Bioavailability of epinephrine from Auvi-Q compared with EpiPen

Adrenaline Auto-Injectors for Preventing Fatal Anaphylaxis

Anaphylaxis affects up to 5% of people during their lifetime. Although anaphylaxis usually resolves without long-term physical consequences, it can result in anxiety and quality of life impairment. Rarely and unpredictably, community anaphylaxis can cause rapid physiological decompensation and death. Adrenaline (epinephrine) is the cornerstone of anaphylaxis treatment, and provision of adrenaline autoinjectors (AAI) has become a standard of care for people at risk of anaphylaxis in the community. In this article, we explore the effectiveness of AAIs for preventing fatal outcomes in anaphylaxis, using information drawn from animal and human in vivo studies and epidemiology. We find that data support the effectiveness of intravenous adrenaline infusions for reversing physiological features of anaphylaxis, typically at doses from 0.05 to 0.5 μg/kg/min for 1-2 h, or ~ 10 μg/kg total dose. Intramuscular injection of doses approximating 10 μg/kg in humans can result in similar peak plasma adrenaline levels to intravenous infusions, at 100-500 pg/mL. However, these levels are typically short-lived following intramuscular adrenaline, and pharmacokinetic and pharmacodynamic outcomes can be unpredictable. Epidemiological data do not support an association between increasing AAI prescriptions and reduced fatal anaphylaxis, although carriage and activation rates remain low. Taken together, these data suggest that current AAIs have little impact on rates of fatal anaphylaxis, perhaps due to a lack of sustained and sufficient plasma adrenaline concentration. Effects of AAI prescription on quality of life may be variable. There is a need to consider alternatives, which can safely deliver a sustained adrenaline infusion via an appropriate route.

Frequencies and predictors of subcutaneous and intraosseous injection with 4 epinephrine autoinjector devices

BACKGROUND

To prevent anaphylaxis-associated illness, intramuscular epinephrine injection is recommended. Subcutaneous injection may reduce efficacy, and intraosseous injection promotes morbidity. A few studies suggested that commercially available thigh epinephrine autoinjectors (EAIs) may induce subcutaneous/intraosseous injection in some adults.

OBJECTIVE

To estimate the subcutaneous/intraosseous-injection rates of 4 EAIs by comparing their needle lengths with the ultrasound-measured skin-to-muscle depth and skin-to-bone depth of the midthigh of adults with allergic diseases in a cross-sectional study and to determine patient factors that predict subcutaneous EAI injection.

METHODS

Thigh ultrasound was conducted in a convenience-recruited cohort with minimal and maximal compression to estimate the effect of EAI-induced compression. Subcutaneous/intraosseous-injection rates were estimated for Anapen (BioProject), EpiPen (Mylan), Jext (ALK), and Emerade (Medeca). Multivariate analyses for subcutaneous-injection risk were conducted with age, male/female sex, abdominal and thigh circumferences, and upper-arm skinfold thickness.

RESULTS

A total of 68 patients were recruited. Compression thinned the subcutaneous tissue and muscle by 1 and 9 mm, respectively, on average. Projected subcutaneous-injection rates with/without compression were high for Anapen (65%-66%), moderate for EpiPen and Jext (29%-38%), and lowest for Emerade (13%-21%). Compression introduced a small intraosseous-injection risk with Emerade (4%). Female sex predicted subcutaneous injection (odds ratio, 1.3-2.0; all P < .001). Depending on the EAI, 29% to 97% of women and 0% to 41% of men would be injected subcutaneously. Older men were at risk of intraosseous Emerade injection. Obesity-related variables predicted subcutaneous injection poorly.

CONCLUSION

Anapen was associated with high subcutaneous-injection rates. EpiPen and Jext were projected to provide intramuscular injection in all men without risk of intraosseous injection. Emerade yielded the lowest subcutaneous-injection rates in women. Compression largely affected the muscle.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02886468.

