The use and the effectiveness of parenteral antihistamines and glucocorticoids in the management of acute allergic conditions and anaphylaxis: a systematic review of the literature.

The use and the effectiveness of parenteral antihistamines and glucocorticoids in the management of acute allergic conditions and anaphylaxis: a systematic review of the literature.

ABSTRACT

Background

Parenteral antihistamines and glucocorticoids are medications used to relieve or prevents allergic symptoms and anaphylaxis, which are administered intravenously (IV) or intramuscular (IM). An acute allergic condition is due to the immune system hypersensitivity to environmental substances. Anaphylaxis is a hypersensitivity response to an offending agent. It has a rapid onset of action, and the signs and symptoms are mild and sometimes life-threatening.

Objectives

The main objective of this paper is to outline the use and the effectiveness of parenteral antihistamines and glucocorticoids in the management of acute allergic conditions and anaphylaxis.

Methods

Several methods were applied to obtain information on the use and effectiveness of parenteral antihistamines and glucocorticoids in managing allergic conditions and anaphylaxis. Online databases were used for systematic reviews, randomized controlled trials (RCTs), quasi-randomized controlled trials (RCTs), controlled clinical trials (CCTs). Controlled before-after designs (CBA), interrupted time series (ITS) studies, and case series. Systematic reviews were performed using standard methods, and appropriate assessment tools were used. Anaphylaxis management plans and allergen-specific immunotherapy were the primary long-term management.

Results

During the study,

Conclusion

Introduction

Development of this

An acute allergic response is an ordinary condition that is evident in the emergency department.  The tendency of allergic disease is due to both genetic and environmental substances. These non-toxic environmental substances comprise of various airborne elements, poison from insect and drugs. Allergens are the antigens that are involved in producing the phenomenal immune response in which it is fought off an anticipated threat that otherwise would cause no harm to the body. The medication of allergic reaction is effected through immune mechanisms, which mainly belong to type I and IV hypersensitivity of Gell and Coombs reaction. The involvement of type II and III is hardly noticed. Symptoms associated with allergies do range from the localized rash to fatal condition-anaphylaxis. To date, no particular definition of anaphylaxis is established. However, it is mainly considered to describe a swift growth, threatening of lives, acute allergic response. Anaphylaxis results from loss of cytoplasmic granules and basophils with successive liberation/discharge of inflammatory mediators; histamine, tryptase, prostaglandins, cytokines – interleukins among other TNF/ILs into the bloodstream. Activation of mast cells and basophils triggers the anaphylactic reaction virtually. However, it implicates mainly on allergens; Foods, Drugs, Stings, Latex, and Allergen immunotherapy injections. The presence of these inflammatory mediators leads to contraction of smooth muscles, excellent vascular permeability and vasodilation, angioedema, low blood pressure, and bronchoconstriction.

To determine the particular allergen causing the skin, allergic reaction patch testing is done. The substances causing the allergy that are in common within the adhesive patches are employed behind the person. Examining the potential local allergies takes approximately 48 hours from patch application. Avoiding known allergens is the first treatment mode for allergies. While managing long term conditions of anaphylaxis, triggers should be strictly avoided. This is confirmed by undertaking allergology research. Besides, there is the use of medications like steroids and antihistamines in allergies treatment. Researchers recommend that acute allergies be prevented from advancing to anaphylaxis by administering injectable adrenaline (epinephrine). Recognizing anaphylaxis remains a challenge regarding the quality of the criteria of diagnosis used. In turn, the requirements lead to a slow administration of suitable medication prompting high chances of death. Validated clinical measures can be applied to aid the diagnosis of anaphylaxis.  It is important to sensitize people regarding the significance of allergic reactions-hay fever since the substantial buildup of allergens is inhibited. Currently, research states that anaphylaxis fatality medical condition cases have risen in a range of specialties, thus enough evidence that the condition perception is not uncommon as previously considered. A different approach has been applied by researchers to investigate the prevalence of anaphylaxis; Emergency department (ED) information, or the count of EAI’s prescribed cases-according to the report the visiting rate of anaphylaxis cases approximated to 0.5%. The mortality cases data report are sparse, and publications indicate noticeable variations approximating to 2.7 million cases yearly. American hospital statistics analysis state that one in three thousand inpatients encounter an anaphylactic reaction at death risk approximating to 1%. Thus, 500-1000 death cases are reported in the US due to anaphylaxis. The Brazilian report state that the mortality rate due to anaphylaxis approximates 1.1 million yearly. Findings made that drugs mainly catalyze responses. Besides, these death cases commonly included deaths that occurred in health facilities, the ED, and patients who were dead on arrival.

