The Australasian Society of Clinical Immunology and Allergy

1. RECOMMENDED

History of anaphylaxis* (if patient is considered to be at continuing risk)

2. MAY BE RECOMMENDED

History of a generalised* allergic reaction with one or more of the following factors:

• Asthma - concurrent or past history
  
• Age
  - Adolescents and young adults have a greater risk of fatal food anaphylaxis. The majority of recorded fatal reactions to foods (~90%) occur in children over the age of 5 years.
  - Adults have a greater risk of fatal stinging insect anaphylaxis than children.
  
• Specific allergic triggers
  Nut allergy (to peanuts or other nuts) - Most deaths from food anaphylaxis occur from nuts. Generalised allergic reactions can be triggered by exposure to trace or small amounts of nuts, which can be difficult to avoid. Subsequent allergic reactions to nuts may be unpredictable.
  Stinging insect allergy (Bees, wasps, Jumper ants) in adults
  
• Co-morbid conditions - Ischaemic heart disease
  
• Limited access to emergency medical care - In remote locations early administration of adrenaline may not be possible unless an EpiPen is available.

These factors should be considered when deciding whether an EpiPen is prescribed, as they are known risk factors for more severe or fatal reactions.

3. NOT NORMALLY RECOMMENDED

• Asthma - in patients with asthma without anaphylaxis or generalised allergic reactions
  
• Elevated specific IgE only (positive RAST and/or skin test) without a history of clinical reactions -
  Positive test results alone do not necessarily mean there is allergic disease. These patients may be referred to an allergy specialist for assessment of their risk of allergy and anaphylaxis. This may include further investigations such as challenge testing.
  
• Family (rather than personal) history of anaphylaxis or allergy
  Whilst the risk for allergic disease is inherited, anaphylaxis is not inherited.
  
• Local reactions to insect stings in adults and children
  
• Generalised skin rash (only) to bee or wasp stings in children
  Prospective follow-up studies of subsequent bee stings in children presenting with local reactions or generalised skin rash (only) show that these children are at a very low risk of experiencing anaphylaxis with subsequent stings.
  
• Resolved food allergy

ADRENALINE AUTOINJECTORS

Adrenaline autoinjectors available in Australia are EpiPen, EpiPen Jr, Anapen, Anapen Jr:

* Refer to definitions
** These are based on expert opinion which is at variance with the approved product information

IMPORTANT: An adrenaline autoinjector should only be prescribed within the context of a
comprehensive ANAPHYLAXIS MANAGEMENT PLAN.

ANAPHYLAXIS MANAGEMENT PLAN

An EpiPen should only be prescribed within the context of a comprehensive anaphylaxis management plan that includes the following;

• REFERRAL TO AN ALLERGY SPECIALIST
  
• IDENTIFICATION OF THE ANAPHYLACTIC TRIGGER(S)
  This should include a comprehensive history, clinical examination, appropriate use and interpretation of allergy testing.
  
  
• EDUCATION ON THE AVOIDANCE OF TRIGGER(S)
  This is particularly important with food anaphylaxis.
  
  
• PROVISION OF AN ANAPHYLAXIS ACTION PLAN
  This should document the following;
  
  • Name of child/adult
    
  • Allergic triggers
    
  • Carer contact details
    
  • Symptoms and signs indicating when to use the EpiPen
    
  • Instructions on how to use the EpiPen.

  
  Anaphylaxis action plans for EpiPen use can also be located at www.allergy.org.au

• APPROPRIATE FOLLOW-UP
  Review by an allergy specialist should occur to;
  
  • Ascertain if the correct trigger(s) have been identified
    
  • Determine whether the allergy persists
    
  • Provide re-education on EpiPen use
    
  • Renew action plan
    
  • Ensure the EpiPen has not expired.

DEFINITIONS

# 1 ANAPHYLAXIS

Anaphylaxis is a rapidly evolving generalised multi-system allergic reaction characterized by one or more symptoms or signs of respiratory and/or cardiovascular involvement and involvement of other systems such as the skin and/or the gastrointestinal tract. Symptoms/signs of respiratory/cardiovascular involvement are:

# 2 GENERALISED ALLERGIC REACTION 

A generalised allergic reaction is a characterized by one or more symptoms or signs of skin and/or gastrointestinal tract involvement without respiratory and/or cardiovascular involvement.

# 3 – ADRENALINE AUTOINJECTOR

Adrenaline autoinjectors are pre-loaded injector ‘pens’ containing an exact dose of adrenaline.

Adrenaline rapidly to reverse the effects of anaphylaxis and should be considered "First Aid" for its treatment.

Adrenaline autoinjectors available in Australia are EpiPen, EpiPen Jr, Anapen and Anapen Jr.

© ASCIA 2009

These revised guidelines are based on the 2003 guidelines developed by ASCIA - www.allergy.org .au ASCIA is the peak professional body of Clinical Immunologists and Allergists in Australia and New Zealand

Content updated September 2009