The GameChanger
A new study looks at the utility of omalizumab in preventing food allergy reactions after accidental exposure.
ACEis and Beta-blockers should be avoided in patients with recurrent anaphylaxis if possible.
Host
Geoff Wall, PharmD, BCPS, FCCP, BCGP
Professor of Pharmacy Practice, Drake University
Internal Medicine/Critical Care, UnityPoint Health
Reference
Study: https://www.nejm.org/doi/full/10.1056/NEJMoa2312382
Anaphylaxis guideline: https://www.annallergy.org/article/S1081-1206(23)01304-2/fulltext
Pharmacist Members, REDEEM YOUR CPE HERE!
Not a member? Get a Pharmacist Membership & earn CE for GameChangers Podcast episodes! (30 mins/episode)
CPE Information
Learning Objectives
Upon successful completion of this knowledge-based activity, participants should be able to:
1. Discuss the OUtMATCH study results and their relevance to patients with food allergies.
2. Interpret the new AAAAI anaphylaxis guidelines in relation to patient care.
0.05 CEU/0.5 Hr
UAN: 0107-0000-24-079-H01-P
Initial release date: 03/18/2024
Expiration date: 03/18/2025
Additional CPE details can be found here.
The GameChanger
A new study looks at the utility of omalizumab in preventing food allergy reactions after accidental exposure.
ACEis and Beta-blockers should be avoided in patients with recurrent anaphylaxis if possible.
Host
Geoff Wall, PharmD, BCPS, FCCP, BCGP
Professor of Pharmacy Practice, Drake University
Internal Medicine/Critical Care, UnityPoint Health
Reference
Study: https://www.nejm.org/doi/full/10.1056/NEJMoa2312382
Anaphylaxis guideline: https://www.annallergy.org/article/S1081-1206(23)01304-2/fulltext
Pharmacist Members, REDEEM YOUR CPE HERE!
Not a member? Get a Pharmacist Membership & earn CE for GameChangers Podcast episodes! (30 mins/episode)
CPE Information
Learning Objectives
Upon successful completion of this knowledge-based activity, participants should be able to:
1. Discuss the OUtMATCH study results and their relevance to patients with food allergies.
2. Interpret the new AAAAI anaphylaxis guidelines in relation to patient care.
0.05 CEU/0.5 Hr
UAN: 0107-0000-24-079-H01-P
Initial release date: 03/18/2024
Expiration date: 03/18/2025
Additional CPE details can be found here.
Hey, ce plan members from CE Impact. This is Game Changers. I'm Jen Moulton, and with me today is our resident Game Changers contributor, jeff Wall. Hey, jeff.
Speaker 2:How you doing.
Speaker 1:Doing well. Today. It's sunny out and we're recording on a Friday, actually to get ready for Monday, so I'm feeling like spring.
Speaker 2:Yeah, and in this part of the world, you know again, it's always hard to remember that podcasts can be all over the world. But yeah, in this part of the world it's usually warm, which is kind of nice.
Speaker 1:Yeah, well, unusually warm at this time of year for us, so that's awesome. So this week, jeff and I were talking about two related but different Game Changers food allergies and anaphylaxis. So we know that amylizumab can help patients who've had an accidental overdose, but in the lay media lately there's been a new study that looks at prevention for that. So we thought that would be a good topic, because a lot of people, a lot of people, have food allergies and that can be really scary. So when we talked about this, jeff, what were the things that we talked about? That, you know, made this kind of a game changer, even though this is kind of a topic that's been around and people have been using, you know, this drug, kind of on more of a rescue, I guess, if there was an accidental overdose. But I think this one talks about prevention. So get into it a little bit and talk to us about why this is a game changer.
Speaker 2:We'll do. And yeah, I mean you know we had talked about whether this was, you know, game changer worthy, if you will, and I think. But you know, we know that amylizumab has been used kind of off label for a while. But this is a relatively large series of studies. It's not just one study, it's an ongoing, you know, three phase study that wanted to look at if patients are at high risk for anaphylaxis is basically routine amylizumab, a drug that will basically lessen their chance of getting into serious trouble if they accidentally get exposed to the whatever food allergy they have. So yeah, that's basically what we're going to talk about and I can start talking about the study if you'd like.
