone treatment. All patients were placed on 2-4 mg ketotifen orally twice daily. Among the 6 patients, one had an episode of recurrence requiring increased dose of ketotifen. Five of the 6 patients were able to come off prednisone without recurrence of symptoms. CONCLUSIONS: Our clinical experience suggests that ketotifen is effective in inducing remission of corticosteroid dependent idiopathic anaphylaxis. More studies are needed to determine the role of Ketotifen in the treatment of idiopathic anaphylaxis.
664
Delayed Urticarial and Anaphylactic Reactions to Red Meat: Age of Onset, Severity, and Immunology Among 353 Cases and 140 Controls Scott P. Commins, MD, PhD1, Alexander J. Schuyler, BS, BA2, Lisa J. Workman, BA3, Luis A. Matos, MD, MBA, FAAAAI4, Saju S. Eapen, MD4, Charles J. Lane, MD5, Theo Rispens, PhD6, Peter W. Heymann, MD7, Timothy F. Platts-Mills, MD, MSc8, Thomas A. E. Platts-Mills, MD, PhD, FAAAAI, FRS1; 1Division of Asthma, Allergy and Immunology, University of Virginia Health System, Charlottesville, VA, 2Department of Medicine, Division of Asthma, Allergy and Immunology, University of Virginia, Charlottesville, VA, 3University of Virginia, Charlottesville, VA, 4Asthma and Allergy Center, Roanoke, VA, 5 Allergy Partners, Lynchburg, VA, 6Sanquin Research, Amsterdam, Netherlands, 7Division of Asthma, Allergy & Immunology, University of Virginia Health System, Charlottesville, VA, 8Department of Emergency Medicine, University of North Carolina, Chapel Hill, NC. RATIONALE: Patients with IgE to galactose-alpha-1,3,-galactose report delayed reactions, which vary from itching or gastrointestinal distress to frank anaphylaxis. METHODS: Patients who presented to allergy clinics in Virginia with histories compatible with delayed reactions to red meat (n5353) or with recurrent urticarial or anaphylactic reactions of other types (n5140), many of which appeared to be idiopathic, completed a questionnaire. Sera were assayed for IgE antibodies, total IgE, and alpha-gal specific IgG. RESULTS: IgE was measured to alpha-gal and mammalian allergens, to six inhalant allergens, to five foods, and to two venoms. Results for IgE and IgG to alpha-gal were analyzed in relation to symptoms and related to evidence of preexisting atopy. The presence of IgE antibodies to inhalant allergens was not correlated with sensitization to alpha-gal. Severity of reactions (urticaria, n587 or anaphylaxis, n5249) was not associated with the titer of IgE antibodies to alpha-gal. In addition, neither the ratio of alpha-gal IgE to total IgE nor IgG antibodies to alpha-gal were correlated to reaction severity. Of those with anaphylaxis, 45% reported their first food reaction after age 40, and in 85% of cases the reactions started 2 hours or more after eating meat. The severity of reactions was not related to age of onset or delay before reactions. CONCLUSIONS: Patients with delayed anaphylaxis to red meat present a novel disease with late onset, delayed expression, no immediate symptoms of food allergy, and a very high incidence of previous exposure to ticks. Atopy was not a predictor of IgE responses or food reactions.
MONDAY
662