A survey of Epi-PEN use in patients with a history of anaphylaxis

Patient Ability to Use Old versus New/Modified Model Adrenaline Autoinjection Emergency Medical Devices for Anaphylaxis in Prehospital Setting: A Systematic Review and Meta-Analysis

Background: The goal of this study was to determine the individual’s ability to use new/modified model AAI compared to old model AAIs devices for anaphylaxis. Methods: The protocol was established a priori and published on PROSPERO (CRD42021229691) and was conducted based on PRISMA guidelines. MEDLINE and CENTRAL were searched until 31 January 2021. Only RCTs were included in this review. Primary studies comparing old model AAI to new/modified model AAI emergency medical devices were included. Primary outcomes included number of successful administrations, and number of individuals to complete all steps. Secondary outcomes included successful removal of device safety guards, placement of correct end of the device against the thigh and holding of the device in place for adequate time after administration; the frequency of an adverse event (digital injection); individual preferences in terms of size, individual preference in terms of ease for carrying, overall patient preference; and the mean time of delivery. Results: Overall, seven trials consisting of 1359 patients were analyzed. Reporting of adverse events was limited to digital injection, which was significantly higher in the old model AAI (RR 6.90, 95% CI 3.27 to 14.57; I2 statistic = 0%; p < 0.001; four trials, 610 participants; high quality evidence). No significant difference was found regarding successful administration between the old model AAI and new/modified model AAI (RR 0.76, 95% CI 0.52 to 1.11; I2 statistic = 96%; p = 0.16; seven trials, 2196 participants; low quality evidence). Conclusions: We cannot make any new recommendations on the effectiveness of different models of AAIs regarding successful administration. However, considering the aspect of safety, we think that mew/modified model AAI can be chosen as the old model AAI was associated with a higher frequency of the adverse event (digital injection).

Effects of a 90-min educational intervention for patients with insect venom allergy: a prospective controlled pilot study

Background

Anaphylactic sting reactions need a prompt management. A structured educational intervention for patients with insect sting allergy has not been implemented so far. The purpose of this study was to analyze the effects of a structured 90-min educational intervention for patients with insect sting allergy.

Methods

Patients with an insect venom allergy were offered to participate in a structured 90-min group education (intervention group (IG)) or to attend a control group (CG). The patients’ subjective self-assurance in using the emergency medication, the willingness to always carry the emergency medication, the mental health status, absolute one-time willingness-to-pay (WTP) for complete cure, a disease knowledge assessment and a simulation test to examine the ability to manage an acute sting reaction were estimated at baseline (t0) and at follow-up (t1) as outcome parameters.

Results

55 patients participated in the IG (n = 25, 52.0% female, mean age 55.9 years) or the CG (n = 30, 56.7% female, mean age 52.0 years). Both arms showed a significant gain in self-assurance in using the emergency medication (IG: 6.1 at t0 vs. 8.6 at t1, p < 0.0001 and CG: 7.1 vs. 8.0, p = 0.0062) and ability to manage an acute sting reaction (IG: 6.7 vs. 11.4, p < 0.0001 and CG: 9.0 vs. 10.5, p = 0.0002) at t1. However, trained participants showed a significantly higher gain in the respective parameters. There were no significant changes regarding the remaining examined outcome parameters.

Conclusions

Patients who are willing to invest 90 min in a patient education intervention benefit significantly by an increased subjective and objective empowerment to manage an acute sting reaction.

Estimation of available epinephrine dose in expired and discolored autoinjectors via quantitative smartphone imaging

Epinephrine autoinjectors (EAIs) are important first aid medications for treating anaphylaxis. A 10-fold price increase over the past 12 years and evidence that expired EAIs may still contain significant doses of available epinephrine have motivated interest in the efficacy of expired EAIs as treatments of last resort. Degradation of expired EAIs, which can be caused by improper storage conditions, results in various degrees of discoloration of the epinephrine solution. Previous studies have determined that significant epinephrine remains available in expired EAIs, but these have only considered EAIs that show no discoloration. Here, we investigate the potential for colorimetric estimation of available epinephrine dose based on the degree of discoloration in expired EAIs. The correlation of available epinephrine dose and time since expiration date was poor (r = - 0.37), as determined by an industry standard UHPLC protocol. Visible absorbance of the samples integrated across the range 430-475 nm correlated well with available epinephrine dose (r = - 0.71). This wavelength corresponds to the blue channel of a typical smartphone camera Bayer filter. Smartphone camera images of the EAI solutions in various illumination conditions were analyzed to assign color indices representing the degree of discoloration. Color index of the samples showed similar correlation (|r| > 0.7) with available epinephrine dose as that of visible spectrophotometry. Smartphone imaging colorimetry is proposed as a potential point-of-use epinephrine dose estimator for expired and degraded EAIs. Graphical abstract.

