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Lefevre S, Goetz C, Hennequin L, Zevering Y, Dinot V. Frequencies and predictors of subcutaneous and intraosseous injection with 4 epinephrine autoinjector devices. Ann Allergy Asthma Immunol 2024; 133:194-202.e5. [PMID: 38740133 DOI: 10.1016/j.anai.2024.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 05/01/2024] [Accepted: 05/01/2024] [Indexed: 05/16/2024]
Abstract
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.
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Affiliation(s)
- Sébastien Lefevre
- Department of Allergology, Mercy Hospital, Regional Hospital Center (CHR) of Metz-Thionville, Metz Cedex, France.
| | - Christophe Goetz
- Clinical Research Support Unit, Mercy Hospital, CHR of Metz-Thionville, Metz Cedex, France
| | - Laurent Hennequin
- Department of Medical Imaging, Mercy Hospital, CHR of Metz-Thionville, Metz Cedex, France
| | - Yinka Zevering
- Clinical Research Support Unit, Mercy Hospital, CHR of Metz-Thionville, Metz Cedex, France
| | - Vincent Dinot
- Clinical Research Support Unit, Mercy Hospital, CHR of Metz-Thionville, Metz Cedex, France
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2
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Golden DBK, Wang J, Waserman S, Akin C, Campbell RL, Ellis AK, Greenhawt M, Lang DM, Ledford DK, Lieberman J, Oppenheimer J, Shaker MS, Wallace DV, Abrams EM, Bernstein JA, Chu DK, Horner CC, Rank MA, Stukus DR, Burrows AG, Cruickshank H, Golden DBK, Wang J, Akin C, Campbell RL, Ellis AK, Greenhawt M, Lang DM, Ledford DK, Lieberman J, Oppenheimer J, Shaker MS, Wallace DV, Waserman S, Abrams EM, Bernstein JA, Chu DK, Ellis AK, Golden DBK, Greenhawt M, Horner CC, Ledford DK, Lieberman J, Rank MA, Shaker MS, Stukus DR, Wang J. Anaphylaxis: A 2023 practice parameter update. Ann Allergy Asthma Immunol 2024; 132:124-176. [PMID: 38108678 DOI: 10.1016/j.anai.2023.09.015] [Citation(s) in RCA: 96] [Impact Index Per Article: 96.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 09/29/2023] [Accepted: 09/29/2023] [Indexed: 12/19/2023]
Abstract
This practice parameter update focuses on 7 areas in which there are new evidence and new recommendations. Diagnostic criteria for anaphylaxis have been revised, and patterns of anaphylaxis are defined. Measurement of serum tryptase is important for diagnosis of anaphylaxis and to identify underlying mast cell disorders. In infants and toddlers, age-specific symptoms may differ from older children and adults, patient age is not correlated with reaction severity, and anaphylaxis is unlikely to be the initial reaction to an allergen on first exposure. Different community settings for anaphylaxis require specific measures for prevention and treatment of anaphylaxis. Optimal prescribing and use of epinephrine autoinjector devices require specific counseling and training of patients and caregivers, including when and how to administer the epinephrine autoinjector and whether and when to call 911. If epinephrine is used promptly, immediate activation of emergency medical services may not be required if the patient experiences a prompt, complete, and durable response. For most medical indications, the risk of stopping or changing beta-blocker or angiotensin-converting enzyme inhibitor medication may exceed the risk of more severe anaphylaxis if the medication is continued, especially in patients with insect sting anaphylaxis. Evaluation for mastocytosis, including a bone marrow biopsy, should be considered for adult patients with severe insect sting anaphylaxis or recurrent idiopathic anaphylaxis. After perioperative anaphylaxis, repeat anesthesia may proceed in the context of shared decision-making and based on the history and results of diagnostic evaluation with skin tests or in vitro tests when available, and supervised challenge when necessary.
