ANDREA CANTY M.D.
PHONE 696-0587 FAX: 696-0787
MICHAEL KEATING M.D.
PHONE 696-6544 FAX: 696-0787
CHRIS VAILLANCOURT M.D. PHONE 696-6544 FAX: 696-0787
ASTHMA & ALLERGY
707 MILLIDGE AVE
SAINT JOHN, N.B. E2K 2N7
ANAPHYLAXIS
Prophylaxis is a word which means any measure taken to prevent disease, such as immunization.
Anaphylaxis means just the opposite and is derived from the Greek language: “ana” meaning
without and “phylaxis” meaning protection.
An anaphylactic reaction is an allergic reaction so severe that is can cause death. Anaphylaxis can
also be called “allergic shock” or “general allergic reaction”. If you have been told that you or
someone you care for is at risk and might experience an anaphylactic reaction, it is vital that you
know what anaphylaxis is, what causes it and how to effectively treat it.
WHAT IS AN ANAPHYLACTIC REACTION?
The first step in understanding anaphylaxis is to understand what causes allergy. Allergy is your
body’s immune (protective) system gone into overdrive. Your immune system is designed to
protect you against viruses and bacteria but in some individuals it uses its defensive mechanisms
to attack harmless substances.
Allergy begins when an individual’s body, for reasons not yet well understood, becomes sensitive
or “sensitized” to a particular substance which becomes an allergen. B lymphocytes, a part of the
body’s immune system, that routinely forms protective antibodies, now form them against the
allergen. The allergic reaction occurs when the allergen subsequently enters the body, encounters
its antibodies and they combine on the surface of mast cells. This causes the mast cell to explode,
releasing many chemicals including histamine. These potent chemicals cause many kinds of
allergic symptoms. One such symptom is the overproduction of mucus causing a runny nose,
watery eyes, and congested lungs or coughing. Another symptoms experienced during an allergic
reaction is swelling , which results in a stuffed up feeling in the nose, ears or chest, headaches,
hives or a general feeling of itchiness. Also a reaction will tighten muscles in the lungs and
gastrointestinal tract to bring on asthma and abdominal cramps.
The usual allergic reaction takes place in only one part of the body. When allergic diseases occur:
 In the upper respiratory tract, it is called rhinitis or hay fever
 In the lungs or lower respiratory system, it is called asthma
 On the skin, it is called eczema/dermatitis or hives/urticaria
 In the digestive system, it causes a multitude of gastrointestinal symptoms including
vomiting and diarrhea.
With the exception of under treated asthma, these allergic diseases are not life- threatening. In an
anaphylactic, all four allergic diseases occur simultaneously and very suddenly.
An anaphylactic reaction incorporates all the above listed symptoms and some additional ones.
The following is a list of symptoms ranging from mild to severe. Any combination on this list
should not be taken lightly and should be reported to and discussed with your doctor.
Itchy eyes
Wheezing
Vomiting
Tingling lips
Diarrhea
Constricted throat
Flushing
Itchy Skin
Shock
Nasal Obstruction
Weakness
Total respiratory failure
Dizziness
Hives
Sudden Drop in Blood Pressure
Shortness of Breath
Loss of Consciousness
Anaphylaxis may begin mildly enough with itching around the eyes, widespread hives, a cough
and a vague feeling of anxiety and discomfort. In rapid succession, often within minutes of
exposure to the allergen, the patient may complain of a constricted feeling in the chest, of
dizziness and abdominal pain. She/ he may begin to wheeze, be nauseated, and vomit. Weakness,
hoarseness of speech, confusion and a terrible sensation of impending disaster may follow. The
victim may become cyanotic as blood pressure falls steeply. Unconsciousness, coma and death
can follow. Anaphylaxis can intensify so rapidly from initial symptoms to potentially fatal shock
that there is often little time to seek medical help.
WHAT CAUSES AN ANAPHYLACTIC REACTION?
All this can occur as a result of a single sting by a bee, an injection of penicillin or the ingestion
of a potentially allergenic food. Fortunately, it does not happen frequently and it can be both
avoided and controlled.
1. Insects as a Cause of Anaphylaxis:
Actually the first record we have of allergy involved a fatal reaction to a stinging insect.
