Curr Allergy Asthma Rep. 2016 Jan;16(1):4. doi: 10.1007/s11882-015-0584-3. Lung sounds. If you are unsure if it is anaphylaxis or asthma: Medical Review: October 2015, updated February 2017. This device is a combined syringe and concealed needle that injects a single dose of medication when pressed against the thigh. 3. The average rate of corticosteroid use in emergency treatment was 67.99% (range 48% to 100%). We found no studies that satisfied the inclusion criteria. When there is no choice but to re-expose the patient to the anaphylactic trigger, desensitization or pretreatment may be attempted. glucocorticosteroid vs albuterol for anaphylaxis. Objectives: We sought to assess the benefits and harms of glucocorticoid treatment during episodes of anaphylaxis. Furthermore, patients should be given written information with suggested strategies for their own care. After reviewing the published evidence, the authors state that the use of corticosteroids has no role in the acute management of anaphylaxis. 2022;183(9):939-945. doi: 10.1159/000524612. Advise patient to wear or carry a medical alert bracelet, necklace, or keychain to warn emergency personnel of anaphylaxis risk. Lee JM, Greenes DS. 60th ed. : CD007596. The dosage of glucagon is 1 to 5 mg (20-30 mcg/kg [maximum dose of 1 mg] in children) administered intravenously over 5 minutes and followed by an infusion (5-15 mcg/ min) titrated to clinical response. A patient information handout on anaphylaxis, written by the author of this article, is provided on page 1339. A significant portion of the U.S. population is at risk for these rare but deadly events which cause approximately 1,500 deaths annually.1 Anaphylaxis is mediated by immunoglobulin E (IgE), while anaphylactoid reactions are not. MD Consult Web site. Carry self-administered epinephrine. (Learn more on our related website for Kids With Food Allergies: Epinephrine Is the First Line of Treatment for Severe Allergic Reactions). A patient with a history of anaphylaxis should be instructed on how to initiate treatment for future episodes using pre-loaded epinephrine syringes. Antihistamines sometimes provide dramatic relief of symptoms. Unauthorized use of these marks is strictly prohibited. An unusual presentation of anaphylaxis with severe hypertension: a case report. "Glucocorticosteroids are often used in the management of anaphylaxis in an attempt to reduce the severity of the acute reaction and decrease the risk of biphasic/protracted reactions. (The U.S. Food and Drug Administration has not approved glucagon for this use.) However, based on the available data, it appears to be beneficial and there was no evidence of adverse outcomes related to the use of corticosteroids in emergency treatment of anaphylaxis. There is no established drug or dosage of choice; Table 510 lists several possible regimens. Epub 2010 Jun 1. Clipboard, Search History, and several other advanced features are temporarily unavailable. Kelso JM. Can albuterol help with anaphylaxis. Should steroids be used for anaphylaxis after the COVID-19 vaccine? Glucocorticosteroids for the treatment and prevention ofanaphylaxis. You might also be given medications, including: If you're with someone who's having an allergic reaction and shows signs of shock, act fast. We found an overall incidence of biphasic reactions of 6%, and an incidence of significant biphasic reactions of 3%, among pediatric patients admitted with anaphylaxis. This site needs JavaScript to work properly. AAFA can connect you to all of the information and resources you need to help you learn more about asthma and allergic diseases. how to change text duration on reels. Li X, Ma Q, Yin J, Zheng Y, Chen R, Chen Y, Li T, Wang Y, Yang K, Zhang H, Tang Y, Chen Y, Dong H, Gu Q, Guo D, Hu X, Xie L, Li B, Li Y, Lin T, Liu F, Liu Z, Lyu L, Mei Q, Shao J, Xin H, Yang F, Yang H, Yang W, Yao X, Yu C, Zhan S, Zhang G, Wang M, Zhu Z, Zhou B, Gu J, Xian M, Lyu Y, Li Z, Zheng H, Cui