Current Treatment Options in Allergy

, Volume 5, Issue 1, pp 11–28 | Cite as

Anaphylaxis in the Workplace

  • Darío Antolín-Amérigo
  • Alberto Alvarez-Perea
  • Ana Fiandor
Occupational Allergy (S Quirce and J Sastre, Section Editors)
Part of the following topical collections:
  1. Topical Collection on Occupational Allergy


Occupational anaphylaxis (OcAn) main causes comprise food, medications, insect stings/bites, and natural rubber latex (NRL). An in-depth investigation is required, before labeling a reaction as OcAn.

A written emergency management plan, health and safety education, and training and surveillance should be implemented after proper diagnosis. Education on when and how to use the adrenaline auto-injector device should be provided likewise. Moreover, surveillance and advice on risk of allergen exposure and how to minimize their risk of sensitization at the beginning of their employment or training is mandatory. Workers who have developed sensitization to an allergen in the occupational setting may also develop anaphylaxis outside the work environment, from exposure to the same or to cross-reacting allergens. We believe that removal from exposure shall avoid subsequent OcAn episodes; therefore, once OcAn has been diagnosed, this intervention shall be implemented.

This review highlights the different causes of OcAn, their physiopathology, cofactors, diagnosis, and its management, focusing on the medication spectrum. Interested readers may acquire knowledge on this severe, potentially life-threatening systemic hypersensitivity reaction, which generally involves an immunologic IgE mechanism.


Anaphylaxis Occupational diseases Epinephrine Hypersensitivity Allergy Environment 


Compliance with ethical standards

Conflict of interest

Darío Antolín-Amérigo declares that he has no conflicts of interest.

Alberto Álvarez-Perea declares that he has no conflicts of interest.

Ana Fiandor declares that she has no conflicts of interest.

