Updated Anaphylaxis Guidelines, Early Management Priorities

In part 1 of this 4-part special report from HCPLive, Contemporary Pediatrics, and Patient Care, experts examine how recent guideline updates are reshaping the clinical approach to anaphylaxis, with a particular emphasis on early recognition and first-line treatment. Moderated by Brian Schroer, MD, of Cleveland Clinic Children’s Hospital, the discussion features Jay Lieberman, MD, of the University of Tennessee Health Science Center, and David Golden, MD, of Johns Hopkins University.

The conversation centers on the evolution of the anaphylaxis practice parameters, particularly the focused 2020 update and the broader 2024 supplemental update from the American Academy and College of Allergy, Asthma & Immunology.1,2 Golden explained that while the 2020 update addressed narrowly defined clinical questions using a GRADE framework, most notably the role of epinephrine versus antihistamines and corticosteroids, the 2024 update took a more comprehensive look at the last decade of evidence. That review resulted in updated recommendations on emergency treatment, risk stratification, recognition of anaphylaxis in infants, and decision-making around emergency department referral.

One of the most consequential shifts highlighted by both panelists is the continued move away from routine use of corticosteroids and antihistamines in the acute management of anaphylaxis. Lieberman noted that accumulating evidence shows no clear benefit of steroids in preventing biphasic reactions or improving acute outcomes, while their adverse effects and delayed onset make them poorly suited for emergency treatment. As a result, some emergency departments have begun removing steroids from standardized anaphylaxis order sets as part of quality improvement initiatives.

The panel also addressed common misconceptions that delay treatment, including uncertainty about diagnostic criteria and fear of adverse effects. Both experts stressed that epinephrine should be used at the first concern for a systemic allergic reaction, even if formal anaphylaxis criteria are not yet met.

Experts include:

Brian Schroer, MD, of Cleveland Clinic Children’s Hospital

Jay Lieberman, MD, of the University of Tennessee Health Science Center

David Golden, MD, of Johns Hopkins University

Disclosures include Novartis Pharmaceuticals, Regeneron Pharmaceuticals, BioCryst, GlaxoSmithKline, Amgen, GENZYME Corporation, AstraZeneca Pharmaceuticals, and LEO Pharma for Schroer; Novartis Pharmaceuticals, ABBVIE, Genentech, Aquestive Therapeutics for Lieberman; and Phadia US and Genentech USA for Golden.

References

1. Shaker MS, Wallace DV, Golden DBK, et al. Anaphylaxis-a 2020 practice parameter update, systematic review, and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) analysis. J Allergy Clin Immunol. 2020;145(4):1082-1123. doi:10.1016/j.jaci.2020.01.017

2. Golden DBK, Wang J, Waserman S, et al. Anaphylaxis: A 2023 practice parameter update. Ann Allergy Asthma Immunol. 2024;132(2):124-176. doi:10.1016/j.anai.2023.09.015