World Allergy Organization subcutaneous immunotherapy systemic reaction grading system

Grade 1	Grade 2	Grade 3	Grade 4	Grade 5
Symptom(s)/sign(s) of one organ system present* Cutaneous Generalized pruritus, urticaria, flushing, or sensation of heat or warmth^¶ or Angioedema (not laryngeal, tongue, or uvular) or Upper respiratory Rhinitis (eg, sneezing, rhinorrhea, nasal pruritus, and/or nasal congestion) or Throat-clearing (itchy throat) or Cough perceived to originate in the upper airway, not the lung, larynx, or trachea or Conjunctival Erythema, pruritus, or tearing Other Nausea, metallic taste, or headache	*Symptom(s)/sign(s) of more than one organ system present* or Lower respiratory Asthma: Cough, wheezing, shortness of breath (eg, less than 40% PEF or FEV₁ drop, responding to an inhaled bronchodilator) or Gastrointestinal Abdominal cramps, vomiting, or diarrhea or Other Uterine cramps	Lower respiratory Asthma (eg, 40% PEF or FEV₁ drop not responding to an inhaled bronchodilator) or Upper respiratory Laryngeal, uvula, or tongue edema with or without stridor	Lower or upper respiratory Respiratory failure with or without loss of consciousness or Cardiovascular Hypotension with or without loss of consciousness	Death
Patients may also have a feeling of impending doom, especially in grades 2, 3, or 4. NOTE: Children with anaphylaxis seldom convey a sense of impending doom, and their behavior changes may be a sign of anaphylaxis (eg, becoming very quiet or irritable and cranky). Scoring includes a suffix that denotes if and when epinephrine is or is not administered in relationship to onset of symptom(s)/sign(s) of the systemic reaction: a: ≤5 minutes; b: >5 minutes to ≤10 minutes; c: >10 to ≤20 minutes; d: >20 minutes; z: epinephrine not administered. The final grade of the reaction will not be determined until the event is over, regardless of the medication administered. The final report should include the first symptom(s)/sign(s) and the time of onset after the subcutaneous allergen immunotherapy injection^Δ and a suffix reflecting if and when epinephrine was or was not administered (eg, Grade 2a; rhinitis: 10 minutes).
Final report: Grade a to d or z___________ First symptom(s)/sign(s)___________ Time of onset of first symptom___________
Comments:^◊

PEF: peak expiratory flow; FEV₁: forced expiratory volume in one second.
* Each grade is based on organ system involved and severity. Organ systems are defined as cutaneous, conjunctival, upper respiratory, lower respiratory, gastrointestinal, cardiovascular, and other. A reaction from a single organ system, such as cutaneous, conjunctival, or upper respiratory, but not asthma, gastrointestinal, or cardiovascular is classified as a grade 1. Symptom(s)/sign(s) from more than one organ system or asthma, gastrointestinal, or cardiovascular are classified as grades 2 or 3. Respiratory failure or hypotension with or without loss of consciousness define grade 4 and death grade 5. The grade is determined by the clinician's clinical judgment.
¶ This constellation of symptoms may rapidly progress to a more severe reaction.
Δ Symptoms occurring within the first minutes after the injection may be a sign of severe anaphylaxis. Mild symptoms may progress rapidly to severe anaphylaxis and death.
◊ If signs or symptoms are not included in the table or the differentiation between a systemic reaction and vasovagal (vasodepressor) reaction, which may occur with any medical intervention, is difficult, please include comments, as appropriate.

Reproduced from: Cox L, Larenas-Linnemann D, Lockey RF, et al. Speaking the same language: The World Allergy Organization subcutaneous immunotherapy systemic reaction grading system. J Allergy Clin Immunol 2010; 125:569. Table used with the permission of Elsevier Inc. All rights reserved.

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World Allergy Organization subcutaneous immunotherapy systemic reaction grading system