Speaker 1:Yeah, that would be great. Let's jump in.
Speaker 2:Sounds like a plan. So, as you point out, food allergy is common. It probably was always common.
Speaker 2:I think there's this perception in the lay media that you know, oh my gosh, all of a sudden, where are all these big kids having food allergy? And I think there is some evidence suggests that that food allergy incidence is increasing in that developed world and there's a number of you know, potential theories for that. You know, because of the fact that we're exposed to less allergens, you know, does our body, you know, have a more difficult time? That you know. I mean again, we, you know you could do an entire set of game changers, kind of theorizing on that. I don't, I don't think that's really important.
Speaker 2:I think the bottom line is that we're certainly recognizing it more and seeing more severe food allergy reactions. Estimates suggest that 15 million patients in the US have severe food allergies, including 6 million children, and that's certainly where I hear about it. A lot is children with severe food allergy. It is actually the most common cause of anaphylaxis and pediatric patients that are seen in emergency rooms. I thought that was kind of interesting and, of course, you know, because it's almost always from accidental exposures and, yeah, almost always with the scenario that happens is someone is accidentally exposed to an offending food they get into trouble.
Speaker 2:They end up in the emergency room and in patients, especially with multiple food allergy, it becomes just an unbelievable like almost a prison for them because there's just so few things they can eat and they have a hard time going out to go out with friends and all that other stuff because of the fear of accidentally being exposed to stuff it has.
Speaker 2:So it has a negative impact on patients quality of life even if they never have more than, say, one anaphylactic reaction in their life because they're pretty careful, they have to. You know, again, it's almost like, almost like being in prison, you know, especially in patients who have multiple food allergies. The food allergy that has been associated with the most anaphylactic reactions, though is is not allergy, right. So tree nut and peanut allergies are the allergies that that that seem to have have been responsible for most anaphylactic reactions. And that's tough because, you know, peanut oil, peanut derivatives are in tons of foods and so that makes it again very, very challenging for these patients. There really is no treatment They've tried. Immunotherapy for peanut allergy may have some utility. The problem is is that it isn't long lasting utility and that it's a very burdensome process because exposure to the immunotherapy in and of itself usually causes reactions because of the sensitivity these patients have. So so unfortunately, we have no real preventative treatment for these patients. A lot of patients, a lot of children, lose their allergy, but recent studies have suggested that a significant number of patients with childhood severe food allergy actually will carry that into adulthood too. So again, it's just, it's a challenging thing and we I think we need to do.
Speaker 2:I know there's a lot of research going on, looking at better treatments. I have been fortunate that that my children didn't have this, but I have several colleagues. One of my colleagues her children have severe peanut allergy and I've unfortunately seen where they had to go to the emergency room with their kids several times. Another colleague of mine who's a professor at another College of Pharmacy has such severe shellfish allergy that if, if he even has, like you know, like a partial bite of something that might have been close to something with shellfish heat, I've literally seen it as I've gone out to eat with the guy that his face swells up like a balloon. And and then I had another friend who has severe tomato allergy. So basically, never ate an Italian restaurant, never had pizzas up like that. So again, it's just, it's a huge problem and all these patients of course need to have EpiPens, which we're going to talk about here in a little while.
Speaker 2:But we're going to focus on this study that looked at Oomolismab, recently published in the New England Journal of Medicine and a study that we will have a link to in our show notes. Again, in small studies it's been looked at as a treatment for severe anaphylaxis of someone who is not responding to regular treatments and small studies have looked at other things, other uses of it in food allergy as well. But what we really don't know is if we just start you on Oomolismab, will that basically increase the threshold of the amount of allergen you may accidentally be exposed to? That leads to an anaphylaxis reaction and that's really the goal of this series of studies. The name of the trial series is called the Outmatch Trial and it's again. It's a three phase study.
