Skip to main content
Log in

Guideline for acute therapy and management of anaphylaxis

S2 Guideline of the German Society for Allergology and Clinical Immunology (DGAKI), the Association of German Allergologists (AeDA), the Society of Pediatric Allergy and Environmental Medicine (GPA), the German Academy of Allergology and Environmental Medicine (DAAU), the German Professional Association of Pediatricians (BVKJ), the Austrian Society for Allergology and Immunology (ÖGAI), the Swiss Society for Allergy and Immunology (SGAI), the German Society of Anaesthesiology and Intensive Care Medicine (DGAI), the German Society of Pharmacology (DGP), the German Society for Psychosomatic Medicine (DGPM), the German Working Group of Anaphylaxis Training and Education (AGATE) and the patient organization German Allergy and Asthma Association (DAAB)

  • Guideline
  • Published:
Allergo Journal International Aims and scope Submit manuscript

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Abbreviations

ACE:

Angiotensin-converting enzyme

FiO2 :

Fraction of inspired oxygen

HES:

Hydroxyethyl starch

NaCl:

odium chloride

NSAID:

Nonsteroidal anti inflammatory drugs

References

  1. Johansson SG, Bieber T, Dahl R, Friedmann PS, Lanier BQ, Lockey RF et al. Revised nomenclature for allergy for global use: Report of the Nomenclature Review Committee of the World Allergy Organization, October 2003. J Allergy Clin Immunol 2004; 113: 832–836

    Article  CAS  PubMed  Google Scholar 

  2. Ring J, Grosber M, Mührenschlager M, Brockow K. Anaphylaxis: acute treatment and management. Chem Immunol Allergy 2010; 95: 201–10

    Article  PubMed  Google Scholar 

  3. Simons FE, Ardusso LR, Bilo MB, El-Gamal YM, Ledford DK, Ring J et al. World Allergy Organization anaphylaxis guidelines: summary. J Allergy Clin Immunol 2011; 127: 587–593.e1-22

    Article  PubMed  Google Scholar 

  4. Tryba M, Ahnefeld F, Barth J, Dick W, Doenicke A, Fuchs T et al. Akuttherapie anaphylaktoider Reaktionen. Ergebnisse einer interdisziplinären Konsensuskonferenz. Allergo J 1994; 3: 211–222

    Google Scholar 

  5. Ring J, Brockow K, Duda D, Eschenhagen T, Fuchs Th, Huttegger I et al. Emergency treatment of anaphylactic reactions. Allergo J 2007; 16: 420–434

    Google Scholar 

  6. Bresser H, Sander CH, Rakoski J. Emergencies by insect stings in Munich in 1992. Allergo J 1995; 4: 373–376

    Google Scholar 

  7. Mehl A, Wahn U, Niggemann B. Anaphylactic reactions in children — a questionnaire-based survey in Germany. Allergy 2005; 60: 1440–1445

    Article  CAS  PubMed  Google Scholar 

  8. Portier P, Richet C. De l’action anaphylactique de certains venins. C R Soc Biol 1902; 54: 170

    Google Scholar 

  9. Sampson HA, Munoz-Furlong A, Campbell RL, Adkinson NF Jr, Bock SA, Branum A et al. Second symposium on the definition and management of anaphylaxis: summary report — Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium. J Allergy Clin Immunol 2006; 117: 391–397

    Article  PubMed  Google Scholar 

  10. Worm M. Epidemiology of anaphylaxis. Chem Immunol Allergy 2010; 95: 12–21

    Article  PubMed  Google Scholar 

  11. Moneret-Vautrin DA, Morisset M, Flabbee J, Beaudouin E, Kanny G. Epidemiology of life-threatening and lethal anaphylaxis: a review. Allergy 2005; 60: 443–451