Administration of adrenaline should not delay the administration of glucocorticoids and the H1-antihistamines management of the anaphylactic patient, thus avoid an end acute episode.  Nevertheless, it is unpopularly more of treatment. Simple allergies are primarily medicated through the symptomatic method with the help of steroids and antihistamines.

Primarily, low blood pressure is the main feature in anaphylaxis, while on the other hand, low blood pressure is not a remarkable feature. Anaphylaxis condition is the onset and rapidly progresses, and the chances of mortality are very high within a short time. Typical allergic response causative agents are not extreme with low chances of death. In the treatment of anaphylaxis, adrenaline is compulsorily recommended and must be inclusive of regime medication. For normal allergic reactions, adrenaline is rarely used for the procedure. Irrespective of their distinguishing traits, both anaphylaxis, and allergic reactions tend to manifest similar characteristics.

Anaphylaxis is the advanced state of life-threatening form of allergies distinguished by circulatory problems. Anaphylaxis presentation involves various a combination of symptoms with mild signs, which progresses to fatal anaphylactic shock an anticipated. Common signs and symptoms include itching skin, generalized hives, swelling of impaired tissues, wheezing, and hypotension. The anaphylactic condition can be manifested in the form of response to any type of foreign substance to the body. Generally, allergens include: insect foods-which are commonly displayed in children, bites, and drugs-are mainly in adults. Food allergies can prompt severe consequences. Adrenaline is the primary medication for anaphylactic patients since it boosts the blood pressure, thus life-saving drugs in anaphylaxis.  Typically, anaphylaxis existence is due to an IgE-dependent immunological mechanism that is mainly triggered by the allergens mentioned above. However, there are other pathophysiological occurrences like IgE-independent immunologic processes and direct mast cell activities that are involved.

In diagnosing the rapid developing anaphylactic condition, many clinical systems are employed concerning the manifestation of signs and symptoms observed within 2 hours of allergen exposure. The prompt diagnosis of the disease assures maximal management.

Most frequent signs and symptoms displayed by anaphylactic conditions mentioned earlier affect the skin, itching, and flushing; thus, approximately 90% of patients are affected. Besides, the respiratory symptoms are other features that mostly change 70% of patients. Gastrointestinal symptoms (GI) – abdominal pain and vomiting affect 40% of the patients. Low blood pressure rarely affects anaphylactic patients, thus ranging to an approximate of 25% of patients.

Statistics show that the UK records the highest percentage of patients affected by allergies. 30% of adults and 40% of children are concerned. The anaphylactic situation is hardly predicted due to insufficient definition and regular failing attempts in diagnosing the condition. On the other hand, an active group of the American College of Allergy, Asthma, and the Immunology Epidemiology of Anaphylactic patients gave an overall approximate of the anaphylactic condition- strongly affected the population at any given time through their lives. Gradually, cases of severe allergic responses and anaphylaxis tend to rise.

An estimate of anaphylaxis mortality tends to be below 1%. Anaphylaxis claim 75% of patients who succumb to death within an hour of allergen vulnerability. Since anaphylaxis is a rapidly developing fatal circulation complication, it has to be managed quickly. Besides, anaphylaxis hinders the reliable epidemiological record since treatment records are the majors of both the national and international registries. Principally, asphyxia due to low blood pressure, failure of circulatory functioning, and upper airway edema. In spite of the flat mortality rate, there is a need for the urgent medication of anaphylaxis due to the rapid progression of the condition and the high possibility of effects.