Physicians prescribe adrenaline autoinjectors, do parents use them when needed?

BACKGROUND

Anaphylaxis is a sudden, severe, and potentially life-threatening allergic reaction, affecting a portion of allergic patients. Adrenaline is the first-line medication for anaphylaxis and available in many parts of the world as adrenaline autoinjectors (AAIs).

OBJECTIVE

Aim of this study was to determine attitudes and knowledge levels of patients/parents regarding the use of AAIs, frequency, and rate of appropriate AAI use and to give a standardized and better education by improving on mistakes during administration.

METHOD

190 patients aged 1-18 years who were prescribed AAIs for any reason between 2012 and 2017 in Hacettepe University Pediatric Allergy Unit. Demographic data were collected during face-to-face interview or by telephone. Parents completed a mini-survey regarding use, carriage, and storage of AAI.

RESULTS

Some 190 patients (64.7% male) aged 7.83 (4.99-12.08) years, median (inter-quartile), were included in the study. The indications for AAI prescription were food allergy (78.9%); venom allergy (14.2%); idiopathic anaphylaxis (3.7%); mastocytosis (2.1%); and drug allergy (1.0%). One-fourth of AAI-prescribed patients experienced anaphylaxis requiring the use of AAI within the past five years. However, only 30% of the patients dared to use AAI; only three-quarters of whom had managed to use it correctly.

CONCLUSION

After prescription of AAI and initial training, patients and parents' concerns and fears should be taken into consideration and necessary support should be provided. At every opportunity and each clinical visit, not only should training sessions be repeated but also the patients and parents should be psychologically supported.

Effects of a structured educational intervention on knowledge and emergency management in patients at risk for anaphylaxis

BACKGROUND

Structured educational programmes for patients at risk for anaphylaxis have not yet been established. Patients and caregivers often lack adequate skills in managing the disease.

METHODS

To investigate effects of structured patient education intervention on knowledge, emergency management skills and psychological parameters in patients with previous episodes of anaphylaxis and caregivers of affected children 95 caregivers (11 male, 84 female, mean age 37 years) of affected children and 98 patients (32 male, 66 female, mean age 47.5 years) were randomly assigned to an intervention (IG) or control group (CG) in a multicentre randomized controlled trial. The IG received two 3-h schooling modules of group education; the CG received standard auto-injector training only. Knowledge of anaphylaxis and emergency management competence in a validated training anaphylaxis situation as main outcome measures as well as secondary psychological parameters were assessed at baseline and 3 months after intervention.

RESULTS

In comparison with controls, the intervention led to significant improvement of knowledge from baseline to 3-month follow-up (caregivers: IG 3.2/13.2 improvement/baseline vs CG 0.7/12.6; P < 0.001; patients: IG 3.9/10.8 vs 1.3/12.6; P < 0.001). Moreover, emergency management competence was increased after intervention as compared to controls (caregivers: IG 8.6/11.2 vs CG 1.2/10.8; P < 0.001; patients: 7.1/11.0 vs 1.1/11.1; P < 0.001). Intervention showed significant reduction of caregiver anxiety (-1.9/8.4 vs -0.7/7.5; P < 0.05). There were no significant changes in the depression scores.

CONCLUSION

Structured patient education programmes may be beneficial in the management of anaphylaxis by increasing patients' empowerment to prevent and treat the disease.