Speaker 2:It's also a phase three study, so it's a phase three study and it's also a three phase study that has three parts to it, and we're going to discuss the first part. That was just recently published again in the England Journal of Medicine. It is a double blind, randomizable CBO controlled study. It was conducted at 10 centers in the United States. It looked at patients from age two to 56. And that's important because, as I said, you know, the bulk of patients with severe food allergy are children. So it was, I think, important that they did have a significant pediatric component to this study. These patients were pretty severely allergic. They had to be allergic to both peanut and two other foods, including milk, egg, wheat, cashew, hazelnut or walnut. So they all had to be severely allergic to penicillin, but they also had to have other food allergies on top of it. So again, these patients were severely allergic to more than one study, or more than one allergen, if you will. This phase is basically where they look at a number of patients and basically just looked at omelismab versus placebo in increasing the threshold of exposure to allergen that would lead to a reaction. And then that's the first phase. The second phase is a continuation study that will go out to 84 weeks after treatment, and then the third phase is where they're going to use omelismab in conjunction with immunotherapy to peanut allergy. So we're going to again talk about the first phase, but we're just going to see what happens here as these phases are published.
Speaker 2:They had a very, very complex inclusion criteria. You know, again, in addition to just people saying, yep, I'm allergic to penicillin, they had to have skin tests. They had to have other laboratory confirmation. In addition, they had to have serum IgE levels measured to make sure that this was IgE-muted reactions, because omelismab, of course, is an anti IgE antibody. Then they basically had to give dose challenges, and so they did placebo dose challenges in a controlled setting and basically marked at which point people started to have severe allergic reactions. I'm surprised they were allowed. I'm surprised they were able to get people in the study to do this. So I suppose, if you can get through that, okay, the thought of being on omelismab and, you know, being able to maybe not be in trouble down the road made it worth it to be on the studies. But again, very complex inclusion criteria to make sure that people were in fact severely allergic to food.
Speaker 2:They excluded patients with asthma. They excluded patients who had had a recent history of a severe anaphylactic reaction, that patients who had received previous immunotherapy or on any monoclonal antibody in the past six months. Once that was done, they were randomized in a two to one ratio to receive omelismab, which was given subcutaneously every two to four weeks for a total of 16 to 20 weeks. They had a dose trial table based on the weight of the patient and the age of the patient so that you know again. You can take a look at that in the show notes and we'll look at the study and see what that is.
Speaker 2:They also looked at IgE levels, as they were looking at doses well, and then after that they basically just monitor the patients to see how they were doing Once at that point. What they did was they basically challenged patients with a single dose of 600 milligrams of peanut protein and basically wanted to see if there were any symptoms or problems associated with that. And then, in patients who did well, they went up to 4,000 milligrams of peanut protein and it just they did an escalating dose to see when patients would start to have problems and then they would stop at that point, because obviously that's the ethical thing to do and basically wanted to look at the number of patients who again had a serious reaction or had symptoms of food allergy at doses of at least 600.
Speaker 2:And then they looked at doses all the way up again. They kept challenging patients up to 4,000 milligrams of a single food. They also looked at other foods as well, but the primary allergy and they looked at here was peanut allergy, which makes sense because that's that severe and it's pretty common. But they also took a look at dose challenges for other allergies depending on what the patient was allergic to. Basically so kind of a complex way to do things. But I'm not really sure there'd be another way to do this kind of study because again, the point of the study was not necessarily to say, okay, you're on a melisma, you can eat whatever you want, because I don't think anybody thought that was going to be a reality. I think the point of the study was not okay, well, you know, you've had a severe peanut allergy, you're on a melisma, you know, go have a big peanut butter sandwich. I don't think they're saying that. What they're saying is you know?
Speaker 2:before basically, if you ate one peanut, you were going to be in serious trouble Now you could be exposed accidentally up to a handful of peanuts before you get in trouble.
Speaker 2:I think that that was the point of the study. Taking a look at the demographics of it again, they were all allergic to penicillin. A significant number over 50% were allergic to cashews. There are other tree nuts. Smaller percentages were allergic to egg. About one third of patients were allergic to egg. About one third of patients were allergic to milk and only about five or 10% of patients were allergic to wheat. They all had very severe allergy.
