In patients receiving a beta-adrenergic blocker who do not respond to epinephrine, glucagon, IV fluids, and other therapy, a risk/benefit assessment rarely may include the use of isoproterenol (Isuprel, a beta agonist with no alpha-agonist properties). airway) Look for cardiac causes (JVD, pedal edema, ascites) Tachycardia, anxiety . Penicillin skin testing includes major and minor determinants; the minor determinants are more predictive of future anaphylactic events. Latex is in gloves, catheters, and countless other medical supplies, as well as thousands of consumer products. Management of anaphylaxis: a systematic review. If insect stings trigger an anaphylactic reaction, a series of allergy shots (immunotherapy) might reduce the body's allergic response and prevent a severe reaction in the future. Ms. Terrie is a clinical pharmacy writer based in Haymarket, Virginia. There was no consensus on whether corticosteroids reduce biphasic anaphylactic reactions. Anaphylaxis-a 2020 practice parameter update, systematic review, and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) analysis. Children who received >1 dose of adrenaline and/or a fluid bolus for treatment of their primary anaphylactic reaction were at increased risk of developing a biphasic reaction.. itchy, watery eyes. Consultation with an allergist can help (1) confirm the diagnosis of anaphylaxis; (2) identify the anaphylactic trigger through history, skin testing, and RAST; (3) educate the patient in the prevention and initial treatment of future episodes; and (4) aid in desensitization and pretreatment when indicated. Copyright 2023 American Academy of Family Physicians. 3,11 Cutaneous symptoms, such as urticaria and angioedema, are the most common. These protocols include materials for educating teachers, office workers, and kitchen staff in the prevention and treatment of anaphylaxis. Prevention Ideally, the optimal management of anaphylaxis is avoidance of known triggers, but if a reaction occurs, being prepared is crucial to successful management and preventing complications. Therefore, current guidelines are mostly based on data from observational studies, animal and laboratory studies. EpiPen [prescribing information]. Sheikh A. Glucocorticosteroids for the treatment and prevention ofanaphylaxis. The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). The patient must be told to seek immediate professional help regardless of initial response to self-treatment. Update in pediatric anaphylaxis: a systematic review. By continuing to browse this site, you are agreeing to our use of cookies. This nongenomic glucocorticosteroid effect has been confirmed in vivo by showing that high-dose ICSs cause a dose-dependent decrease in airway blood flow (Qaw) that can be blocked with an 1-adrenergic antagonist5, 6 and by showing that the airway vascular smooth muscle response to inhaled albuterol is potentiated by pretreatment with a . Mol Biomed. J Allergy Clin Immunol Pract. Systematic reviews of these prophylactic approaches undertaken in patients being investigated with iodinated contrast media and treated with snake anti-venom therapy have found routine prophylaxis to be of questionable value. Campbell RL, et al. Journal of Allergy and Clinical Immunology. (LogOut/ As anaphylaxis is a medical emergency, there are no randomized controlled clinical trials on its emergency management. When history of exposure to an offending agent is elicited, the diagnosis of anaphylaxis is often obvious. A recent Cochrane systematic review failed to identify any randomized controlled or quasi-randomized trials investigating the effectiveness of glucocorticosteroids in the emergency management of anaphylaxis. 2013 May;52(5):451-61. Reactivation of latent tuberculosis. We advocate for federal and state legislation as well as regulatory actions that will help you. Identifying and. Aspirin sensitivity affects about 10 percent of persons with asthma, particularly those who also have nasal polyps. 2022 Mar 28;13:845689. doi: 10.3389/fphar.2022.845689. Immunotherapy is recommended for insect sting anaphylaxis, because it is 97 percent effective at preventing recurrent severe reactions.16 Protocols are available for oral and parenteral desensitization to penicillin, as well as a number of other antibiotics and medications.17,18 Desensitization must be repeated if treatment with the agent is interrupted. Anaphylaxis is common in children and has many differences across age groups. 