Development of neffy, an Epinephrine Nasal Spray, for Severe Allergic Reactions

Epinephrine autoinjectors (EAIs) are used for the treatment of severe allergic reactions in a community setting; however, their utility is limited by low prescription fulfillment rates, failure to carry, and failure to use due to fear of needles. Given that delayed administration of epinephrine is associated with increased morbidity/mortality, there has been a growing interest in developing needle-free, easy-to-use delivery devices. neffy (epinephrine nasal spray) consists of three Food and Drug Administration (FDA)-approved components: epinephrine, Intravail A3 (absorption enhancer), and a Unit Dose Spray (UDS). neffy's development pathway was established in conjunction with the FDA and the European Medicines Agency and included multiple clinical trials to evaluate pharmacokinetic and pharmacodynamic responses under a variety of conditions, such as self-administration and allergic and infectious rhinitis, as well as an animal anaphylaxis model of severe hypotension, where neffy demonstrated a pharmacokinetic profile that is within the range of approved injection products and a pharmacodynamic response that is as good or better than injections. The increased pulse rate (PR) and blood pressure (BP) observed even one minute following the administration of neffy confirm the activation of α and β adrenergic receptors, which are the key components of epinephrine's mechanism of action. The results suggest that neffy will provide a safe and effective needle-free option for the treatment of severe allergic reactions, including anaphylaxis.

Fast Acting, Dry Powder, Needle-Free, Intranasal Epinephrine Spray: A Promising Future Treatment for Anaphylaxis

BACKGROUND

Epinephrine intramuscular (IM) autoinjector is a life-saving drug for the emergency treatment of immediate-type allergic reactions (type I). Nevertheless, it is sometimes applied incorrectly or underused because of short shelf life, high costs, fear of use, or inconvenience of carrying. FMXIN002, a nasal powder spray of epinephrine, was developed as a needle-free alternative.

OBJECTIVE

To compare epinephrine pharmacokinetics, pharmacodynamics, and safety after the administration of the FMXIN002 nasal spray versus autoinjector.

METHODS

An open-label trial was performed in 12 adults with seasonal allergic rhinitis without asthma. Epinephrine pharmacokinetics, pharmacodynamics, and safety were compared between FMXIN002 (1.6 mg and 3.2 mg) administered intranasally with/without a nasal allergen challenge and IM (0.3 mg) EpiPen.

RESULTS

FMXIN002 3.2 mg, administered after a nasal allergen challenge, displayed a shorter Tmax than EpiPen (median: 2.5 minutes vs 9.0 minutes, statistically nonsignificant [NS]) and a significantly shorter time when the measured analyte concentration is 100 pg/mL during the absorption phase pg/mL (median: 1.0 minutes vs 3.0 minutes for FMXIN002, P < .02). Moreover, FMXIN002 3.2 mg administered after the challenge test has resulted in a doubling of the maximal measured plasma analyte concentration over the sampling period (1110 vs 551 pg/mL, NS); area under the curve from 0 to 8 hours was 56% higher (672 vs 431 hours pg/mL, compared with EpiPen, NS). Pharmacodynamic response was comparable at all treatments. FMXIN002 was well tolerated, and treatment-emergent adverse events (AEs) were mild, local, and resolved spontaneously. No AEs were reported after the administration of EpiPen in our study. FMXIN002 was stable for 2 years at room temperature conditions. However, variability in the pharmacokinetics (expressed in coefficient of variation) is high. Having a prior nasal allergen challenge results in a substantial increase and speed of absorption.

CONCLUSIONS

Intranasal absorption of dry powder epinephrine is faster than EpiPen offering a clinical advantage in the short therapeutic window for the treatment of anaphylaxis. The FMXIN002 product offers a needle-free, pocket-size, safe, user-friendly, and stable alternative to epinephrine autoinjectors.

Epinephrine autoinjectors: individualizing device and dosage to optimize anaphylaxis management in the community setting

Background: Anaphylaxis is the most severe manifestation of a systemic allergic reaction, and, in the community setting, the immediate administration of an epinephrine autoinjector (EAI) can be life-saving. Physicians are tasked with selecting the most appropriate EAI for each individual and counseling patients and/or their caregivers to maximize the likelihood of successful deployment of the EAI. Objective: To offer an evidence-based expert clinical perspective on how physicians might best tailor EAI selection to their patients with anaphylaxis. Methods: A group of eight adult and pediatric allergists with expertise in anaphylaxis management reviewed and assessed the published data and guidelines on anaphylaxis management and EAI device selection. Results: Personalized EAI selection is influenced by intrinsic individual factors, extrinsic factors such as the properties of the individual EAI (e.g., dose, needle length, overall design) as well as cost and coverage. The number and the variety of EAIs available have expanded in most jurisdictions in recent years, which provide a greater diversity of options to meet the characteristics and needs of patients with anaphylaxis. Conclusion: There currently are no EAIs with customizable dose and needle length. Although precise personalization of each patient's EAI remains an optimistic future aspiration, careful consideration of all variables when prescribing EAIs can support optimal management of anaphylaxis.