Speaker 2:And if we just focus on on peanut, remember that these patients were going to get a 600 milligram exposure dose, that the maximum tolerated peanut dose in the, in the, in the both groups, was 30 milligrams. So basically, you know a very, very, very tiny amount I mean, that's not even one peanut, that's, that's an eighth of a peanut, basically, and then these people would have a reaction. That was the maximum tolerated dose. So these people were, seeing you know, severely allergic to, to, to, to peanuts. Anyway, looking at at at the end point. So again, these are patients who then received a single 600 milligram peanut challenge and they found that in that group only 7% of placebo patients were able to tolerate that without symptoms, whereas an astounding 67% of patients who were on the Omelizumab group were able to tolerate that 600 milligram challenge without a severe reaction. So a dramatic increase in the amount of allergen these patients could tolerate without developing a reaction. So pretty impressive really. When they took a look at other and so patients who were allergic to other substances, other allergens, they exposed them to high, various doses of these other allergens and the numbers were actually pretty similar. About 60% of people, for example, who had an allergy to egg, were able to tolerate an egg challenge, whereas nobody in the placebo group was able to tolerate an egg challenge. And that 60% was was pretty consistent across the board, with the exception of cashew allergy. We're only about 40% of patients in the Omelizumab group were able to tolerate a challenge with cashews, compared to to to about 3% of placebo. But when we just focus on peanut allergy, you know very impressive a much, much higher dose than these people could tolerate normally, and they were able to do that without having a serious reaction. So fairly impressive really.
Speaker 2:Unfortunately, quality of life when they looked at tools didn't change and I think that that surprised the authors, I think it surprised me a little bit too, but I mean, I mean part of it. I think it's two fold. One, when you've been told your whole life to never even go near a peanut. You know you're on this, on this drug, and you're in, you know, like, oh no, you know, I'm not saying you need to eat peanuts, but you can be less scared. Well, would you be, though, you know, I mean, especially if you've had a really bad anaphylactic reaction to peanuts, would you be like, okay, well, I can, I can relax a little more. Maybe I can go out to dinner sometime with friends, and it, you know, won't be that big a deal.
Speaker 2:And again, the point of the study was not to make things okay for these people to eat peanuts, and so for all those reasons I think I understand why quality of life scores really didn't improve in the omelizumab group. They had no major anaphylactic events during the challenge, so you know that that was good to hear, and in fact they mostly had had just minor skin reactions. In patients who are getting challenged Now, of course they did have injection site reactions of the omelizumab, but that's a known side effect of that medication. So the authors kind of concluded by saying you know, in patients with multiple food allergies as young as one year of age, omelizumab treatment for 16 weeks with superior placebo, increasing the reaction threshold for basically almost everything. They tested patients again but again, you know, 67% of patients were able to tolerate 600 milligrams of peanut protein without having a serious reaction.
Speaker 2:Where again, the median dose they were able to tolerate before was 30. So so again, again, you know, fairly impressive. They picked 600 milligrams because they felt that this was the typical amount of peanuts somebody would be exposed to in most accidental exposure. So again, assuming that person isn't trying to on purpose, you know, eat peanuts, but would be accidentally exposed to them, this, this seemed to be much more effective at preventing those sort of things. They noted that that the majority of these patients were children. In fact, the average age in the study was seven years old. So again, the vast majority of these patients were children and again, that's that stands to reason.
Speaker 2:his children seem to have the highest risk of food allergy and the ones you know to tend to have the severe reactions associated with it.
Speaker 2:They noted that many patients weren't qualified, they didn't qualify, to be in the study because they couldn't even tolerate 30 milligrams of a challenge. In fact they, you know they had a severe, severe challenge at even lower levels than that. They also noted that there are some patients who weren't able to be in the study because they had only an allergy to one food. And again, they, these patients, had to be allergic to a lot of other foods. And then the third reason people weren't allowed to be in the study was that they had that concomitant asthma or something along those lines. So again, you know, external validity is something to kind of think a little bit on the study, but the bottom line was that was that this was, I think, a big breakthrough for patients, especially children, who are severely, severely allergic, particularly to peanuts that this will decrease the risk of them developing a severe anaphylactic reaction if they're accidentally supposed to expose the peanuts, at least for 16 weeks.
