Emergency Medicine, Allergy Physicians Partner to Create New Standards

A partnership between clinicians and researchers at the College of Medicine has led to a new set of practical guidelines for emergency medicine physicians in treating a potentially life-threatening condition.

The guideline for treating angioedema arose from a partnership between associate professor of emergency medicine Joseph Moellman, MD, and professor of internal medicine, allergy/immunology Jonathan Bernstein, MD.

After two years of work, their recommendations were endorsed by the American College of Allergy, Asthma and Immunology and the Society for Academic Emergency Medicine, and were published in the journal Academic Emergency Medicine this spring.

The need for a standard of care
In angioedema, patients experience a rapid swelling of the skin and subcutaneous tissues—which, in some cases, can lead to airway obstruction and suffocation. Angioedema can be hereditary, or caused by the use of ACE inhibitors, a common class of drugs used to treat congestive heart failure and hypertension.

According to the National Hospital Ambulatory Medical Care Survey, there are as many as 80,000 to 112,000 ED visits for angioedema annually, and it ranks as the top allergic disorder resulting in hospitalization in the U.S.

For those patients who arrive in the emergency department with angioedema, Moellman says it can be a “matter of minutes” before swelling of the tongue and throat requires physicians to establish an airway, which can be challenging due to the amount of swelling. But he says recent progress in the pharmaceutical treatment of the condition has opened up more opportunities for care.

“There are new targeted therapies available for angioedema, but a lot of emergency medicine physicians aren’t familiar with them,” he says. “In emergency medicine, the old dogma was that you put people on corticosteroids and antihistamines and watch them—but we’ve found that with the advance of these new drugs, you don’t need to treat everyone the same way.”

With the largest population of Greater Cincinnati angioedema patients in his clinical practice, Bernstein especially is interested in advancing the care for these patients in an emergency setting.

“These guidelines represent an important advancement for the management of angioedema, as these patients typically first present to the emergency room,” says Bernstein. “Having a consensus recommendations on how to evaluate these patients should lead to a more directed treatment approach and improved clinical outcomes.”

Setting a consensus
Working with associate dean for clinical research Christopher Lindsell, PhD, Moellman and Bernstein hosted a day-long meeting of roughly a dozen allergy and emergency medicine experts in October 2012.

The workgroup started with a systematic literature review and then worked in allergist-emergency medicine physician pairs to develop each element of the practice guidelines.

“The goal was to generate a practical, evidence-based tool that could be used by emergency physicians to guide their practice—and one that is supported by a broad consensus of physicians across specialties,” says Lindsell.

The finished guidelines also identify areas where lack of evidence suggests a role for future research, as well as possible barriers to implementation.

“I think this demonstrates the strength of inter-departmental bonds and collaborative efforts within the College of Medicine,” says Moellman. “Up until this point, there has been very little research in the field of emergency medicine in treating such patients, mainly due to the lack of available therapies. We are fortunate at UC to have a world-class expert in angioedema, Dr. Bernstein, coupled with an emergency medicine research group that is able to test these cutting-edge therapies.

“The endorsement of such guidelines by both emergency medicine and allergy was a rigorous process involving national experts from both specialties,” he adds. “Ultimately, these guidelines will enhance patient care across the country.”

Next steps: studying new therapies
Moellman and Bernstein are also working on clinical trials in the ED to test new therapies for angioedema. Their most recent phase-2 trial examined the use of the drug Ecallantide for ACE inhibitor induced angioedema, and they recently joined a multicenter trial exploring the use of the drug Icantibant to treat this form of angioedema.

“What is still lacking in angioedema care is the availability of therapeutic agents effective in the treatment of angioedema unresponsive to conventional therapy,” says Bernstein, “Hopefully the current studies being conducted by the UC Department of Emergency Medicine in collaboration with the Division of Immunology will address this unmet need in the near future.

“This partnership has been invaluable, as it has permitted us to conduct a number of studies that are best suited for an acute care environment,” he adds. “I believe this collaboration is a fantastic model that should be adapted by any specialty that manages acute care patients.”

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