When we visit the doctor, we place all our trust in that he or she can help us with our ailments. But doctors are human – one reason why they must continue their education even while in practice. One area of medicine that more primary doctors and emergency physicians need more knowledge is that of allergic reactions, particularly anaphylaxis treatment.
A survey of 318 physicians sponsored by the Asthma and Allergy Foundation of America (AAFA) found that there are many who do not know the correct ways to treat anaphylaxis and prevent recurrences. For example, a “substantial number” do not always provide epinephrine to patients whom they believe to be having such a reaction.
Epinephrine is the first line of treatment for patients suffering from anaphylaxis, a life-threatening allergic reaction with symptoms that include skin reactions (including hives and flushed or pale skin), a sensation of a lump in the throat, constriction of airways and swollen tongue or throat causing difficulty breathing, weak and rapid pulse, nausea or vomiting, and dizziness or fainting. A delay in using the drug is common in severe food allergic reaction deaths.
The survey population consisted of approximately 100 emergency room physicians, 100 allergists, 50 adult primary care physicians and 50 pediatricians. Between 82 and 99% of respondents in each group had treated at least one anaphylaxis case. However, the number of doctors treating anaphylaxis with epinephrine was not 100%. About 10% of the ER doctors and 20% of the primary care and pediatric physicians said they had either prescribed another drug, such as an antihistamine or steroid, sent the patient to a hospital, or completed an “other action”.
Surprisingly, not all (but most – 97%) of the allergists gave epinephrine to their patients.
Follow-up care for anaphylaxis patients was not consistent, the survey results found. The doctors may not always refer patients for follow-up care, in which they may receive an auto-injector, such as an Epi-Pen, for their home use. And only 60% of the ER physicians prescribed one themselves. One reason for this – some of the doctors mistakenly believe that some patients should never receive epinephrine.
Dr. Myron Zitt MD of the State University of New York at Stony Brook presented these results at the American College of Allergy, Asthma and Immunology (ACAAI) annual meeting. He notes that his findings are consistent with results of earlier studies that show similar deficiencies in anaphylaxis care.
Interestingly, a separate speaker at the meeting revealed study results that show that even at major teaching hospitals, doctors do not always receive adequate education about anaphylaxis treatment.
Akhil Chouksey MD MBA of Case Western Reserve University conducted a 10-year review of research studies which included 575 cases between 2002 and 2011 and found that in only 15% were major national recommendations followed. These are that epinephrine be administered within 30 minutes of triage, that auto-injectors (such as an Epi-Pen) be prescribed at discharge, and that patients be referred to an allergist or immunologist for follow-up investigations and treatment.
According to the Centers for Disease Control and Prevention, food allergies have increased in recent years in the US by 20%. The increasing number of anaphylaxis reactions due to allergies should prompt physicians to educate themselves more about treatment and follow-up care. Parents of allergic children should also strive to be well-educated about the use of epinephrine in the case of a severe reaction.
Wood R, et al "Anaphylaxis in America: Results from a national physician survey" ACAAI 2012.
Chouksey A, et al "Management of anaphylaxis: are we compliant with the guidelines?" ACAAI 2012.
Sanadi NE, “ Paramedic Assessment and Treatment of Patients with Allergic Reactions and Anaphylaxis in a Large Urban Pre-Hospital System”