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Affiliation(s)
| | - Julie Wang
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Susan Waserman
- Division of Clinical Immunology and Allergy, McMaster University, Hamilton, Canada
| | - Cem Akin
- Division of Allergy and Clinical Immunology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Ronna L Campbell
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota
| | - Anne K Ellis
- Division of Allergy & Immunology, Department of Medicine, Queen's University, Kingston, Canada
| | - Matthew Greenhawt
- Section of Allergy and Immunology, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Denver, Colorado
| | - David M Lang
- Department of Allergy and Clinical Immunology, Cleveland Clinic, Cleveland, Ohio
| | - Dennis K Ledford
- James A. Haley VA Hospital, Tampa, Florida; Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Jay Lieberman
- The University of Tennessee Health Science Center, Memphis, Tennessee
| | - John Oppenheimer
- Department of Internal Medicine, University of Medicine and Dentistry of New Jersey-Rutgers New Jersey Medical School, Newark, New Jersey
| | - Marcus S Shaker
- Geisel School of Medicine, Hanover, New Hampshire; Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Elissa M Abrams
- Department of Pediatrics and Child Health, Section of Allergy and Clinical Immunology, Children's Hospital Research Institute of Manitoba, Winnipeg, Canada
| | - Jonathan A Bernstein
- Division of Rheumatology, Allergy, and Immunology, University of Cincinnati College of Medicine, Cincinnati, Ohio; Bernstein Allergy Group and Bernstein Clinical Research Center, Cincinnati, Ohio
| | - Derek K Chu
- Department of Medicine and Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Canada
| | - Caroline C Horner
- Division of Allergy & Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Matthew A Rank
- Mayo Clinic in Arizona and Phoenix Children's Hospital, Scottsdale and Phoenix, Arizona
| | - David R Stukus
- Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio
| | - Alyssa G Burrows
- Division of Allergy & Immunology, Department of Medicine, Queen's University, Kingston, Canada
| | - Heather Cruickshank
- Division of Clinical Immunology and Allergy, McMaster University, Hamilton, Canada
| | | | - Julie Wang
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Cem Akin
- Division of Allergy and Clinical Immunology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Ronna L Campbell
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota
| | - Anne K Ellis
- Division of Allergy & Immunology, Department of Medicine, Queen's University, Kingston, Canada
| | - Matthew Greenhawt
- Section of Allergy and Immunology, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Denver, Colorado
| | - David M Lang
- Department of Allergy and Clinical Immunology, Cleveland Clinic, Cleveland, Ohio
| | - Dennis K Ledford
- James A. Haley VA Hospital, Tampa, Florida; Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Jay Lieberman
- The University of Tennessee Health Science Center, Memphis, Tennessee
| | - John Oppenheimer
- Department of Internal Medicine, University of Medicine and Dentistry of New Jersey-Rutgers New Jersey Medical School, Newark, New Jersey
| | - Marcus S Shaker
- Geisel School of Medicine, Hanover, New Hampshire; Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Susan Waserman
- Division of Clinical Immunology and Allergy, McMaster University, Hamilton, Canada
| | - Elissa M Abrams
- Department of Pediatrics and Child Health, Section of Allergy and Clinical Immunology, Children's Hospital Research Institute of Manitoba, Winnipeg, Canada
| | - Jonathan A Bernstein
- Division of Rheumatology, Allergy, and Immunology, University of Cincinnati College of Medicine, Cincinnati, Ohio; Bernstein Allergy Group and Bernstein Clinical Research Center, Cincinnati, Ohio
| | - Derek K Chu
- Department of Medicine and Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Canada
| | - Anne K Ellis
- Division of Allergy & Immunology, Department of Medicine, Queen's University, Kingston, Canada
| | | | - Matthew Greenhawt
- Section of Allergy and Immunology, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Denver, Colorado
| | - Caroline C Horner
- Division of Allergy & Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Dennis K Ledford
- James A. Haley VA Hospital, Tampa, Florida; Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Jay Lieberman
- The University of Tennessee Health Science Center, Memphis, Tennessee
| | - Matthew A Rank
- Mayo Clinic in Arizona and Phoenix Children's Hospital, Scottsdale and Phoenix, Arizona
| | - Marcus S Shaker
- Geisel School of Medicine, Hanover, New Hampshire; Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - David R Stukus
- Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio
| | - Julie Wang
- Icahn School of Medicine at Mount Sinai, New York, New York
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Kim H, Alizadehfar R, Alqurashi W, Ellis AK, Fischer DA, Roberts H, Torabi B, Waserman S. Epinephrine autoinjectors: individualizing device and dosage to optimize anaphylaxis management in the community setting. Allergy Asthma Proc 2023; 44:45-50. [PMID: 36719691 DOI: 10.2500/aap.2023.44.220073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
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.
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Affiliation(s)
- Harold Kim
- From the Division of Clinical Immunology and Allergy, Department of Medicine, Western University, London, Ontario, Canada
| | - Reza Alizadehfar
- Division of Allergy and Clinical Immunology, McGill University, Montreal, Quebec, Canada
| | - Waleed Alqurashi
- Department of Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Anne K Ellis
- Division of Allergy and Immunology, Department of Medicine, Queen's University, Kingston, Ontario, Canada, and
| | - David A Fischer
- From the Division of Clinical Immunology and Allergy, Department of Medicine, Western University, London, Ontario, Canada
| | - Hannah Roberts
- From the Division of Clinical Immunology and Allergy, Department of Medicine, Western University, London, Ontario, Canada
| | - Bahar Torabi
- Pediatric Allergy and Clinical Immunology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Susan Waserman
- Clinical Immunology and Allergy, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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4
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Li LDX, Abrams EM, Lavine E, Hildebrand K, Mack DP. CSACI position statement: transition recommendations on existing epinephrine autoinjectors. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2021; 17:130. [PMID: 34903280 PMCID: PMC8670273 DOI: 10.1186/s13223-021-00634-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 11/26/2021] [Indexed: 11/10/2022]
Abstract
Epinephrine is the first line treatment for anaphylaxis, an acute potentially life-threatening allergic reaction. It is typically administered intramuscularly in the anterolateral thigh at a dose of 0.01 mg/kg of 1:1000 (1 mg/ml) solution to a maximum initial dose of 0.5 mg. Currently in Canada, epinephrine autoinjectors (EAI) are available in three doses, 0.15 mg, 0.30 mg, and 0.50 mg. There are currently no published studies comparing 0.3 mg and 0.5 mg EAIs in the paediatric or adult populations to compare clinical effectiveness. However, as weight increases above 30 kg, the percentage of the recommended 0.01 mg/kg epinephrine dose from an existing 0.3 mg EAI decreases resulting in potential underdosing. As such, The Canadian Society of Allergy and Immunology (CSACI) recommends that for those who weigh ≥ 45 kg, physicians could consider prescribing the 0.50 mg EAI based on shared decision making with patients.