Speaker 2:Now we will see how the continuation phase of the study that goes out to 84 weeks goes, and we'll also see down the road if patients who are also receiving immunotherapy for peanut allergy, if this helps in that area as well. So, jen, that's that's kind of you know the study in no pun intended. A nutshell.
Speaker 1:Sorry about that. I'm not funny to others, probably yeah probably that's, that's.
Speaker 2:that's so much my dad joke for the week.
Speaker 1:Yeah, that's your dad joke. I love it. The progressive commercial right like a community accused of being that in my house. I mean I think it is kind of a game changer. I mean I know so many people where this, like you said, it is debilitating. I mean my son had a friend who was allergic to beef, pork, eggs, nuts, milk, like he couldn't go anywhere. And you know, as a mother, you're like going to the store in the morning before they cut any other meat and getting that. You know it's just, it's a way of life. And so I think you know to your point when you were like who's going to be in the study. I think people are really wanting some sort of, you know, give them a feeling where they can go out to dinner or they can be around people, or, because it can be debilitating, it's really scary and you know my, my daughter, actually has.
Speaker 2:Celiac disease and and while it's not nearly as bad as this, I mean.
Speaker 1:I get I yeah.
Speaker 2:I have a flavor, you know I mean, of what it's like to live, kind of, in this world where everybody else seems to be able to eat whatever they want and you can, and you know, when you're a kid that means no birthday parties, that means don't not going out with friends to the mall and getting, you know, a shake, or you know, you know the kids go to malls anymore. You know, you know, I think, I think I mean, you know, I certainly if I had child who had that kind of severe allergic reaction, with the basis of this study, I would be lining up with my pediatricologist or whoever to say is there any way I can get on this rug? Now? The problem, of course, is $1000 a month, right, and if insurance are going to pay for it, you know, like you know, this constant refrain of where, if insurance don't pay for this, you know what are we going to do? One would assume that assurances would realize that omelism that's going to be cheaper than an emergency room visit, but absolutely.
Speaker 1:Well, and even if you don't have kids with allergies in your home, I mean I remember like being nervous to have those kids over because you know that's a lot of responsibility for me and so that you know it is it's just a social thing and all these kids just have so much social going on anyway that this is just one more thing in the arsenal to make people recluse and you know it just makes it harder Totally agree with you so yeah, yeah, okay.
Speaker 1:Well, let's move on to the second thing. So the anaphylaxis guidelines are a good next step to discuss because obviously you know, when you do have a severe food allergy, you need to have an antidote for that. So you know, I know we've been through a lot with these epipens in the past few years and you know huge price increases and availability issues. So you know, do the guide new guidelines give any reprieve to that or let's, let's talk about what, what these new guidelines say, that could be different.
Speaker 2:Yeah, so I mean these are guidelines were just published in February by the American Academy of Asthma, allergy and Immunology, the so-called quad AI Guidelines, and they're like all practice parameters, you know, kind of you know an update to previous parameters.
Speaker 2:This focus and again, for time purposes we're gonna go through the whole thing but to kind of focus on some of the changes that that the updates have from Comprave compared to previous guidelines and a couple of things they note when they talk about anaphylaxis is one they note that a lot of clinicians miss the fact that that a significant number of Anaphylaxis reactions are biphasic. So patients will have an initial sign of symptom, then it'll seem to resolve and then they'll have a recurrence of either anaphylaxis or even just minor reactions within 48 hours without reexposure, the exposure, the allergen trigger. And they note that you know there's been studies that suggest, like emergency rooms, kind of forget that part. So someone comes in with an anaphylaxis reaction because they got a bee sting and they're washed for a few hours, get some IV fluids, get some benadryl, get you know, and if they hypotensive, get an EpiPen. You know, you know that then they seem to kind of recover and then they kind of get sent home.
