Predictors of epinephrine dispensing and allergy follow-up after emergency department visit for anaphylaxis

Changes in anaphylaxis trends and characteristics in emergency department admissions in Türkiye: From 2015 to 2021 based on the Ministry of Health database

Background

The incidence of anaphylaxis is increasing worldwide. However, there is a lack of data on anaphylaxis trends in Türkiye. This study aims to analyse trends in anaphylaxis-related emergency department (ED) visits and examines factors associated with fatal anaphylaxis in Türkiye.

Methods

We retrospectively analyzed data from Türkiye's Ministry of Health database from 2015 to 2022. Codes from the International Classification of Diseases, 10th revision (ICD-10), were used to identify anaphylaxis.

Results

During the study period, a total 21,370 ED admissions for anaphylaxis were identified, and anaphylaxis admissions increased 1.23-fold from 3.90 to 4.79 per 105 population per year. The anaphylaxis trigger was unknown in 79.9% of cases, followed by drugs (11.7%), food (5.7%) and venom (2.7%). Epinephrine was administered in 49.6% of cases, and a total of 424 patients (2.1% of total cases) died. The frequency of intensive care unit (ICU) hospitalization increased 6.0-fold from 2015 to 2021, and age-adjusted average-weighted mortality rate for anaphylaxis was 0.66 per million. Older age, presence of asthma, and ICU hospitalization were found to be significantly associated with fatal anaphylaxis (p < 0.001 for all). Frequencies of death were 9.1% for venom anaphylaxis, 1.2% in drug anaphylaxis, and 0.2% for food anaphylaxis. Epinephrine autoinjector (EAI) was prescribed for 6.9% of all patients.

Conclusions

This is the first study of ED admissions for anaphylaxis using a large, nationwide data from Türkiye. Increasing numbers of ED admissions, ICU hospitalizations and mortality show that anaphylaxis is an important public health issue in Türkiye.

Who Needs Epinephrine? Anaphylaxis, Autoinjectors, and Parachutes

International guidelines stipulate that intramuscular (IM) epinephrine (adrenaline) is the first-line treatment for anaphylaxis, with an established good safety profile. The availability of epinephrine autoinjectors (EAI) has greatly facilitated the lay administration of IM epinephrine in community settings. However, key areas of uncertainty remain around epinephrine usage. These include variations in prescribing EAI, what symptoms should prompt epinephrine administration, whether emergency medical services (EMS) need to be contacted after administration, and whether epinephrine administered via EAI reduces mortality from anaphylaxis or improves quality of life measures. We provide a balanced commentary on these issues. There is increasing recognition that a poor response to epinephrine, particularly after 2 doses, is a useful marker of severity and the need for urgent escalation. It is likely that patients who respond to a single epinephrine dose do not require EMS activation or emergency department transfer, but data are needed to demonstrate the safety of this approach. Lastly, patients at risk of anaphylaxis must be counseled against over-reliance on EAI alone.

Comparison of two diagnostic criteria in the diagnosis of anaphylaxis in a tertiary adult allergy clinic

Background

Anaphylaxis is a very dynamic issue with its incidence and trigger profile changing over the years. We aimed to compile the characteristics of anaphylaxis cases diagnosed in our clinic prospectively and to make a comparison between diagnostic criteria proposed by National Institute of Allergy and Infectious Diseases/Food Allergy and Anaphylaxis Network (NIAID/FAAN) and World Allergy Organization (WAO).

Method

Three-item diagnostic criteria recommended by NIAID/FAAN (2006) were used in the diagnosis of anaphylaxis. The clinical features of the cases, risk factors, etiologies, severity of anaphylaxis, and treatment approach were determined. The same patients were also classified by current WAO diagnostic criteria.

Results

A total of 204 patients (158F/46 M, median age 45.3 years) were included. Drugs (65.2%), venom (9.8%) and food allergies (9.3%) were the top 3 etiologies. Among drug triggers, chemotherapeutics were the most common (17.7%), followed by antibiotics (15.3%) and non-steroidal anti-inflammatory drugs (14.2%). The patients were mostly diagnosed with the second criterion (84.8%), followed by the first criterion (11.8%) and the third criterion (3.4%) of the NIAID/FAAN criteria. In terms of WAO criteria, 82.8% of the patients were diagnosed with the first criterion, and 14.3% with the second criterion while 2.9% of the patients did not meet the WAO criteria. The severity of anaphylaxis was evaluated as grade-2, 3 and 4 in 30.9%, 64.2%, and 4.9% of the patients, respectively. Adrenaline was administered to 31.9% of the patients especially who had angioedema and bronchospasm (p = 0.04).