Similar to all emergencies, the management of anaphylaxis at the beginning involves airway, breathing, and circulation assessment with immediate administration of adrenaline. Anaphylaxis emergency medication involves intramuscular adrenaline. At the emergency department, etiological elements are foreseen and frequently vary from primary causes of anaphylaxis. The necessity of the procedures Supplements medication with oxygen is strictly followed in the system, intravenous fluids, and the second-line drug therapy with the antihistamines or the glucocorticoids. Nevertheless, the unpredictability and possibility of life-endangering nature of anaphylaxis, performing randomized, controlled clinical tests makes it unethical. Thus, these treatment prescriptions are mainly on clinical observations. Significant principles of pathophysiology and selected laboratory research are preferable to clinical attest.

Adrenaline is regarded most important in the anaphylaxis management though there is the little manifestation in its use to this setting. Medical history for anaphylactic patients needs to be incorporated in the report during the assessment to minimize risk opportunities due to age, among other additional factors. Attentively, the anaphylaxis cause can quickly be established when these co-factors are considered. For effective management of anaphylaxis phenomenon in the emergency department self-injection of adrenaline and education regarding individual emergency action plans. This action plan has provided enough evidence concerning further medication of an anaphylaxis attack. Prevention and medicine of anaphylaxis is a significant role of the primary care physicians in a health facility setting. However, not many researchers have studied the management of anaphylaxis at the primary care level.  A significant number of gaps have been identified through the study in the management of anaphylaxis. The existence of these gaps in the management of anaphylaxis at this stage is due to ignorance, adrenaline treatment, and auto-injectors prescription of the adrenaline. The first approach used during the management evaluation of anaphylaxis by the primary care providers involves case studies and the use of questionnaires.

Recent studies carried out by various countries outsource their information from general practitioners, paramedics, and more common form the pediatrics in which they do not vary much from one another. There is still much to be done regarding epinephrine initial treatment approach of the anaphylaxis, administration through the muscles, dosages, and EAIs prescription. Researchers from Canada and the Netherlands reported common findings after reviewing healthcare databases, respectively. However, the primary treatment of anaphylactic patients that stands out to remain is the adrenaline. Glucocorticoids are administered after the first resuscitation episode. Another recent study in the emergency departments, findings made were that in the earlier years, corticosteroids were administered mainly than adrenaline at the initial medication of preference for anaphylaxis. For this report to be useful common reasoning with the gradual rise of glucocorticoids use. The H1-antihistamines are also mainly used to administer anaphylaxis in spite of insufficient and justifiable publications for the intervention.  Present Resuscitation Council (UK) recommends that initial hydrocortisone 200 mg should be conducted through muscles or slowly through the veins after the resuscitating process as the adult treatment and children ten years of age and above. Instructions from other researchers suggest that the treatment medication administered orally, intramuscularly, or intravenously, should be used with different dosages. Corticosteroids are usually applied on a single dose basis regularly. Glucocorticoids primarily down-regulates the late-phase progression. Short term corticosteroid medication is rarely considered with extreme effects.

Among anaphylactic patients, the late-phase and the extended lasting response happen to approximately 20%of patients. The reactions tend to be either mild or moderate. Risking of life seem to be rare. Biphasic responses that are endangered involve an extreme initial response, the presence of low blood pressure, delayed epinephrine administration, small adrenaline dosages, and also biphasic response previously observed.