Human and animal rights and informed consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    •• Muraro A, Roberts G, Worm M, Bilò MB, Brockow K, Fernández Rivas M, et al. Anaphylaxis: guidelines from the European Academy of Allergy and Clinical Immunology. Allergy. 2014;69(8):1026–45. These guidelines have been prepared by the European Academy of Allergy and Clinical Immunology (EAACI) Taskforce on Anaphylaxis. They aim to provide evidence-based recommendations for the recognition, risk factor assessment, and the management of patients who are at risk of, are experiencing, or have experienced anaphylaxis. While the primary audience is allergists, these guidelines are also relevant to all other healthcare professionals.
  2. 2.
    •• Simons FE, Ardusso LR, Bilò MB, Cardona V, Ebisawa M, El-Gamal YM, et al. International consensus on (ICON) anaphylaxis. World Allergy Organ J. 2014;7(1):9 This international consensus is published as an information resource about anaphylaxis for worldwide use by healthcare professionals, academics, policy-makers, patients, caregivers, and the public.
  3. 3.
    Moscato G, Pala G, Crivellaro M, Siracusa A. Anaphylaxis as occupational risk. Curr Opin Allergy Clin Immunol. 2014;14(4):328–33. Scholar
  4. 4.
    • Siracusa A, Folletti I, Gerth van Wijk R, Jeebhay MF, Moscato G, Quirce S, et al. Occupational anaphylaxis: an EAACI task force consensus statement. Allergy. 2015;70:141–52. This comprehensive paper delves into the causes of occupational anaphylaxis and also gives practical management strategies for healthcare professionals. CrossRefPubMedGoogle Scholar
  5. 5.
    Worm M, Moneret-Vautrin A, Scherer K, Lang R, Fernandez-Rivas M, Cardona V, et al. First European data from the network of severe allergic reactions (NORA). Allergy. 2014;69(10):1397–404.
  6. 6.
    de Silva IL, Mehr SS, Tey D, Tang MLK. Paediatric anaphylaxis: a 5 year retrospective review. Allergy. 2008;63(8):1071–6. Scholar
  7. 7.
    Pumphrey RSH. Lessons for management of anaphylaxis from a study of fatal reactions. Clin Exp Allergy. 2000;30(8):1144–50. Scholar
  8. 8.
    Quirce S, Fiandor A. How should occupational anaphylaxis be investigated and managed? Curr Opin Allergy Clin Immunol. 2016;16(2):86–92. Scholar
  9. 9.
    Jeebhay MF, Robins TG, Lehrer SB, Lopata AL. Occupational seafood allergy: a review. Occup Environ Med. 2001;58(9):553–62. Scholar
  10. 10.
    Monsalve RI, González de la Peña MA, López-Otín C, Fiandor A, Fernández C, Villalba M, et al. Detection, isolation and complete amino acid sequence of an aeroallergenic protein from rapeseed flour. Clin Exp Allergy. 1997;27(7):833–41.
  11. 11.
    Davidson AE, Passero MA, Settipane GA. Buckwheat-induced anaphylaxis: a case report. Ann Allergy. 1992;69(5):439–40.PubMedGoogle Scholar
  12. 12.
    Garcia-Abujeta JL, Rodriguez F, Maquiera E, Picans I, Fernandez L, Sanchez I, et al. Occupational protein contact dermatitis in a fishmonger. Contact Dermatitis. 1997;36(3):163–4.
  13. 13.
    Escudero C, Quirce S, Fernández-Nieto M, de Miguel J, Cuesta J, Sastre J. Egg white proteins as inhalant allergens associated with baker’s asthma. Allergy. 2003;58(7):616–20. Scholar
  14. 14.
    Jones M, Skidmore A, Glozier N, Welch J, Hunter AS, Cullinan P. Occupational egg allergy in an embryological research facility. Occup Med. 2013;63(5):348–53. Scholar
  15. 15.