2. Asthma and Allergy Foundation of America. Dhami S, Panesar SS, Roberts G, Muraro A, Worm M, Bil MB, Cardona V, Dubois AE, DunnGalvin A, Eigenmann P, Fernandez-Rivas M, Halken S, Lack G, Niggemann B, Rueff F, Santos AF, Vlieg-Boerstra B, Zolkipli ZQ, Sheikh A; EAACI Food Allergy and Anaphylaxis Guidelines Group. 2014 Feb;69(2):168-75. doi: 10.1111/all.12318. Campbell RL et al. Routine premedication with glucocorticosteroids in patients receiving iodinated contrast media, snake anti-venom therapy or allergen immunotherapy is unlikely to confer clinical benefit. This site uses cookies. Glucocorticosteroids are often used in the management of anaphylaxis in an attempt to reduce the severity of the acute reaction and decrease the risk of biphasic/protracted reactions. Alqurashi W and Ellis AK. Recent findings: Specific clinical circumstances must be considered in these decisions, however.18. Although epinephrine is the mainstay of recommended treatment, corticosteroids are also frequently used. Emergency department diagnosis and treatment of anaphylaxis. Oswalt ML, Kemp SF. Medical offices in which the occurrence of anaphylaxis is likely should consider periodic anaphylaxis drills. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Make sure the person is lying down and elevate the legs. Summary: Glucocorticosteroids should be regarded, at best, as a second-line agent in the emergency management of anaphylaxis, and administration of epinephrine should therefore not be delayed whilst glucocorticosteroids are drawn up and administered. For a sensitive patient urgently requiring radiocontrast, 50 mg of oral prednisone 13 hours, seven hours, and one hour before contrast plus 50 mg of diphenhydramine one hour before the procedure dramatically reduce the rate of recurrent reaction.19 Some experts advocate the addition of 25 mg of ephedrine, and 300 mg of cimetidine orally one hour before the procedure.20 If the patient cannot take oral medications, 200 mg of hydrocortisone intravenously may replace prednisone in these regimens. Mehr S, Liew WK, Tey D, Tang ML. Unfortunately, in most other cases there's no way to treat the underlying immune system condition that can lead to anaphylaxis. Glucocorticoids can treat this . Shaker MS, Wallace DV, Golden DBK, Oppenheimer J, Bernstein JA, Campbell RL, Dinakar C, Ellis A, Greenhawt M, Khan DA, Lang DM, Lang ES, Lieberman JA, Portnoy J, Rank MA, Stukus DR, Wang J; Collaborators; Riblet N, Bobrownicki AMP, Bontrager T, Dusin J, Foley J, Frederick B, Fregene E, Hellerstedt S, Hassan F, Hess K, Horner C, Huntington K, Kasireddy P, Keeler D, Kim B, Lieberman P, Lindhorst E, McEnany F, Milbank J, Murphy H, Pando O, Patel AK, Ratliff N, Rhodes R, Robertson K, Scott H, Snell A, Sullivan R, Trivedi V, Wickham A; Chief Editors; Shaker MS, Wallace DV; Workgroup Contributors; Shaker MS, Wallace DV, Bernstein JA, Campbell RL, Dinakar C, Ellis A, Golden DBK, Greenhawt M, Lieberman JA, Rank MA, Stukus DR, Wang J; Joint Task Force on Practice Parameters Reviewers; Shaker MS, Wallace DV, Golden DBK, Bernstein JA, Dinakar C, Ellis A, Greenhawt M, Horner C, Khan DA, Lieberman JA, Oppenheimer J, Rank MA, Shaker MS, Stukus DR, Wang J. J Allergy Clin Immunol. Lee JM, Greenes DS. Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) may produce a range of reactions, including asthma, urticaria, angioedema, and anaphylactoid reactions. Glucocorticosteroids should be regarded, at best, as a second-line agent in the emergency management of anaphylaxis, and administration of epinephrine should therefore not be delayed whilst glucocorticosteroids are drawn up and administered. and transmitted securely. Be sure you know how to use the autoinjector. Expert: Infusion Pharmacy Technicians Can Reduce Workload in Oncology Pharmacy, Clinical Forum Recap Data Show Melanoma Site to Be Independent High-Risk Factor for Recurrence, Poor Outcomes, E-Pedigree: An Inevitability for the Industry, CCPA Speaks Out: Obama's Health Care Reform Offers Opportunities for Pharmacy. If anaphylaxis is caused by an injection, administer aqueous . RAST checks in vitro for the presence of IgE to antigen and carries no risk of anaphylaxis. glucocorticosteroid vs albuterol for anaphylaxis Inhaled beta agonists lack some of the adverse effects of epinephrine and are useful for cases of bronchospasm, but they may not have additional effects when optimal doses of epinephrine are