Conclusion

Our data suggest that covering more details in patient's history may prevent possible underdiagnosis and WAO diagnostic criteria seem to be insufficient in some patients. We believe that our results will contribute to the literature on anaphylaxis and would be groundwork for future studies.

Trends and determinants of epinephrine prescriptions: a proxy of anaphylaxis epidemiology?

PURPOSE OF REVIEW

Epinephrine autoinjectors (EAIs) are recommended to all patients previously experiencing anaphylaxis reaction in order to prevent further reactions and fatalities. Under that perspective, EAI prescription could be considered as a proxy of anaphylaxis epidemiology. Nevertheless EAI prescription rates are still unacceptably low.

RECENT FINDINGS

The review focuses on potential determinants, in addition to clinical indications, which might impact EAI prescription rates by exploring the scientific literature published within the past 18 months, wherever available. Although some controversial results, age, sex, ethnicity, geographical setting and socioeconomic conditions might influence both physician prescription behaviour and EAIs' accessibility from the patient's side, which hampers the accuracy of EAI prescription as a proxy of anaphylaxis. Low EAI prescription and refill rates have been recorded even in the absence of significant socioeconomic barriers, suggesting that economical limitations only partially account for the issue, and cultural restrictions have also to be considered and addressed.

SUMMARY

In addition to providing the same opportunities in terms of EAI availability in all countries worldwide, implementing the resources for anaphylaxis management in terms of practical knowledge, education, and allergy specialist networks is an urgent need, even in the absence of socioeconomic barriers.

Epinephrine autoinjector prescription filling after pediatric emergency department discharge

Background: There are known racial and socioeconomic disparities in the use of epinephrine autoinjectors (EAI) for anaphylaxis. Objective: To measure the rates of EAI prescription filling and identify patient demographic factors associated with filling rates among patients discharged from the pediatric emergency department. Methods: This was a retrospective observational cohort study of all patients discharged from a pediatric emergency department who received an outpatient prescription for an EAI between January 1, 2018, and October 31, 2019. The rates of prescription filling were calculated, and multivariable logistic regression was performed to identify sociodemographic factors associated with prescription filling. Results: Of 717 patients included in the analysis, 54.8% (95% confidence interval {CI}, 51.1%-58.5%) filled their prescription. There were no significant associations between EAI fill rates and patient age or sex. In bivariable analysis, non-Hispanic white patients were more likely to fill EAI prescriptions compared with non-Hispanic Black patients (odds ratio [OR] 1.89 [95% CI, 1.11-3.20]), and patients with in-state Medicaid were significantly less likely to fill EAI prescriptions compared with those patients with private insurance (OR 0.69 [95% CI, 0.48-0.98]). However, after multivariable adjustment, there was no significant difference in filling by age, insurance status, or race or ethnicity. Conclusions: Only approximately half the patients had their EAI prescriptions filled after discharge. Filling rates did not vary by sociodemographic characteristics.

Trends in US Emergency Department Visits for Anaphylaxis Among Infants and Toddlers: 2006-2015

BACKGROUND

Anaphylaxis is a potentially life-threatening allergic reaction. The overall prevalence of anaphylaxis appears to be rising in children, but temporal trends among infants and toddlers are not well studied.

OBJECTIVE

To characterize the trends in US emergency department (ED) visits and hospitalizations among infants and toddlers with anaphylaxis from 2006 to 2015.

METHODS

We conducted a study of temporal trends in anaphylaxis among children (age <18 years) and, more specifically, infants and toddlers (age <3 years) presenting to the ED between 2006 and 2015 using a large, nationally representative database. For internal consistency, we defined anaphylaxis using International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes and excluded visits with International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes (late 2015). We calculated trends in the number and proportion of ED visits and hospitalizations and used multivariable logistic regression to identify predictors of hospitalization.

RESULTS

Among infants and toddlers, the proportion of ED visits for anaphylaxis per year increased from 20 per 100,000 visits to 50 per 100,000 visits (P_trend < .001). The rate of ED visits for anaphylaxis increased from 15 to 32 ED visits per 100,000 population of infants and toddlers (P_trend < .001). Food was the most commonly identified trigger. The proportion of hospitalization among anaphylaxis-related ED visits decreased from 19% to 6% (P_trend < .001). Among ED patients, those more likely to be hospitalized were male, privately insured, from higher income families, and presenting to urban, metropolitan teaching hospital EDs.