C, Deng S, Huang C, Li L, Liu P, Men P, Shao C, Wang S, Ma X, Wang Q, Zhai S. Front Pharmacol. Glucocorticoids can treat this . result from sudden release of multiple mediators, with broad classification of anaphylaxis being subdivided into immunological causes (i.e. In 2017, Alqurashi and Ellis published a review about whether corticosteroids are useful in acute anaphylaxis and also whether they prevent biphasic reactions. Like antihistamines, there is concern regarding inappropriate use as first-line therapy instead of epinephrine.. differentiating location of. An allergy occurs when the bodys immune system sees a substance as harmful and overreacts to it. If anaphylaxis is caused by an injection, administer aqueous epinephrine, 0.15 to 0.3 mL, into injection site to inhibit further absorption of the injected substance. Summary: 2010 Feb;125(2 Suppl 2):S161-81. Oxygen administration is especially important in patients who have a history of cardiac or respiratory disease, inhaled b2-agonist use, and who have required multiple doses of epinephrine. Campbell RL et al. This will help you know what to do if you experience anaphylaxis. If they are given, use should stop in 2 to 3 days, after the strongest potential for a biphasic reaction has passed. Administer epinephrine 1:1,000 (weight-based) (adults: 0.01 mL per kg, up to a maximum of 0.2 to 0.5 mL every 10 to 15 minutes as needed; children: 0.01 mL per kg, up to a maximum dose of 0.2 to 0.5 mL) by SC or IM route and, if necessary, repeat every 15 minutes, up to two doses). Both skin testing and RAST have imperfect sensitivity and specificity. An official website of the United States government. As many as 25% of people who have an anaphylactic reaction will experience biphasic anaphylaxis, a recurrence in the hours following the beginning of the reaction, and will require further medical treatment, including additional epinephrine injections.9, Symptoms of anaphylaxis typically occur within 5 to 30 minutes of exposure. Anaphylaxis; allergy; corticosteroids; emergency management; prednisolone. Human Identical Sequences, hyaluronan, and hymecromone the newmechanism and management of COVID-19. Anaphylaxis can be protracted, lasting for more than 24 hours, or recur after initial resolution.5,6. Between 500 and 1000 fatal cases of anaphylaxis are estimated to occur in the United States every year.7, Reactions to penicillin account for 75% of all anaphylactic deaths.3 An estimated 33% of anaphylactic reactions are triggered by food, such as shellfish, peanuts, eggs, fish, and milk.3. Chipps BE. The patient should be placed supine or in Trendelenburg's position. Sicherer SH, Simmons, FE. Accessed January 29, 2009. [ corrected] The following regimen is reasonable: 1:10,000 (100 mcg per mL) epinephrine at 1 mcg per minute, increased to 10 mcg per minute as needed. Some symptoms include: Ask your doctor for a complete list of symptoms and an anaphylaxis action plan. glucocorticosteroid vs albuterol for anaphylaxis. Oral administration of glucocorticosteroids (eg, prednisone, 0.5 mg/kg) might be sufficient for less critical anaphylactic reactions.
glucocorticosteroid vs albuterol for anaphylaxis Anaphlaxis.com Web site. MeSH In 2007, the American Academy of Pediatrics released guidelines on the treatment of anaphylaxis which stated that on the basis of limited data, children who are healthy and weigh 22 to 55 lb (10-25 kg) can be given 0.15 mg of epinephrine, and those who weigh .55 lb can receive 0.30 mg. It showed that biphasic reactors tended to receive less corticosteroid; however, this association was not statistically significant. Although epinephrine is the mainstay of recommended treatment, corticosteroids are also frequently used. This site uses cookies. A biphasic reaction is seen in some, with recurrence usually within 8 hours of the initial episode. 2020 Apr;145(4):1082-1123. doi: 10.1016/j.jaci.2020.01.017. Maintain airway with an oropharyngeal airway device.