Pharmacokinetics of adrenaline autoinjectors

Anaphylaxis is a medical emergency with adrenaline acknowledged as the first-line therapy. It is therefore important that patients have access to self-injectable adrenaline in the community. Manufacturers have been requested by European Medicine Regulators to generate pharmacokinetic data for these autoinjector devices. For the first time, these data provide an insight into how individual devices work in different populations, and how they compare. We undertook a thorough literature search and also accessed grey literature, using searches of medicine regulators' websites and freedom of information requests. The data demonstrate that it takes at least 5-10 min to achieve early peak plasma concentration for most devices. The specific autoinjector device seems to be the most important determinant of pharmacokinetics, with different devices giving rise to different plasma adrenaline profiles. Needle length does not seem to be the most important factor; rather, the force and speed of injection (which varies from one device to another) is likely to be of greater importance. In general, peak plasma adrenaline concentration is lower and time-to-peak concentration longer with increased skin-to-muscle depth. However, it is difficult to draw conclusions with the current available data, due to a lack of head-to-head comparisons, small numbers of study participants and the failure to acknowledge the biphasic nature of intramuscular adrenaline absorption for analysis purposes.

The pharmacokinetics of epinephrine/adrenaline autoinjectors

Background

For a century, epinephrine has been the drug of choice for acute treatment of systemic allergic reactions/anaphylaxis. For 40 years, autoinjectors have been used for the treatment of anaphylaxis. Over the last 20 years, intramuscular epinephrine injected into the thigh has been recommended for optimal effect.

Objective

To review the literature on pharmacokinetics of epinephrine autoinjectors.

Results

Six studies assessing epinephrine autoinjector pharmacokinetics were identified. The studies, all on healthy volunteers, were completed by Simons, Edwards, Duvauchelle, Worm and Turner over the span of 2 decades. Simons et al. published two small studies that suggested that intramuscular injection was superior to subcutaneous injection. These findings were partially supported by Duvauchelle. Duvauchelle showed a proportional increase in C_max and AUC_0-20 when increasing the dose from 0.3 to 0.5 mg epinephrine intramuscularly. Turner confirmed these findings. Simons, Edwards and Duvauchelle documented the impact of epinephrine on heart rate and blood pressure. Turner confirmed a dose-dependent increase in heart rate, cardiac output and stroke volume. Based on limited data, confirmed intramuscular injections appeared to lead to faster C_max. Two discernable C_max’s were identified in most of the studies. We identified similarities and discrepancies in a number of variables in the aforementioned studies.

Conclusions

Intramuscular injection with higher doses of epinephrine appears to lead to a higher C_max. There is a dose dependent increase in plasma concentration and AUC_0-20. Most investigators found two C_max’s with T_max 5–10 min and 30–50 min, respectively. There is a need for conclusive trials to evaluate the differences between intramuscular and subcutaneous injections with the epinephrine delivery site confirmed with ultrasound.

Autoinjector device for rapid administration of drugs and antidotes in emergency situations and in mass casualty management

There are several situations such as medical emergencies and incidents involving mass casualties where drugs and antidotes have to be administered immediately along with other first aid at the site of the event. Self-administration by the affected person or by a companion is required as a life-saving measure. Autoinjector devices (AIDs) are useful for the rapid administration of drugs and antidotes and they can also be used by those who have not been medically trained. This makes them very convenient for emergency and mass casualty management. An AID has a drug cartridge with an embedded needle for subcutaneous or intramuscular injection, which is usually painless. The drugs are delivered slowly by the AID across a large area in the muscle, which increases the absorption and the drug effects are equal to that of intravenous administration. A variety of AIDs are available, such as atropine and pralidoxime for nerve agent poisoning, epinephrine for anaphylactic shock and allergy, diazepam for seizures, sumatriptan for migraine, amikacin for antibacterial treatment, buprenorphine for pain relief and monoclonal antibodies for a variety of diseases. This review describes the published peer-reviewed literature identified by online searches of journal databases.

