CHAPTER 37 • ALLERGIC DISEASES IN ATHLETES 227should be suspected in any athlete with a reaction that
occurs outdoors, even if the patient does not recall
being stung.
•Exercise-induced anaphylaxis is a rare condition asso-
ciated with exercising within 2–4 h after food inges-
tion. It is characterized by the usual manifestations of
anaphylaxis beginning within 5 to 30 min of exercise
and lasting up to 3 h. The medical history should
explore the relationship of symptom onset to physical
exercise to assess for this rare trigger.
- The physical manifestations of anaphylaxis involve
multiple sites including the skin, upper airway,
lower airway, and cardiovascular system. The phys-
ical examination should start by evaluating upper
airway patency by listening for inspiratory stridor
and looking for oral or pharyngeal edema. The res-
piratory status can be assessed by observing work of
breathing and accessory muscle use. Auscultation
may reveal wheezing indicating acute bron-
chospasm. A set of vital signs is critical to patient
management, looking for any evidence of cardio-
vascular or respiratory compromise. Once the ABCs
are assessed and secured, the skin can be examined
for the presence of generalized erythema, urticaria,
and angioedema.
ACUTE MANAGEMENT
- Initial management of anaphylaxis should always
start with epinephrine 0.2–0.5 cc intramuscular
(IM) or subcutaneous(SQ) of 1:1000, even if symp-
toms are mild. The IM route is preferred, especially
in children, as SQ injection may delay absorption.
Doses may be repeated every 10–15 min if symp-
toms persist. Intravenous (IV) epinephrine at
1 mcg/min of 1:10,000 (10 mcg/mL) can be consid-
ered for symptoms resistant to repeated SQ or IM
administration. The IV dosage can be increased to
2–10 mcg/min for severe reactions. Patients on beta-
blockers may not respond to epinephrine. In these
cases Glucagon 2–5 mg IM/SQ is beneficial.
Supportive therapy includes: oxygen for hypox-
emia, recumbent positioning and IV fluids for
hypotension, and inhaled beta-agonists or racemic
epinephrine for bronchospasm. Antihistamines
(diphenhydramine 1–2 mg/kg or 25–50 mg IV/po)
may provide additional benefit. Corticosteroids,
(prednisone 0.5–2.0 mg/kg up 125 mg) should also
be considered to prevent late phase reactions.
Neither antihistamines nor steroids should be used
as substitutes for epinephrine. Their onset of action
is much slower and they are insufficient to prevent
or treat more severe anaphylaxis with respiratory or
cardiovascular involvement.- Mild anaphylaxis cases should be observed a mini-
mum of 3 h after symptoms have resolved. Severe
reactions should be observed at least 6 h and hospital-
ization should be strongly considered to monitor for
late phase reactions.
LONG-TERM MANAGEMENT- All patients with anaphylaxis need an action plan to
include allergen identification, symptom recognition,
and appropriate treatment. A provider knowledgeable
in allergic disease should provide education on aller-
gen avoidance, hidden allergens, and cross-reacting
substances. All individuals should have an epineph-
rine autoinjector with them at all times and be edu-
cated on the indications and proper technique for its
use. The trainer and coach should be familiar with
anaphylaxis recognition and epinephrine use as well.
The athlete should wear a medical alert bracelet at all
times, indicating their condition and allergy if
known. - Because there are no measures proven to prevent
exercise-induced anaphylaxis, affected athletes
should never exercise alone. Pretreatment with anti-
histamines is not effective. The primary preventative
strategy is to avoid eating for 4 h prior to exercise.
Other measures that may limit attacks are to avoid
NSAIDs and aspirin prior to exercise and to avoid
outdoor exercise during periods of high humidity,
temperature extremes, and the individual’s allergy
season (Shadick, 1999). Occasionally skin testing
can identify a specific food that the patient can
avoid, but often the results are inconclusive. Athletes
should carry an epinephrine autoinjector on their
person when they don’t have immediate access to
their gear bag. They should discontinue exercise at
the first sign of symptoms and self-administer epi-
nephrine. - Indications for allergy referral include: when further
testing is necessary for an unclear diagnosis or an
unknown inciting agent, when reactions are recurrent
and difficult to control, or when desensitization is
required such as for stinging insects or antibiotic
administration. Allergists also serve as an impor-
tant resource for athletes, parents, and coaches
needing education on allergen avoidance as well as
institution or reinforcement of an individual’s
action plan.