Morbidity and mortality of epidemiological of anaphylaxis report remain to be insufficient. Most research tends to be biased, primarily due to the limited validation of external resources. Changes in methods used to obtain the samples for a particular population; thus, the frequently used cumulative rates of incidence hinder the generalization of the findings to other people. The stated evidence concerning the effectiveness of the glucocorticoids use seems to primarily involve the case reports, related studies, and descriptive literature forms — uncertainties regarding the efficacy of glucocorticoids administration in anaphylaxis treatment by providing prevention or worsening the protracted responses. A shred of evidence has been published about the possibilities of the ineffectiveness of the glucocorticoids. There is room for more research to be done and ascertain the merits and demerits or dangers associated with short term glucocorticoid medication of anaphylaxis. The study will justify or object the recommendation of using glucocorticoids in the life-endangering disease. This systematic review aims to outline the use and the effectiveness of parenteral antihistamines and glucocorticoids in the management of acute allergic conditions and anaphylaxis, thus improve the care field’s clinical efficiency.

Literature review

Objectives

Outline the use and the benefits of glucocorticoid treatment of the anaphylaxis attack.

Describe anaphylaxis as any form of an acute allergic reaction, which is mainly associated with life-threatening evidence. Since the responses are inclusive of more than one body system, thus purpose to include all anaphylactic incidences irrespective of the trigger.

Methodology

To establish the use and benefits of the glucocorticoids in anaphylactic condition management. Various factors need to be considered.  A guideline that was developed used a novel that had recently been put into practice in the cardiothoracic surgery. A variety of instructions perform a single systematic review of the literature to be used to answer all relevant clinical queries. To ensure maximum sensitivity, a systematic review of the research was done for each clinical question identified.

Guideline development was established and designed at various levels. The initial lead guideline developer gathered to review the entire scope of the guideline and to determine all clinical questions that might have been relevant to the task. To answer the clinical questions identified the performance of series structured short-cut systematic reviews in which they are the best evidence topic summaries, (BETs), from which the principles have previously been identified. In cases where there are relevant BETs, have already been established, the search strategies were confirmed and updated in case of necessity.

Having put together the evidence for each clinical query, the principle guideline developers achieved to create the guideline series of recommendations used to generate an evidence-based chart followed by the consultation with the lead guideline developer.

Evidence and recommendations grading

Research in this guideline was graded according to evidence levels from previous studies as accepted the definitions. Generally, level 1 evidence obtained from a properly designed randomized controlled trials (RCT’s), level 2 evidence from a large group of studies or a poorly structured RCT’s, level 3 evidence from a manageable small group of studies (case-control) education and the level 4 evidence from the experimental setups research (case studies or case series). Suffix ‘a’ stands for confirmation at this level obtained from the original research. Suffix ‘b’ stands for approval from a systematic review. Recommendations made were concerning the level of evidence-based upon.

Grade A: Structured upon multiple level 1a and 1b papers.

Grade B: Structured upon personal level 1a or 1b papers or the multiple level 2a or 2b papers.

Grade C: Structured upon personal level 2a or 2b papers or multiple levels of 3a or 3b documents.

Grade D: Structured upon personal level 3a or 3b papers or level 4.

Grade E: Structured on expert research opinions or consensus guidelines.

Define what is Acute allergic reaction

To fulfill the guideline instructions, an acute allergic response is a combination of signs and symptoms reacting to an allergen inclusive of medication prescriptions.

RECOMMENDATIONS SUMMARY

Adrenaline

Administered through veins (intravenous) or muscles (intramuscular) for anaphylaxis

Adrenaline administration through muscles is fit for early progression to moderate acute allergies (Grade D).

Titrated adrenaline IV doses are keenly regarded in the case of peri-cardiac arrest episodes or refractory low blood pressure (hypotension) (Grade D).

Subcutaneous or muscle administration of adrenaline for anaphylaxis.

Administration through muscles is highly preferred over the subcutaneous model for injecting the adrenaline in acute allergies (Grade D).

Self-injection of adrenaline for anaphylaxis in children

Adrenaline auto-injectors can be used within the community during the early stages of severe anaphylactic responses. Though there is no specific evidence provided (Grade C).

Ensuring an optimum possibility of benefit, it is worth patients, care providers, and parents are enlightened about the injection technique and also confirm the availability of auto-injector all through (Grade C).