Pharmacokinetic and pharmacodynamic evidence of adrenaline administered via auto-injector for anaphylactic reactions: A review of literature

Anaphylaxis is a severe allergic reaction that can lead to death if not treated quickly. Adrenaline (epinephrine) is the first-line treatment for anaphylaxis and its prompt administration is vital to reduce mortality. Following a number of high-profile cases, serious concerns have been raised, both about the optimal dose of intramuscular adrenaline via an auto-injector and the correct needle length to ensure maximal penetration every time. To date, the public data are sparse on the pharmacokinetics-pharmacodynamics of adrenaline administered via an auto-injector. The limited available literature showed a huge variation in the plasma concentrations of adrenaline administered through an auto-injector, as well as variations in the auto-injector needle length. Hence, delivering an effective dose during an anaphylaxis remains a challenge for both patients and healthcare professionals. Collaborative work between pharmacokinetics-pharmacodynamics experts, clinical triallists and licence holders is imperative to address this gap in evidence so that we can improve outcomes of anaphylaxis. In addition, we advise inclusion of expertise of human factors in usability studies given the necessity of carer or self-administration in the uniquely stressful nature of anaphylaxis.

Intranasal epinephrine in dogs: Pharmacokinetic and heart rate effects

Epinephrine is the standard of care for the treatment of severe allergy and anaphylaxis. Epinephrine is most often administered through the intramuscular (IM) route via autoinjector. The current study aimed to evaluate an alternative method of epinephrine treatment through intranasal (IN) delivery in dogs. The pharmacokinetic (PK) parameters of maximum plasma concentration (Cmax ), time to reach maximum plasma concentration (Tmax ), and area under the plasma concentration-time curve from 0 to 90 minutes (AUC0-90 ) were observed after IN epinephrine (2, 3, 4, 5, 10, and 20 mg) and IM epinephrine via autoinjector (0.15 and 0.3 mg) for 90 minutes. Heart rate effects were measured after IN (2 and 5 mg) and IM (0.15 and 0.3 mg) epinephrine administration. IN epinephrine (5 mg) demonstrated significantly greater plasma epinephrine concentration at 1 minute as compared with IM epinephrine (0.3 mg) (1.68 ± 0.65 ng/mL vs 0.21 ± 0.08 ng/mL, P = .03). There were no significant differences in Cmax , Tmax , and AUC0-90 between 2-mg IN and 0.15-mg IM epinephrine or between 5-mg IN and 0.3-mg IM epinephrine. IN epinephrine reduced heart rate increases, as compared to IM epinephrine. IN and IM epinephrine were both well-tolerated. Overall, IN epinephrine demonstrated advantages over IM epinephrine, including the rapid increase in plasma epinephrine and lack of increased heart rate over time.

In Vivo Evaluation of Taste-Masked Fast-Disintegrating Sublingual Tablets of Epinephrine Microcrystals

In community settings, IM injection of 0.3 mg epinephrine (Epi) using an auto-injector is the drug of choice for treatment of anaphylaxis. Previously, a taste-masking (TM) formulation of fast-disintegrating sublingual tablets (FDSTs) was developed in our lab. Also, Epi was micronized (Epi-MC) successfully and reduced the previously achieved bioequivalent sublingual Epi dose to 0.3 mg IM injection by half using non-taste-masked fast-disintegrating sublingual tablets (TM-FDSTs). Our objective for this study was to evaluate the sublingual absorption of Epi-MC using TM-FDST. These sublingual Epi tablets have potential for out-of-hospital treatment of anaphylaxis and are suitable for human studies. TM-FDSTs containing Epi-MC were manufactured by direct compression. The rate and extent of Epi absorption from our developed 20 mg Epi-MC-TM-FDSTs (n = 5) were evaluated in rabbits and compared to the previous result from 20 mg Epi-MC in non-TM-FDSTs and EpiPen® auto-injector. Blood samples were collected over 1 h, and Epi concentrations were measured using HPLC with electrochemical detection. Mean ± SEM AUC0-1 h and Cmax from 20 mg Epi-MC-TM-FDSTs (733 ± 78 ng/ml/min and 30 ± 8 ng/ml) and 20 mg Epi-MC-non-TM-FDSTs (942 ± 109 ng/ml/min and 38 ± 4 ng/ml) were not significantly different (p > 0.05) from each other or from EpiPen® (592 ± 50 ng/ml/min and 28 ± 3 ng/ml) but were significantly higher (p < 0.05) than endogenous Epi after placebo FDSTs (220 ± 32 ng/ml/min and 8 ± 1 ng/ml). Mean ± SD Tmax was not significantly different (p > 0.05) among all formulations. Epi-MC-TM-FDSTs formulation improved Epi absorption twofold and reduced the required bioequivalent dose by 50%, similar to results obtained using non-TM-FDSTs. The incorporation of TM excipients did not interfere with the absorption of Epi-MC.