    Article  CAS  PubMed  Google Scholar 

  12. Helbling A, Hurni T, Mueller UR, Pichler WJ. Incidence of anaphylaxis with circulatory symptoms: a study over a 3-year period comprising 940,000 inhabitants of the Swiss Canton Bern. Clin Exp Allergy 2004; 34: 285–290

    Article  CAS  PubMed  Google Scholar 

  13. Decker WW, Campbell RL, Manivannan V, Luke A, St Sauver JL, Weaver A et al. The etiology and incidence of anaphylaxis in Rochester, Minnesota: a report from the Rochester Epidemiology Project. J Allergy Clin Immunol 2008; 122: 1161–1165

    Article  PubMed Central  PubMed  Google Scholar 

  14. Sheikh A, Hippisley-Cox J, Newton J, Fenty J. Trends in national incidence, lifetime prevalence and adrenaline prescribing for anaphylaxis in England. J R Soc Med 2008; 101: 139–143

    Article  PubMed Central  PubMed  Google Scholar 

  15. Poulos LM, Waters AM, Correll PK, Loblay RH, Marks GB. Trends in hospitalizations for anaphylaxis, angioedema, and urticaria in Australia, 1993–1994 to 2004–2005. J Allergy Clin Immunol 2007; 120: 878–884

    Article  PubMed  Google Scholar 

  16. Worm M, Edenharter G, Rueff F, Scherer K, Pföhler C, Mahler V et al. Symptom profile and risk factors of anaphylaxis in Central Europe. Allergy 2012; 67: 691–698

    Article  CAS  PubMed  Google Scholar 

  17. Smith PL, Kagey-Sobotka A, Bleecker ER, Traystman R, Kaplan AP, Gralnick H et al. Physiologic manifestations of human anaphylaxis. J Clin Invest 1980; 66: 1072–1080

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  18. Vadas P, Perelman B, Liss G. Platelet-activating factor, histamine, and tryptase levels in human anaphylaxis. J Allergy Clin Immunol 2013; 131: 144–149

    Article  CAS  PubMed  Google Scholar 

  19. Lee JK, Vadas P. Anaphylaxis: mechanisms and management. Clin Exp Allergy 2011; 41: 923–938

    Article  CAS  PubMed  Google Scholar 

  20. Ring J. Angewandte Allergologie. München: Urban & Vogel 2004

    Google Scholar 

  21. Rueff F, Przybilla B, Bilo MB, Müller U, Scheipl F, Aberer W et al. Predictors of severe systemic anaphylactic reactions in patients with Hymenoptera venom allergy: importance of baseline serum tryptase-a study of the European Academy of Allergology and Clinical Immunology Interest Group on Insect Venom Hypersensitivity. J Allergy Clin Immunol 2009; 124: 1047–1054

    Article  CAS  PubMed  Google Scholar 

  22. Brockow K, Jofer C, Behrendt H, Ring J. Anaphylaxis in patients with mastocytosis: a study on history, clinical features and risk factors in 120 patients. Allergy 2008; 63: 226–232

    Article  CAS  PubMed  Google Scholar 

  23. Guenova E, Volz T, Eichner M, Hoetzenecker W, Caroli U, Griesinger G et al. Basal serum tryptase as risk assessment for severe Hymenoptera sting reactions in elderly. Allergy 2010; 65: 919–923

    Article  CAS  PubMed  Google Scholar 

  24. Przybilla B, Ruëff F, Walker B, Räwer HC, Aberer W, Bauer CP et al. Diagnosis and therapy of bee and wasp venom allergy. Allergo J 2011; 20: 318–339

    Google Scholar 

  25. Muraro A, Roberts G, Clark A, Eigenmann PA, Halken S, Lack G et al. The management of anaphylaxis in childhood: position paper of the European academy of allergology and clinical immunology. Allergy 2007; 62: 857–871

    Article  CAS  PubMed  Google Scholar 

  26. Ring J, Messmer K. Incidence and severity of anaphylactoid reactions to colloid volume substitutes. Lancet 1977; 1: 466–469