Demonstration of epinephrine autoinjectors (EpiPen and Anapen) by pharmacists in a randomised, simulated patient assessment: acceptable, but room for improvement

BACKGROUND

Successful treatment of anaphylaxis in the community relies on early and correct use of epinephrine autoinjectors. Community pharmacists supply these devices and have a crucial role teaching patients how to use them. Supply of epinephrine autoinjectors in Australia increased 70-fold in the past decade. New EpiPen and Anapen autoinjectors were launched in Australia in 2011 and 2012, with the potential to cause confusion. However there is no information about how pharmacists demonstrate epinephrine autoinjectors to patients. Therefore the aim of this study was to assess real-world community pharmacist demonstrations of EpiPen and Anapen. We also sought to identify consultation-based predictors of accurate demonstration.

METHODS

Demonstration accuracy was assessed in simulated patient visits to 300 randomly selected pharmacies. Pharmacists were asked by the simulated patient how to use original EpiPen, new-look EpiPen or Anapen, and assessed against the relevant Australasian Society of Clinical Immunology and Allergy (ASCIA) Action Plan for Anaphylaxis. Other anaphylaxis advice provided by the pharmacist was also recorded. Accuracy was analysed descriptively. Binary logistic regression was used to identify predictors of accurate demonstration.

RESULTS

All 300 pharmacies were visited. Of 250 pharmacist demonstrations, 46 (18.4%) accurately demonstrated all four steps on ASCIA Action Plan. Failure to state 'do not touch the needle' (74.8%) or 'massage injection site' (68.8%) reduced accuracy. However 163 (65.2%) accurately demonstrated the three steps required to inject epinephrine (no difference by device, p = 0.15). Associations with accurate demonstration were: checking if the patient had an anaphylaxis action plan (odds ratio, OR = 16.1; 95% CI: 3.86-67.3); stating to call an ambulance after use (OR = 4.0; 95% CI: 1.44-11.1); or explaining side effects of epinephrine (OR = 4.5; 95% CI: 1.48-13.4).

CONCLUSIONS

It is critical that anaphylaxis patients know how to use their prescribed epinephrine autoinjector correctly. Pharmacists have acceptable rates of EpiPen and Anapen demonstration accuracy, although more is needed to improve this. Those who pay attention to the need for action plans, emergency care after epinephrine use, and informing patients about the side effects of epinephrine may have better knowledge about anaphylaxis, and in turn significantly improve demonstration accuracy.

Pediatric anaphylaxis management in the prehospital setting

PURPOSE

Anaphylaxis is a life-threatening systemic allergic reaction that occurs after contact with an allergy-causing substance. Timely administration of intramuscular epinephrine is the treatment of choice for controlling symptoms and decreasing fatalities. Our purpose was to investigate the prehospital management of anaphylaxis among patients receiving care in an urban tertiary care pediatric emergency department (PED).

METHODS

We performed a retrospective chart review from May 2008 to January 2010 of patients 18 years or younger who received care in the PED for anaphylaxis. Data were extracted by one investigator and included demographic information, patient symptoms, past medical history, medications administered (including route and provider), and final disposition.

RESULTS

We reviewed 218 cases of anaphylaxis in 202 children. Mean age of patients was 7.4 years; 56% of patients were male. A total of 214 (98%) manifested symptoms in the skin/mucosal system, 68% had respiratory symptoms, 44% had gastrointestinal symptoms, and 2% had hypotension. Sixty-seven percent had a previous history of allergic reaction and 38% had a history of asthma. Seventy-six percent of the patients presented with anaphylaxis to food products, 8% to medications, 1% to stings, and 16% to unknown allergens. Reactions occurred at home or with family members 87% of the time, and at school 12% of the time. Only 36% of the patients who met criteria for anaphylaxis had epinephrine administered by emergency medical services (EMS). Among 26 patients with anaphylactic reactions at school, 69% received epinephrine by the school nurse. Of the 117 patients with known allergies who were with their parents at the time of anaphylactic reaction, 41% received epinephrine. Thirteen patients were seen by a physician prior to coming to the PED; all received epinephrine at the physician's office. In total, epinephrine was given to 41% (89) of the 218 cases prior to coming to the PED.

CONCLUSIONS

Our evaluation revealed low rates of epinephrine administration by EMS providers and parents/patients. Education about anaphylaxis is imperative to encourage earlier administration of epinephrine.