    • Feldweg AM. Food-dependent, exercise-induced anaphylaxis: diagnosis and management in the outpatient setting. J Allergy Clin Immunol Pract. 2017;5(2):283–8. Recently, it was demonstrated that exercise is not essential for the development of symptoms, and that if enough of the culprit food is ingested, often with additional augmentation factors, such as alcohol or acetylsalicylic acid, symptoms can be induced at rest in the challenge setting. Thus, food-dependent, exercise-induced anaphylaxis appears to be more correctly characterized as a food allergy syndrome in which symptoms develop only in the presence of various augmentation factors, with exercise being the primary one. Scholar
  16. 16.
    Brockow K, Kneissl D, Valentini L, Zelger O, Grosber M, Kugler C, et al. Using a gluten oral food challenge protocol to improve diagnosis of wheat- dependent exercise-induced anaphylaxis. J Allergy Clin Immunol. 2015;135(4):977–984.e4.
  17. 17.
    Scherf KA, Brockow K, Biedermann T, Koehler P, Wieser H. Wheat-dependent exercise-induced anaphylaxis. Clin Exp Allergy. 2016;46(1):10–20. Scholar
  18. 18.
    Fukutomi Y, Taniguchi M, Nakamura H, Akiyama K. Epidemiological link between wheat allergy and exposure to hydrolyzed wheat protein in facial soap. Allergy. 2014;69(10):1405–11. Scholar
  19. 19.
    Chinuki Y, Morita E. Wheat-dependent exercise-induced anaphylaxis sensitized with hydrolyzed wheat protein in soap. Allergol Int. 2012;61(4):529–37. Scholar
  20. 20.
    Airaksinen L, Pallasaho P, Voutilainen R, Pesonen M. Occupational rhinitis, asthma, and contact urticaria caused by hydrolyzed wheat protein in hairdressers. Ann Allergy Asthma Immunol. 2013;111(6):577–9. Scholar
  21. 21.
    Khalili B, Bardana EJ, Yunginger JW. Psyllium-associated anaphylaxis and death: a case report and review of the literature. Ann Allergy Asthma Immunol. 2003;91(6):579–84. Scholar
  22. 22.
    Antolin-Amerigo D, Sánchez-González MJ, Barbarroja- Escudero J, Rodríguez-Rodríguez M, Álvarez-Perea A, Alvarez-Mon M. Allergic reaction to polyethylene glycol in a painter. Occup Med (Lond). 2015;65(6):502–4. Scholar
  23. 23.
    •• Whitaker P. Occupational allergy to pharmaceutical products. Curr Opin Allergy Clin Immunol. 2016;16:101–6. Interesting review about the diagnosis of occupational allergy to drugs, which can be complicated and has been shown to take up to 5 years from the onset of symptoms.
  24. 24.
    Kim JE, Kim SH, Jin JH, Bahn JW, Jin HJ, Ye YM, et al. A case of piperacilline-induced occupational anaphylaxis: detection of serum IgE to piperacillin-HAS conjugate. J Korean Med Sci. 2011;26(5):682–5.
  25. 25.
    Wittczak T, Dudek W, Walusiak-Skorupa J, Swierczynska-Machura D, Palczynski C. Chlorhexidine: still an underestimated allergic hazard for healthcare professionals. Occup Med. 2013;63(4):301–5. Scholar
  26. 26.
    Sussman GL, Dorian W. Psyllium anaphylaxis. Allergy Proc. 1990;11(5):241–2. Scholar
  27. 27.
    Newman MJ, Goel P. An anesthesiologist with an allergy to multiple neuromuscular blocking drugs: a new occupational hazard. Anesth Analg. 2010;110(2):601–2. Scholar
  28. 28.
    Bandino ML, Tankersley MS. Anaphylaxis in an allergy immunotherapy extract-compounding technician after an extract needle stick. J Allergy Clin Immunol. 2012;129(1):250–1. Scholar
  29. 29.
    Toletone A, Voltolini S, Passalacqua G, Dini G, Bignardi D, Minale P. Hymenoptera venom allergy in outdoor workers: occupational exposure, clinical features and effects of allergen immunotherapy. Hum Vaccin Immunother. 2017;13(2):477–83. Scholar
  30. 30.
    Cruz S, Vega A, Fernández S, Marqués L, Baltasar M, Alonso A, et al. Report from the Hymenoptera Committee of the Spanish Society of Allergology and Clinical Immunology: immunotherapy with bumblebee venom. J Investig Allergol Clin Immunol. 2012;22:372–92.Google Scholar
  31. 31.