Speaker 2:And it's like you know, we can reduce the the chances of a biphasic reaction If we give steroids and something like that, but it certainly doesn't eliminate that and they note that it's much more likely in patients who have had multiple episodes of Anaphylaxis and interesting patients where one dose of epinephrine does not help alleviate symptoms and they say if you need more than one dose, you really have to keep your eye out for for biphasic reaction, so that you know, they talk a lot about that in the first part of the of the of the guidelines, but then they get into the actual updates.
Speaker 2:And, as you point out, jen, you know Anyone, anyone who has this problem, and certainly pharmacists who work in this, working the community. You know that we've had, you know, ever escalating problems with epinephrine auto injectors, that you know we. There was really one or two on the market and then there were supply issues and then several more came on the market, but they were unbelievably expensive and you know so we came into a case where you either couldn't get auto injectors or, if you could get them and insurance wouldn't pay for them, you were paying through the nose for them. Now, of course, the theory is that you hardly, hopefully, will ever need to use auto injectors, but if again you're at high risk or you're the kind of person who may have one or two or three Anaphylactic reactions during the year, you know this might really, you know, bite into your pocketbook because you may end up having to pay cash money for all this. And so the guidelines talk a little bit about this. They obviously don't, they really haven't, have an answer right, because you know the these allergies aren't gonna, you know, be making epinephrine in their bathtub to hang out to people. So they just basically know that they. They recommend that that manufacturers and insurers work to make sure that all patients at high risk Of anaphylactic have access to affordable auto injectors.
Speaker 2:I hope that too, but I'm not really sure that has any sort of real you know, import the people who make this stuff, that they but they do note that one of the things they do talk about is that Patients need, you know, if they, if they don't have already access line to auto injectors and they don't have the good education to Understand how to use them, that they should work closely with their pharmacist and actually call that out in the text, which I was, I was gratified to see about.
Speaker 2:You know, you know, if you're going to one community pharmacy and I hope everybody listening to my voice is only going to one community pharmacy for their prescriptions that they they establish a good rapport with the pharmacist who working there, you know saying, hey, you know I, you know I know you're super busy and all that, but you know, you know I'm at high risk for for anaphylaxis.
Speaker 2:You know, can we work together to make sure that you know I have the highest chance of having an auto injector when I need it and All that sort of stuff, and, you know, having the pharmacist basically do their best to to counsel a patient on appropriate use and when this, when to use it and all that other stuff. My colleague, lynn Kessel, who's been as an a friend of mine and a colleague of mine, or Drake, actually did an interesting study With a couple of colleagues, mine in my pharmaceutical sciences department, where they took a look at the amount of epinephrine and outdated auto injectors and found, as you might suspect, that that you know even relatively long after the Period is passed, that there's still significant amounts of epinephrine in the auto injector, probably enough to avoid it, or shreed an older reaction.
Speaker 2:So again, again, unfortunately, you know we can't recommend that and then the guidelines certainly don't. But I think what I kind of taken from that is you know, if you're struggling to get a new auto injector that's been outdated, you know you should throw it away or anything. You certainly should, should keep that, and until you can get a new one that's in date to replace that, you know that may be your chance. You know you're only chance to use something if you need to use it. So they also note that that the main route that food induced anaphylaxis occurs is my ingestion, and so you know it's not like. You know you're walking by. You know a cafeteria where they've got.
Speaker 2:You know they're making something with peanuts in it, you accidentally just inhale a particle or two of Peanut oil as you're passing them, that you're gonna get a reaction.
Speaker 2:They say nearly all reactions of severe food induced anaphylaxis are due to ingestion, not contact or insulation.
Speaker 2:And so, because of that, one of the biggest questions that that I think gets asked at school levels is you know, should schools specifically prohibit certain foods site wide or orally?
Speaker 2:Because there are especially private schools that are that are our so-called allergen free or nut free schools, where they just do not allow any of that and, interestingly, because of that, they actually do not recommend that.