Anaphylaxis - Diagnosis and treatment - Mayo Clinic Do corticosteroids prevent biphasic anaphylaxis? Epub 2015 Mar 25. Glucocorticosteroids should be regarded, at best, as a second-line agent in the emergency management of anaphylaxis, and administration of epinephrine should therefore not be delayed whilst glucocorticosteroids are drawn up and administered. These patients may have resistant severe hypotension, bradycardia, and a prolonged course. It is important to note that because these agents have a much slower onset of action than epinephrine, they should never be administered alone as a treatment for anaphylaxis.15,16, Diphenhydramine is approved by the FDA for treatment of anaphylaxis, and IV administration provides faster onset of action.15 It blocks the effects of released histamine at the H1 receptor, therefore treating flushing, urticarial lesions, vasodilatation, and smooth muscle contraction in the bronchial tree and GI tract. Knowledge and attitude toward anaphylaxis during local anesthesia among dental practitioners in Chennai - a cross-sectional study. Therefore, current guidelines are mostly based on data from observational studies, animal and laboratory studies. 3 de junho de 2022 . The dose may be repeated two or three times at 10 to 15 minutes intervals. Give hydrocortisone, 5 mg per kg, or approximately 250 mg intravenously (prednisone, 20 mg orally, can be given in mild cases). Cutaneous manifestations of urticaria, itching, and angioedema assist in the diagnosis by suggesting an allergic reaction. Steroids (glucocorticoids) are often recommended for use in the management of people experiencing anaphylaxis. The https:// ensures that you are connecting to the and transmitted securely. Work with your own or your child's provider to develop this written, step-by-step plan of what to do in the event of a reaction. Corticosteroids appear to reduce the length of hospital stay, but did not reduce revisits to the emergency department. https://www.uptodate.com/contents/search. If the diagnosis of anaphylaxis is not clear, laboratory evaluation can include plasma histamine levels, which rise as soon as five to 10 minutes after onset but remain elevated for only 30 to 60 minutes. Why not use albuterol for anaphylaxis. Consider vasopressor infusion for hypotension refractory to volume replacement and epinephrine injections. Does albuterol help anaphylaxis. Anaphylaxis may include any combination of common signs and symptoms (Table 2).2 Cutaneous manifestations of anaphylaxis, including urticaria and angioedema, are by far the most common.3,4 The respiratory system is commonly involved, producing symptoms such as dyspnea, wheezing, and upper airway obstruction from edema. For a complete list of side effects, please refer to the individual drug monographs. For children with concomitant asthma, inhaled 2-adrenergic agonists (eg, albuterol) can provide additional relief of lower respiratory tract symptoms but, like antihistamines and glucocorticoids, are not appropriate for use as the initial or only treatment in anaphylaxis.
Corticosteroids in management of anaphylaxis; a systematic - PubMed The patient must be told to seek immediate professional help regardless of initial response to self-treatment. Pediatr Neonatol. official website and that any information you provide is encrypted Disclaimer. Campbell RL, et al.
Anaphylaxis: Emergency treatment - UpToDate Avoid administering cross-reactive agents. Fill in your details below or click an icon to log in: You are commenting using your WordPress.com account. Cardiac asthma, airway obstruction, allergic reaction, inhalation injury. Diagnose the presence or likely presence of anaphylaxis. AAFA offers a variety of educational programs, resources and tools for patients, caregivers, and health professionals. Peavy RD, Metcalfe DD. Federal government websites often end in .gov or .mil. The rationale is to reduce the risk of recurring or protracted anaphylaxis.
Rapid Response: Anaphylaxis--Avoiding a Fatal Reaction - Pharmacy Times 3,11 Cutaneous symptoms, such as urticaria and angioedema, are the most common. Pediatric Respiratory Emergencies.
glucocorticosteroid vs albuterol for anaphylaxis Accessed June 27, 2021. Epub 2018 May 9. Anaphylaxis A 2020 practice parameter update, systematic review, and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) analysis. Anaphylaxis is a serious allergic reaction that is rapid in onset and may result in death. Avoid prescribing beta blockers, angiotensin-converting enzyme inhibitors, angiotensin-II receptor blockers, monoamine oxidase inhibitors, and some tricyclic antidepressants.