    Bonifazi F, Jutel M, Bilò BM, Birnbaum J, Muller U, and the EAACI Interest Group on Insect Venom Hypersensitivity. Prevention and treatment of hymenoptera venom allergy: guidelines for clinical practice. Allergy. 2005;60(12):1459–70. Scholar
  32. 32.
    Antolín-Amérigo D, Moreno Aguilar C, Vega A, Alvarez-Mon M. Venom immunotherapy: an updated review. Curr Allergy Asthma Rep. 2014;14(7):449. Scholar
  33. 33.
    • Alfaya Arias T, Soriano Gómis V, Soto Mera T, Vega Castro A, Vega Gutiérrez JM, Alonso Llamazares A, et al. Key issues in hymenoptera venom allergy: an update. J Investig Allergol Clin Immunol. 2017;27(1):19–31. Updated review on important diagnostic and management solutions to hymenoptera venom allergy.
  34. 34.
    Valls A, Pineda F, Belver MT, Caballero T, López-Serrano MC. Anaphylactic shock caused by tick (Rhipicephalus sanguineous). J Investig Allergol Clin Immunol. 2007;17:277–85.Google Scholar
  35. 35.
    Acero S, Blanco R, Bartolomé B. Anaphylaxis due to a tick bite. Allergy. 2003;58(8):824–5. Scholar
  36. 36.•
    Fischer J, Lupberger E, Hebsaker J, Blumenstock G, Aichinger E, Yazdi AS, et al. Prevalence of type I sensitization to alpha-gal in forest service employees and hunters. Allergy. 2017; Interesting paper which shows the importance of alpha-gal, a new occupational allergen, cross-reactive with red meat.
  37. 37.
    Vega JM, Moneo I, Armentia A, López-Rico R, Curiel G, Bartolomé B, et al. Anaphylaxis to a pine caterpillar. Allergy. 1997;52(12):1244–5. Scholar
  38. 38.
    Morales-Cabeza C, Prieto-García A, Acero S, Bartolomé-Zavala B, Morgado JM, Matito A, et al. Systemic mastocytosis presenting as occupational IgE-mediated anaphylaxis to pine processionary caterpillar. Ann Allergy Asthma Immunol. 2016;117:318–37.
  39. 39.
    Meseguer J, Sánchez-Guerrero IM, Iraola V, Carnés J, Fernández Caldas E. Occupational allergy to aquarium fish food: red midge larva, freshwater shrimp, and earthworm. A clinical and immunological study. J Investig Allergol Clin Immunol. 2013;23:462–70.Google Scholar
  40. 40.
    Rankin TJ, Hill RJ, Overton D. Anaphylactic reaction after a laboratory rat bite. Am J Emerg Med. 2007;25:985.
  41. 41.
    Kampitak T, Betschel SD. Anaphylaxis in laboratory workers because of rodent handling: two case reports. J Occup Health. 2016;58(4):381–3. Scholar
  42. 42.
    Torres JA, Pastor-Vargas C, de las Heras M, Vivanco F, Cuesta J, Sastre J. An odorant-binding protein as a new allergen from Siberian hamster (Phodopus sungorus). Int Arch Allergy Immunol. 2012;157(1):109–12. Scholar
  43. 43.
    Watt AD, McSharry CP. Laboratory animal allergy: anaphylaxis from a needle injury. Occup Environ Med. 1996;53(8):573–4. Scholar
  44. 44.
    Gawlik R, Pitsch T, DuBuske L. Anaphylaxis as a manifestation of horse allergy. World Allergy Organ J. 2009;2(8):185–9. Scholar
  45. 45.
    Cavkaytar Ö, Soyer Ö, Skerel BE. A rare cause of aeroallergen-induced anaphylaxis: horse allergy. Turk J Pediatr. 2014;56(4):437–9.PubMedGoogle Scholar
  46. 46.
    Moghtaderi M, Farjadian S, Abbaszadeh Hasiri M. Animal allergen sensitization in veterinarians and laboratory animal workers. Occup Med. 2014;64(7):516–20. Scholar
  47. 47.
    de Medeiros CR, Barbaro KC, de Siqueira França FO, Zanotti AP, Castro FF. Anaphylactic reaction secondary to Bothrops snakebite. Allergy. 2008;63(2):242–3. Scholar
  48. 48.
    Prescott RA, Potter PC. Hypersensitivity to airborne spitting cobra snake venom. Ann Allergy Asthma Immunol. 2005;94(5):600–3. Scholar
  49. 49.
    Madero MF, Gámez C, Madero MA, Fernández-Nieto M, Sastre J, del Pozo V. Characterization of allergens in four South American snake species. Int Arch Allergy Immunol. 2009;150(3):307–10. Scholar
  50. 50.