Adrenaline inhaler alternative to intramuscular adrenaline

Researchers have not yet recommended the administration of adrenaline inhaler as an alternate of intramuscular due to lack of sufficient evidence adrenaline to patients of acute allergies (Grade D).

Sublingual adrenaline tablets: Test the effectiveness of the approach to the treatment of acute allergies.

Insufficient human research has failed the recommendations for sublingual adrenaline to be used in acute allergies treatment.

Nebulized adrenaline for wheeze in anaphylaxis

No specific evidence to affirm the use of nebulized adrenaline in anaphylaxis management (Grade D).

Injection of adrenaline in acute allergies: Do thighs appear better than the deltoid?

There is a high rate of absorption of adrenaline injections administered through the thigh than through the upper arm. Thus, the lateral thigh is the more preferred site to manage the intramuscular adrenaline injection (Grade C).

Allergen Removal

Shaving of hair to remove an allergen (hair dye) in acute allergies management.

To date, no publication regarding the evidence that hair shaving inhibits the acute allergic reaction from progression to hair dye (Grade E).

Effect of gastric lavage on the prevention of acute biphasic allergies.

Currently, there is no evidence established in a suggestion of the effect of gastric lavage to prevent biphasic allergies to ingested allergens (Grade E).

Anaphylaxis investigation

Mast cell tryptase and histamine levels in acute allergies.

No adequate sensitive evidence provided for tryptase and histamine as diagnostic measures of acute allergies. Nevertheless, the lack of alternative biomarkers, serial monitor of tryptase levels might be of use to routine monitoring that provides substantial evidence to affirm or challenge its usefulness.

Antihistamines

Oral antihistamines in acute allergies discharge.

No randomized regulation of trials to affirm the use of oral antihistamines to minimize the allergies from recurring. However, some allergic symptoms might be relieved (Grade D).

Corticosteroids

Hydrocortisone in acute allergies

No specific randomized controlled trials that provide support to the use of hydrocortisone in the aim of preventing or providing treatment of biphasic or protracted allergies. Nevertheless, considering that corticosteroids are more effective in acute asthma allergies and might be in confusion with anaphylaxis. The use of these might be warranted (Grade C).

Oral prednisolone on acute allergies discharge

No particular evidence to affirm the oral prednisolone prescription in the prevention of severe allergies recurrence, though corticosteroids might be of much help to urticaria symptoms (Grade C).

RESULTS

RECOMMENDATIONS EVIDENCE

Summaries of the evidence for the short cut systematic review used in establishing and make recommendations for this particular guideline. Three-section questions and research information are expressed with comments and clinically. Search strategies are shown in summary and can be seen in full in the appendix.

Adrenaline

Intravenous or intramuscular adrenaline for anaphylaxis

Three-section question

[Anaphylactic patients] is the [intramuscular adrenaline better than the intravenous adrenaline] at [treatment of anaphylaxis and toxicity prevention]?

The search strategies

Ovid Medline 1950 – May week 2 2008

Ovid Embase 1980 – June week 2 2008

One thousand five hundred six protocol views were discovered and were relevant to the three-part three-part question.

Findings

Adrenaline causes vasospasm and inotropic impact to the heart. Adrenaline was found to be much useful in the management of anaphylaxis though it can have severe adverse effects if inappropriate dosage or route of administering is used. Research from various case studies adrenaline-induced coronary vasospasm, pulmonary oedema and arrhythmias can be life-threatening. Rarely is the intramuscular adrenaline associated with the adverse occurrences and its benefits in managing the anaphylaxis disease.

Clinical background

It is much safer to use the intramuscular injection of adrenaline for early and moderate stages of allergies. In cases of arrest situations, the titrated dosage of IV adrenaline has to be put into consideration.

Recommendations

It is safe that, administration of intramuscular adrenaline injection for early progression to moderate acute allergies (Grade D). For severe cases of acute allergies, intravenous adrenaline should be regarded as inclusive of refractory hypotension and peri-cardiac attacks (Grade D).