used.. Nausea, vomiting, diarrhea, cramping abdominal pain, Bananas, beets, buckwheat, Chamomile tea, citrus fruits, cow's milk,* egg whites,* fish,* kiwis, mustard, pinto beans, potatoes, rice, seeds and nuts (peanuts, Brazil nuts, almonds, hazelnuts, pistachios, pine nuts, cashews, sesame seeds, cottonseeds, sunflower seeds, millet seeds),* shellfish*, Amphotericin B (Fungizone), cephalosporins, chloramphenicol (Chloroptic), ciprofloxacin (Cipro), nitrofurantoin (Furadantin), penicillins,* streptomycin, tetracycline, vancomycin (Vancocin), Aspirin and nonsteroidal anti-inflammatory drugs*, Allergy extracts, antilymphocyte and antithymocyte globulins, antitoxins, carboplatin (Paraplatin), corticotropin (H.P. glucocorticosteroid vs albuterol for anaphylaxis. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. glucocorticosteroid vs albuterol for anaphylaxis A practice parameter update in 2015 by Lieberman et al includes an excellent discussion about the topic. 2010 Feb;125(2 Suppl 2):S161-81. Two authors independently assessed articles for inclusion. daisy yellow color flower; nfl players on steroids before and after; trailers for rent in globe, az New Service; Anaphylaxis: Emergency treatment. peel police collective agreement 2020 peel police collective agreement 2020 Nagata S, Ohbe H, Jo T, Matsui H, Fushimi K, Yasunaga H. Int Arch Allergy Immunol. Glucocorticosteroid vs albuterol for anaphylaxis. Tang AW. The report notes that the time to onset of corticosteroid effect is too slow to prevent severe outcomes, such as cardiorespiratory arrest or death, which tend to occur within 5-30 minutes for allergens such as medications, insect stings and foods. If the antigen was injected (e.g., insect sting), the portal of entry may be noted. They also state that patients with complete resolution of symptoms after treatment with epinephrine do not need to be prescribed corticosteroids. The initial management of anaphylaxis includes a focused examination, procurement of a stable airway and intravenous access, and administration of epinephrine.2,10 [Evidence level C, consensus and expert opinion] Vital signs and level of consciousness should be documented. how to change text duration on reels. 2019 Sep-Oct;7(7):2232-2238.e3. Fill in your details below or click an icon to log in: You are commenting using your WordPress.com account. The physician's primary tool is a detailed history of recent exposures to foods, medications, latex, and insects known to cause anaphylaxis. From the Publisher: Economic Impact on Pharmacy Patients, www.epipen.com/anaphylaxis_whatis.aspx#stats, www.mdconsult.com/das/book/body/119041677-2/0/1621/383.html, http://emedicine.medscape.com/article/756150-overview, www.mdconsult.com/das/book/body/118764067-3/799184944/1365/534.html#4-u1.0-B0-323-02845-4..50172-4--cesec63_8572, www.twinject.com/downloads/twinject_Prescribing_Information.pdf, http://emedicine.medscape.com/article/135065-overview. Acute Effect of an Inhaled Glucocorticosteroid on Albuterol-Induced Developing an anaphylaxis emergency action plan can help put your mind at ease. Medscape Web site. Through research, we gain better understanding of illnesses and diseases, new medicines, ways to improve quality of life and cures. Urinary and serum histamine levels and plasma tryptase levels drawn after onset of symptoms may assist in diagnosis. eCollection 2022. Anaphylaxis: Office Management and Prevention. Please enable it to take advantage of the complete set of features! For a complete list of side effects, please refer to the individual drug monographs. PMC Philadelphia: Saunders; 2007:chap 188. trouble breathing. Glucocorticoids: List, Uses, Side Effects, and More - Healthline EpiPen Web site. This is a corrected version of the article that appeared in print. In addition, we contacted experts in this health area and the relevant pharmaceutical companies. In refractory cases not responding to epinephrine because a beta-adrenergic blocker is complicating management, glucagon, 1 mg intravenously as a bolus, may be useful. Our community is here for you 24/7. Management of anaphylaxis. This content does not have an Arabic version. Clinical predictors for biphasic reactions inchildren presenting with anaphylaxis. Accessed January 29, 2009. Like antihistamines, there is concern regarding inappropriate use as first-line therapy instead of epinephrine.. Enfermedades de Inmunodeficiencia Primaria, AAAAI Diversity Equity and Inclusion Statement, Corticosteroids for treatment of anaphylaxis. Dreskin SC, Palmer GW. Anaphylaxis: acute treatment and management. Gabrielli S, Clarke A, Morris J, Eisman H, Gravel J, Enarson P, Chan ES, O'Keefe A, Porter R, Lim R, Yanishevsky Y, Gerdts J, Adatia A, La Vieille S, Zhang X, Ben-Shoshan M. J Allergy Clin Immunol Pract. Glucocorticoids for the treatment of anaphylaxis - PubMed Whether epinephrine administration could benefit subgroups of patients with co-morbid conditions such as asthma is not known. 