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Affiliation(s)
- Lucy Dong Xuan Li
- Department of Paediatrics, Division of Clinical Immunology and Allergy, University of Toronto, Toronto, ON Canada
| | - Elissa M. Abrams
- Department of Paediatrics, Section of Allergy and Clinical Immunology, University of Manitoba, Winnipeg, MB Canada
| | - Elana Lavine
- Department of Paediatrics, University of Toronto, Toronto, ON Canada
- Department of Paediatrics, Queen’s University, Kingston, ON Canada
| | - Kyla Hildebrand
- Department of Paediatrics, Division of Allergy and Immunology, University of British Columbia, Vancouver, BC Canada
| | - Douglas Paul Mack
- Department of Paediatrics, Paediatric Allergy, Asthma, and Immunology, McMaster University, Hamilton, ON Canada
- Halton Pediatric Allergy, Burlington, ON Canada
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5
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Ramsey N, Wang J. Management of Anaphylaxis in Infants and Toddlers. Immunol Allergy Clin North Am 2021; 42:77-90. [PMID: 34823752 DOI: 10.1016/j.iac.2021.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Anaphylaxis is a systemic allergic reaction that can be caused by food, drugs, insect bites, or unknown triggers in infants and toddlers. Anaphylaxis rates are increasing. Infants and toddlers may have increased exposure to known and unknown allergens, decreased ability to describe their symptoms, and an expanded differential diagnosis for consideration on presentation. The most common symptoms in these age groups are cutaneous and gastrointestinal. Age-specific language may be helpful for caregivers to identify and describe the symptoms of anaphylaxis in infants and toddlers. Long-term management of anaphylaxis includes allergy evaluation to guide avoidance and assess prognosis and education on allergic reaction management; this incorporates the prescription of epinephrine autoinjector and provision of an allergy emergency plan.
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Affiliation(s)
- Nicole Ramsey
- Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1198, New York, NY 10029, USA
| | - Julie Wang
- Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1198, New York, NY 10029, USA.
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6
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Carlisle A, Lieberman J. Clinical Management of Infant Anaphylaxis. J Asthma Allergy 2021; 14:821-827. [PMID: 34267527 PMCID: PMC8275199 DOI: 10.2147/jaa.s286692] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 06/11/2021] [Indexed: 11/23/2022] Open
Abstract
Anaphylaxis is a condition that is likely increasing in prevalence and commonly treated by allergists as well as other first responders and emergency room providers. Although a relatively rare event, anaphylaxis can occur in infants, with the most common cause attributed to foods. Infant anaphylaxis can present with unique diagnostic challenges and treatment considerations. While infants can present with classic signs and symptoms of anaphylaxis (eg, urticaria, angioedema, dyspnea, wheeze, and vomiting) they can also present with non-classical signs. Non-classical signs of infant anaphylaxis can include ear pulling, tongue thrusting, fussiness, and increase clinginess to the caregiver. These non-classic signs of infant anaphylaxis can often mimic normal infant behavior further complicating the diagnosis. Additionally, when treating infant anaphylaxis, there are special considerations regarding the use of epinephrine. These include determining appropriate needle length, dosages appropriate to administer depending on the weight of the infant, and the availability of different epinephrine auto-injectors. In this article, we aim to review the clinical management of infant anaphylaxis including diagnosis, recognition, treatment, strategies for follow-up and special considerations regarding epinephrine administration in this demographics.
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Affiliation(s)
- Annette Carlisle
- Department of Pediatrics, Division of Pediatric Pulmonary, Sleep, Allergy & Immunology, The University of Tennessee Health Science Center, Le Bonheur Children's Hospital, Memphis, TN, USA
| | - Jay Lieberman
- Department of Pediatrics, Division of Pediatric Pulmonary, Sleep, Allergy & Immunology, The University of Tennessee Health Science Center, Le Bonheur Children's Hospital, Memphis, TN, USA
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7
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Choosing the Optimal Self-Injector Epinephrine. CURRENT TREATMENT OPTIONS IN ALLERGY 2021. [DOI: 10.1007/s40521-020-00276-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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8
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Tsuang A, Chan ES, Wang J. Food-Induced Anaphylaxis in Infants: Can New Evidence Assist with Implementation of Food Allergy Prevention and Treatment? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:57-69. [DOI: 10.1016/j.jaip.2020.09.018] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/16/2020] [Accepted: 09/16/2020] [Indexed: 01/06/2023]
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9
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Moss J, Jani Y, Edwards B, Tomlin S, Rashed AN. Pharmacokinetic and pharmacodynamic evidence of adrenaline administered via auto-injector for anaphylactic reactions: A review of literature. Br J Clin Pharmacol 2020; 87:816-824. [PMID: 32559814 DOI: 10.1111/bcp.14438] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 06/01/2020] [Accepted: 06/02/2020] [Indexed: 01/23/2023] Open
Abstract
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.