    de Pontes LG, Cavassan NR, Creste CF, Junior AL, Arcuri HA, Ferreira RS, et al. Crotoxin: a novel allergen to occupational anaphylaxis. Ann Allergy Asthma Immunol. 2016;116(6):579–81. Scholar
  51. 51.
    • Caballero ML, Quirce S. Identification and practical management of latex allergy in occupational settings. Expert Rev Clin Immunol. 2015;11:977–92. An up-to-date and comprehensive review of occupational allergy to natural rubber latex.
  52. 52.
    Miaozong W, James M, Jian L. Current prevalence rate of latex allergy: why it remains a problem? J Occup Health. 2016;58:138–44.CrossRefGoogle Scholar
  53. 53.
    Salcedo G, Diaz-Perales A, Sanchez-Monge R. The role of plant panallergens in sensitization to natural rubber latex. Curr Opin Allergy Clin Immunol. 2001;1(2):177–83. Scholar
  54. 54.
    Raulf-Heimsoth M, Rihs HP, Rozynek P, Cremer R, Gaspar A, Pires G, et al. Quantitative analysis of immunoglobulin E reactivity profiles in patients allergic or sensitized to natural rubber latex (Hevea brasiliensis). Clin Exp Allergy. 2007;37(11):1657–67.
  55. 55.
    Spaner D, Dolovich J, Tarlo S, Sussman G, Buttoo K. Hypersensitivity to natural latex. J Allergy Clin Immunol. 1989;83(6):1135–7. Scholar
  56. 56.
    Sussman GL, Tarlo S, Dolovich J. The spectrum of IgE-mediated responses to latex. JAMA. 1991;265(21):2844–7. Scholar
  57. 57.
    de Groot H, Patiwael JA, de Jong N, Burdorf A, van Wijk RG. Research into sensitization and allergies to latex: results after 10 years of the use of powder-free latex gloves. Ned Tijdschr Geneeskd. 2013;157:A5835.PubMedGoogle Scholar
  58. 58.
    Helaskoski E, Suojalehto H, Virtanen H, Airaksinen L, Kuuliala O, Aalto-Korte K, et al. Occupational asthma, rhinitis, and contact urticaria caused by oxidative hair dyes in hairdressers. Ann Allergy Asthma Immunol. 2014;112(1):46–52.
  59. 59.
    Fukunaga T, Kawagoe R, Hozumi H, Kanzaki T. Contact anaphylaxis due to paraphenylenediamine. Contact Dermatitis. 1996;35(3):185–6. Scholar
  60. 60.
    Oshima H, Tamaki T, Oh-I T, Koga M. Contact anaphylaxis due to para-aminophenol and para-methylaminophenol in hair dye. Contact Dermatitis. 2001;45(6):359. Scholar
  61. 61.
    Kleniewska A, Wiszniewska M, Krawczyk-Szulc P, Nowakowska-Świrta E, Walusiak-Skorupa J. Anaphylactic reaction in a hairdresser due to sensitization to persulphates. Occup Med (Lond). 2016;66(7):584–5. Scholar
  62. 62.
    Romano C, Sulotto F, Pavan I, Chiesa A, Scansetti G. A new case of occupational asthma from reactive dyes with severe anaphylactic response to the specific challenge. Am J Ind Med. 1992;21(2):209–16. Scholar
  63. 63.
    Nowak D, Panaszek B. Anaphylactic reactions to low-molecular weight chemicals. Postepy Hig Med Dosw (Online). 2015;69:197–206.Google Scholar
  64. 64.
    Krecisz B, Kiec-Swierczynska M, Krawczyk P, Chomiczewska D, Palczynski C. Cobalt-induced anaphylaxis, contact urticaria, and delayed allergy in a ceramics decorator. Contact Dermatitis. 2009;60(3):173–4. Scholar
  65. 65.
    Littorin M, Truedsson L, Welinder H, Skarping G, Martensson U, Sjöholm AG. Acute respiratory disorder, rhinoconjunctivitis and fever associated with the pyrolysis of polyurethane derived from diphenylmethane diisocyanate. Scand J Work Environ Health. 1994;20(3):216–22.
  66. 66.
    Scolnick B, Collins J. Systemic reaction to methylmethacrylate in an operating room nurse. J Occup Med. 1986;28(3):196–8.PubMedGoogle Scholar
  67. 67.
    Li LF, Sujan SA, Li QX. Contact urticaria syndrome from occupational benzonitrile exposure. Contact Dermatitis. 2004;50(6):377–8. Scholar
  68. 68.
    Lessenger JE. Occupational acute anaphylactic reaction to assault by perfume spray in the face. J Am Board Fam Pract. 2001;14(2):137–40.PubMedGoogle Scholar