2013. Biphasic anaphylaxis: A review of the literature and implications for emergency management. Pediatrics. MeSH An allergy occurs when the bodys immune system sees something as harmful and reacts. The use of nonionic contrast media provides additional protection.13. Research is an important part of our pursuit of better health. During an anaphylactic attack, you might receive cardiopulmonary resuscitation (CPR) if you stop breathing or your heart stops beating. Advocacy and public policy work are important for protecting the health and safety of those with asthma and allergies. Emergency Department Corticosteroid Use for Allergy or Anaphylaxis Is Not Associated With Decreased Relapses. Update in pediatric anaphylaxis: a systematic review. You might also be given medications, including: If you're with someone who's having an allergic reaction and shows signs of shock, act fast. Work with your own or your child's provider to develop this written, step-by-step plan of what to do in the event of a reaction. Purpose of review: Rarely, airway edema prevents endotracheal intubation and a surgical airway (e.g., emergency tracheostomy) is needed. Persons allergic to latex also may be sensitive to fruits such as bananas, kiwis, pears, pineapples, grapes, and papayas. PDF CLINICAL PATHWAY - Children's Hospital Colorado Anaphylaxis. We teach the general public about asthma and allergic diseases. In our previous version we searched the literature until September 2009. Dosing for the pediatric population is 5 mg/kg/day in divided doses 3 to 4 times a day, not to exceed 300 mg/day.15, H2RAs, such as ranitidine and cimetidine, block the effects of released histamine at H2 receptors, therefore treating vasodilatation and possibly some cardiac effects, as well as glandular hypersecretion.15, Some research suggests that H2 blockers with H1 blockers have additive benefit over H1 blockers alone in treating anaphylaxis.6,15,16 Ranitidine is probably preferred over cimetidine in anaphylaxis, because of the risk for hypotension with rapidly infused cimetidine and the multiple, complex drug interactions associated with the drug.15 Cimetidine should not be administered to children with anaphylaxis, because dosages have not been established.15,16. Review our cookies information for more details. According to the practice parameter update and another recent review, the evidence that corticosteroids reduce or prevent biphasic reactions is weak. All biphasic reactors, in which the second phase was anaphylactic, received either >1 dose of adrenaline and/or a fluid bolus. Corticosteroids appear to reduce the length of hospital stay, but did not reduce revisits to the emergency department. Nausea and vomiting may limit therapy with glucagon. BACKGROUND: We have previously shown that in patients with asthma a single dose of an inhaled glucocorticosteroid (ICS) acutely potentiates inhaled albuterol-induced airway vascular smooth muscle relaxation through a nongenomic action. Continuous hemodynamic monitoring is important. Cochrane Database Syst Rev. Your doctor may tell you to see an allergist An allergist can help you identify your allergies and learn to manage your risk of severe reactions, Ask your doctor for an anaphylaxis action plan. Anaphylaxis is a life-threatening reaction with respiratory, cardiovascular, cutaneous, or gastrointestinal manifestations resulting from exposure to an offending agent, usually a food, insect sting, medication, or physical factor. Shaker MC, et al. Diagnose the presence or likely presence of anaphylaxis. Overall, aspirin accounts for an estimated 3 percent of anaphylactic reactions.8 Symptoms may start immediately or several hours after ingestion. Animal studies demonstrated that corticosteroids act through multiple mechanisms. Osteoporosis due to a suppression of the body's ability to absorb calcium. There are several ways you can support AAFA in its mission to provide education and support to patients and families living with asthma and allergies. 