Food, drug, insect sting allergy, and anaphylaxis
Antihypertensive medication use is associated with increased organ system involvement and hospitalization in emergency department patients with anaphylaxis

https://doi.org/10.1016/j.jaci.2013.01.011Get rights and content

Background

Risk factors for increased anaphylaxis severity are poorly understood. Angiotensin-converting enzyme (ACE) inhibitors have been associated with severe anaphylactic reactions in patients with hymenoptera venom allergy. Studies evaluating the association between beta-blockers and severe anaphylaxis have been conflicting.

Objective

To evaluate the association between antihypertensive medication use and increased anaphylaxis severity.

Methods

We included emergency department anaphylaxis patients aged 18 years and older. Markers of severe anaphylaxis were defined as (1) syncope, hypotension, or hypoxia; (2) signs and symptoms involving 3 or more organ systems; and (3) hospitalization. Antihypertensive medications evaluated included beta-blockers, ACE inhibitors, calcium channel blockers, angiotensin receptor blockers, and diuretics. Simple and multiple logistic regression analyses were conducted to estimate the association between antihypertensive medication use and markers of increased anaphylaxis severity.

Results

Among 302 patients with anaphylaxis, 55 (18%) had syncope, hypoxia, or hypotension, 57 (19%) required hospitalization, and 139 (46%) had 3 or more organ system involvement. After adjusting for age, gender, suspected trigger, and preexisting lung disease, beta-blocker, ACE-inhibitor, diuretic, or antihypertensive medication use in aggregate remained associated with both 3 or more organ system involvement and need for hospital admission. The adjusted associations between antihypertensive medication use in aggregate and 3 or more organ system involvement yielded an odds ratio of 2.8 (95% CI, 1.5-5.2; P = .0008) and with hospitalization an odds ratio of 4.0 (95% CI, 1.9-8.4; P = .0001).

Conclusions

In emergency department anaphylaxis patients, antihypertensive medication use is associated with increased organ system involvement and increased odds of hospital admission, independent of age, gender, suspected trigger, or preexisting lung disease.

Section snippets

Study design and setting

The study had a retrospective observational cohort design. Patients were consecutively included at the Saint Mary's Hospital ED, a tertiary care academic ED with 72,000 annual patient visits.

Selection of participants

Electronic medical records of ED patients aged 18 years and older were electronically queried. Records of all patients who had any ED diagnosis containing “allerg,” “anaphy,” or “sting” were reviewed, and those who met the National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis

Results

From April 2008 to July 2011, we included 302 adults who met NIAID/FAAN diagnostic criteria for anaphylaxis. Baseline characteristics, suspected triggers of anaphylaxis, underlying lung disease, and outcomes of the study cohort are summarized in Table I. Median age of the study sample was 44.3 years (interquartile range, 31.5-58.0). Two hundred four patients (68%) were female, and 91% were white, reflecting the relatively small proportion of minorities in the community. Eighty-seven (29%)

Discussion

In our cohort we observed that antihypertensive medication use was associated with increased organ system involvement and hospital admission after adjusting for age, gender, suspected trigger, and preexisting lung disease. Although the associations between ACE inhibitors and beta-blockers and anaphylaxis severity have been evaluated previously, our study includes a larger spectrum of potential markers of increased severity and collected data on additional antihypertensive medications.

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This publication was supported by National Institutes of Health/NCRR/NCATS CTSA grant no. UL1 RR024150. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health.

Disclosure of potential conflict of interest: S. Lee, E. P. Hess, D. M. Nestler, V. R. Bellamkonda Athmaram, M. F. Bellolio, W. W. Decker, V. Manivannan, S. C. Vukov, and R. L. Campbell have received research support from the National Institutes of Health (NIH). J. T. C. Li has received research support from the NIH and has stock options in Novartis, Abbott, and Johnson & Johnson. J. B. Hagan has received research support from the NIH, National Heart, Lung, and Blood Institute, National Institute of Allergy and Infectious Diseases, and MedImmune; was chairman of the Dyax Adjudication panel of KALBITOR; and has held stock in Johnson & Johnson and TEVA in the last 3 years.

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