    Article  CAS  PubMed  Google Scholar 

  27. Stark BJ, Sullivan TJ. Biphasic and protracted anaphylaxis. J Allergy Clin Immunol 1986; 78: 76–83

    Article  CAS  PubMed  Google Scholar 

  28. Commins SP, Platts-Mills TA. Anaphylaxis syndromes related to a new mammalian cross-reactive carbohydrate determinant. J Allergy Clin Immunol 2009; 124: 652–657

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  29. Barnard JH. Studies of 400 Hymenoptera sting deaths in the United States. J Allergy Clin Immunol 1973; 52: 259–264

    Article  CAS  PubMed  Google Scholar 

  30. Delage C, Irey NS. Anaphylactic deaths: a clinicopathologic study of 43 cases. J Forensic Sci 1972; 17: 525–540

    CAS  PubMed  Google Scholar 

  31. Fisher MM. Clinical observations on the pathophysiology and treatment of anaphylactic cardiovascular collapse. Anaesth Intensive Care 1986; 14: 17–21

    CAS  PubMed  Google Scholar 

  32. Pumphrey RS, Roberts IS. Postmortem findings after fatal anaphylactic reactions. J Clin Pathol 2000; 53: 273–276

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  33. Krogh G von, Maibach HI. The contact urticaria syndrome — an updated review. J Am Acad Dermatol 1981; 5: 328–342

    Article  Google Scholar 

  34. Kemp SF, Lockey RF. Anaphylaxis: a review of causes and mechanisms. J Allergy Clin Immunol 2002; 110: 341–348

    Article  CAS  PubMed  Google Scholar 

  35. Morita E, Kunie K, Matsuo H. Food-dependent exercise-induced anaphylaxis. J Dermatol Sci 2007; 47: 109–117

    Article  CAS  PubMed  Google Scholar 

  36. Pumphrey RS. Lessons for management of anaphylaxis from a study of fatal reactions. Clin Exp Allergy 2000; 30: 1144–1150

    Article  CAS  PubMed  Google Scholar 

  37. Mullins RJ, Dear KB, Tang ML. Characteristics of childhood peanut allergy in the Australian Capital Territory, 1995 to 2007. J Allergy Clin Immunol 2009; 123: 689–693

    Article  PubMed  Google Scholar 

  38. Schwartz LB. Clinical utility of tryptase levels in systemic mastocytosis and associated hematologic disorders. Leuk Res 2001; 25: 553–562

    Article  CAS  PubMed  Google Scholar 

  39. Brockow K, Vieluf D, Püschel K, Grosch J, Ring J. Increased postmortem serum mast cell tryptase in a fatal anaphylactoid reaction to nonionic radiocontrast medium. J Allergy Clin Immunol 1999; 104: 237–238

    Article  CAS  PubMed  Google Scholar 

  40. Nolan JP, Soar J, Zideman DA, Biarent D, Bossaert LL, Deakin C et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 1. Executive summary. Resuscitation 2010; 81: 1219–1276

    Article  PubMed  Google Scholar 

  41. Thomas M, Crawford I. Best evidence topic report. Glucagon infusion in refractory anaphylactic shock in patients on beta-blockers. Emerg Med J 2005; 22: 272–273

    Article  PubMed Central  PubMed  Google Scholar 

  42. Simons FE, Schatz M. Anaphylaxis during pregnancy. J Allergy Clin Immunol 2012; 130: 597–606

    Article  CAS  PubMed  Google Scholar 

  43. Bellomo R, Chapman M, Finfer S, Hickling K, Myburgh J. Low-dose dopamine in patients with early renal dysfunction: a placebo-controlled randomised trial. Australian and New Zealand Intensive Care Society (ANZICS) Clinical Trials Group. Lancet 2000; 356: 2139–2143