1235 South Clark Street Suite 305, Arlington, VA 22202 Phone: 1-800-7-ASTHMA (1-800-727-8462). This puts them at higher risk of developing anaphylaxis, which also can cause breathing problems. 2021 Dec;8(4):251-254. doi: 10.15441/ceem.21.087. Unable to load your collection due to an error, Unable to load your delegates due to an error. For that reason, it is important to manage your asthma well. If a decision is made to administer isoproterenol intravenously, the proper dose is 1 mg in 500 mL D5W titrated at 0.1 mg per kg per minute; this can be doubled every 15 minutes. Two strengths are available: 0.3 mL of 1:1,000 epinephrine for adults, and 0.3 mL of 1:2,000 for children. Understanding the mechanisms of anaphylaxis. The dosage of glucagon is 1 to 5 mg (20-30 mcg/kg [maximum dose of 1 mg] in children) administered intravenously over 5 minutes and followed by an infusion (5-15 mcg/ min) titrated to clinical response. More than 25 million people in the United States have asthma. Your provider might want to rule out other conditions. glucocorticosteroid vs albuterol for anaphylaxis Albuterol may cause serious allergic reactions, including anaphylaxis, which can be life-threatening and require immediate medical attention. In addition, Lieberman et al suggest the following interventions16: Ideally, the optimal management of anaphylaxis is avoidance of known triggers, but if a reaction occurs, being prepared is crucial to successful management and preventing complications. The Asthma and Allergy Foundation of America (AAFA) conducts and promotes research for asthma and allergic diseases. Anaphylaxis-a practice parameter update 2015. This requires identification of the anaphylactic trigger, which is often difficult. We were unable to find any randomized controlled trials on this subject through our searches. MD Consult Web site. Patients receiving intravenous epinephrine require cardiac monitoring because of potential arrhythmias and ischemia. Replace epinephrine before its expiration date, or it might not work properly. Advise patient to keep epinephrine self-injection kit and oral diphenhydramine (Benadryl) for future exposures. Epub 2020 Jan 28. The common etiologies of anaphylaxis include drugs, foods, insect stings, and physical factors/exercise (Table 3).2 Idiopathic anaphylaxis (or reacting where no cause is identified) accounts for up to two thirds of persons who present to an allergist/immunologist. Darr CD. Before The site is secure. glucocorticosteroid vs albuterol for anaphylaxis Ring J, Grosber M, Mhrenschlager M, Brockow K. Chem Immunol Allergy. Oxygen administration is especially important in patients who have a history of cardiac or respiratory disease, inhaled b2-agonist use, and who have required multiple doses of epinephrine. Twinject [prescribing information]. If possible, the patient should avoid taking beta blockers, angiotensin-converting enzyme (ACE) inhibitors, angiotensin-II receptor blockers, and monoamine oxidase inhibitors, because these drugs may interfere with successful treatment of future anaphylactic episodes or with the endogenous compensatory responses to hypotension. Search methods: In our previous version we searched the literature until September 2009. Can albuterol help with anaphylaxis. A helpful clue to tell the these apart is that anaphylaxis may closely follow ingestion of a medication, eating a specific food, or getting stung or bitten by an insect. Administer the antihistamine diphenhydramine (Benadryl, adults: 25 to 50 mg; children: 1 to 2 mg per kg), usually given parenterally. Otolaryngology Clinics of North America. The devices are available in 2 strengths0.15 mg for patients weighing between 33 and 66 lb, and 0.30 mg for those patients weighing >66 lb. To review recent evidence on the effectiveness of glucocorticosteroids in the treatment and prevention of anaphylaxis. See permissionsforcopyrightquestions and/or permission requests. AAFA offers a variety of educational programs, resources and tools for patients, caregivers, and health professionals. (LogOut/ For bronchospasms resistant to adequate doses of epinephrine, the use of an inhaled agonist (eg, nebulized albuterol, 2.5-5 mg in 3 mL of saline and repeat as necessary) may be employed. Protocols for use in schools to manage children at risk of anaphylaxis are available through the Food Allergy Network. sneezing and stuffy or runny nose. They also reviewed 22 studies that specifically addressed the association of corticosteroids with biphasic anaphylaxis and only 1 study suggested a beneficial effect. If re-exposure to an offending medicine is necessary, administer the questionable medicine orally and observe the patient for the following 20 to 30 minutes; consider pretreatment with steroids and antihistamines. Bethesda, MD 20894, Web Policies These patients may have resistant severe hypotension, bradycardia, and a prolonged course. 