Explore Mayo Clinic studies testing new treatments, interventions and tests as a means to prevent, detect, treat or manage this condition. Simultaneous H1 and H2 blockade may be superior to H1 blockade alone, so diphenhydramine (Benadryl), 1 to 2 mg per kg (maximum 50 mg) intravenously or intramuscularly, may be used in conjunction with ranitidine (Zantac), 1 mg per kg intravenously, or cimetidine (Tagamet), 4 mg per kg intravenously. After reviewing the published evidence, the authors state that the use of corticosteroids has no role in the acute management of anaphylaxis. Accessed June 27, 2021. Increase in the risk of gastric ulcers or gastritis. This review evaluates the evidence on the use of corticosteroids in emergency management of anaphylaxis from published human and animal or laboratories studies. 2022 May 20;3(1):15. doi: 10.1186/s43556-022-00077-0. The diagnosis and management of anaphylaxis: an updated practice parameter. Anaphylaxis is thought to be increasing in prevalence with the most common The .gov means its official. Bethesda, MD 20894, Web Policies Sleeplessness. Consultation with an allergist can help (1) confirm the diagnosis of anaphylaxis; (2) identify the anaphylactic trigger through history, skin testing, and RAST; (3) educate the patient in the prevention and initial treatment of future episodes; and (4) aid in desensitization and pretreatment when indicated. Clin Pediatr(Phila). Endotracheal intubation may be needed to secure the airway. official website and that any information you provide is encrypted If you think you are having anaphylaxis, use your self-injectable epinephrine and call 911. We conclude that there is no evidence from high quality studies for the use of steroids in the emergency management of anaphylaxis. Clin Exp Allergy. Epub 2022 May 6. Full-text for Childrens and Emory users. The initial management of anaphylaxis includes a focused examination, procurement of a stable airway and intravenous access, and administration of epinephrine.2,10 [Evidence level C, consensus and expert opinion] Vital signs and level of consciousness should be documented. Make sure school officials have a current autoinjector. Please enable it to take advantage of the complete set of features! Weight gain. These modulate gene expression, with effects becoming evident 4 to 24 hours after administration. Epinephrine is the most effective treatment for anaphylaxis. 2022 May 28;10(6):1260. doi: 10.3390/biomedicines10061260. While volume replacement is central to management of hypotension in anaphylaxis, other pressors such as dopamine (Intropin), 2 to 20 mcg per kg per minute, may be required. Patients receiving intravenous epinephrine require cardiac monitoring because of potential arrhythmias and ischemia. Patients should be reminded to seek medical care regardless of response to self-treatment, so that they can access additional therapies, such as oxygen, intravenous (IV) fluids, corticosteroids, respiratory support, inotropic agents, albuterol, and histamine2 receptor antagonists (H2RAs).14,15 Furthermore, patients should be observed for biphasic reactions, which usually occur within 4 hours of the reaction.14,15, Adjunctive therapies include antihistamines, corticosteroids, and albuterol. Review our cookies information for more details. For example, dopamine (400 mg in 500 mL of 5% dextrose) can be infused at 2 to 20 mcg/kg/min and titrated to maintain systolic blood pressure of >90 mm Hg. If insect stings trigger an anaphylactic reaction, a series of allergy shots (immunotherapy) might reduce the body's allergic response and prevent a severe reaction in the future. Symptom onset varies widely but generally occurs within seconds or minutes of exposure. Recent findings: The reaction typically occurs without warning and can be a frightening experience both for those at risk and their families and friends. The primary action of glucocorticoids is down-regulation of the late-phase eosinophilic inflammatory response, as opposed to the early-phase response. Training kits containing empty syringes are available for patient education. https://www.aaaai.org/Conditions-Treatments/allergies/anaphylaxis Accessed June 27, 2021. Clinical predictors for biphasic reactions in. In refractory cases not responding to epinephrine because a beta-adrenergic blocker is complicating management, glucagon, 1 mg intravenously as a bolus, may be useful. The report notes that the time to onset of corticosteroid effect is too slow to prevent severe outcomes, such as cardiorespiratory arrest or death, which tend to occur within 5-30 minutes for allergens such as medications, insect stings and foods. RAST checks in vitro for the presence of IgE to antigen and carries no risk of anaphylaxis. AAFA launches educational awareness campaigns throughout the year. 2018 Aug;36(8):1480-1485. doi: 10.1016/j.ajem.2018.05.009. glucocorticosteroid vs albuterol for anaphylaxis. Check out these best-sellers and special offers on books and newsletters from Mayo Clinic Press. https://www.uptodate.com/contents/search. In this procedure, the patient is exposed to gradually increasing amounts of antigen, usually via intradermal, then subcutaneous, then intravenous routes. or SVN. You must seek medical care. This nongenomic glucocorticosteroid effect has been confirmed in vivo by showing that high-dose ICSs cause a dose-dependent decrease in airway blood flow (Qaw) that can be blocked with an 1-adrenergic antagonist5, 6 and by showing that the airway vascular smooth muscle response to inhaled albuterol is potentiated by pretreatment with a . In contrast, randomized controlled trials have been undertaken of glucocorticosteroids, given individually or in combination with other drugs, in preventing anaphylaxis. A patient may underestimate the importance of a food antigen, or the antigen may be one of many ingredients in a complex product. dxterity stock symbol / nice houses for sale near amsterdam / nice houses for sale near amsterdam Our community is here for you 24/7. Headache, rhinitis, substernal pain, pruritus, and seizure occur less frequently. The patient also may take an antihistamine at the onset of symptoms. We were unable to find any randomized controlled trials on this subject through our searches. Change), You are commenting using your Twitter account. A more recent article on anaphylaxis is available. Hung SI, Preclaro IAC, Chung WH, Wang CW. National Library of Medicine Emergency department diagnosis and treatment of anaphylaxis. Some persons may react just by handling the culprit food. Philadelphia: Saunders; 2007:chap 188.