Speaker 2:They suggest that child care centers and schools do not implement site wide food specific prohibition because current research does not support consistent benefits and that unless patients are accidentally ingesting the stuff just being around the people you know who are eating peanuts, it's unlikely to trigger anaphylaxis in those patients. Now they do note that it might be appropriate to implement allergy, allergen restricted zones, for example a milk free table in children who have the, who lack the capacity to self-manage, right. So if you have a smaller child who you know may not know, you know what, what they're allergic to or what what's in stuff, it may be reasonable to have a section walled off, for example, in the school cafeteria, or sectioned off in the school cafeteria for those students, but to have entire schools or health care or daycare centers that are like, no, we just don't allow or use peanuts at all. They actually don't recommend it because of all that.
Speaker 2:So I thought that was kind of interesting that certainly knew that, that that I had known they. They do, however, also suggest that that child care centers and schools do stock epinephrine auto injectors on site, with nurses or other people who experience it how to use them in case anybody does develop anaphylaxis. They do recommend that that clinicians routinely prescribe auto injectors patients at higher risk. I know there's a couple of states where a pharmacist are working with allergists and stuff to making sure that there's a good supply or, you know, can refill them even though the prescription has so called, you know, has has expired. They can give another auto injector and I think that that will definitely help in these and these patients. And they say in patients who are at lower risk for anaphylaxis, that there's kind of a shared decision-making process. But the bottom line is probably they should, should get it. When should you train patients to give their epinephrine auto injectors? They basically say don't wait at basically the first sign of suspected anaphylaxis. They start to feel swelling, they start to get itchy. You know you don't wait until oh wow, now I can't breathe, or oh wow, I. You know I'm feeling really dizzy and I'm going to pass out. Basically, you want to give the, the auto injector, at the first sign of suspected anaphylaxis. However, they also say and apparently this is a thing I didn't realize, this was a thing that if you are going to enter, for example, enter a restaurant that you suspect you may be accidentally exposed, something that you can't help to prophylactically give yourself an auto injector. I didn't realize people were doing that, but apparently people are and, as you might imagine, they don't recommend that, which I'm like. Okay, well, I'm going to give myself an epinephrine. Make my heart go to 180 and get super sweaty before I walk into this McDonald's make a lot of sense to me, but they actually do recommend that they don't do that. So I think don't use it prophylactically but don't wait. Is, is, is the is the key message, I think, from the QuadAA guidelines. They also note that there's a lot of fear about side effects from epinephrine and they actually note that, other than tachycardia, severe side effects from epinephrine are actually extremely rare and actually fade away very quickly. The protective effect or treatment effect of epinephrine in anaphylaxis is long lasting, usually over four hours, but the actual effects on the, on the sympathetic nervous system, are much less, much less quickly. So you know, fear of using epinephrine auto injectors really shouldn't be a thing.
Speaker 2:As far as as adverse drug reactions are concerned, the next piece I think that's worth let's work discussing is is the use of beta blockers and ACE inhibitors in patients who are at risk for anaphylaxis. Now again, I'm not an expert in anything other than drug allergy, so I was unaware this was the thing. But they noted, they know that specifically for for venom induced allergy, particularly bee stings or wasps things, people who are severely allergic to those should not receive beta blockers or ACE inhibitors because of the risk of increasing the reaction or not having a good enough response to epinephrine auto injectors. I was unaware of that. I'm sure probably allergen allergenist out there were aware of it and and so that I thought that was interesting and so they note that that's been the, the, the recommendation for, for for many, many, many years.
Speaker 2:However, they note that recent studies have suggested that that's probably not true and that, especially for beta blockers using cardioselective agents such as metoprolol and the tenolol, that neither of those should be an absolute contraindication in patients who have severe allergy, again, particularly to two things like bee stings and wasp stings, they note that if the patient has a has a, a disease state where the the benefit of the drug outweighs the risk, that it's probably okay to start or initiate those those medications or maintain them basically.
Speaker 2:And so they of course note that cardioselective beta blockers are the way to go there. But it's been a long time since I've seen anybody on perpranol, all or or any of the other non-cardioselective beta blockers, and so you know again, if the benefit so someone has a heart failure or somebody has, you know, has had a heart attack in the last two years, something along those lines, where those drugs would be very, very beneficial that it's reasonable to continue or or or maintain though maybe start or continue those medications even in a patient who has severe allergic reactions to things like bees and wasps or other types of of anaphylactic reaction.