Epinephrine, auto-injectors, and anaphylaxis: Challenges of dose, depth, and device

OBJECTIVE

This review was undertaken to review epinephrine dosing, site and route of administration, focusing on special populations (patients weighing less than 15 kg, and obese patients); and to discuss storage and delivery of epinephrine in prehospital and hospital settings.

DATA SOURCES

Review of published literature.

STUDY SELECTION

Relevance.

RESULTS

The recommended 0.01-mg/kg (maximum 0.3-0.5 mg) epinephrine dose in anaphylaxis is based on limited pharmacokinetic data in healthy volunteers. No pharmacokinetic or pharmacodynamics studies involving patients in anaphylaxis have been published. When epinephrine auto-injectors (EAIs) are used in infants, the dose increasingly exceeds the recommended dose as weight decreases, although the clinical significance of this is unclear. Limited data indicate that the intramuscular route and lateral thigh site are superior. Ultrasound studies suggest that 0.15 EAI needles may be too long for many patients weighing less than 15 kg, and 0.3 mg EAI needles may be too short for obese patients weighing more than 30 kg. A newly available 0.1 mg EAI has a lower dose and shorter needle better suited to patients weighing 7.5 to 15 kg. In some medical settings, vials and syringes may provide a safe, efficient alternative with substantial cost savings over EAIs.

CONCLUSION

EAIs should be available in the community with doses and needle depths that meet the needs of all patients. More research on epinephrine pharmacodynamics are needed in children and adults in anaphylaxis, to better delineate what optimal doses should be. Optimizing epinephrine dose and delivery has the potential to improve anaphylaxis outcomes and prevent adverse events.

Inadequacy of current pediatric epinephrine autoinjector needle length for use in infants and toddlers

BACKGROUND

Epinephrine injection represents the standard of care for anaphylaxis treatment. It is most effective if delivered intramuscularly, whereas inadvertent intraosseous injection may be harmful. The needle length in current pediatric epinephrine autoinjectors (EAIs) is 12.7 mm; however, the ideal needle length for infants and toddlers weighing less than 15 kg is unknown.

OBJECTIVE

To determine the skin-to-bone distance (STBD) and skin-to-muscle distance (STMD) at baseline and after simulated EAI application in infants and toddlers (weighing 7.5-15 kg).

METHODS

Study participants recruited from 2 North American allergy clinics underwent baseline and compression (10-lb pressure) ultrasonography of the anterolateral thigh with a modified ultrasound transducer mimicking the footprint and maximum pressure application of an EAI device. Ultrasound images, with clinical data masked, were analyzed offline for STBD and STMD in short-axis approach.

RESULTS

Of 53 infants (mean age, 18.9 months; 54.7% male; 81.1% white; mean weight, 11.0 kg), 51 had adequate images for short-axis STBD measurements. In these infants, the mean (SD) baseline STBD was 22.4 (3.8 mm), and the mean (SD) STMD was 7.9 (1.7) mm. With 10-lb compression, the mean (SD) STBD was 13.3 (2.1) mm, and the mean (SD) STMD was 6.3 (1.2) mm. An EAI with a needle length of 12.7 mm applying 10-lb pressure could strike the bone in 43.1% of infants and toddlers in this cohort.

CONCLUSION

Our data suggest that the optimal EAI needle length for infants and toddlers weighing 7.5 to 15 kg should be shorter than the needle length in currently available pediatric EAIs to avoid accidental intraosseous injections.

Do epinephrine auto-injectors have an unsuitable needle length in children and adolescents at risk for anaphylaxis from food allergy?

Background

Food allergy is the most common cause of anaphylaxis in children. Intramuscular delivery of epinephrine auto-injectors (EAI) is the standard of care for the treatment of anaphylaxis. We examined if children and adolescents at risk of anaphylaxis weighing 15–30 kg and >30 kg would receive epinephrine into the intramuscular space with the currently available EAI in North America and Europe.