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Affiliation(s)
- James Moss
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK.,Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, UK
| | - Yogini Jani
- Centre for Medicines Optimisation Research & Education, University College London Hospitals NHS Foundation Trust & UCL School of Pharmacy, London, UK
| | - Brian Edwards
- International Society of Pharmacovigilance, London, UK
| | - Stephen Tomlin
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Asia N Rashed
- Evelina Pharmacy, Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Institute of Pharmaceutical Science, King's College London, London, UK
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10
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Dreborg S, Tsai G, Kim H. Epinephrine auto-injector needle length: The impact of winter clothing. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2020; 16:24. [PMID: 32322286 PMCID: PMC7160976 DOI: 10.1186/s13223-020-00422-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Accepted: 04/02/2020] [Indexed: 12/02/2022]
Abstract
BACKGROUND Epinephrine auto-injectors are expected to deliver the drug intramuscularly. OBJECTIVE To study whether injection through clothing influences the frequency of subcutaneous and intraosseous/periosteal deposition of epinephrine. METHODS Skin to muscle and skin to bone distances were measured for 303 children and adolescents and 99 adults. Distance was determined by ultrasound, with high or low pressure on the ultrasound probe. The risk/percentage of subcutaneous and intraosseous/periosteal injections was calculated using the lower and upper limits for the authority-approved length of EAI needles as provided by two high pressure EAI manufacturers and one low pressure EAI manufacturer. The addition winter clothing on the delivery of epinephrine was illustrated by comparing drug delivery fissue depth with no clothes. Furthermore, the riof non-intramuscular delivery for the shortest and longest approved needle length was calculated. RESULTS When using EpipenJr® in children < 15 kg the risk of intraosseous/periostal injection was reduced from 1% and 59% for the shortest and longest approved needle length to 0 and 15% with winter clothes. The Auvi-Q® 0.1 mg had no risk of intraosseous/periosteal injection. However, the subcutaneous deposition risk increased from 94% and 28% to 100% and 99% with winter clothes. The risk of subcutaneous injection using EpipenJr® in the youngest children increased from 13% and 0% to 81% and 1% with winter clothes, and with Epipen® in adults from 45% and 17% to 60% and 38%. Emerade®, had a risk of subcutaneous injection in adults increasing from 14% and 10% to 28% and 21% adding winter clothes. CONCLUSION The risk of intraosseous/periosteal injections decreases and the risk of subcutaneous injection increases when injecting through winter clothes for all EAIs.
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Affiliation(s)
- Sten Dreborg
- Department Child and Adolescent Allergology, Women’s and Children’s Health, University of Uppsala, Uppsala, Sweden
| | - Gina Tsai
- Department of Medicine, Western University, London, Canada
| | - Harold Kim
- Department of Medicine, Western University, London, Canada
- Department of Medicine, McMaster University, Hamilton, Canada
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11
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Brown JC, Simons E, Rudders SA. Epinephrine in the Management of Anaphylaxis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:1186-1195. [DOI: 10.1016/j.jaip.2019.12.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 12/13/2019] [Accepted: 12/18/2019] [Indexed: 10/24/2022]
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Abstract
Immediate administration of intramuscular epinephrine to a patient experiencing anaphylaxis is the first-line therapy for this life-threatening allergic reaction. Alhough anaphylaxis is generally a rare occurrence, it has dire consequences if left untreated. In infants, anaphylaxis is typically triggered by exposure to egg, cow's milk, or peanuts. The rapid onset of symptoms in multiple organ systems makes an accurate diagnosis in infants difficult because there are numerous ways in which anaphylaxis may present. The symptoms of infant anaphylaxis are often underrecognized or misdiagnosed for less serious illnesses or even normal findings, including drooling, loose stools, and irritability. Because infants are mostly nonverbal-and most pediatric emergency department visits for anaphylaxis cases are the first diagnosis-ascertaining potential exposure to common allergens is difficult; this further complicates diagnosis in these youngest patients for whom the clinical presentation of anaphylaxis varies widely. A key factor in diagnosing anaphylaxis is the temporal profile of symptom development following allergen exposure; however, some children with anaphylaxis develop symptoms that reoccur hours or days after an initial anaphylactic reaction, making diagnosis challenging. Advanced practice nurses are often the first health care provider to encounter a patient who may be experiencing anaphylaxis. Although diagnostic criteria exist for anaphylaxis, specific criteria for the diagnosis of anaphylaxis in infants have not been developed. As such, it is important to understand and recognize the variable presentation of anaphylaxis in infants and to rapidly diagnose and treat with epinephrine.
