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Should beta-blockers and angiotensin-converting enzyme inhibitors be avoided in all patients at risk of anaphylaxis?

Published online: November 5, 2018

The usual practice by allergists of avoiding beta-blockers (BB) and angiotensin-converting enzyme inhibitors (ACEI) in patients at risk of anaphylaxis has not been assessed in terms of level of evidence.

In a recently published article in The Journal of Allergy and Clinical Immunology: In Practice, Tejedor-Alonso et al carried out a systematic review and meta-analysis of observational studies where BB and ACEI were assessed as risk factors for anaphylaxis or increasing its severity. The study examined whether the possible effects of these drugs can be explained by the concomitant presence of cardiovascular diseases (the main indication for the drugs) and other risk factors for more severe anaphylaxis.

The meta-analysis did not show that BB and ACEI favored new anaphylaxis episodes, although these drugs increased the severity of anaphylaxis. However, the quality of evidence for BB and ACEI assessed using the GRADE scale (specifically designed for this purpose) was low and very low, respectively, owing to heterogenous control or lack of control for cardiovascular diseases in the studies assessed. Only 1 study each for BBs and ACEIs, respectively, had adjusted data for cardiovascular diseases.

With available studies on anaphylaxis in patients taking BB and ACEI, it is not possible to establish whether the increased severity of anaphylaxis detected is due to a direct effect of these drugs or to the presence of cardiovascular diseases, for which these drugs are usually prescribed. On the other hand, the authors suggest that the benefits of BB and ACEI in cardiovascular disease probably outweigh those of avoiding them to prevent more severe anaphylaxis.

The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI, focusing on practical information for the practicing clinician.