Anaphylaxis Medication - Medscape Understanding the mechanisms of anaphylaxis. Patients with a history of anaphylactic reactions should be encouraged to wear Medic Alert bracelets indicating known allergies. A continuous infusion of glucagon, 1 to 5 mg per hour, may be given if required.
PMC If a decision is made to administer isoproterenol intravenously, the proper dose is 1 mg in 500 mL D5W titrated at 0.1 mg per kg per minute; this can be doubled every 15 minutes.
Glucocorticoids for the treatment of anaphylaxis - PubMed glucocorticosteroid vs albuterol for anaphylaxis Epinephrine Epinephrine is the first and most important treatment for anaphylaxis, and it should be administered as soon as anaphylaxis is recognized to prevent the progression to life-threatening symptoms as described in the rapid overviews of the emergency management of anaphylaxis in adults ( table 1) and children ( table 2 ). Direct skin testing and radioallergosorbent testing (RAST) are available for some antigens, including heterologous sera, Hymenoptera venom, some foods, hormones, and penicillin. Patients should be observed for delayed or protracted anaphylaxis and instructed on how to initiate urgent treatment for future episodes. Albuterol may cause serious allergic reactions, including anaphylaxis, which can be life-threatening and require immediate medical attention. Lee SE. Prompt treatment of anaphylaxis is critical, with subcutaneous or intramuscular epinephrine and intravenous fluids remaining the mainstay of management. Medical content developed and reviewed by the leading experts in allergy, asthma and immunology. If you react to insect stings or exercise, talk to your doctor about how to avoid these reactions. During an anaphylactic attack, you might receive cardiopulmonary resuscitation (CPR) if you stop breathing or your heart stops beating. Pharmacists also should supply patients with written instructions to reinforce proper use. Monitor vital signs frequently (every two to five minutes) and stay with the patient. doi: 10.1016/j.jaci.2009.12.981. To review recent evidence on the effectiveness of glucocorticosteroids in the treatment and prevention of anaphylaxis. Anaphylaxis must be treated right away to provide the best chance for improvement and prevent serious, potentially life-threatening complications. But you can take steps to prevent a future attack and be prepared if one occurs. Anaphylaxis. Patients taking beta-adrenergic blockers present a special challenge because beta blockade may limit the effectiveness of epinephrine. Accessed Aug. 25, 2021. Patients should have ready access to 2 doses of an epinephrine autoinjector, with thorough training regarding correct use of a given device and an emergency action plan. A practice parameter update in 2015 by Lieberman et al includes an excellent discussion about the topic.
glucocorticosteroid vs albuterol for anaphylaxis Cardiac monitoring is necessary and isoproterenol should be given cautiously when the heart rate exceeds 150 to 189 beats per minute. In this version we searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 3), MEDLINE (Ovid) (1956 to September 2011), EMBASE (Ovid) (1982 to September 2011), CINAHL (EBSCOhost) (to September 2011). Pourmand A, Robinson C, Syed W, Mazer-Amirshahi M. Am J Emerg Med. 2014 Feb;69(2):168-75. doi: 10.1111/all.12318. Jacqueline A. Pongracic, MD, FAAAAI. There was no consensus on whether corticosteroids reduce biphasic anaphylactic reactions. Unfortunately, in most other cases there's no way to treat the underlying immune system condition that can lead to anaphylaxis. document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); Click to email a link to a friend (Opens in new window), Click to share on Twitter (Opens in new window), Click to share on LinkedIn (Opens in new window), Click to share on Facebook (Opens in new window), Glucocorticoids for the treatment of anaphylaxis (includes information about biphasicanaphylaxis). American Academy of Pediatrics Web site. Twinject [prescribing information].