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13
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Pouessel G, Jean-Bart C, Deschildre A, Van der Brempt X, Tanno LK, Beaumont P, Dumond P, Sabouraud-Leclerc D, Beaudouin E, Ramdane N, Liabeuf V, Renaudin JM. Food-induced anaphylaxis in infancy compared to preschool age: A retrospective analysis. Clin Exp Allergy 2019; 50:74-81. [PMID: 31651059 DOI: 10.1111/cea.13519] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 09/17/2019] [Accepted: 09/17/2019] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Little is known regarding food anaphylaxis in infancy. We aimed to describe specificities of food anaphylaxis in infants (≤12 months) as compared to preschool children (1-6 years). METHODS We conducted a retrospective study of all food anaphylaxis cases recorded by the Allergy Vigilance Network from 2002 to 2018, in preschool children focusing on infants. RESULTS Of 1951 food anaphylaxis reactions, 61 (3%) occurred in infants and 386 (20%) in preschool children. Two infants had two anaphylaxis reactions; thus, we analyzed data among 59 infants (male: 51%; mean age: 6 months [SD: 2.9]); 31% had a history of atopic dermatitis, 11% of previous food allergy. The main food allergens were cow's milk (59%), hen's egg (20%), wheat (7%) and peanut (3%) in infants as compared with peanut (27%) and cashew (23%) in preschool children. Anaphylaxis occurred in 28/61 (46%) cases at the first cow's milk intake after breastfeeding discontinuation. Clinical manifestations were mainly mucocutaneous (79%), gastrointestinal (49%), respiratory (48%) and cardiovascular (21%); 25% of infants received adrenaline. Hives, hypotension and neurologic symptoms were more likely to be reported in infants than in preschool children (P = .02; P = .004; P = .002, respectively). Antihistamines and corticosteroids were more often prescribed in preschool children than in infants (P = .005; P = .025, respectively). CONCLUSION Our study found that in infants presenting with their first food allergy, in a setting with a high rate of infant formula use, the most predominant trigger was cow's milk. As compared to older preschool children, hives, hypotonia and hypotension were more likely to be reported in infants. We believe that this represents a distinct food anaphylaxis phenotype that can further support developing the clinical anaphylaxis criteria in infants.
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Affiliation(s)
- Guillaume Pouessel
- Department of Pediatrics, Children's Hospital, Roubaix, France.,Pediatric Pulmonology and Allergy Department, CHU Lille, Lille, France.,Allergy Vigilance Network, Vandoeuvre-lès-Nancy, France
| | | | - Antoine Deschildre
- Pediatric Pulmonology and Allergy Department, CHU Lille, Lille, France.,Allergy Vigilance Network, Vandoeuvre-lès-Nancy, France
| | - Xavier Van der Brempt
- Allergy Vigilance Network, Vandoeuvre-lès-Nancy, France.,Allergopôle, Clinique Saint-Luc, Bouge, Belgium
| | - Luciana Kase Tanno
- Allergy Vigilance Network, Vandoeuvre-lès-Nancy, France.,University Hospital, Montpellier, France.,INSERM UMR-S 1136, IPLESP, Equipe EPAR, Sorbonne Université, Paris, France.,Hospital Sírio Libanês, São Paulo, Brazil
| | - Pascale Beaumont
- Allergy Vigilance Network, Vandoeuvre-lès-Nancy, France.,Medical office, Saint-Maur des Fossés, France
| | - Pascale Dumond
- Allergy Vigilance Network, Vandoeuvre-lès-Nancy, France.,Pediatric Allergology Department, Children's hospital, University Hospital Nancy, Vandoeuvre-lès-Nancy, France
| | - Dominique Sabouraud-Leclerc
- Allergy Vigilance Network, Vandoeuvre-lès-Nancy, France.,Pediatric Department, American Memorial Hospital, Reims, France
| | - Etienne Beaudouin
- Department of Allergology and Clinical Immunology, Mercy Hospital, Metz-Thionville, France
| | - Nassima Ramdane
- EA 2694, Public health epidemiology and quality of care, University of Lille, Lille, France
| | - Valérie Liabeuf
- Department of Dermatology, La Timone Hospital, Aix-Marseille University, Marseille, France
| | - Jean-Marie Renaudin
- Allergy Vigilance Network, Vandoeuvre-lès-Nancy, France.,Pediatric Allergy Care Unit University Hospital, Vandoeuvre-lès-Nancy, France
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- Allergy Vigilance Network, Vandoeuvre-lès-Nancy, France
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14
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Authors' response. Ann Allergy Asthma Immunol 2019; 121:644-645. [PMID: 30389088 DOI: 10.1016/j.anai.2018.09.456] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 09/13/2018] [Indexed: 11/24/2022]
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15
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Dreborg S, Tsai G, Kim H. Implications of variation of epinephrine auto-injector needle length. Ann Allergy Asthma Immunol 2019; 123:89-94. [PMID: 31071440 DOI: 10.1016/j.anai.2019.04.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 04/25/2019] [Accepted: 04/29/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND The variation of needle lengths of epinephrine auto-injectors (EAIs) has not been investigated. OBJECTIVE To investigate the impact of the variation of the needle length of EAIs. METHODS Skin-to-muscle (STMD) and skin-to-bone distances (STBD) were measured for 303 children and adolescents and 99 adults. Distance was determined by ultrasound, applying high or low pressure on the probe. The risk of subcutaneous and periosteal/intraosseous injection was calculated using the lower and upper acceptance limits for length of EAI needles as provided for 3 high-pressure EAIs (HPEAI) and 1 low-pressure EAI (LPEAI). RESULTS The variation in needle length of the HPEAIs are for Epipen Jr/Epipen 5 mm, for Jext 2 mm, for Auvi-Q 2.5 mm, and for the LPEAI, Emerade, 1.5 mm. When using the longest acceptable needles for Epipen Jr, the risk of intraosseous/periosteal penetration was highest in children weighing less than 15 kg at 60% and for Jext at 43%. The risk was low for Auvi-Q and Emerade. The risk of subcutaneous injection was greatest with the shortest needles of the Auvi-Q 0.1 mg at 94% in children weighing less than 15 kg. In adults, the risk of subcutaneous injection using the shortest needles was for Epi-Pen at 41%, Jext at 36%, Auvi-Q at 38%, and Emerade at 12%. CONCLUSION The variation in needle length of EAIs influences the risk of subcutaneous and intraosseous/periosteal injections. Compared with Epipen Jr, the Auvi-Q 0.1 mg for children weighing less than 15 kg had a low risk of intraosseous/periosteal injection but a very high risk of subcutaneous injection. For adults, there is a significant risk of subcutaneous injection.
