Anaphylaxis case management

Background: Anaphylaxis management has historically paired prompt intramuscular epinephrine administration with automatic activation of emergency medical services (EMS). Contemporary evidence, however, challenges many of the historical assumptions that underpin this recommendation. Methods: Narrative review of cohort studies, systematic reviews and guidance that informs a shift in anaphylaxis recommendations to at home anaphylaxis management. Results: Recent systematic reviews and large cohort studies demonstrate that biphasic anaphylaxis is less frequent and typically less severe than previously reported, fatalities due to anaphylaxis are exceedingly rare, and serious adverse events from intramuscular epinephrine are uncommon. Moreover, adjunctive therapies such as antihistamines and corticosteroids do not prevent biphasic anaphylaxis or reduce anaphylaxis severity. At the same time, routine EMS activation has not been shown to reduce mortality and is associated with substantial health-care utilization; emergency department burden; and unintended consequences, including caregiver hesitation to administer epinephrine promptly. These findings have prompted a shift toward risk-stratified, patient-centered care. Updated guidance from international allergy organizations now supports consideration of at-home anaphylaxis observation after complete symptom resolution in carefully selected patients at low risk and who have access to additional epinephrine and appropriate supervision. This approach has the potential to improve timely epinephrine use, enhance patient autonomy, and promote health-care stewardship. However, safe implementation requires attention beyond clinical criteria alone. Home-based management presumes health literacy, reliable medication access, caregiver confidence, and proximity to emergency services, resources that are not equitably distributed. Without deliberate safeguards, these recommendations risk exacerbating disparities in anaphylaxis outcomes. Conclusion: In this review, we synthesize contemporary evidence and propose a risk-stratified framework for anaphylaxis case management, including circumstances in which home observation may be appropriate in patients at low risk and their families.