King Menes, an Egyptian Pharaoh was reviewing his troops when he was stung and died.
Should you visit Egypt, this little vignette from history is recorded in hieroglyphics on his
pyramid.
Insects that bite can cause uncomfortable, but not fatal, reactions. It is the insects which
sting – honeybees, bumble bees, hornets, yellow-jackets and wasps- that cause fatal
reactions.
Everyone who is stung suffers from a reaction. For most it is merely a momentary
localized pain. For a few individuals a sting results in an anaphylactic reaction. If you
have had a very severe reaction to a stinging insect, you would be wise to discuss this
with your allergist. She/he or a colleague can test you for reactions to stinging insects.
This will confirm whether or not you are at risk and the test results will determine what
treatment and/or precautionary measures you need.
2. Drugs as a Cause of Anaphylaxis:
The medication which is most apt to cause anaphylaxis is penicillin. The next most
common is aspirin. In addition, there are isolated reports of individuals reacting to a
variety of medications, including anesthetics, contrast dyes used to take X rays and other
antibiotics.
The important issue with drug reactions is to separate the so called normal side effects,
reactions which can be expected as a result of taking the drug, from allergic reactions
which are not a normal component of the action of that particular medication. In the case
of an allergic reaction, it is important to differentiate between those allergic reactions
which while uncomfortable and even frightening, are not life threatening and those
reactions which are potentially fatal. Any reactions to a drug should be reported to the
prescribing physician and she/he can tell if the reaction is a normal side effect or an
allergic reaction and, if it is allergy, whether it is severe enough to cause an anaphylactic
reaction.
Here are some points to keep in mind:
 Most people experience a very severe but not anaphylactic reaction to a medication which
serves as a warning that they are sensitized to that drug.
 Even people with no previous allergy problems can become sensitized to a medication
 Medications which are injected are more likely to cause anaphylaxis than are medications
taken by mouth
 Most diagnosis of drug reactions are based on medical history because the tests for drug
reactions are not satisfactory.
 Allergy to penicillin is the exception. There are reliable valid tests for penicillin allergy.
The standard procedure for dealing with confirmed and sometimes with suspected
penicillin allergy is to avoid the antibiotic. If a penicillin allergic person becomes ill and
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the best treatment is a course of penicillin, than the doctor may use a special method of
administering penicillin.
ASA sensitive persons should avoid preparations which obviously contain ASA such as
Aspirin, Bufferin and Anacin, but should also be aware that there are many medications
which contain ASA as a component including PMS remedies (i.e. Midol) and most
“cold” preparations (i.e. Coricidin).
Any reaction experienced while on medication should be reported.
3. Foods as a Cause of Anaphylaxis:
In recent months, there have been an increasing number of media reports of individuals
who have died from an anaphylactic reaction to a food. Allergy to foods does not usually
pose a threat to life. There are however, certain foods which in some persons can cause
death. Foods which can cause life threatening reactions caused by other foods but these
are extremely rare.
A severe reaction to a food should be reported to your physician. In most instances, the
allergic reaction to the food can be confirmed by history and, if necessary, by testing
under controlled circumstances.
People do not take medications or expose themselves to stinging insects every day, but
people must eat. The psychological trauma of knowing that you are at risk is handled
very differently by each person. Thus physicians instructing patients about food allergies
severe enough to cause anaphylaxis are in a difficult position. They are darned if they do
and darned if they don’t. When a doctor tries to tell a patient in a matter of fact way that
an allergic reaction to such and such a food could cause “a general reaction” then the
patient says, “why was I never told that this food could kill me?” On the other hand, if the
doctor is too specific in trying to describe the risk, the patient becomes so horrified that
she/he is terrified to eat anything and becomes malnourished and reclusive. The doctor
must try to understand the psychological make up of the patient and tell the patient in a
way that he /she will understand the risks, the methods that are available for protection
and adjust to a new lifestyle.
HOW IS ANAPHYLAXIS TREATED?
Before treatment can begin, it is essential that the condition be accurately diagnosed, preferably
by an allergy specialist (allergist), rather than a specialist in another field or a family physician.
