Should beta-blockers be given to patients with heart disease and peanut-induced anaphylaxis? A decision analysis.
BACKGROUND
Beta-blocker therapy postmyocardial infarction is generally recommended because it reduces mortality. However, beta-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 beta-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) beta-blocker and (2) no beta-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 beta-blockers outweighs the increased likelihood of dying from anaphylaxis, increasing life expectancy by 9.4 and 17.4 months, respectively. Beta-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) beta-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) beta-blocker therapy increased anaphylaxis case fatality >25-fold postmyocardial infarction.


CONCLUSIONS
Our results suggest that for patients postmyocardial infarction or with congestive heart failure who are at risk for peanut-induced anaphylaxis, beta-blocker use should still improve survival. However, the epidemiology of anaphylaxis and effects of beta-blocker therapy on anaphylaxis incidence and mortality require further study.
TenBrook
John A
JA
Division of Clinical Decision Making, Informatics, and Telemedicine, Department of Medicine, Tufts-New England Medical Center, 750 Washington Street, Boston, MA 02111, USA.
Wolf
Michael P
MP
Hoffman
Stuart N
SN
Rosenwasser
Lanny J
LJ
Konstam
Marvin A
MA
Salem
Deeb N
DN
Wong
John B
JB
D000319:Adrenergic beta-Antagonists / Q000009:adverse effects / Q000627:therapeutic use*; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000707:Anaphylaxis / Q000209:etiology; D003661:Decision Support Techniques; D006331:Heart Diseases / Q000150:complications* / Q000188:drug therapy*; D006333:Heart Failure / Q000150:complications / Q000188:drug therapy; D006801:Humans; D008875:Middle Aged; D008954:Models, Biological; D009203:Myocardial Infarction / Q000150:complications / Q000188:drug therapy; D021183:Peanut Hypersensitivity / Q000150:complications*; D012307:Risk Factors
D000319:Adrenergic beta-Antagonists