  69. 69.
    Hannu T, Alanko K, Keskinen H. Anaphylaxis and allergic contact urticaria from occupational airborne exposure to HBTU. Occup Med (Lond). 2006;56(6):430–3. Scholar
  70. 70.
    Álvarez-Twose I, González de Olano D, Sánchez-Muñoz L, Matito A, Jara-Acevedo M, Teodosio C, et al. Validation of the REMA score for predicting mast cell clonality and systemic mastocytosis in patients with systemic mast cell activation symptoms. Int Arch Allergy Immunol. 2012;157(3):275–80. Scholar
  71. 71.
    •• Alvarez-Perea A, Tomás-Pérez M, Martínez-Lezcano P, Marco G, Pérez D, Zubeldia JM, et al. Anaphylaxis in adolescent/adult patients treated in the emergency department: differences between initial impressions and the definitive diagnosis. J Investig Allergol Clin Immunol. 2015;25:288–94. This papers highlights the importance of a correct diagnosis of anaphylaxis, which conditions the administration of epinephrine, regardless of the severity of symptoms. The real etiology of anaphylaxis should only be proposed after an allergy workup, which is recommended in all cases, as the real cause can differ considerably from the initial impression in the ED.PubMedGoogle Scholar
  72. 72.
    Sala-Cunill A, Cardona V, Labrador-Horrillo M, Luengo O, Esteso O, Garriga T, et al. Usefulness and limitations of sequential serum tryptase for the diagnosis of anaphylaxis in 102 patients. Int Arch Allergy Immunol. 2013;160(2):192–9.
  73. 73.
    Cardona V, Álvarez-Perea A, Ansotegui IJ, Arias-Cruz A, González-Díaz SN, Latour-Staffeld P, et al. Management of anaphylaxis in Latin America: current situation. Rev Alerg Mex. 2017;64(2):171–7.Google Scholar
  74. 74.
    Sampson HA, Munoz-Furlong A, Campbell RL, Adkinson NF Jr, Bock SA, Branum A, et al. Second symposium on the definition and management of anaphylaxis: summary report—Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium. J Allergy Clin Immunol. 2006;117(2):391–7. Scholar
  75. 75.
    Campbell RL, Hagan JB, Manivannan V, Decker WW, Kanthala AR, Bellolio MF, et al. Evaluation of national institute of allergy and infectious diseases/food allergy and anaphylaxis network criteria for the diagnosis of anaphylaxis in emergency department patients. J Allergy Clin Immunol. 2012;129(3):748–52.
  76. 76.
    Loprinzi Brauer CE, Motosue MS, Li JT, Hagan JB, Bellolio MF, Lee S, et al. Prospective validation of the NIAID/FAAN criteria for emergency department diagnosis of anaphylaxis. J Allergy Clin Immunol Pract. 2016;4(6):1220–6.
  77. 77.
    Campbell RL, Park MA, Kueber MA, Lee S, Hagan JB. Outcomes of allergy/immunology follow-up after an emergency department evaluation for anaphylaxis. J Allergy Clin Immunol Pract. 2015;3(1):88–93. Scholar
  78. 78.
    Alvarez-Perea A, Ameiro B, Morales C, Zambrano G, Rodríguez A, Guzmán M, et al. Anaphylaxis in the pediatric emergency department: analysis of 133 cases after an allergy workup. J Allergy Clin Immunol Pract. 2017;5(5):1256–63.
  79. 79.
    Simons FE, Ardusso LR, Bilò MB, El-Gamal YM, Ledford MD, Ring J, et al. World Allergy Organization anaphylaxis guidelines: summary. J Allergy Clin Immunol. 2011;127(3):587–93. Scholar
  80. 80.
    Quirce S. IgE antibodies in occupational asthma: are they causative or an associated phenomenon? Curr Opin Allergy Clin Immunol. 2014;14(2):100–5. Scholar
  81. 81.
    Caballero ML, Ordaz E, Bermejo M, Rodriguez-Perez R, Alday E, Maqueda J, et al. Characterization of occupational sensitization by multiallergen immunoblotting in workers exposed to laboratory animals. Ann Allergy Asthma Immunol. 2012;108(3):178–81.
  82. 82.
    Cardona V, Ansotegui IJ. Component-resolved diagnosis in anaphylaxis. Curr Opin Allergy Clin Immunol. 2016;16:244–9.CrossRefPubMedGoogle Scholar