An incorrect diagnosis could be fatal to you. If you are actually at risk from anaphylaxis, there are
a great many constraints on your life. If you are not truly at risk, why limit yourself?
As with any allergic reaction, there are three treatment methods: avoidance, medications and
immunotherapy. In the case of anaphylaxis there is an additional treatment mode, the emergency
treatment.
THE WHOLE PURPOSE OF THE FOLLOWING EMERGENCY PROCEDURE IS TO
BUY TIME TO ENABLE THE PATIENT TO LIVE LONG ENOUGH TO GET TO A
HOSPITAL FUR FURTHER TREATMENT.
1. Emergency treatment in anaphylaxis
a) Always carry an emergency adrenalin kit. There are 2 available and they can be
obtained by prescription.
 The EPIPEN (made by Center Laboratories and distributed by Laboratories Allerex Ltd.)
contained a pre determined dose of adrenalin (epinephrine). The Epipen bears no
resemblance to the usual syringe. It is always ready for use as it requires no filling, no
assembly, no sterile swabs or tourniquet. Because it is compact and easy to carry, it is
more likely to be carried and thus available when needed.
 The TWINJECT AUTO-INJECTOR (made by Hollister – Stier Laboratories and
distributed by Paladin Laboratories) contains two separate doses of epinephrine; the first
dose administered by pen, the second dose by a needle/syringe contained within the pen.
Approximately 20% of all anaphylactic reactions are biphasic, meaning a second dose is
required, sometimes within ten minutes. Both Epipen and Twinject are available in
children’s doses (Jr. for children up to 15 kg or 33 pounds; Senior for children and adults
over 33 pounds).
b) If you have experienced shortness of breath, asthma or difficulty in swallowing
as a symptom, your doctor may advise you to also carry a bronchodilator
medication, which can be inhaled. There are several on the market, available by
prescription, such as Ventolin, Berotec or Bricanyl. Bronchodilators, as their
name implies, release the tightened or spasmed lungs and alleviate breathing
difficulties.
c) An antihistamine taken almost immediately will also help some people. Your
doctor or pharmacist can advice you which is the best suited to you. The usual
recommendation is Benadryl.
2. Avoidance as a treatment for Anaphylaxis
a) Avoiding Stinging Insects: In Canada, the months of highest risk of being stung
are July, August and September. Always wear shoes for extra protection when
walking. Keep a can of insect spray in your home and in the car.
Stinging insects are attracted to sweet smells and vivid colours as a part of their
instinctive drive to collect pollens from flowers. They are provoked when this
urge is frustrated. Therefore, the allergic individual should refrain from wearing
perfumes, bright colours and floppy clothing when outdoors.
Stinging insects will attack if their nest is distributed or if they are provoked.
Nesting sites are usually found in hollow trees, hedges, low bushes, eaves, log
piles and under rubbish. Inspect your property in the spring for signs of insect
activity and eliminate the nesting places before the nests are built.
b) Avoiding medications: Having experienced an anaphylactic reaction to a
medication, you must avoid that medication. It is vital that someone, either your
doctor or your pharmacist, provide you with the following information:
 The name of the drug, both its trade name (what it is called on the
label) and its generic name (its medication classification name).
 The name of the manufacturer
 The names of other similar drugs presently available
Whenever you are purchasing an over the counter medication, check with the pharmacist
that the therapeutic ingredients are not related to or are not the same as the therapeutic
ingredients in the drug which caused your reaction. Whenever your physician prescribes a
medication, remind him/her of your reaction to ensure that the new medication is not of
the same type and will not give you a reaction.
All this assumes that it is the therapeutic ingredients in medications which are causing the
reaction. It could be the excipients of a medication which caused the reaction. Excipients
are the non medical ingredients which are mixed with the therapeutic ingredients to form
color, preserve etc. the medication in its final form. Sulfites are a common preservative in
medications and such medications should be avoided by people who have experienced
severe reactions to foods containing sulfites. When full ingredient listings are required on
drug packaging, it will be easier to trace the caused of reactions to medications.
c) Avoiding foods:
 If the food package does not have ingredients listed, DO NOT PURCHASE
OR EAT this food.