Methods

The distance from skin to muscle (STMD) and skin to bone (STBD) on the mid third anterolateral area of the right thigh was measured by ultrasound applying either high pressure (_max) or slight pressure (_min) in 102 children weighing 15–30 kg (group 1) and 100 children and adolescents, weighing more than 30 kg (group 2).

Results

Using a high pressure EAI (HPEAI), Epipen Jr^® and Auvi-Q^®/Allerject^® 0.15 mg, 11/102 (11 %) children in group 1 and 38/102 (38 %) using another HPEAI, Jext^®, had a STMD_max that showed a risk of intraosseous injection. There was a 1 % risk of subcutaneous injection with these devices. There was no risk of intraosseous injection using a low pressure EAI (LPEAI), Emerade^®. In group 2, the risk of intraosseous injection using a HPEAI was 3 % and no risk using a LPEAI. However, the risk of subcutaneous injection using HPEAI was 9 % and using LPEAI was 2 %.

Conclusion

There is a risk of intraosseous injection using HPEAI (Epipen^®/Epipen Jr^®, Auvi-Q^®/Allerject^® and especially Jext^®) in children at risk of anaphylaxis. There was also a risk of subcutaneous injection using the currently available HPEAI in children and adolescents.

Electronic supplementary material

The online version of this article (doi:10.1186/s13223-016-0110-8) contains supplementary material, which is available to authorized users.

Optimal treatment of anaphylaxis: antihistamines versus epinephrine

Anaphylaxis is a rapid, systemic, often unanticipated, and potentially life-threatening immune reaction occurring after exposure to certain foreign substances. The main immunologic triggers include food, insect venom, and medications. Multiple immunologic pathways underlie anaphylaxis, but most involve immune activation and release of immunomodulators. Anaphylaxis can be difficult to recognize clinically, making differential diagnosis key. The incidence of anaphylaxis has at least doubled during the past few decades, and in the United States alone, an estimated 1500 fatalities are attributed to anaphylaxis annually. The increasing incidence and potentially life-threatening nature of anaphylaxis coupled with diagnostic challenges make appropriate and timely treatment critical. Epinephrine is universally recommended as the first-line therapy for anaphylaxis, and early treatment is critical to prevent a potentially fatal outcome. Despite the evidence and guideline recommendations supporting its use for anaphylaxis, epinephrine remains underused. Data indicate that antihistamines are more commonly used to treat patients with anaphylaxis. Although histamine is involved in anaphylaxis, treatment with antihistamines does not relieve or prevent all of the pathophysiological symptoms of anaphylaxis, including the more serious complications such as airway obstruction, hypotension, and shock. Additionally, antihistamines do not act as rapidly as epinephrine; maximal plasma concentrations are reached between 1 and 3 hours for antihistamines compared with < 10 minutes for intramuscular epinephrine injection. This demonstrates the need for improved approaches to educate physicians and patients regarding the appropriate treatment of anaphylaxis.

Adrenaline (epinephrine) microcrystal sublingual tablet formulation: enhanced absorption in a preclinical model

Objectives

For anaphylaxis treatment in community settings, adrenaline (epinephrine) administration using an auto-injector in the thigh is universally recommended. Despite this, many people at risk of anaphylaxis in community settings do not carry their prescribed auto-injectors consistently and hesitate to use them when anaphylaxis occurs.The objective of this research was to study the effect of a substantial reduction in adrenaline (Epi) particle size to a few micrometres (Epi microcrystals (Epi-MC)) on enhancing adrenaline dissolution and increasing the rate and extent of sublingual absorption from a previously developed rapidly disintegrating sublingual tablet (RDST) formulation in a validated preclinical model.

Methods

The in-vivo absorption of Epi-MC 20 mg RDSTs and Epi 40 mg RDSTs was evaluated in rabbits. Epi 0.3 mg intramuscular (IM) injection in the thigh and placebo RDSTs were used as positive and negative controls, respectively.

Key findings

Epimean(standard deviation) area under the plasma concentration vs time curves up to 60 min and Cmax from Epi-MC 20 mg and Epi 40 mg RDSTs did not differ significantly (P &gt; 0.05) from Epi 0.3 mg IM injection. After adrenaline, regardless of route of administration, pharmacokinetic parameters were significantly higher (P &lt; 0.05) than after placebo RDSTs administration (reflecting endogenous adrenaline levels).

Conclusion

Epi-MC RDSTs facilitated a twofold increase in Epi absorption and a 50% reduction in the sublingual dose. This novel sublingual tablet formulation is potentially useful for the first-aid treatment of anaphylaxis in community settings.