Subcutaneous or intramuscular adrenaline for anaphylaxis

Three-part question

[Anaphylactic patients] is the [subcutaneous adrenaline better than the intramuscular adrenaline] at [treatment of anaphylaxis and toxicity prevention]?

Search strategy

Ovid Medline 1950 – May week 2 2008

Ovid Embase 1980 – June week 2 2008

Search results

Nine hundred fifty-two papers identified among them two identified original and relevant to three section questions.

Findings

Intramuscular injection of adrenaline creates a rapid systematic absorption of adrenaline than the subcutaneous route. The reason adrenaline reduces the cutaneous flow of blood for about 30 minutes. Besides, adrenaline is a potent cutaneous vasoconstrictor. Significantly this effect minimizes the rate of absorption of the adrenaline administered. self-injectable adrenaline is administered through intramuscular mode into the lateral thigh.

Nevertheless, the high rise of obesity, the delivery might, in a real sense, be subcutaneous in many ways. Thus, treatment in the initial stage is failed, and the absorption after as a secondary impact. Patients should be closely monitored and maintained to make observations of the lagged effects of subcutaneous adrenaline.

Clinical background

Mainly, the intramuscular route is most preferred over the subcutaneous course for adrenaline injection in acute allergies.

Recommendation

Intramuscular injection of adrenaline is mainly preferred over the subcutaneous route in acute allergies (Grade D).

Adrenaline self-injection for anaphylactic children

For [anaphylactic children] does [self-injectable of adrenaline] [minimize and morbidity mortality rate].

Search strategy

Ovid Medline 1950-May week 2 2008

Ovid Embase 1980-June week 2 2008

Search results

Seven hundred five papers were recognized. Three of the documents provided evidence relevant to the three-part question.

Findings

Initial treatment of severe anaphylaxis adrenaline is typically used as the drug choice since it blocks the mediator release and reverses the systematic effects. Thus many children are prescribed for auto-injectors during an emergency in the community.

The study suggests that adrenaline self-injection might decline subsequently with hospital admission and the need for adrenaline in the health facility set up. Approximately 75% of parents recorded not to be conversant with the correct procedures to use of devices in spite of prior instruction.

Evidence recorded regarding prompt use of adrenaline that it improves prognosis in extreme anaphylaxis reactions. Research findings in the UK and Ireland state that 53% of children reported cases with an allergic response. However, there are no justifiable evidence traces to answer the three-part question. Physiologically, the first use of adrenaline in acute anaphylaxis. Thus, it would be unethical to undertake a randomized controlled trial. Early adrenaline administration can be considered lifesaving and in with no manifestation of enough evidence of harm following self-injection. High levels of evidence should not be the core to regulate measures of regulating the availability of the resource.

Clinical baseline

With availability, adrenaline auto-injectors need to be used in the community as the early stage manifests its symptoms for severe anaphylactic responses. Though high quality evidence is not present. Maximizing any possible benefits is worth creating awareness to parents, patients, and care providers regarding injection techniques and ensure the availability of the auto-injectors.

Recommendations

Irrespective of the lack of high quality evidence of adrenaline auto-injectors should be in use when available.

Adrenaline inhaler: an alternative to intramuscular adrenaline

Three-part question

For [patients with acute allergies] is [intramuscular adrenaline better than adrenaline inhaler] in the case of [reversing symptoms].

Search strategy

Ovid Medline 1950-May week 2 2008

Ovid Embase 1980-June week 2 2008

Search outcomes

Seventy-one papers were obtained, and only two had relevant information to answer three-part questions.

Findings

Due to the lack of substantial evidence to affirm the beneficial impacts, inhaled adrenaline should not be in use as an alternative to intramuscular adrenaline in patients with acute allergies.

Recommendation

No recommendation is given for the use of adrenaline inhaler as an alternate in acute allergies due to a lack of evidence.

Sublingual adrenaline tablets: how effective is this novel approach to acute allergies?

[Patient with severe allergies] are [sublingual adrenaline tablets better over intramuscular adrenaline injections] in [reverse of symptoms and prevention of various effects of adrenaline]?

