Adrenaline (epinephrine) for the treatment of anaphylaxis with and without shock

 

Abstract

Background

Anaphylaxis is a serious hypersensitivity reaction that is rapid in onset and may cause death. Adrenaline is recommended as the initial treatment of choice for anaphylaxis.

Objectives

To assess the benefits and harms of adrenaline (epinephrine) in the treatment of anaphylaxis.

Search methods

In the previous version of our review, we searched the databases until March 2007. In this version we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 11), MEDLINE (1966 to November 2010), EMBASE (1966 to November 2010), CINAHL (1982 to November 2010), BIOSIS (to November 2010), ISI Web of Knowledge (to November 2010 and LILACS (1982 to November 2010). We also searched websites listing ongoing trials and contacted pharmaceutical companies and international experts in anaphylaxis in an attempt to locate unpublished material.

Selection criteria

We included randomized and quasi-randomized controlled trials comparing adrenaline with no intervention, placebo or other adrenergic agonists were eligible for inclusion.

Data collection and analysis

Two authors independently assessed articles for inclusion.

Main results

We found no studies that satisfied the inclusion criteria.

Authors' conclusions

Based on this review, we are unable to make any new recommendations on the use of adrenaline for the treatment of anaphylaxis. Although there is a need for randomized, double-blind, placebo-controlled clinical trials of high methodological quality in order to define the true extent of benefits from the administration of adrenaline in anaphylaxis, such trials are unlikely to be performed in individuals with anaphylaxis. Indeed, they might be unethical because prompt treatment with adrenaline is deemed to be critically important for survival in anaphylaxis. Also, such studies would be difficult to conduct because anaphylactic episodes usually occur without warning, often in a non-medical setting, and differ in severity both among individuals and from one episode to another in the same individual. Consequently, obtaining baseline measurements and frequent timed measurements might be difficult, or impossible, to obtain. In the absence of appropriate trials, we recommend, albeit on the basis of less than optimal evidence, that adrenaline administration by intramuscular (i.m.) injection should still be regarded as first-line treatment for the management of anaphylaxis.

 

Plain language summary

Adrenaline for the emergency treatment of anaphylaxis

Anaphylaxis is a serious allergic reaction that is rapid in onset and may cause death. It is commonly triggered by a food, insect sting, medication, or natural rubber latex. The reaction occurs without warning and can be a frightening experience for those at risk and for their families and friends. Adrenaline (epinephrine) is widely advocated as the main treatment in those individuals experiencing anaphylaxis. There is no other medication with a similar effect on the many body systems that are potentially involved in anaphylaxis. The evidence base in support of the use of adrenaline is unclear. We therefore conducted a systematic review of the literature searching key databases for high quality published and unpublished material on the use of adrenaline for emergency treatment; in addition, we contacted experts in this area and the relevant pharmaceutical companies. Our searches retrieved no randomized controlled trials on this subject. We concluded that the use of adrenaline in anaphylaxis is based on tradition and on evidence from fatality series in which most individuals dying from anaphylaxis had not received prompt adrenaline treatment. Adrenaline appears to be life saving when injected promptly, however, there is no evidence from randomized controlled trials for or against the use of adrenaline in the emergency treatment of anaphylaxis. Given the infrequency of anaphylaxis, its unpredictability and the speed of onset of reactions, conducting such trials is fraught with ethical and methodological difficulties.

 

摘要

背景

腎上腺素用於治療有或無休克之過敏反應

Anaphylaxis是一種嚴重且發病迅速的過敏反應，且可能導致死亡。腎上腺素被建議作為初始治療過敏反應的首選用藥。

目標

為了評估腎上腺素治療過敏反應的效益和傷害，

搜尋策略

我們檢索了Cochrane Central Register of Controlled Trials (CENTRAL)(Cochrane資料庫 2007年第1期)，MEDLINE(1966年至2007年3月)，EMBASE(1966年至2007年3月)，CINAHL(1982年至2007年3月)，BIOSIS(至3月2007年)，ISI Web of Knowledge(至2007年3月)和 LILACS(至2007年3月)。我們還由網路搜尋了進行中的試驗：http://clinicaltrials.gov/，http://www.controlledtrials.com和http://www.actr.org.au/;也接觸了藥廠和各國的過敏專家，試圖找到未發表的題材。

選擇標準

在隨機和半隨機的對照試驗中，比較單純腎上腺素、安慰劑、或其他腎上腺素啟動劑者符合納入標準。

資料收集與分析

兩位作者獨立評估納入的文獻。

主要結論

我們發現沒有研究符合納入標準。

作者結論

經由此篇回顧文獻，對於使用腎上腺素治療過敏反應，我們無法作出任何新的建議。雖然對於腎上腺素治療過敏症的實際效益，需要有良好設計品質的隨機，雙盲，安慰劑對照的臨床試驗來確定，這類試驗卻不能用於有過敏反應的病人。事實上，這可能是不道德的，因為及時投予腎上腺素治療過敏反應對於存活是極為重要的。此外，這些研究通常難以進行，因為過敏性反應通常是無預警地發生，往往在非醫療環境，而且嚴重程度因人而異，甚至同一個體在不同次的過敏反應也不同。因此，在基準測量和定時測量上可能有困難。我們建議，在缺乏適當的試驗下，儘管缺乏最佳證據，肌肉注射腎上腺素仍應被視為治療過敏反應的第一線用藥。

翻譯人

本摘要由臺灣大學附設醫院陳心言翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

腎上腺素用於緊急治療過敏反應：Anaphylaxis是一種嚴重且發病迅速的過敏反應，且可能導致死亡。它通常經由食物、昆蟲叮咬、藥物、或天然橡膠乳膠引起。對於有風險的人及其親友，無預警下發生的反應可以是可怕的經驗。對於曾發生過敏反應的人，腎上腺素被廣泛提倡為主要治療的藥物。目前沒有其他藥物對於大多數人體系統發生的過敏反應有類似作用。支持使用腎上腺素的證據仍不明。因此，我們進行了系統回顧的文獻檢索，在資料庫尋找高品質，且與使用腎上腺素急救相關的文章。另外，我們也接觸這一領域的專家和製藥公司。我們沒有找到相關的隨機對照試驗。我們的結論是，使用腎上腺素在過敏性反應是基於傳統和死亡病例，其中多數死於過敏反應的人沒有得到立即的腎上腺素治療。及時使用腎上腺素似乎是救命關鍵，但是，沒有隨機對照試驗來證明或反對使用腎上腺素在過敏性反應的緊急治療。由於過敏反應有不常發生、不可預測、和快速發病等特色，進行這類試驗是充滿了倫理和方法上的困難。