    Article  CAS  PubMed  Google Scholar 

  44. Friedrich JO, Adhikari N, Herridge MS, Beyene J. Meta-analysis: low-dose dopamine increases urine output but does not prevent renal dysfunction or death. Ann Intern Med 2005; 142: 510–524

    Article  CAS  PubMed  Google Scholar 

  45. Gronemeyer. Noradrenalin statt Adrenalin beim anaphylaktischen Schock. Dtsch Med Wochenschr 1980, 102: 101

    Google Scholar 

  46. Hoffmann BB. Catecholamines, sympathomimetic drugs and adrenergic receptor anatagonists. In: Hardman JG, Limbird LE, Goodman A, eds. Goodman & Gilman’s. The pharmaceutical basis of therapeutics.NewYork: Mc Graw Hill, 2002

    Google Scholar 

  47. Schummer C, Wirsing M, Schummer W. The pivotal role of vasopressin in refractory anaphylactic shock. Anesth Analg 2008; 107: 620–624

    Article  CAS  PubMed  Google Scholar 

  48. Meßmer K. Plasma substitutes and indications for their use. In: Tinker J, Rapin M, eds. Care of the critically ill patient. Berlin — Heidelberg — New York: Springer, 1983. S. 569–575

    Chapter  Google Scholar 

  49. Stölting RK: Systemic circulation. Pharmacology & physiology in anesthetic practice. Philadelphia: J.B. Lippincott Company, 2006. S. 661–678

    Google Scholar 

  50. Walther A, Böttiger BW: Anaphylaktoide Reaktionen in der Prähospitalphase. Internist 2004; 45: 296–304

    Article  CAS  PubMed  Google Scholar 

  51. Vincent JL, De Backer D. Circulatory shock. N Engl J Med 2013; 369: 1726–1734

    Article  CAS  PubMed  Google Scholar 

  52. Martin C, Jacob M, Vicaut E, Guidet B, Van Aken H, Kurz A. Effect of waxy maize-derived hydroxyethyl starch 130/0.4 on renal function in surgical patients. Anesthesiology 2013; 118: 387–394

    Article  CAS  PubMed  Google Scholar 

  53. Myburgh JA, Finfer S, Bellomo R, Billot L, Cass A, Gattas D. Hydroxyethyl starch or saline for fluid resuscitation in intensive care. N Engl J Med 2012; 367: 1901–1911

    Article  CAS  PubMed  Google Scholar 

  54. Sheikh A, Ten Broek V, Brown SG, Simons FE. H1-antihistamines for the treatment of anaphylaxis: Cochrane systematic review. Allergy 2007; 62: 830–837

    Article  CAS  PubMed  Google Scholar 

  55. Zuberbier T, Asero R, Bindslev-Jensen C, Walter Canonica G, Church MK, Giménez-Arnau AM et al. EAACI/GA(2)LEN/EDF/WAO guideline: management of urticaria. Allergy 2009; 64: 1427–1443

    Article  CAS  PubMed  Google Scholar 

  56. Pragst F, Herre S, Bakdash A. Poisonings with diphenhydramine — a survey of 68 clinical and 55 death cases. Forensic Sci Int 2006; 161: 189–197

    Article  CAS  PubMed  Google Scholar 

  57. Lin RY, Curry A, Pesola GR, Knight RJ, Lee HS, Bakalchuk L et al. Improved outcomes in patients with acute allergic syndromes who are treated with combined H1 and H2 antagonists. Ann Emerg Med 2000; 36: 462–468

    Article  CAS  PubMed  Google Scholar 

  58. Ring J, Rothenberger KH, Clauss W. Prevention of anaphylactoid reactions after radiographic contrast media infusion by combined histamine H1- and H2-receptor antagonists: results of a prospective controlled trial. Int Arch Allergy Appl Immunol 1985; 78: 9–14

