Food allergy, dermatologic diseases, and anaphylaxis
Should β-blockers be given to patients with heart disease and peanut-induced anaphylaxis? A decision analysis☆

https://doi.org/10.1016/j.jaci.2004.02.043Get rights and content

Abstract

Background

β-Blocker therapy postmyocardial infarction is generally recommended because it reduces mortality. However, β-blockers may increase anaphylaxis mortality in the growing population of patients with peanut-induced anaphylaxis.

Objective

We sought to assess the risks and benefits of β-blocker therapy among patients with peanut allergy and heart disease.

Methods

We created a Markov model for patients with heart disease at risk for peanut-induced anaphylaxis to compare life expectancy with the following strategies: (1) β-blocker and (2) no β-blocker. Meta-analysis and a literature review were used to estimate model parameters. We performed sensitivity analysis to explore parameter uncertainty.

Results

For peanut-allergic patients who are postmyocardial infarction or who have congestive heart failure, the heart disease benefit of β-blockers outweighs the increased likelihood of dying from anaphylaxis, increasing life expectancy by 9.4 and 17.4 months, respectively. β-Blocker was preferred unless (1) the annual rate of moderate to severe anaphylaxis exceeded 6.0% for postmyocardial infarction and 15% for congestive heart failure patients; (2) β-blocker therapy increased the incidence of moderate to severe anaphylaxis >2.5-fold for postmyocardial infarction and >5.8-fold for congestive heart failure patients; (3) anaphylaxis case fatality exceeded 6.5% postmyocardial infarction; or (4) β-blocker therapy increased anaphylaxis case fatality >25-fold postmyocardial infarction.

Conclusion

Our results suggest that for patients postmyocardial infarction or with congestive heart failure who are at risk for peanut-induced anaphylaxis, β-blocker use should still improve survival. However, the epidemiology of anaphylaxis and effects of β-blocker therapy on anaphylaxis incidence and mortality require further study.

Section snippets

Methods

We used a computer simulation model to capture the risks of death from heart disease and from anaphylaxis for a population of patients with heart disease and peanut allergy. In this Markov model, cohorts of 10,000 identical adults with peanut allergy and heart disease were assigned to 1 of 2 strategies: (1) β-blocker therapy or (2) no β-blocker. To capture prognostic uncertainty, patients might move among predefined states of health over time. Each month, patients might remain in a particular

Postmyocardial infarction model

Under the baseline assumptions, patients treated with β-blockers had a higher lifetime risk for anaphylaxis mortality but a much lower lifetime risk of cardiac mortality. As a result, the average life expectancy for 58-year-old patients allergic to peanut post-MI was about 9.4 months longer with β-blocker therapy than without β-blocker (Table II). This is about 60% of the benefit of β-blocker therapy seen in the model when risk of anaphylaxis was removed.

Congestive heart failure model

Both baseline annual mortality and

Discussion

Our analysis suggests that patients with heart disease and peanut allergy, who may be at increased risk for anaphylaxis mortality with β-blocker therapy, should benefit from β-blocker therapy because of reduced heart disease mortality. The average life expectancy gains range from 9.4 to ∼17 months, with greater benefits for patients with CHF. For comparison, 35-year-old cigarette smokers who stops smoking increase their life expectancy by 8 to 10 months, and prophylaxis against Pneumocystis

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    ☆

    The authors report no conflicts of interest, but for full disclosure, Dr Wong was a coinvestigator in the Patient Outcome Research Team grant for Ischemic Heart Disease from the then Agency for Health Care Policy and Research from 1990 to 1995 and is currently the content editor for Coronary Artery Disease for the nonprofit Foundation for Informed Medical Decision Making. In both of these cases, he has complete independence from the funding source in study design, interpretation of data, report writing, and publication regardless of results.

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    Copyright © 2004 American Academy of Allergy, Asthma and Immunology. Published by Mosby, Inc. All rights reserved.