Exercise-induced anaphylaxis: Management and prognosis
- Anna M Feldweg, MD
Anna M Feldweg, MD
- Director, Editorial Management — UpToDate
- Deputy Editor — Allergy and Immunology
- Assistant Professor of Medicine, Part-time
- Harvard Medical School
Exercise-induced anaphylaxis (EIAn) is a disorder in which anaphylaxis occurs in response to physical exertion. Food-dependent, exercise-induced anaphylaxis (FDEIAn) is a disorder in which patients only develop symptoms if exercise takes place within a few hours of eating, and in most cases, only if a specific food is eaten during the pre-exercise period.
There are no randomized trials of therapy for EIAn or FDEIAn. Thus, there are only low quality evidence and clinical experience on which to base recommendations. The authors' approach is described here. The management of EIAn and FDEIAn must be individualized for each patient, to some extent, depending upon the severity and frequency of symptoms, the importance of food or other co-triggers, and the patient's desire to continue participating in the particular sports or types of exercise that trigger symptoms.
The management of FDEIAn is relatively straightforward and is centered on avoidance of the culprit food prior to exercise. In contrast, the management of EIAn is more challenging, as attacks tend to be unpredictable.
In all but the most severe cases, patients typically have a strong desire to continue some form of exercise, and we make every attempt to construct a personalized management plan that allows them to do so, because of the many health benefits of regular exercise. However, modifications in the patient's choice of activities may be required. (See 'Resumption of exercise' below.)
The management and prognosis of patients with EIAn and FDEIAn are discussed in this topic review. The clinical manifestations, epidemiology, pathogenesis, and diagnosis are presented elsewhere. (See "Exercise-induced anaphylaxis: Clinical manifestations, epidemiology, pathogenesis, and diagnosis".)
- Juji F, Suko M. Effectiveness of disodium cromoglycate in food-dependent, exercise-induced anaphylaxis: a case report. Ann Allergy 1994; 72:452.
- Sugimura T, Tananari Y, Ozaki Y, et al. Effect of oral sodium cromoglycate in 2 children with food-dependent exercise-induced anaphylaxis (FDEIA). Clin Pediatr (Phila) 2009; 48:945.
- Aihara Y, Kotoyori T, Takahashi Y, et al. The necessity for dual food intake to provoke food-dependent exercise-induced anaphylaxis (FEIAn): a case report of FEIAn with simultaneous intake of wheat and umeboshi. J Allergy Clin Immunol 2001; 107:1100.
- Ueno M, Adachi A, Shimoura S, et al. A case of wheat-dependent exercise-induced anaphylaxis controlled by sodium chromoglycate, but not controlled by misoprostol. J Environ Dermatol Cutan Allergol 2008; 2:118.
- Takahashi A, Nakajima K, Ikeda M, et al. Pre-treatment with misoprostol prevents food-dependent exercise-induced anaphylaxis (FDEIA). Int J Dermatol 2011; 50:237.
- Sheffer AL, Austen KF. Exercise-induced anaphylaxis. J Allergy Clin Immunol 1980; 66:106.
- Inoue Y, Adachi A, Ueno M, et al. [The inhibition effect of a synthetic analogue of prostaglandin E1 to the provocation by aspirin in the patients of WDEIA]. Arerugi 2009; 58:1418.
- Bray SM, Fajt ML, Petrov AA. Successful treatment of exercise-induced anaphylaxis with omalizumab. Ann Allergy Asthma Immunol 2012; 109:281.
- Shadick NA, Liang MH, Partridge AJ, et al. The natural history of exercise-induced anaphylaxis: survey results from a 10-year follow-up study. J Allergy Clin Immunol 1999; 104:123.
- Ausdenmoore RW. Fatality in a teenager secondary to exercise-induced anaphylaxis. Pediatr Asthma Allergy Immunol 1991; 5:21.
- Drouet M, Sabbah A, Le Sellin J, et al. [Fatal anaphylaxis after eating wild boar meat in a patient with pork-cat syndrome]. Allerg Immunol (Paris) 2001; 33:163.
- Flannagan LM, Wolf BC. Sudden death associated with food and exercise. J Forensic Sci 2004; 49:543.
- Noma T, Yoshizawa I, Ogawa N, et al. Fatal buckwheat dependent exercised-induced anaphylaxis. Asian Pac J Allergy Immunol 2001; 19:283.
- Kano H, Juji F, Shibuya N, et al. [Clinical courses of 18 cases with food-dependent exercise-induced anaphylaxis]. Arerugi 2000; 49:472.
- Fujii H, Kambe N, Fujisawa A, et al. Food-dependent exercise-induced anaphylaxis induced by low dose aspirin therapy. Allergol Int 2008; 57:97.
- CO-FACTOR AVOIDANCE
- Patients with EIAn
- Food avoidance in patients with FDEIAn
- PROPHYLACTIC PHARMACOTHERAPY
- Cromoglycates in FDEIAn
- H1 antihistamines
- Other agents
- RESUMPTION OF EXERCISE
- Stopping at the first sign of symptoms
- Access to epinephrine
- Other precautions
- PATIENT EDUCATION
- SUMMARY AND RECOMMENDATIONS