    Article  CAS  PubMed  Google Scholar 

  59. Brockow K, Kiehn M, Riethmüller C, Vieluf D, Berger J, Ring J. Efficacy of antihistamine pretreatment in the prevention of adverse reactions to Hymenoptera immunotherapy: a prospective, randomized, placebo-controlled trial. J Allergy Clin Immunol 1997; 100: 458–463

    Article  CAS  PubMed  Google Scholar 

  60. Aouam K, Bouida W, Ben Fredj N, Chaabane A, Boubaker H, Boukef R et al. Severe ranitidine-induced anaphylaxis: a case report and literature review. J Clin Pharm Ther 2012; 37: 494–496

    Article  CAS  PubMed  Google Scholar 

  61. Winbery SL, Lieberman PL. Histamine and antihistamines in anaphylaxis. Clin Allergy Immunol 2002; 17: 287–317

    CAS  PubMed  Google Scholar 

  62. Choo KJ, Simons E, Sheikh A. Glucocorticoids for the treatment of anaphylaxis: Cochrane systematic review. Allergy 2010; 65: 1205–1211

    Article  CAS  PubMed  Google Scholar 

  63. Fischer J, Biedermann T. Anaphylaxis due to allergological testing or therapy — a compact compendium for emergency management Allergo J 2009; 18: 124–131

    Google Scholar 

  64. Bundesärztekammer (BÄK), Kassenärztliche Bundesvereinigung (KBV), Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF). Nationale Versorgungsleitlinie Asthma — Langfassung, 2. Aufl. Version 5. 2009, zuletzt geändert: August 2013 [cited: 26.02.2014]; http://www.versorgungsleitlinien.de/themen/asthma

  65. Hartmann K, Biedermann T, Brockow K, Grabbe J, Horny H-P, Lippert U et al. Mastocytosis. Guideline of the German Society for Allergology an Clinical Immunology (DGAKI) and the German Society for Dermatology (DDG). Allergo J 2009; 18: 196–207

    Google Scholar 

  66. Simons FE, Ardusso LR, Dimov V, Ebisawa M, El-Gamal YM, Lockey RF et al. World Allergy Organization Anaphylaxis Guidelines: 2013 update of the evidence base. Int Arch Allergy Immunol 2013; 162: 193–204

    Article  CAS  PubMed  Google Scholar 

  67. Lieberman JA, Chehade M. Use of omalizumab in the treatment of food allergy and anaphylaxis. Curr Allergy Asthma Rep 2013; 13: 78–84

    Article  CAS  PubMed  Google Scholar 

  68. Ring J, Beyer K, Dorsch A, Biedermann T, Fischer J, Friedrichs F et al. Anaphylaxis school — a new educational program for tertiary prevention in patients with anaphylaxis. Allergo J 2012; 21: 96–102

    Article  Google Scholar 

  69. Fischer J, Kupfer J, Grosber M, Friedl T, Schallmeyer S, Rueff F, et al. Practical skills in the self therapy of anaphylaxis — development and evaluation of a test on decision making and prctical performance. Allergo J 2013; 22: 18–24

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Johannes Ring.

Additional information

Cite this as: Ring J, Beyer K, Biedermann T, Bircher A, Duda D, Fischer J et al. Guideline for acute therapy and management of anaphylaxis — S2 Guideline of DGAKI, AeDA, GPA, DAAU, BVKJ, ÖGAI, SGAI, DGAI, DGP, DGPM, AGATE and DAAB. Allergo J Int 2014; 23: 96–112 DOI 10.1007/s40629-014-0009-1

Conflict of Interest

The authors declare that there is no conflict of interest. More detailed information can be seen on the AWMF website (www.awmf.org).

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Ring, J., Beyer, K., Biedermann, T. et al. Guideline for acute therapy and management of anaphylaxis. Allergo J Int 23, 96–112 (2014). https://doi.org/10.1007/s40629-014-0009-1

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40629-014-0009-1

Keywords

Navigation