Asthma, age, cardiovascular disease associated with severe anaphylaxis
Key takeaways:
- Peanuts, tree nuts and shellfish were the most common triggers.
- 21.3% of patients had no prior history of anaphylaxis.
- 7.8% of patients required admission to the ICU.
SAN DIEGO — About a third of adults with anaphylaxis due to food allergy have visited the ED for their allergy before, with asthma, age and cardiovascular disease associated with severe cases, according to a pair of posters presented here.
There also were racial disparities in epinephrine use, Niraj Lawande, BS, a second-year student at Feinberg School of Medicine, said during his presentations at the 2025 American Academy of Allergy, Asthma & Immunology/World Allergy Organization Joint Congress.
“Much of the foundational work surrounding food allergies and anaphylaxis has been done in children, other countries or through registries. While these all provide very helpful knowledge, there is very limited knowledge about adult food-induced anaphylaxis,” Lawande told Healio.
“To address this, we conducted a retrospective clinical analysis of our institution’s ED to characterize the adult population coming to our ED and identify factors that can predict the most severe patients,” he continued.
The study analyzed the medical records of 333 adults (median age, 28 years; 50.5% women; 61.6% white) who presented at an urban ED with food-induced anaphylaxis between November 2008 and November 2023.
The cohort included 30.3% who had previously been to the ED for a food allergy and 21.3% with no previous history of anaphylaxis. The most common triggers included peanuts (26.1%; n = 87), tree nuts (24%; n = 80) and shellfish (11.4%; n = 39).
The most common involved organ systems included mucosal (86.5%; n = 288), skin (69.4%; n = 231) and respiratory (64.3%; n = 214). Also, 5.4% (n = 18) of the cases were hypotensive.
Before arriving at the hospital, 25.5% (n = 85) of the patients administered epinephrine to themselves, with 21.3% (n = 71) requiring more than one dose and 6.6% (n = 22) requiring intravenous epinephrine.
After adjusting for age, sex and asthma status, 29.8% of white patients and 15.5% of Black patients administered epinephrine to themselves (OR = 0.41; 95% CI, 0.2-0.86).
“This racial disparity in prehospital epinephrine use is important to emphasize,” Lawande said. “This suggests to us an important area to address in the care of our patients with food allergies.”
Additionally, 4.8% (n = 16) experienced biphasic anaphylaxis, and 18% (n = 60) had severe anaphylaxis, defined as refractory anaphylaxis (requiring three or more doses of epinephrine or intravenous epinephrine) and/or hospitalization.
Specifically, 7.5% (n = 25) experienced refractory anaphylaxis, 16.8% (n = 56) were hospitalized and 7.8% (n = 26) were admitted to the ICU with five intubations.
“These numbers are higher that what has previously been published,” Lawande said.
Hospitalization rates included 28.8% among patients with asthma (41.7% of the cohort) and 8.2% among patients who did not have asthma (P < .0001). Similarly, 13.7% of those with asthma and 3.6% of those who did not have asthma were admitted to the ICU (P = .0007).
Severe anaphylaxis was significantly more common among patients with asthma than among patients who did not have asthma (30.2% vs. 9.3%; P < .0001), the researchers said, adding that 32.4% of those with asthma and 13.4% of those who did not have asthma required multiple doses of epinephrine as well (P < .0001).
These differences between patients who did and did not have asthma persisted with adjustments based on age, sex and race, the researchers added.
Compared with patients with cardiovascular disease, patients who did not have cardiovascular disease had lower rates of hospitalization (36.2% vs. 13.6%; P = .0001), severe anaphylaxis (36.2% vs. 15%; P = .0005) and ICU admission (17% vs. 6.3%; P = .009).
Finally, compared with patients aged older than 50 years, patients who were younger than age 50 had lower rates of severe anaphylaxis (34.5% vs. 16.4%; P = .016), ICU admission (17.2% vs. 6.9%; P = .047), and hospitalization (31% vs. 15.5%; P = .032).
Based on these findings, the researchers concluded that there was an association between significant morbidity and food-induced anaphylaxis among adults, with asthma, cardiovascular disease and age increasing risks for severe outcomes.
“Asthma was the strongest predictor of severe anaphylaxis (OR = 4.2; 95% CI, 2.27-7.79) and ICU admission (OR = 4.46; 95% CI, 1.79-11.09),” Lawande said. “This was in spite of patients with asthma self-administering epinephrine at higher rates (OR = 2.15; 1.29-3.6).”
Considering the low rates and racial disparities in prehospital use, Lawande urged physicians to continue advocating for equitable access to epinephrine, which he called lifesaving. He also said that physicians should educate patients about when and how to use it.
“Patients should continue to be reminded to carry two epinephrine doses with them, as over one in five required more than one dose,” Lawande said. “This risk was significantly higher in those with asthma.”
Next, Lawande and his colleagues are going to further investigate patients who self-administered their own epinephrine and compare them with those who received epinephrine via EMS and those who received it in the ED.
“We also are looking more closely at patients with anaphylaxis requiring ICU level care to better understand what can be done earlier to prevent that sequelae,” he said.
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For more information:
Niraj Lawande, PhD, can be reached at niraj.lawande@northwestern.edu.