A majority of parents of children with peanut allergy fear using the epinephrine auto-injector

Prompt epinephrine administration is crucial in managing anaphylaxis, but epinephrine auto-injectors (EAIs) are underutilized by patients and their families. Children with peanut allergy were recruited from the Allergy Clinics at the Montreal Children's Hospital, food allergy advocacy organizations and organizations providing products to allergic individuals. Parents of children who had been prescribed an EAI were queried on whether they were fearful of using it and on factors that may contribute to fear. A majority of parents (672/1209 = 56%) expressed fear regarding the use of the EAI. Parents attributed the fear to hurting the child, using the EAI incorrectly or a bad outcome. Parents whose child had longer disease duration or a severe reaction and parents who were satisfied with the EAI training or found it easy to use were less likely to be afraid. Families may benefit from simulation training and more education on the recognition and management of anaphylaxis.

Epinephrine: the drug of choice for anaphylaxis-a statement of the world allergy organization

Anaphylaxis is an acute and potentially lethal multisystem allergic reaction. Most consensus guidelines for the past 30 years have held that epinephrine is the drug of choice and the first drug that should be administered in acute anaphylaxis. Some state that properly administered epinephrine has no absolute contraindication in this clinical setting. A committee of anaphylaxis experts assembled by the World Allergy Organization has examined the evidence from the medical literature concerning the appropriate use of epinephrine for anaphylaxis. The committee strongly believes that epinephrine is currently underused and often dosed suboptimally to treat anaphylaxis, is underprescribed for potential future self-administration, that most of the reasons proposed to withhold its clinical use are flawed, and that the therapeutic benefits of epinephrine exceed the risk when given in appropriate intramuscular doses.

Adrenaline auto-injectors for the treatment of anaphylaxis with and without cardiovascular collapse in the community

BACKGROUND

Anaphylaxis is a serious hypersensitivity reaction that is rapid in onset and may cause death. Adrenaline (epinephrine) auto-injectors are recommended as the initial, potentially life-saving treatment of choice for anaphylaxis in the community, but they are not universally available and have limitations in their use.

OBJECTIVES

To assess the effectiveness of adrenaline (epinephrine) auto-injectors in relieving respiratory, cardiovascular, and other symptoms during episodes of anaphylaxis that occur in the community.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 1), MEDLINE (Ovid SP) (1950 to January 2012), EMBASE (Ovid SP) (1980 to January 2012 ), CINAHL (EBSCO host) (1982 to January 2012 ), AMED (EBSCO host) (1985 to January 2012 ), LILACS, (BIREME) (1980 to January 2012 ), ISI Web of Science (1950 to January 2012 ). We adapted our search terms for other databases. We also searched websites listing on-going trials: the World Health Organization International Clinical Trials Registry Platform, the UK Clinical Research Network Study Portfolio, and the meta Register of Controlled Trials; and contacted pharmaceutical companies who manufacture adrenaline auto-injectors in an attempt to locate unpublished material.

SELECTION CRITERIA

Randomized and quasi-randomized controlled trials comparing auto-injector administration of adrenaline with any control including no intervention, placebo, or other adrenergic agonists were eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed articles for inclusion.

MAIN RESULTS

None of the 1328 studies that were identified satisfied the inclusion criteria.

AUTHORS' CONCLUSIONS

Based on this review, we cannot make any new recommendations on the effectiveness of adrenaline auto-injectors for the treatment of anaphylaxis. Although randomized, double-blind, placebo-controlled clinical trials of high methodological quality are necessary to define the true extent of benefits from the administration of adrenaline in anaphylaxis via an auto-injector, such trials are unlikely to be performed in individuals experiencing anaphylaxis because of ethical concerns associated with randomization to placebo. There is, however, a need to consider trials in which, for example, auto-injectors of different doses of adrenaline and differing devices are compared in order to provide greater clarity on the dose and device of choice. Such trials would be practically challenging to conduct. In the absence of appropriate trials, we recommend that adrenaline administration by auto-injector should still be regarded as the most effective first-line treatment for the management of anaphylaxis in the community. In countries where auto-injectors are not commonly used, it may be possible to conduct trials to compare administration of adrenaline via auto-injector with adrenaline administered by syringe and ampoule, or comparing the effectiveness of two different types of auto-injector.

Make-up of the epinephrine autoinjector: the effect on its use by untrained users

BACKGROUND

Part of the problems related to proper use of the epinephrine autoinjector may be related to the design of the autoinjector itself.