CONCLUSIONS

In a large, nationally representative US database, from 2006 to 2015, ED visits by infants and toddlers with anaphylaxis increased, whereas hospitalization of these patients decreased.

Self-injectable epinephrine: doctors' attitude and patients' adherence in real-life

PURPOSE OF REVIEW

Epinephrine is the only life-saving treatment of anaphylaxis. Prescription and administration rates of self-injectable epinephrine are generally low. It is unclear whether this is because of availability, low prescription rates, fear of using epinephrine, or a combination of these issues.

RECENT FINDINGS

This review focuses on what self-injectable epinephrine devices (SIED), such as auto-injectors and prefilled syringes, are preferred by patients and healthcare professionals (HCP). Our findings suggest that a device's ease to use, proper and frequent training on its operability, and availability have an impact on preferences and adherence to treatment with SIEDs. After prescribing a patient with a SIED, clinicians should emphasize its use in anaphylaxis, educate patients/caregivers to identify anaphylaxis and on how to use the SIED, and encourage constant practicing with training devices.

SUMMARY

Epinephrine is the sole recommended anaphylaxis treatment and SIEDs are of critical usefulness in the community setting. Further studying of these devices is needed to optimize education for HCPs and patients and their accessibility to SIEDs.

Fill rates and access to self-injectable epinephrine prescribed in a pediatric emergency department

BACKGROUND

Despite its life-saving potential in anaphylaxis, self-injectable epinephrine (SIE) is frequently not administered by caregivers prior to arrival in the emergency department (ED). Prescriptions from the ED often go unfilled which may contribute to the failure to receive SIE when needed.

OBJECTIVE

To determine the prescription filling rate and accessibility of SIE devices among families discharged from the Pediatric ED with an SIE prescription.

METHODS

A phone survey was administered to parents of children <18 years of age prescribed SIE in the pediatric ED over 12 months. The survey inquired if they own an SIE device, the device's expiration date as confirmation, and details of their child's allergy. Variables were analyzed for association with owning SIE, having SIE accessible when prompted, and having unexpired SIE accessible.

RESULTS

170 children received prescriptions for SIE and 100 (59%) completed the survey. Eighty-four of 100 (84%) had filled the initial SIE prescription. Sixty-five of 100 (65%) had proof of having SIE, of which 29% (19/65) were expired. Only 46% (46/100) of all respondents had an accessible unexpired SIE. Patients with food allergies and those who'd visited an allergist after their ED visit had higher odds of having unexpired accessible devices.

CONCLUSION

A majority of patients prescribed SIE from the ED fill their prescription; however, less than half have unexpired SIE readily available despite high rates of recurrent anaphylactic emergencies. Focusing on post-discharge planning, particularly follow-up, may prevent children with allergies from being left dangerously unprepared.

Risk factors for recurrent anaphylaxis-related emergency department visits in the United States

BACKGROUND

Anaphylaxis is a potentially life-threatening allergic reaction with a strong risk of recurrence.

OBJECTIVE

To assess risk factors associated with recurrent anaphylaxis-related emergency department (ED) visits within 1 year of an ED visit for anaphylaxis in a large observational cohort study.

METHODS

We used an administrative claims database to identify patients seen from 2008 through 2012 in the ED for anaphylaxis based on an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code algorithm. Patients with at least 2 years of continuous enrollment in a health plan were included. Multivariable logistic regression analysis was used to determine associations with recurrence of anaphylaxis within 1 year.

RESULTS

During the 5-year study period, 7,367 patients (median age, 42 years; <18 years old, 23.3%) met the inclusion criteria. The most common anaphylaxis trigger was unspecified (56.2%), followed by food (25.3%), medication (14.6%), and venom (3.9%). Overall, 3.0% of patients had an additional anaphylaxis-related ED visit within 1 year (3.61 episodes per 100 patient-years). On multivariable analysis, risk factors associated with anaphylaxis recurrence were food trigger (odds ratio [OR], 2.31; 95% confidence interval [CI], 1.34-3.99), history of asthma (OR, 1.30; 95% CI, 1.13-1.51), and intensive care unit admission at the index anaphylaxis event (OR, 1.95; 95% CI, 1.41-2.69).

CONCLUSION

In this contemporary cohort study, history of asthma, food trigger, and greater index anaphylaxis severity, as measured by intensive care unit admission, were associated with a higher likelihood of a recurrent anaphylaxis-related ED visit within 1 year.