Anaphylaxis treatment: current barriers to adrenaline auto-injector use

Anaphylaxis is a life-threatening condition that is increasing in prevalence in the developed world. There is universal expert agreement that rapid intramuscular injection of adrenaline is life-saving and constitutes the first-line treatment of anaphylaxis. The unpredictable nature of anaphylaxis and its rapid progression makes necessary the availability of a portable emergency treatment suitable for self-administration. Thus, anaphylaxis treatment guidelines recommend that at-risk patients are provided with adrenaline auto-injectors (AAIs). Despite these clear recommendations, current emergency treatment of anaphylaxis continues to be inadequate in many cases. The aim of this review is to highlight the barriers that exist to the use and availability of AAIs and that prevent proper management of anaphylaxis. In addition, we review the characteristics of all AAIs that are presently available in Europe and the USA and discuss the need for regulatory requirements to establish the performance characteristics of these devices.

Systematic review of outcome measures in trials of pediatric anaphylaxis treatment

BACKGROUND

Considerable heterogeneity has been observed in the selection and reporting of disease-specific pediatric outcome measures in randomized controlled trials (RCTs). This makes interpretation of results and comparison across trials challenging. Outcome measures in pediatric anaphylaxis trials have never previously been systematically assessed. This systematic review (SR) identified and assessed outcome measures used in RCTs of anaphylaxis treatment in children. As a secondary objective, this SR assessed the evidence for current treatment modalities for anaphylaxis in the pediatric population.

METHODS

We searched MEDLINE, EMBASE, The Cochrane Library, Cochrane Central Register of Controlled Trials (CENTRAL), and CINAHL from 2001 until December 2012. We also searched websites listing ongoing trials. We included randomized and controlled trials of anaphylaxis treatment in patients 0-18 years of age. Two authors independently assessed articles for inclusion.

RESULTS

No published studies fulfilled the inclusion criteria.

CONCLUSIONS

There is an alarming absence of RCTs evaluating the treatments for anaphylaxis in children. High quality studies are needed and are possible to design, despite the severe and acute nature of this condition. Consensus about the selection and validation of appropriate outcome measures will enhance the quality of research and improve the care of children with anaphylaxis.

TRIAL REGISTRATION

CRD42012002685.

International consensus on (ICON) anaphylaxis

ICON: Anaphylaxis provides a unique perspective on the principal evidence-based anaphylaxis guidelines developed and published independently from 2010 through 2014 by four allergy/immunology organizations. These guidelines concur with regard to the clinical features that indicate a likely diagnosis of anaphylaxis -- a life-threatening generalized or systemic allergic or hypersensitivity reaction. They also concur about prompt initial treatment with intramuscular injection of epinephrine (adrenaline) in the mid-outer thigh, positioning the patient supine (semi-reclining if dyspneic or vomiting), calling for help, and when indicated, providing supplemental oxygen, intravenous fluid resuscitation and cardiopulmonary resuscitation, along with concomitant monitoring of vital signs and oxygenation. Additionally, they concur that H1-antihistamines, H2-antihistamines, and glucocorticoids are not initial medications of choice. For self-management of patients at risk of anaphylaxis in community settings, they recommend carrying epinephrine auto-injectors and personalized emergency action plans, as well as follow-up with a physician (ideally an allergy/immunology specialist) to help prevent anaphylaxis recurrences. ICON: Anaphylaxis describes unmet needs in anaphylaxis, noting that although epinephrine in 1 mg/mL ampules is available worldwide, other essentials, including supplemental oxygen, intravenous fluid resuscitation, and epinephrine auto-injectors are not universally available. ICON: Anaphylaxis proposes a comprehensive international research agenda that calls for additional prospective studies of anaphylaxis epidemiology, patient risk factors and co-factors, triggers, clinical criteria for diagnosis, randomized controlled trials of therapeutic interventions, and measures to prevent anaphylaxis recurrences. It also calls for facilitation of global collaborations in anaphylaxis research. IN ADDITION TO CONFIRMING THE ALIGNMENT OF MAJOR ANAPHYLAXIS GUIDELINES, ICON: Anaphylaxis adds value by including summary tables and citing 130 key references. It is published as an information resource about anaphylaxis for worldwide use by healthcare professionals, academics, policy-makers, patients, caregivers, and the public.