New guidelines released for treatment of anaphylaxis and atopic dermatitis

Two new practice parameters from the Joint Task Force for Practice Parameters (JTFPP) offer evidence-based recommendations for the diagnosis and management of anaphylaxis and atopic dermatitis (AD) in pediatric and adult patients. The Joint Task Force is a partnership between the American College of Allergy, Asthma and Immunology (ACAAI) and the American Academy of Allergy, Asthma and Immunology.

“Both anaphylaxis and atopic dermatitis are allergic conditions that affect millions of people-in the United States and around the world,” says allergist Jay Lieberman, MD, co-chair of the JTFPP Task Force. “We regularly update our practice parameters to make sure allergists and other healthcare practitioners are aware of best practices when diagnosing and managing these disorders. When physicians and their staffs are aware of updated guidance, it means patients are getting the best, most appropriate care.”

Anaphylaxis

“The 2023 JTFPP anaphylaxis practice parameter provides evidence-based recommendations to support optimal contextual care across contemporary practice settings,” says allergist David B.K. Golden, MDCM, lead author of the practice parameter. “With important new guidance related to diagnostic evaluation, anaphylaxis in infants and in community settings, epinephrine treatment, mast cell conditions, beta-blockers and ACE inhibitors, and peri-operative anaphylaxis, these guidelines translate recent advances in the understanding of severe allergic reactions to help all healthcare professionals provide individualized care to each patient at the right time, in the right place, every time.”

The practice parameter on anaphylaxis focuses on areas where new evidence has emerged, and recommendations have evolved.

Key anaphylaxis guideline highlights include:

• Updates on recommendations regarding if a patient must go to the emergency room if they use epinephrine for anaphylaxis. Calling emergency services (EMS) after use of an epinephrine auto injector (EAI) may not be required if the patient experiences prompt, complete, and durable response to treatment and has access to additional EAIs. Situations that would warrant EMS activation include severe anaphylaxis, symptoms that do not resolve promptly, completely or nearly completely, or symptoms that return or worsen.
• Recommendations on how, where and by whom epinephrine auto injectors should be stored.
• Updates on the diagnosis of anaphylaxis. Revised criteria by the World Allergy Organization (WAO), Brighton, and Delphi Consensus groups aim to create more universally accepted definitions and criteria for anaphylactic reactions.
• Updates on how to recognize and treat anaphylaxis in infants. Diagnosing anaphylaxis in infants and toddlers can be challenging, and there are no age-specific anaphylaxis diagnostic criteria. Therefore, the current National Institute of Allergy and Infectious Diseases/Food Allergy & Anaphylaxis Network or World Allergy Organization anaphylaxis criteria should be used to establish the diagnosis of anaphylaxis in infants/toddlers.
• Updates on how to evaluate and treat anaphylaxis in relation to a surgery.
• Updates on nuances regarding the use of beta-blockers and ACE inhibitors in patients at risk for anaphylaxis.

Atopic Dermatitis

“The 2023 JTFPP atopic dermatitis guideline represents an advancement in trustworthy allergy guidelines,” says allergist Derek Chu, M.D., Ph.D. “It is distinguished from other guidelines through systematic reviews of the evidence with multidisciplinary panelist engagement, adherence to GRADE – a rigorous guideline development process, as well as the involvement of the patient and caregiver voice from start to finish. Clear translation of evidence to clinically actionable and contextual recommendations, and novel approaches to facilitate knowledge translation were paramount. The guidelines emphasize, in addition to standards of trustworthiness, the third principle of evidence-based medicine: that evidence alone is never enough; that patient values and preferences are crucial to arriving at optimal recommendations. The new recommendations also reflect the evolution of diversity, equity and inclusion in approaching diagnosis and management of this condition.”

Key atopic dermatitis guideline highlights include:

• Recommends the use of topical corticosteroids or topical calcineurin inhibitors in patients with uncontrolled AD, despite moisturizers.
• Highlights the safety of the topical calcineurin inhibitors with typical usage once or twice daily.
• Recommends proactive therapy with topical corticosteroids or topical calcineurin inhibitors for patients with a relapsing course.
• Consideration for once daily dosing of topical medications. Recommends dupilumab for patients 6 months of age or older with moderate-severe AD refractory, intolerant, or unable to use mid-potency topical treatment, or tralokinumab for similar patients ages 12 years and older.
• Suggests against elimination diets for AD.
• Suggests the usage of crisaborole 2% ointment for mild to moderate atopic dermatitis.
• Suggests against the use of topical antibiotics for AD alone with no infection.
• Suggests bleach baths for AD patients with moderate to severe disease as an additive therapy; suggests against use for mild AD.
• Suggests consideration of allergen immunotherapy for moderate to severe AD.
• Suggests use of oral JAK inhibitors after careful consideration of risks and benefits in adults and adolescents with moderate-severe AD refractory, intolerant, or unable to use mid to high potency topical treatment and biologics.
• Suggests against immunosuppressant medications such as baricitinib (a JAK inhibitor), azathioprine, methotrexate and, mycophenylate mofetil
• Suggests consideration of cyclosporin in adults and adolescents with moderate-severe AD refractory, intolerant, or unable to use mid to high potency topical treatment and biologics.
• Suggests against the use of systemic corticosteroids for AD.

The practice parameters are published in Annals of Allergy, Asthma & Immunology, the scientific journal of the American College of Allergy, Asthma & Immunology.

Reference:

Golden DBK, Wang J, Waserman S, Akin C, Campbell RL, Ellis AK, Greenhawt M, Lang DM, Ledford DK, Lieberman J, Oppenheimer J, Shaker MS, Wallace DV, Abrams EM, Bernstein JA, Chu DK, Horner CC, Rank MA, Stukus DR; Collaborators; Burrows AG, Cruickshank H; Workgroup Contributors; Golden DBK, Wang J, Akin C, Campbell RL, Ellis AK, Greenhawt M, Lang DM, Ledford DK, Lieberman J, Oppenheimer J, Shaker MS, Wallace DV, Waserman S; Joint Task Force on Practice Parameters Reviewers; Abrams EM, Bernstein JA, Chu DK, Ellis AK, Golden DBK, Greenhawt M, Horner CC, Ledford DK, Lieberman J, Rank MA, Shaker MS, Stukus DR, Wang J. Anaphylaxis: A 2023 practice parameter update. Ann Allergy Asthma Immunol. 2023 Dec 5:S1081-1206(23)01304-2. doi: 10.1016/j.anai.2023.09.015.