Treatment / Management
The type of treatment provided to the patient for type I hypersensitivity depends on the presentation and the etiology of the reaction.[15][16]
Anaphylaxis
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The need for emergent treatment is vital with anaphylaxis, at it is usually rapid in onset and may cause death. The recommendation is that if possible, the offending agent is removed immediately, and patients are placed in a supine position with the elevation of lower extremities unless there is a significant obstruction or airway inflammation. If there is marked stridor or severe respiratory distress, immediate intubation may be required. If the patient has a history of allergic reactions, they will be provided with emergency self-treatment prescriptions, which include: an epinephrine IM autoinjector or 1:1,000 solution, bronchodilators, antihistamines, and/or corticosteroids. The first-line therapy that is recommended to be administered without delay is epinephrine intramuscular (IM) injection and thereafter adjunctive therapy is utilized for symptom control:[13]
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Other adjunctive therapies for anaphylaxis include supplemental oxygenation, IV fluids for volume resuscitation, glucagon or vasopressors for refractory hypotension, and/or atropine for bradycardia. During and post anaphylaxis, the following should be ideally monitored: blood pressure, respiratory status, oxygenation, urine output, cardiac function, and heart rate at continuous intervals or frequently.[13]
Urticaria/Angioedema
Treatment of urticaria is similar to anaphylaxis where the offending agent is removed if known, and then the patient is given an H1 antihistamine and glucocorticoids (see above for dosing). There is not a need for epinephrine unless there is suspicion for anaphylaxis.[18] Patients with chronic urticaria who are refractory to H1 antihistamines may benefit from omalizumab, which is a monoclonal antibody that inhibits the binding of IgE to receptors on mast cells and basophils, or cyclosporine, which is an immunomodulator.[19]
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Allergic Asthma/Allergic Rhinitis/ Allergic Conjunctivitis/Allergic Dermatitis/Eczema/Wasp or bee venom/Drug Allergy/Food Allergy
For allergic conditions, avoidance of the offending agent is the first step in treatment. Oral or topical H1 antihistamine and oral or inhaled glucocorticoids may be used for symptomatic control. For allergic rhinitis, topical nasal or optical decongestants can provide temporary relief of symptoms. For allergic asthma, patients can be prescribed inhaled beta-agonists with or without inhaled corticosteroids based on steps of asthma therapy guidelines by the National Heart, Lung, and Blood Institute.
Patients with significant symptoms despite avoidance of the allergen and who have a lack of relief from adjunctive therapy can undergo allergen immunotherapy, such as desensitization or hypo-sensitization (allergy shots). The patient must have a documented IgE-mediated allergy (allergic: asthma, rhinitis, conjunctivitis, dermatitis, drug allergy) prior to initiation of immunotherapy. The treatment is carried out in a clinical setting for the first doses, where certain allergens are administered in a slow escalation of subclinical doses. The route of administration is either via subcutaneous immunotherapy (SCIT), sublingual/sallow immunotherapy (SLIT), or mucosal route.
The goal of desensitization is to stimulate the production of immunoglobulin G (IgG) antibodies on mast cells instead of IgE. This technique is known as isotype switching and usually lasts for three years. Desensitization treatment is successful in about 67% of patients and is usually more beneficial in younger patients and those who have a sensitivity to a monovalent allergen. Patients need to be prescribed and educated about the proper use of epinephrine autoinjectors prior to the initiation of immunotherapy.[18][20]
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