Speaker 2:So I thought that was kind of interesting. They do note that if it's possible to not use those medications, certainly don't, but if you need to, you certainly can. They also note, though, that if at all possible, you should hold those drugs when you're starting immunotherapy, just because of a decreased risk of effectiveness or increased risk of ineffectiveness and an increased risk of patients who may have reactions to the immunotherapy.
Speaker 1:So kind of interesting.
Speaker 2:I thought that you know, as they kind of went along there, they finally and we'll only spend a minute on this, talking about post opatoplaxis. So you know, people who undergo in surgery and then immediately in the surgical period or post operative period develop significant anaphylaxis. It's one of the most challenging types of patients with severe allergic reactions because they've received a host of medications in the in the perioperative phase. They've you know they've received, you know induction drugs, they've received paralytics, they've received you know they've received, you know pain medications. They've received all sorts of medications and so someone who has an immediate hypersensitive reaction in the OR or post op.
Speaker 2:It's incredibly difficult to to figure out exactly what triggered that and in those cases, as you might imagine, anesthesiologists are extremely reluctant to ever you know, you know, you know, you know, you know, you know, you know you retest these patients, but the sad fact is is they very well may need a surgery in the future, right, I mean, you know? I mean, most of us are probably not going to get off this planet without having having some sort of, either even minor, surgery in our lives. So you know, it's one of those things where it's like you know, so what do you do with these patients? And so they know that that that those patients, of course, should receive immediate referral to an allergist, who should try to try and figure out, you know, using either skin testing or other laboratory testing to figure out what they may be allergic to. They also note, though, that that's really challenging because, for example, if a person might have had an allergy to the lauded you know, which might be given in the perioperative timeframe, allergists are not probably going to get the lauded for them to do skin testing on right, because it's control substance and all those sort of things. If they have an allergy to a paralytic, you're probably not going to give a paralytic to somebody who's sitting in an allergist office.
Speaker 2:So they notice that there's there's some real challenges, but they also notice that the youth. They also note that you can probably work with anesthesiologists to, you know, be in a controlled setting and make sure patients have a clear airway and things along those lines as your skin testing. But they basically note that, if at all possible, rather than just tell these patients yep, sorry, I guess you're just never going to get a surgery again in your life, so hope you don't ever get into a car accident that that we should really be more aggressive about assessing why these patients develop anaphylaxis, try and figure out exactly what they, what they were allergic to, and try and use alternative agents that are structurally dissimilar, or I'll just alternative agents in general. So kind of a summary of the anaphylaxis guidelines, but I think some some interesting pieces that do impact primary care providers as well as pharmacists. Jeff.
Speaker 1:Yeah, super interesting, particularly the part about the, the recommendations for schools and daycares, because I remember a time where there was like a allergy table where you know, I just remember thinking like you know, in the lunchroom and I remember thinking, oh my gosh, it's like leprosy, like these poor kids are, you know, called out and I understand the fear behind it, but it's also just such a social thing like we talked about earlier. So that's an interesting recommendation, that's a no, and?
Speaker 2:and a surprise, because I mean I think that there are a lot of schools that have gone to basically a you know no allergen policy and again I mean, if they can do that successfully, I think that's, you know, that's fine. But they again, the guidelines, just note that, because you usually have to ingest this stuff that you don't just, you know, breathe in the molecules that that there's really no benefit of doing that.
Speaker 1:Yeah, yeah, yeah, a little bit of freedom there, so that's exactly Well thank you so much, jeff. These were interesting topics this week and I have to say this has been really fun doing with you, so doing this with you. So there's never a shortage of of game changers, it feels like. So I'm glad we can squeeze two into this week.
Speaker 2:Me too. Me too, john, thank you.
Speaker 1:Yeah, yeah. Well, that's it for this week. If you're a CE plan member, be sure to claim your CE credit for this episode by logging in at ceimpactcom and, as always, have a great week and keep learning. Thanks.