Manish Ramesh, MD, PhD, chief of the division of allergy and immunology at Montefiore Einstein

Manish Ramesh, MD, PhD

 Manish Ramesh, MD, PhD, chief of the division of allergy and immunology at Montefiore Einstein, identified fear of mandatory emergency care after epinephrine use as the largest gap in 

Under the 2023 anaphylaxis practice parameter update, immediate activation of emergency medical services may not be required if a patient has a prompt, complete, and durable response to epinephrine.¹ Ramesh said the change responds to a long-standing behavioral problem, in which patients withheld epinephrine to avoid a trip to the emergency department.

“The fear of epinephrine requiring hospital care is the biggest problem we see in anaphylaxis,” Ramesh said. He emphasized patients go to the emergency department for monitoring of delayed symptoms or because a single dose proved inadequate, not because epinephrine itself demands hospital care.

Anaphylaxis, Allergic Rhinitis Care Gaps, With Manish Ramesh, MD, PhD

Epinephrine Dosing and Home Monitoring in Anaphylaxis

For patients with mild or moderate anaphylaxis and no severe features, such as cardiovascular involvement, Ramesh said a single dose of epinephrine followed by symptom resolution allows for monitoring at home. This approach applies to patients living close to health care, such as those in urban areas with ready access to emergency services. Any recurrence of symptoms or other concerns should prompt emergency medical care.

Severe anaphylaxis calls for a different response. Ramesh recommended activating emergency medical services and administering a second dose of epinephrine in patients with significant hypotension, significant bronchospasm, or no response to the first dose. According to Ramesh, 80% of food-induced anaphylactic episodes resolve with 1 dose of epinephrine and 98% resolve with 2 doses, the rationale for prescribing a twin pack with every epinephrine prescription.

Ramesh identified a second persistent misconception: routine reliance on antihistamines and corticosteroids as first-line management. He highlighted a guideline shift away from oral antihistamines and decongestants as primary treatment. Intranasal corticosteroids are now first-line therapy for most patients with moderate to severe allergic rhinitis, and the 2020 rhinitis update names them the preferred monotherapy for persistent disease.²

Mild symptoms, such as a few hives or a single episode of emesis, can be managed appropriately with an antihistamine if they resolve. Any presentation beyond those symptoms warrants epinephrine as first-line therapy, with antihistamines and corticosteroids reserved as adjuncts, since data do not show these agents resolve anaphylaxis the way epinephrine does.

Allergen Immunotherapy Underuse in Allergic Rhinitis

Subcutaneous immunotherapy, commonly called allergy shots, has been in use since 1911, predating the discovery of penicillin. Ramesh noted more than 50 clinical trials each in allergic rhinitis and asthma support its efficacy across multiple allergens, and the therapy is considered standard of care for allergic rhinitis, asthma, and venom allergy.

“We grossly underutilize subcutaneous immunotherapy,” Ramesh said.

The 2020 rhinitis practice parameter update includes recommendations for both subcutaneous and sublingual tablet immunotherapy in allergic rhinitis.²

Sublingual immunotherapy offers a daily alternative, with the allergen placed under the tongue to dissolve and act through the oral mucosa. Ramesh explained both modalities work by shifting immune recognition of allergens from an allergic response to a nonallergic immune response.

Golden DBK, Wang J, Waserman S, et al. Anaphylaxis: a 2023 practice parameter update. 

Dykewicz MS, Wallace DV, Amrol DJ, et al. Rhinitis 2020: a practice parameter update. 

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Montefiore allergist outlines updated guidance on home monitoring after epinephrine and why immunotherapy remains underused in allergic rhinitis.

Manish Ramesh, MD, PhD

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