 Read labels of packaged , prepared foods carefully
 There are some ingredient names that mean that the food you are avoiding is
present. Learn what these words are.

Read the labels of packaged, prepared foods every time you buy them. Food
Manufacturers often change ingredients without notifying consumers
conspicuously.
Eating out places you are at the greatest risk. When eating out, in a home, restaurant,
bakery etc. it is important to ask the person who actually prepared the food and if your
allergen is in that food. Unfortunately, they often do not know and give uninformed
information and wrong answers. BE CAREFUL! Consider the answers carefully and if
the answers are incomplete or do not ring true, do not eat the food. It is more important to
protect yourself. Do not be afraid of appearing impolite or foolish.
3. Medications as a treatment for Anaphylaxis:
Medications used to treat anaphylactic reactions range from antihistamines and
bronchodilators and bronchodilators to adrenalin emergency kits. Their use and
administration is discussed in the section entitled “Emergency Treatment in
Anaphylaxis”. Any treatment should be discussed with your physicians for correct
dosage, usage and procedures. Working with your doctor, an exact plan of action should
be discussed and written out. In this way, if you are in distress/under duress, the
instructions are clearly written down and can be correctly followed. There are no drugs
which can be taken as a preventative.
4. Immunotherapy as a treatment for Anaphylaxis:
The only anaphylactic condition for which immunotherapy is appropriate is stinging insect
allergy. Avoidance is the only preventative if food or drugs cause anaphylaxis.
The concept of using immunotherapy (allergy shots) to protect persons who are allergic to
Hymenoptera (stinging insect) venom has been around for a long time. Until 1978 the only
products available for this treatment were processed from the bodies of the insect, and known
as Whole Body Extract (WBE). Unfortunately, WBE did not contain enough insect venom to
provide consistent protection. When a cost effective way to collect the pure venom was
finally developed, a new method of immunotherapy became available – venom extract. If you
have been previously tested and/or treated with the old whole body preparations, investigate
the venom extract. For any history of sting reaction, your allergist can now use this new,
specific venom preparation to not only confirm an allergy to Hymenoptera venom, but also to
treat you with the specific correct venom.
Testing for venom hypersensitivity is usually restricted to patients who have had an
immediate reaction to an insect sting, such as respiratory difficulty, hypotension (falling
blood pressure), or generalized urticaria (hives and swelling). The treatment is accomplished
by using graduated increases in doses of the appropriate insect venoms to lessen the severity
of symptoms from subsequent stings.
Insect venom extracts are effective for the diagnosis and treatment of patients at risk of life
threatening allergic reactions to insect stings. They can, however, cause adverse effects and
should be used only by physicians to treat life threatening reactions.
PSYCHOLOGICAL MANAGEMENT OF ANAPHYLAXIS
Books of suspense have been written in which the hero or heroine is aware that some unknown
person is trying to poison him/her. The reader can really relate to the mental anguish suffered by
the hero/ heroine as she/ her tries to avoid the fatal potion. Those at risk of any anaphylactic
reaction are in the same position, yet their very justifiable fears are too often minimized. Perhaps
this is because it is difficult for an unaffected person to accept that anything as small as an insect,
as life saving as a drug as delicious as a food could kill a person.
How does the person cope with this threat hanging over his/her head? Obviously, some people
simply ignore the whole issue; make no attempt to protect themselves, fatalistically assuming that
there is nothing that can be done and that “when your number’s up, your numbers up’.
Others are so frightened that they become non-functional. Those with stinging insect allergy stay
indoors during the summer, drive with all the windows up and become hysterical at the sight of
an insect. Those with drug reactions will suffer pain and illness rather than take any medications.
Those with food allergies begin to withdraw from any social function and sometimes become
malnourished because they are literally “too scared to ear”.
Obviously the healthiest response is somewhere between these two extremes. Actually facing this
potentially fatal situation realistically is easier said than done. A good analogy is driving a car.
You can learn how to be a good driver and practice good road safety methods such as defensive
driving skills. But if a truck blows a tire and crashes into you, there is nothing you could have
done to protect yourself. If you dwell on such a possibility, you would never leave your house.
But since such a possibility is very remote, you do you best and are prepared for the unforeseen.
REV 12/07