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Possible risk factors for biphasic anaphylaxis

Possible risk factors for biphasic anaphylaxis
More certain (consistently associated in studies)
  • Severe initial presentation (eg, hypotension or severe respiratory compromise)
  • Delayed time to first epinephrine treatment (eg, >60 minutes)
  • Need for >1 dose of epinephrine
Less certain (implicated in some studies but not others)
  • Unknown trigger
  • Possible ongoing exposure to trigger: sustained-release medications or depot medications, foods
  • A prolonged interval (eg, hours) between contact with the trigger and the start of initial symptoms
  • Treatment with antihistamines or glucocorticoids without epinephrine
The table lists possible risk factors for biphasic anaphylaxis based on several meta-analyses and studies. Refer to UpToDate topics on anaphylaxis for recommendations on duration of observation in patients with anaphylaxis and one or more risk factors.
References:
  1. Shaker MS, Wallace DV, Golden DBK, et al. Anaphylaxis—a 2020 practice parameter update, systematic review, and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) analysis. J Allergy Clin Immunol 2020; 145:1082.
  2. Lee S, Bellolio MF, Hess EP, et al. Time of onset and predictors of biphasic anaphylactic reactions: A systematic review and meta-analysis. J Allergy Clin Immunol Pract 2015; 3:408.
  3. Kraft M, Hofmeier KS, Ruëff F, et al. Risk factors and characteristics of biphasic anaphylaxis. J Allergy Clin Immunol Pract 2020; 8:3388.
  4. Liu X, Lee S, Lohse CM, et al. Biphasic reactions in emergency department anaphylaxis patients: A prospective cohort study. J Allergy Clin Immunol Pract 2020; 8:1230.
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