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ALI-2. Patients with a history of anaphylaxis: to beta block or not to beta block?

Learning objectives were to recognize the importance of medication history in patients with anaphylaxis or on immunotherapy. A 39-year-old male with venom anaphylaxis from a single Honey Bee sting 5 years prior presented to establish care. He continues to keep bees as a hobby. He received 5 years of venom immunotherapy. He also had liver cirrhosis complicated by esophageal varices requiring beta-blocker treatment. On presentation he wanted advice on his immunotherapy. As for our patient, since he had been stung multiple times recently without reaction, and having completed 5 years of immunotherapy, he was able to be discontinued on immunotherapy and continue his beta-blocker. The true incidence of venom anaphylaxis and death is unknown however, at least 50 people die yearly. Venom immunotherapy is effective and statistically safe. Beta-blocker use in combination with epinephrine therapy has proven to be detrimental for anaphylaxis treatment. Standard of care is to not test or treat any patient with immunotherapy who is also on beta-blockers. In our patient though beta-blockers are indicated to prevent further morbidity from varices, they have the potential to produce interactions with his immunotherapy, a picture worsened by his reluctance to stop bee hiving. Management of his immunotherapy and liver disease is complicated as he has two potentially fatal diseases requiring antagonistic treatments which are appropriate for decreasing the overall mortality. To our knowledge, there have not been any cases reported in which immunotherapy and beta blockers for varices management, have been used concomitantly. Though it is the standard of care not to use immunotherapy with beta-blockers, we recommend that management for each patient should be individualized, taking into consideration all the comorbidities and the informed understanding by the patient.

James Byrd, MD, Mukta Panda, MD, and Hyman Kaplan MD. University of Tennessee-Chattanooga Unit, Chattanooga, TN.
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Title Annotation:Section on Allergy and Immunology
Author:Kaplan, Hyman
Publication:Southern Medical Journal
Article Type:Brief Article
Date:Oct 1, 2004
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