AIM

We investigated whether minor modifications in the design of the currently available epinephrine autoinjector ease its use and abrogate common use errors.

METHODS

All interns other than those who had previously worked in allergy department in a medical school were invited to the study. Two identical epinephrine autoinjector trainers (Epipen trainer(®) ) were used, one of which was modified by changing the gray safety cap to red and placing a yellow arrow pointing to the black injection tip. A written and visual instruction sheet for each trainer was provided. Participants were asked to demonstrate the use of the Epipen trainer either with the original or with the modified one. They were scored and timed for their demonstration.

RESULTS

Out of the 224 interns who were invited to participate, one hundred and sixty-four interns (73.2%) participated in the study. The number of participants correctly demonstrating the use of epinephrine autoinjectors was 22.6% and 65% in unmodified and modified trainer groups, respectively (p < 0.001). The mean time to administer trainers was 26.78 ± 10.6 and 15.88 ± 2.55 s; total median scores were 3.08 ± 1.48 and 4.47 ± 0.84 in unmodified and modified groups, respectively (p < 0.001 for both). Significantly fewer participants had presumptive unintentional injection injury while using modified (5%) compared with unmodified trainer (45.2%) (p < 0.001).

CONCLUSION

Few and simple modifications in the design of epinephrine autoinjector were found effective in increasing its correct use and decreasing common use errors by untrained users. (Clinical trials identifier: NCT01217138).

Training of trainers on epinephrine autoinjector use

The majority of physicians do not know how to use epinephrine autoinjectors. This displays that current education of physicians on anaphylaxis is inadequate for a thorough practice. We hypothesize that a theoretical lecture together with a practical session on epinephrine autoinjector use will improve its proper use by physicians. Residents, specialists, and consultants from General Pediatrics excluding allergists and allergy fellows were included in this study. All physicians were given an eight-item questionnaire followed by a practical session scoring and timing ability to use epinephrine autoinjector trainer. This ensued with one-to-one hands-on training on correct autoinjector use. Finally, a joint theoretical lecture on anaphylaxis including re-demonstration of epinephrine autoinjector use was given. All physicians were scored a second time on use of epinephrine autoinjector 6 months later. One hundred fifty-one of 196 participants completed all steps of the study in four tertiary hospitals. Correct use of epinephrine autoinjector improved from 23.3% to 74.2%, mean score from 3.49 ± 1.14 to 4.66 ± 0.65, need for prospectus from 91.4% to 29.1%, and mean time to administer autoinjector from 28.01 ± 6.22 s to 19.62 ± 5.01 s (p < 0.001 for each). The rate of most common mistakes during autoinjector use decreased but the ranking did not change. An integrated theoretical and practical education increased correct of epinephrine autoinjector use by physicians. Ongoing mistakes despite this education may be related with its design.

Why do people die of anaphylaxis? A clinical review

Anaphylaxis is a source of anxiety for patients and healthcare providers. It is a medical emergency that presents with a broad array of symptoms and signs, many of which can be deceptively similar to other diseases such as myocardial infarction, asthma, or panic attacks. In addition to these diagnostic challenges, anaphylaxis presents management difficulties due to rapid onset and progression, lack of appropriate self-treatment education and implementation by patients, severity of the allergic response, exacerbating medications or concurrent disease, and unpredictability. The most common causes of anaphylaxis are food allergies, stinging insects and immunotherapy (allergy shots) but idiopathic anaphylaxis, latex allergy and drug hypersensitive all contribute to the epidemiology. Reactions to IVP and other dyes are coined anaphylactoid reactions but have identical pathophysiology and treatment, once the mast cell has been degranulated. As many antigens can be the trigger for fatal anaphylaxis, it is useful to examine the features of each etiology individually, highlighting factors common to all fatal anaphylaxis and some specific to certain etiologies. Generally what distinguishes a fatal from non fatal reaction is often just the rapidity to apply correct therapy. Prevention is clearly the key and should identify high-risk patients in an attempt to minimize the likely of a severe reaction. Although fatal anaphylaxis is rare, it is likely underreported.