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Affiliation(s)
- Sten Dreborg
- Child and Adolescent Allergology, Women's and Children's Health, University of Uppsala, Uppsala, Sweden.
| | - Gina Tsai
- Department of Medicine, Western University, London, Canada
| | - Harold Kim
- Department of Medicine, Western University, London, Canada; Department of Medicine, McMaster University, Hamilton, Canada
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16
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Point-of-care ultrasonography in the allergy and immunology clinic. Ann Allergy Asthma Immunol 2019; 123:42-47. [PMID: 30776445 DOI: 10.1016/j.anai.2019.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 02/09/2019] [Accepted: 02/10/2019] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To summarize evidence supporting the use of point-of-care ultrasonography as a clinical tool for allergists and immunologists. DATA SOURCES Cochrane Library, Medline, EMBASE, and Scopus databases were searched for articles published before December 18, 2018. STUDY SELECTIONS We included any retrospective or prospective study that evaluated ultrasonography in allergy and immunology and epinephrine autoinjector (EAI) needle length. RESULTS The standard EAI needle length may be inadequate for intramuscular delivery of epinephrine, particularly for women, at risk of anaphylaxis. In patients who weigh less than 15 kg, the lengths of commercially available EAIs may be too long, risking inadvertent intraosseous injection and resultant complications. Ultrasonography can be routinely used in the allergy clinic to guide needle length and angle for subcutaneous allergen immunotherapy injections to minimize systemic adverse effects. CONCLUSION Point-of-care ultrasonography can be a useful tool to enhance patient care and safety in an allergy clinic. Ideally, all patients prescribed EAIs should have ultrasonographic measurement of the skin to muscle distance and skin to bone distance to assist in identifying patients at risk of subcutaneous or intraosseous injection in anaphylaxis and those at risk of intramuscular injection during subcutaneous allergen immunotherapy injections.
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Greenhawt M, Gupta RS, Meadows JA, Pistiner M, Spergel JM, Camargo CA, Simons FER, Lieberman PL. Guiding Principles for the Recognition, Diagnosis, and Management of Infants with Anaphylaxis: An Expert Panel Consensus. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:1148-1156.e5. [PMID: 30737191 DOI: 10.1016/j.jaip.2018.10.052] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 10/25/2018] [Accepted: 10/31/2018] [Indexed: 12/23/2022]
Abstract
Infant anaphylaxis is an emerging risk, with food allergy the most common cause. Although the presentation of anaphylaxis involves the same systems as in older children and adults, there are real-world challenges to identifying symptoms of an allergic emergency in nonverbal children, as well as implementing optimal treatment. Recognition of anaphylaxis in infants can be challenging because allergic symptoms and certain normal infant behaviors may overlap. Intramuscular epinephrine is the treatment of choice for infants, as it is for older children and adults, and an epinephrine autoinjector approved by the Food and Drug Administration is now available for infants weighing between 7.5 and 15 kg. A panel of experts sought to develop guiding principles for the recognition, diagnosis, and management of anaphylaxis in infants, and provide a framework for the development of new guidelines and future research. Accordingly, anaphylaxis emergency action planning for infants was addressed by the panel. In considering formation of future infant anaphylaxis guidelines, health care providers should be aware of the needs to improve the recognition, diagnosis, and management of infants with anaphylaxis. Future research should identify and validate clinical criteria for the diagnosis of anaphylaxis in infants, as well as risk factors for the most severe reactions.