  83. 83.
    Simons FE, Frew AJ, Ansotegui IJ, Bochner BS, Golden DB, Finkelman FD, et al. Risk assessment in anaphylaxis: current and future approaches. J Allergy Clin Immunol. 2007;120(1 Suppl):S2–24. Scholar
  84. 84.
    Hompes S, Kohli A, Nemat K, Scherer K, Lange L, Rueff F, et al. Provoking allergens and treatment of anaphylaxis in children and adolescents—data from the anaphylaxis registry of German-speaking countries. Pediatr Allergy Immunol. 2011;22(6):568–74. Scholar
  85. 85.
    Tewari A, TG D, Lack G. The difficulties of diagnosing food-dependent exercise-induced anaphylaxis in childhood—a case study and review. Pediatr Allergy Immunol. 2006;17(2):157–60. Scholar
  86. 86.
    •• Lieberman P, Nicklas RA, Randolph C, Oppenheimer J, Berstein D, Berstein J, et al. Anaphylaxis—a practice parameter update. Ann Allergy Asthma Immunol. 2015;115:341–84. An extensive review and recommendations about anaphylaxis and its management written by the American Academy of Allergy, Asthma and Immunology (AAAAI).CrossRefPubMedGoogle Scholar
  87. 87.
    Bilò MB, Cichocka-Jarosz E, Pumphrey R, Oude-Elberink JN, Lange J, Jakob T, et al. Self-medication of anaphylactic reactions due to Hymenoptera stings—an EAACI Task Force Consensus Statement. Allergy. 2016;71(7):931–43.
  88. 88.
    Simons FE, Ebisawa M, Sanchez-Borges M, Thong BY, Worm M, Tanno LK, et al. 2015 update of the evidence base: World Allergy Organization Anaphylaxis Guidelines. World Allergy Organ J. 2015;8:32.CrossRefPubMedPubMedCentralGoogle Scholar
  89. 89.
    Lieberman P, Simons FER. Anaphylaxis and cardiovascular disease: therapeutic dilemmas. Clin Exp Allergy. 2015;45(8):1288–95. Scholar
  90. 90.
    Triggiani M, Patella V, Staiano RI, Granata F, Marone G. Allergy and the cardiovascular system. Clin Exp Immunol. 2008;153(Suppl 1):7–11. Scholar
  91. 91.
    Niggemann B, Beyer K. Adrenaline autoinjectors in food allergy: in for a cent, in for a euro? Pediatr Allergy Immunol. 2012;23(6):506–8. Scholar
  92. 92.•
    Sturm GJ, Varga EM, Roberts G, Mosbech H, Bilò MB, Akdis CA, et al. EAACI guidelines on allergen immunotherapy: Hymenoptera venom allergy. Allergy. 2017. Comprehensive up-to-date systematic review about the evidence on venom immunotherapy of the European Academy of Allergy and Clinical Immunology.Google Scholar
  93. 93.
    Castells MCA. New era for drug desensitizations. J Allergy Clin Immunol Pract. 2015;3(4):639–40. Scholar
  94. 94.
    Nurmatov U, Dhami S, Arasi S, Pajno GB, Fernandez-Rivas M, Muraro A, et al. Allergen immunotherapy for IgE-mediated food allergy: a systematic review and meta-analysis. Allergy. 2017;72(8):1133–47.
  95. 95.
    El-Qutob D. Off-label uses of omalizumab. Clin Rev Allergy Immunol. 2016;50(1):84–96. Scholar
  96. 96.
    Simons FE, Ardusso LR, Dimov V, Ebisawa M, El-Gamal YM, Lockey RF, et al. World Allergy Organization Anaphylaxis Guidelines: 2013 update of the evidence base. Int Arch Allergy Immunol. 2013;162(3):193–204.

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Darío Antolín-Amérigo
    • 1
  • Alberto Alvarez-Perea
    • 2
    • 3
  • Ana Fiandor
    • 4
  1. 1.Servicio de Enfermedades del Sistema Inmune-Alergia, Departamento de Medicina y Especialidades MédicasHospital Universitario Príncipe de Asturias, Universidad de Alcalá (IRYCIS)MadridSpain
  2. 2.Allergy ServiceHospital General Universitario Gregorio MarañónMadridSpain
  3. 3.Gregorio Marañón Health Research InstituteMadridSpain
  4. 4.Department of AllergyHospital La Paz Institute for Health Research (IdiPAZ)MadridSpain

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