PDF Albuterol for anaphylaxis Ms. Terrie is a clinical pharmacy writer based in Haymarket, Virginia. Protocols for use in schools to manage children at risk of anaphylaxis are available through the Food Allergy Network. The best way to manage asthma is to avoid triggers, take medications to prevent symptoms, and prepare to treat asthma episodes if they occur. The Sakine IA * k1, Sule SOUND zmen Caglayan1, Suna Asilsoy2 Nevin Uzuner2 and zkan Karaman2 1Department of Pediatric Allergy and .
Acute Effect of an Inhaled Glucocorticosteroid on Albuterol-Induced Look for pale, cool and clammy skin; a weak, rapid pulse; trouble breathing; confusion; and loss of consciousness. Alqurashi W and Ellis AK. Please enable it to take advantage of the complete set of features! Look for pale, cool and clammy skin; a weak, rapid pulse; trouble breathing; confusion; and loss of consciousness. These products only should be injected into the anterolateral aspect of the thigh.12,13 The epinephrine autoinjectors should not be injected into the buttock or injected intravenously.12,13 Patient education is crucial to preventing the incidence of anaphylaxis, and patients need to be aware of proper administration, storage, and handling. Choo KJL, Simons FER, Sheikh A. Glucocorticoids for the treatment of anaphylaxis. Administer the antihistamine diphenhydramine (Benadryl, adults: 25 to 50 mg; children: 1 to 2 mg per kg), usually given parenterally. Would you like email updates of new search results? Bookshelf The use of nonionic contrast media provides additional protection.13. and transmitted securely. itchy, watery eyes. You may need other treatments, in addition to epinephrine. You can make a donation, fundraise for AAFA, take action in May for Asthma and Allergy Awareness Month, and join a community to get the help and support you need. The use of normal IV saline also is recommended. Use an epinephrine autoinjector, if available, by pressing it into the person's thigh. Anaphylaxis. Dreskin SC, Palmer GW. exercise induced anaphylaxis) and idiopathic causes. Two authors independently assessed articles for inclusion. Tang AW. Urinary histamine levels remain elevated somewhat longer. The Asthma and Allergy Foundation of America (AAFA) conducts and promotes research for asthma and allergic diseases. Mehr S, Liew WK, Tey D, Tang ML. Supplemental oxygen may be administered.
These doses can be repeated every six hours, as required. FOIA I hope this answer is helpful to you. Rarely, anaphylaxis may be delayed for several hours. Change), You are commenting using your Facebook account. All patients with anaphylaxis should be monitored for the possibility of recurrent symptoms after initial resolution.5,6 An observation period of two to six hours after mild episodes, and 24 hours after more severe episodes, seems prudent. 2019 Sep-Oct;7(7):2232-2238.e3. For a sensitive patient urgently requiring radiocontrast, 50 mg of oral prednisone 13 hours, seven hours, and one hour before contrast plus 50 mg of diphenhydramine one hour before the procedure dramatically reduce the rate of recurrent reaction.19 Some experts advocate the addition of 25 mg of ephedrine, and 300 mg of cimetidine orally one hour before the procedure.20 If the patient cannot take oral medications, 200 mg of hydrocortisone intravenously may replace prednisone in these regimens. The estimated lifetime risk per individual in the United States is 1% to 3%, with a mortality rate of 1%.6 Although fatalities are relatively rare, milder forms of anaphylaxis occur much more frequently, and this has been linked to exposure to a greater number of potential allergens. Do not delay. Some patients have isolated abnormal tryptase or histamine levels without the other. Written instructions should be given. Rakel RE and Bope ET. 2. Glucagon exerts positive inotropic and chronotropic effects on the heart, independent of catecholamines. (LogOut/ eCollection 2022. If an intravenous line cannot be established, the intramuscular dose can be injected into the posterior one third of the sublingual area, or the intravenous dose may be injected into an endotracheal tube.