8600 Rockville Pike We conclude that there is no evidence from high quality studies for the use of steroids in the emergency management of anaphylaxis. More PubMed results on management of anaphylaxis. Accessed Nov. 20, 2016. https://www.aaaai.org/Conditions-Treatments/allergies/anaphylaxis Accessed June 27, 2021. swelling of your face, lips, or throat. Therefore, we can neither support nor refute the use of these drugs for this purpose.. Another common cause of anaphylaxis is a sting from a fire ant or Hymenoptera (bee, wasp, hornet, yellow jacket, and sawfly). These doses can be repeated every six hours, as required. doi: 10.1016/j.jaci.2009.12.981. Approximately 40 to 100 deaths per year in the United States result from insect stings, and up to 3 percent of the U.S. population may be sensitized.1,2 A history of systemic reaction to an insect sting and positive venom skin test confers a 50 to 60 percent risk of reaction to future stings.7. Summary: 17, Antihistamines (H1 and H2 antagonists) are often used as adjunctive therapy for anaphylaxis. Glucagon exerts positive inotropic and chronotropic effects on the heart, independent of catecholamines. In addition, we contacted experts in this health area and the relevant pharmaceutical companies. Ann Allergy Asthma Immunol 115(2015):341-84. Mayo Clinic on Incontinence - Mayo Clinic Press, NEW The Essential Diabetes Book - Mayo Clinic Press, NEW Ending the Opioid Crisis - Mayo Clinic Press, FREE Mayo Clinic Diet Assessment - Mayo Clinic Press, Mayo Clinic Health Letter - FREE book - Mayo Clinic Press, Mayo Clinic Graduate School of Biomedical Sciences, Mayo Clinic School of Continuous Professional Development, Mayo Clinic School of Graduate Medical Education, Book: Mayo Clinic Family Health Book, 5th Edition, Newsletter: Mayo Clinic Health Letter Digital Edition. Disclaimer. Vega-Rioja A, Chacn P, Fernndez-Delgado L, Doukkali B, Del Valle Rodrguez A, Perkins JR, Ranea JAG, Dominguez-Cereijo L, Prez-Machuca BM, Palacios R, Rodrguez D, Monteseirn J, Ribas-Prez D. Front Immunol. We found an overall incidence of biphasic reactions of 6%, and an incidence of significant biphasic reactions of 3%, among pediatric patients admitted with anaphylaxis. An allergy occurs when the bodys immune system sees a substance as harmful and overreacts to it. Choo KJL, Simons FER, Sheikh A. Glucocorticoids for the treatment of anaphylaxis. Youre not alone. Corticosteroids for treatment of anaphylaxis - American Academy of Accessed June 27, 2021. glucocorticosteroid vs albuterol for anaphylaxis wheezing or. Eight to 17 percent of health care workers experience some form of allergic reaction to latex, although not all of these reactions are anaphylaxis.12 Recognizing latex allergy is critical because physicians may inadvertently expose the patient to more latex during treatment. Advertising revenue supports our not-for-profit mission. This site complies with the HONcode standard for trustworthy health information: verify here. When a concomitant -adrenergic blocking agent complicates treatment, consider glucagon infusion. A patient with a history of anaphylaxis should be instructed on how to initiate treatment for future episodes using pre-loaded epinephrine syringes. Beer MH, Porter RS, Jones TV, eds. Cochrane Database of Systematic Reviews 2012, Issue 4. Epub 2019 Apr 26. It causes approximately 1,500 deaths in the United States annually. 1/31/2018 : CD007596. It is commonly triggered by a food, insect sting, medication, or natural rubber latex. Additional measures then may be individualized.2,10 [Evidence level C, consensus and expert opinion] To slow absorption of injected antigens (e.g., insect stings), a tourniquet may be placed proximal to the injection site. Epub 2010 Jun 1. Krishnamurthy M, Venugopal NK, Leburu A, Kasiswamy Elangovan S, Nehrudhas P. Clin Cosmet Investig Dent.
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