Epinephrine: the drug of choice for anaphylaxis. A statement of the World Allergy Organization

Anaphylaxis is an acute and potentially lethal multi-system allergic reaction. Most consensus guidelines for the past 30 years have held that epinephrine is the drug of choice and the first drug that should be administered in acute anaphylaxis. Some state that properly administered epinephrine has no absolute contraindication in this clinical setting. A committee of anaphylaxis experts assembled by the World Allergy Organization has examined the evidence from the medical literature concerning the appropriate use of epinephrine for anaphylaxis. The Committee strongly believes that epinephrine is currently underutilized and often dosed suboptimally to treat anaphylaxis, is under-prescribed for potential future self-administration, that most of the reasons proposed to withhold its clinical use are flawed, and that the therapeutic benefits of epinephrine exceed the risk when given in appropriate i.m. doses.

Epinephrine: the drug of choice for anaphylaxis-a statement of the world allergy organization

Anaphylaxis is an acute and potentially lethal multisystem allergic reaction. Most consensus guidelines for the past 30 years have held that epinephrine is the drug of choice and the first drug that should be administered in acute anaphylaxis. Some state that properly administered epinephrine has no absolute contraindication in this clinical setting. A committee of anaphylaxis experts assembled by the World Allergy Organization has examined the evidence from the medical literature concerning the appropriate use of epinephrine for anaphylaxis. The committee strongly believes that epinephrine is currently underused and often dosed suboptimally to treat anaphylaxis, is underprescribed for potential future self-administration, that most of the reasons proposed to withhold its clinical use are flawed, and that the therapeutic benefits of epinephrine exceed the risk when given in appropriate intramuscular doses.

Self-injectable epinephrine for allergic emergencies

Anaphylaxis is a severe, life-threatening systemic reaction that can affect all ages. Epinephrine is frequently cited as the first-line and single most important agent in the treatment of severe allergic emergencies. Prompt administration of self-injectable epinephrine by patients and caretakers remains a key component in effective out-of-hospital management. This article will review the technique for self-injectable epinephrine administration in allergic emergencies, including discussion of the available dosages and formulations, indications, as well as other issues related to its use.

Parental food allergy information needs: a qualitative study

OBJECTIVE

To examine information needs and preferences of parents regarding food allergy.

DESIGN

Qualitative study including in-depth semi-structured interviews and focus group discussions. Data were audio-recorded, transcribed verbatim and analysed using the constant comparative method, aided by participant checking of interview summaries, independent reviewers and qualitative analysis software.

PARTICIPANTS

84 parents of children with food allergy.

SETTING

Three paediatric allergy clinics and a national consumer organisation.

RESULTS

Most parent participants had received third level education (72%) and 39% had occupational backgrounds in health and education. Parents experienced different phases in their need for information: at diagnosis when there is an intense desire for information, at follow-up when there is continuing uncertainty about allergy severity and appropriate management, and at new events and milestones. They preferred information to be provided in a variety of formats, with access to reliable individualised advice between clinic appointments, within the context of an ongoing relationship with a health professional. Parents wished to know the reasoning behind doctor's opinions and identified areas of core information content, including unaddressed topics such as what to feed their child rather than what to avoid. Suboptimal information provision was cited by parents as a key reason for seeking second opinions.

CONCLUSION

Parents with children with food allergies have unmet information needs. Study findings may assist in the design and implementation of targeted educational strategies which better meet parental needs and preferences.

The management of anaphylaxis in childhood: position paper of the European academy of allergology and clinical immunology

Anaphylaxis is a growing paediatric clinical emergency that is difficult to diagnose because a consensus definition was lacking until recently. Many European countries have no specific guidelines for anaphylaxis. This position paper prepared by the EAACI Taskforce on Anaphylaxis in Children aims to provide practical guidelines for managing anaphylaxis in childhood based on the limited evidence available. Intramuscular adrenaline is the acknowledged first-line therapy for anaphylaxis, in hospital and in the community, and should be given as soon as the condition is recognized. Additional therapies such as volume support, nebulized bronchodilators, antihistamines or corticosteroids are supplementary to adrenaline. There are no absolute contraindications to administering adrenaline in children. Allergy assessment is mandatory in all children with a history of anaphylaxis because it is essential to identify and avoid the allergen to prevent its recurrence. A tailored anaphylaxis management plan is needed, based on an individual risk assessment, which is influenced by the child's previous allergic reactions, other medical conditions and social circumstances. Collaborative partnerships should be established, involving school staff, healthcare professionals and patients' organizations. Absolute indications for prescribing self-injectable adrenaline are prior cardiorespiratory reactions, exercise-induced anaphylaxis, idiopathic anaphylaxis and persistent asthma with food allergy. Relative indications include peanut or tree nut allergy, reactions to small quantities of a given food, food allergy in teenagers and living far away from a medical facility. The creation of national and European databases is expected to generate better-quality data and help develop a stepwise approach for a better management of paediatric anaphylaxis.