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Affiliation(s)
- Matthew Greenhawt
- Section of Allergy and Immunology, Food Challenge and Research Unit, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colo.
| | - Ruchi S Gupta
- Departments of Pediatrics and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Ill
| | | | - Michael Pistiner
- Department of Pediatrics, MassGeneral Hospital for Children, Harvard Medical School, Boston, Mass
| | - Jonathan M Spergel
- Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pa
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - F Estelle R Simons
- Department of Pediatrics & Child Health, Department of Immunology, Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Philip L Lieberman
- Division of Allergy and Immunology, University of Tennessee Health Science Center, Memphis, Tenn
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18
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Ponvert C. Quoi de neuf en allergologie pédiatrique de fin 2015 à début 2018 ? Anaphylaxie, allergie médicamenteuse et aux venins et salives d’insectes (une revue de la littérature internationale). REVUE FRANCAISE D ALLERGOLOGIE 2018. [DOI: 10.1016/j.reval.2018.02.219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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19
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Ibrahim M, Kim H. Unintentional injection to the bone with a pediatric epinephrine auto-injector. Allergy Asthma Clin Immunol 2018; 14:32. [PMID: 30151016 PMCID: PMC6100716 DOI: 10.1186/s13223-018-0257-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 04/18/2018] [Indexed: 11/25/2022] Open
Abstract
Background Skin-to-bone distance (STBD) in children prescribed a pediatric epinephrine auto-injector (EAI) for anaphylaxis is not commonly measured in practice. Recent evidence suggests that children with STBD less than the exposed needle length of available pediatric EAIs (dose: 0.15 mg, needle length: 12.7 mm) are at risk for unintentional injections to the bone during their use for an allergic emergency. Case presentation Described here is a case of a female child with multiple food allergies prescribed a pediatric EAI (0.15 mg EpiPen Jr®) who experienced an unintentional injection to her femur. The patient’s STBD at the recommended injection site (vastus lateralis) was shorter than the needle length of her prescribed EAI (12.7 mm) at the time of the injury (age: 7, height: 122 cm; weight: 25 kg), even though her weight was within the indication for this EAI (15–30 kg). The patient and her family were made aware of the risk of unintentional bone injection at the time the EAI was prescribed. Conclusions Some children, even those at an appropriate weight per the indication of available pediatric EAIs (0.15 mg), may be at risk for unintentional injections to the bone. The effects of an unintentional bone injection with an EAI can have lasting effects on a child, including pain. Healthcare providers who prescribe pediatric EAIs for any child should consider evaluating this risk, inform patients and parents of the risk, and take measures to potentially mitigate unintentional bone injections. For some children, an EAI with a shorter needle length may be a more appropriate choice of treatment for anaphylaxis.
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Affiliation(s)
- Mariam Ibrahim
- 1Department of Engineering, University of Guelph, Guelph, ON Canada
| | - Harold Kim
- 2Department of Medicine, Division of Clinical Immunology & Allergy, Western University, 525 Belmont Ave W, Ste 205, Kitchener, ON N2M 5E2 Canada
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Epinephrine Needle Length in Autoinjectors and Why It Matters. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:1264-1265. [DOI: 10.1016/j.jaip.2017.11.035] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 11/29/2017] [Indexed: 11/22/2022]
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21
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Brown JC. Epinephrine, auto-injectors, and anaphylaxis: Challenges of dose, depth, and device. Ann Allergy Asthma Immunol 2018; 121:53-60. [PMID: 29746901 DOI: 10.1016/j.anai.2018.05.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 05/02/2018] [Accepted: 05/03/2018] [Indexed: 10/17/2022]
Abstract
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.
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Affiliation(s)
- Julie C Brown
- Seattle Children's Hospital and University of Washington, Seattle, Washington.
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22
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Dreborg S, Kim L, Tsai G, Kim H. Epinephrine auto-injector needle lengths: Can both subcutaneous and periosteal/intraosseous injection be avoided? Ann Allergy Asthma Immunol 2018; 120:648-653.e1. [PMID: 29499370 DOI: 10.1016/j.anai.2018.02.028] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 02/15/2018] [Accepted: 02/20/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Epinephrine should be administered intramuscularly in the anterolateral aspect of the thigh. The length of the epinephrine auto-injector (EAI) needle should ensure intramuscular injection. OBJECTIVE To discuss suitable EAI needle lengths based on ultrasound measurements related to weight. METHODS The skin-to-muscle distance (STMD) and skin-to-bone distance (STBD) were measured by ultrasound in the mid-third of the anterolateral area of the right thigh when applying high pressure (8 lb; high-pressure EAI [HPEAI]) or low pressure (low-pressure EAI [LPEAI]) on the ultrasound probe. The study included 302 children and adolescents and 99 adults. The maximum and minimum STMD and the maximum and minimum STBD were estimated. RESULTS Using HPEAIs, the risk of periosteal or intraosseous penetration was 32% in children weighing less than 15 kg. The risk of subcutaneous injection was 12% in adolescents and 33% in adults. With LPEAIs, there was no risk of periosteal or intraosseous injection and the risk of subcutaneous injections in adolescents and adults was lower at 2% and 10%, respectively. A new EAI for injection in small children would have no risk of periosteal or intraosseous injection but would have 71% chance of subcutaneous deposit of epinephrine. CONCLUSION Common HPEAIs have a high risk of periosteal or intraosseous penetration in children and subcutaneous injections in overweight and obese adults. LPEAIs have some risk of subcutaneous injection in adults. HPEAIs with 0.1 mg of epinephrine and shorter needles have no risk of periosteal or intraosseous injection but have a high risk of subcutaneous deposit. For adult or overweight or obese patients, HPEAIs and LPEAIs should have longer needles. Future studies should focus on triggering pressures and variations in needle length.
