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Expert Rev Clin Immunol. 2018 Apr;14(4):307-314. doi: 10.1080/1744666X.2018.1450140. Epub 2018 Mar 30.

Risk factors and treatment of refractory anaphylaxis - a review of case reports.

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a Division of Allergy and Immunology, Department of Dermatology, Venerology and Allergology , Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health , Berlin , Germany.


Patients experiencing anaphylaxis who do not recover after treatment with intramuscular adrenaline are regarded as suffering from refractory anaphylaxis. The incidence of refractory anaphylaxis is estimated to range between 3-5% of anaphylaxis cases. The risk factors for refractory anaphylaxis are unknown. Areas covered: In the present analysis, we aimed to evaluate the management and risk factors of refractory anaphylaxis to highlight possible clinical implications for updating current management algorithms. Expert commentary: According to international guidelines, adrenaline given through the intramuscular (i.m.) route is a rapid and safe treatment but may be insufficient. Therefore, defined standardized treatment protocols for such cases of refractory anaphylaxis are needed to optimize the treatment. Point-of-care diagnostics may enable doctors to identify patients experiencing severe, refractory anaphylaxis early in order to initiate intensified critical care treatment.


Anaphylaxis; epinephrine; glucagon; hypotension; methylene blue; shock

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