Need for community pharmacist-provided food-allergy education and auto-injectable epinephrine training

OBJECTIVE

To determine whether community pharmacist-provided food-allergy education and auto-injectable epinephrine training is needed.

DESIGN

Cross-sectional assessment.

SETTING

United States.

PARTICIPANTS

1,887 recently joined members of the Food Allergy & Anaphylaxis Network.

INTERVENTION

Electronic survey.

MAIN OUTCOME MEASURES

35 items covering past education and training associated with food allergy and use of auto-injectable epinephrine, demographics, attitudes toward pharmacist-provided education about food allergy, training in the use of auto-injectable epinephrine, confidence in managing food allergies on a daily basis and in emergency situations, and the necessity for pharmacists to provide education and training about food allergy and auto-injectable epinephrine use.

RESULTS

Prescriber-provided food-allergy education and auto-injectable epinephrine training is incomplete (60.7%) or absent (16.3%) at the time auto-injectable epinephrine is first prescribed. These initial prescriptions are being dispensed from community pharmacies (94%), and written information is commonly provided with the medication (73.6%); however, oral counseling is largely absent (86.6%), and training in administration of auto-injectable epinephrine occurs infrequently (13.3%). Food-allergic patients and their care-givers are receptive to the idea of pharmacist-provided education and training. The majority (63.6% or more) feel confident about managing their food allergies. They are not requesting counseling when refill prescriptions are dispensed (81.4%); however, they would like to see routine review at refill time of the signs of allergic reaction (54.5%) and use of the epinephrine auto-injector (79.3%).

CONCLUSION

Community pharmacists have an opportunity to assist newly diagnosed food-allergic patients by working collaboratively with their pediatricians and allergists. Community pharmacists can provide ongoing assistance at refill time by retraining patients in the use of the epinephrine auto-injector and reviewing the signs of allergic reaction.

Parental knowledge and use of epinephrine auto-injector for children with food allergy

Epinephrine should be prescribed for patients at risk of anaphylaxis. Our purpose was to determine the use of Anapen prescribed for food-allergic children, to assess parental knowledge regarding Anapen, and to evaluate the arrangements for emergency kits and personalized care projects in everyday life. A prospective study was performed with a questionnaire sent to families with a food-allergic child previously prescribed Anapen. One hundred and fifty two families were contacted and finally 111 children included (median age 6.5 yrs). Main food allergens were peanuts (n = 89), egg (n = 39) and cow's milk (n = 10). The use of Anapen had been demonstrated to 90% of parents (by prescribing physician, 69%; pharmacist, 25%; general practitioner, 5%; nurse 1%), with a training device (76%) and/or written instructions (49%). When asked to list symptoms requiring injection, 48% of parents cited more than one response: breathing difficulties only (23%), or with angio-edema (41%), collapse or faintness (38%), anaphylactic shock (48%). Of 107 children attending school, 54% had a personalized care project, 72% an Anapen device, and 60% a complete emergency kit (epinephrine, inhaled beta-agonist, corticosteroid, anti-H1 drug). Beta-agonists were forgotten at school by 34 children (13 asthmatics). Anapen was used in one child for angio-edema and dyspnea after inadvertent ingestion of egg at home. In our population, epinephrine auto-injectors and emergency kits were insufficiently available at schools and in daily life. The use of auto-injectors was not adequately demonstrated. The prescription of epinephrine for food-allergic children at risk of anaphylaxis requires accurate diagnosis, educational programs, information, and follow up.

Parental use of EpiPen for children with food allergies

BACKGROUND

EpiPen is often underused in children with food allergy experiencing anaphylaxis.

OBJECTIVE

We explored whether underuse of EpiPen might be attributed to parental discomfort with administration, as measured by a lack of parental empowerment and knowledge of proper administration.

