When indicated at any time during the episode, additional important steps include administering supplemental oxygen and maintaining the airway, establishing intravenous access and giving fluid resuscitation, and initiating cardiopulmonary resuscitation with continuous chest compressions before rescue breathing.\n Intravenous Chlorpheniramine or Diphenhydramine; Oral Cetirizine) Beta-2 Adrenergic Agonistsa (eg. Intravenous Hydrocortisone or Methylprednisolone; Oral Prednisone or Prednisolone) Strength of recommendation for use in anaphylaxisb C C C Pharmacologic effects At H1-receptor, inverse agonist effect; stabilize receptors in inactive conformation; decrease skin and mucosal symptoms At beta-2 receptor, increase bronchodilation Switch off transcription of activated genes that encode pro-inflammatory proteins; decrease late phase allergic response Clinical relevance Decrease itch, flush, urticaria, sneezing, and rhinorrhea, but are not life-saving because they do not prevent or relieve obstruction to airflow or hypotension/shock Decrease wheeze, cough and shortness of breath but are not life-saving because they do not prevent or relieve upper airway obstruction or hypotension/shock Onset of action takes several hours; therefore, are not life-saving in initial hours of an anaphylactic episode; used to prevent and relieve protracted or biphasic anaphylaxis; however, these effects have not been proven Potential adverse effects (usual dose) First-generation drugs cause drowsiness, somnolence, and impaired cognitive functionc Tremor, tachycardia, dizziness, jitteriness Unlikely during a short course Potential adverse effects (overdose) Extreme drowsiness, confusion, coma, respiratory depression, paradoxical central nervous system stimulation, eg. seizures in infants and children Headache, hypokalemia, vasodilation Unlikely Comment From 0 to 14 different H1-antihistamines,c and different dose regimens, are listed as adjunctive medications in anaphylaxis guidelines; role not proven Use in anaphylaxis is extrapolated from use in acute asthma; if given as adjunctive treatment for bronchospasm not relieved by epinephrine, should optimally be delivered by face mask and nebulization From 0 to 3 different glucocorticoids,d and different dose regimens,d are listed as adjunctive medications in anaphylaxis guidelines; role not proven Table 8 Second-Line Medications for Anaphylaxis Treatment Medication Epinephrine/adrenaline auto-injectora Epinephrine from an ampule/syringeb or prefilled syringec (alternative but not preferred formulations) Other aspects of discharge management Anaphylaxis emergency action plan (personalized, written) Medical identification (eg, bracelet, wallet card) Medical record electronic flag (or chart sticker) Emphasize the importance of follow-up, preferably with an allergy/immunology specialist Assessment of sensitization to allergen Before discharge, consider assessing sensitization to allergens suggested in the history of the acute episode, by measuring serum IgE levels to relevant allergen(s), if the test is availabled 3-4 weeks after the episode, confirm allergen sensitization using skin testse Challenge/provocation tests might be needed in some patients, for example, with food or medication allergy, in order to assess risk of future anaphylactic episodes furtherf Long-term risk reduction: avoidance and/or immunomodulation Food-triggered anaphylaxis: avoidance of relevant food(s) Stinging insect-triggered anaphylaxis: avoidance of stinging insects; subcutaneous venom immunotherapy (protects up to 80-90% of adults and 98% of children) Medication-triggered anaphylaxis: avoidance of relevant medications; if indicated, medically supervised desensitization in a healthcare setting according to published protocols Idiopathic anaphylaxis: for frequent episodes, consider glucocorticoid and H1-antihistamine prophylaxis for 2-3 months Optimal management of asthma and other concomitant diseases Table 9 Recommendations at Time of Discharge From the Healthcare Setting