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Affiliation(s)
- Sten Dreborg
- Child and Adolescent Allergology, Women's and Children's Health, University of Uppsala, Uppsala, Sweden.
| | - Laura Kim
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Gina Tsai
- Department of Medicine, Western University, London, Ontario, Canada
| | - Harold Kim
- Department of Medicine, Western University, London, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Duvauchelle T, Robert P, Donazzolo Y, Loyau S, Orlandini B, Lehert P, Lecomte JM, Schwartz JC. Bioavailability and Cardiovascular Effects of Adrenaline Administered by Anapen Autoinjector in Healthy Volunteers. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 6:1257-1263. [PMID: 29109047 DOI: 10.1016/j.jaip.2017.09.021] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 09/19/2017] [Accepted: 09/28/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND The administration of adrenaline is a life-saving intervention for anaphylactic reactions. However, it has been questioned whether the needle length of the autoinjectors is sufficient to achieve genuine intramuscular delivery and optimal bioavailability. OBJECTIVE To assess the adequacy of Anapen, which has a relatively short needle length (10.5 mm), through a comparison of the depot localization, plasma pharmacokinetics, and cardiovascular responses of adrenaline delivered via Anapen versus a prefilled syringe with a 25.4-mm needle, which is generally used for intramuscular injections. METHODS This randomized, open-label, crossover study compared the impact of adrenaline administration at 2 sites in the thigh of 18 normal weight male volunteers, using either Anapen or the prefilled syringe; in addition, we studied the treatment of 12 overweight women with Anapen. The depot depth was measured by ultrasonography, plasma adrenaline level was evaluated by ultra performance liquid chromatography-mass spectrometry (UPLC-MS), and heart rates were measured using a Holter monitor. RESULTS Intramuscular injections were given with both devices at both thigh sites in nonobese men, but not in overweight women. Adrenaline levels showed a double peak, with parallel changes in the heart rate. The first peak, of potential vital importance in anaphylaxis treatment, occurred at approximately 10 minutes postinjection, with maximum concentration and area under the curve significantly higher with Anapen than with prefilled syringes; the magnitude of the second peak did not differ among the various conditions. Unexpectedly, in overweight women treated with Anapen, the magnitude of the first peak was similar to that observed in men, despite the injection being subcutaneous, and the overall bioavailability was enhanced. CONCLUSIONS Needle length and intramuscular injection are not absolute requirements for autoinjector efficacy, but the monitoring of injection location, biphasic adrenaline levels, and cardiovascular responses is important for the assessment of their therapeutic relevance in anaphylaxis.
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Affiliation(s)
| | | | | | | | | | - Philippe Lehert
- Faculty of Economics, University of Louvain, Louvain, Belgium; Faculty of Medicine, University of Melbourne, Melbourne, Victoria, Australia
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Contemporary issues in anaphylaxis and the evolution of epinephrine autoinjectors: What will the future bring? Ann Allergy Asthma Immunol 2017; 119:333-338. [PMID: 28958374 DOI: 10.1016/j.anai.2017.07.030] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 07/17/2017] [Accepted: 07/24/2017] [Indexed: 01/14/2023]
Abstract
BACKGROUND Food allergy and anaphylaxis appear to be increasing in the United States, especially in young children, and preparedness is paramount to successful emergency management in the community. Although the treatment of choice for anaphylaxis is epinephrine delivered by autoinjection, some devices are challenged by less user-friendly designs or pose the risk of injury, especially in young patients. Human factors engineering has played a larger role in the development of more recent epinephrine autoinjector technologies and will continue to play a role in the evolution and future design of epinephrine autoinjectors. OBJECTIVE To discuss contemporary issues related to the identification and management of anaphylaxis, current and future epinephrine autoinjector design, and unmet needs for the treatment of special populations, namely, young children weighing less than 15 kg. METHODS The literature was reviewed and select articles retrieved to support expert clinical opinions on the need for improved recognition of anaphylaxis, epinephrine autoinjector design, and unmet needs in special populations. RESULTS Anaphylaxis may be underrecognized and poorly defined in infant- and toddler-aged children, current devices may not be adequate to safely treat these patients (ie, inappropriate needle length), and health care professionals may not be aware of these issues. CONCLUSION As epinephrine autoinjector technology continues to evolve, device characteristics that promote safe, user-friendly experiences and give clinicians and their patients confidence to successfully treat anaphylaxis during an emergency, without injury, will be favored.
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25
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Golden DB. Anaphylaxis: Recognizing Risk and Targeting Treatment. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:1224-1226. [DOI: 10.1016/j.jaip.2017.06.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 06/20/2017] [Indexed: 02/08/2023]
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