Search strategy

Ovid Medline 1950-May week 2 2008

Ovid Embase 1980-June week 2 2008

Search results

One hundred forty-seven papers were obtained, and one had relevant information about the three-part question.

Findings

There are many disadvantages associated with adrenaline auto-injectors inclusive of the cost of the injection, size of the injector device, improper technique for injection, inadequate dosages and pain, fear, and anxiety involving the intramuscular injections. The sublingual route administration of adrenaline has some benefits alternate to the intramuscular administration of adrenaline. Pharmacologists justify that sublingual medication drugs with them have fast and reliable impacts. Sublingual tablets are easily absorbed into the circulatory system allowing the possible metabolic gastrointestinal conversion problems and hepatic metabolism first-pass.

Clinical baseline

There is insufficient human study. Thus sublingual adrenaline is not recommended for general use in the treatment of acute allergies.

Recommendations

There is a need for human study for this novel approach.

Nebulized adrenaline for wheeze in anaphylaxis

[Anaphylactic patients] are [nebulized salbutamol better than the nebulized adrenaline] to [minimize wheeze]?

Search strategy

Ovid Medline 1950-May week 2 2008

Ovid Embase 1980-June week 2 2008

Search results

Thirty-six papers were collected, but none had relevant information to address the particular question.

Findings

In the management of wheeze brought about by acute allergies, nebulized adrenaline has been preferred as an alternative of salbutamol. No studies regarding the nebulized adrenalin with salbutamol in severe allergies.

Clinical baseline

No supporting evidence to support the use of nebulized adrenaline in anaphylaxis management.

Recommendations

Due to a lack of evidence, the use of nebulized adrenaline in acute allergies is not recommended.

Adrenaline: administration site

Adrenalin injection in the management of acute allergies.

Three-part question

[Patients with acute allergies] does the [injection of adrenaline into the vastus laterals or deltoid] to produce [faster and better effects].

Search strategy

Ovid Medline 1950-May week 2 2008

Ovid Embase 1980-June week 2 2008

Search results

Forty-one papers were obtained, and only one that had relevant information to the three-part question.

Findings

Sources show that adrenaline has high absorption if administered through muscles into the thigh or subcutaneously through the upper arm. Nevertheless, the plasma and tissues accumulation of adrenaline required for the effective treatment of acute allergies. In an ideal situation, adrenaline recommendations regarding administration have to be structured on the prospective, randomized, and double-blind, among other controlled trials in patients experiencing acute allergies. Thus, this method of a clinical trial would be so unethical and challenging to conduct due to the possible death risks of anaphylaxis.

Clinical baseline

There is a faster absorption of adrenaline from the thigh than from the upper arm. The lateral thigh is the most preferred site of administration of intramuscular adrenaline injection.

Recommendation

In comparison to deltoid for adrenaline, the intramuscular injection lateral thigh is the most preferred site (Grade C).

Allergen removal

Three-part question

For [patients with acute allergies to hair dye, does shaving of hair dye] inhibit [further progression of the response].?

Search strategy

Ovid Medline 1950-May week 2 2008

Ovid Embase 1980-June week 2 2008

Search results

One hundred eighty-nine papers were obtained, and none of them was found to have the relevant information to the three-part questions.

Findings

The hair dye allergy increased with the increase in the use of the dye, especially in young people. Components of hair dye are potent contact allergens. Recent research in the UK concerning the guidelines on the emergency addressing of anaphylaxis response to the removal of the allergen of anaphylactic reactions where feasible was recommended. Nevertheless, it is still not clear whether hair shaving would remove allergens present in the hair dye effectively to prevent acute allergies from progressing.

Clinical baseline

No evidence is published with a shaving of hair inhibits the progression of acute allergies to the hair dye. There is a need for more research to be done.

Recommendation

No evidence that shaving of hair stops the progression of the reaction (Grade C).

Discussion & Conclusion

Recommendations

References

Appendices