METHODS

A written survey was mailed to parents of children with food allergy. Those children with physician-diagnosed food allergy who had been prescribed EpiPen were included in the analysis. Parents were recruited from a local food-allergy support group and private allergy practice. Perceived comfort with administering EpiPen was measured by using a 10-cm visual analog scale. Knowledge of EpiPen use and anaphylaxis was tested by using a series of multiple-choice questions. Empowerment was measured with a 16-item instrument that included statements from the Family Empowerment Scale. Multiple regression analysis was used to determine how much of the variance in the comfort ratings could be explained by knowledge, empowerment, and other factors assessed in the survey.

RESULTS

Of 360 mailed surveys, 165 (46%) completed surveys met the inclusion criteria and were analyzed. Anaphylaxis was reported in 42% of children (n = 70); 8% of parents (n = 14) had administered EpiPen to their child. Factors correlating with comfort included prior administration of EpiPen ( P = .009), EpiPen training ( P = .005), and empowerment ( P < .0005). Neither a history of anaphylaxis nor knowledge correlated with an increased level of comfort with administration.

CONCLUSIONS

Empowerment directly correlated with increased comfort with EpiPen use, but knowledge did not. Physicians should continue to instruct all parents on EpiPen administration because this correlated significantly with comfort. Other psychological factors beyond empowerment might contribute to underuse of EpiPen.

Anaphylaxis in the prehospital setting

Many Emergency Medical Services (EMS) systems have adopted epinephrine auto-injector (EAI) use by Basic Life Support (BLS) personnel, and several states now require that BLS personnel be trained and authorized to use EAIs. The objectives of this observational study were: 1) to examine EMS case definitions of allergy/anaphylaxis, 2) to ascertain the incidence of EMS calls for allergy/anaphylaxis and administration of epinephrine, and 3) to quantify the rate of deaths due to anaphylaxis. Data were solicited by e-mail, mail, and telephone from National Association of State EMS Directors (NASEMSD) members, state EMS offices, and state medical examiner and vital statistics offices. Simple descriptive statistics were used to analyze the data. The following was found: 1) there is no standardization of case definitions among states. Some use the terms "allergic reaction" and "anaphylaxis" in EMS protocols without definition, whereas others provide lengthy, specific definitions, with detailed criteria for epinephrine administration; 2) excluding two outliers at 0.04% and 3.9%, nine EMS system databases totaling over 2.8 million runs contained between 0.34% and 0.82% of runs for allergy/anaphylaxis. Seven of these databases reported on epinephrine administration, with rates between 0.16% and 31.1%, and four of the seven clustered between 8.8% and 14.8%. There was little uniformity in the data provided by seven states on deaths due to anaphylaxis, with rates from 0% to 0.94%. Although limited by the lack of data from many states, roughly 0.5% of EMS runs are for allergy/anaphylaxis complaints, with epinephrine administered in roughly one-tenth of these. State death rates from anaphylaxis vary considerably, with rates from 0% to 0.94% reported.

Nuts! I can't figure out how to use my life-saving epinephrine auto-injector!

BACKGROUND

Epinephrine auto-injectors for food allergy emergency treatment is used as a case study to illustrate how human factors in device design has an impact on proper management of anaphylaxis. Because timely injection is so crucial, epinephrine comes in preloaded syringes or auto-injectors that patients can carry with them. However, many factors influence whether treatment is carried out properly.

HUMAN FACTORS ENGINEERING (HFE) ANALYSIS

The incidence of incorrectly using auto-injectors is not isolated; studies have shown that a significant proportion of patients, and even physicians, do not know how to correctly use the devices. Some auto-injectors appear to be modeled with a metaphor in mind (a pen), but they do not appear and operate consistently with the metaphor. In addition, the device is difficult to transport. The portability issue creates a challenge that cannot be adequately addressed with traditional intervention measures--reminders or more education. They are all human factors issues and require human factors-based interventions.

SUMMARY

Although education and training in how to use an auto-injector are important for effective management of anaphylaxis, a poorly designed device can lead to incorrect operation of such a device. HFE can improve device design so that it is reliably and correctly used even with minimal training. Manufacturers, allergists/immunologists, and pharmacists all have critical roles to play to ensure the correct use of this life-saving device.

Anaphylaxis: a 7-year follow-up survey of 46 children

BACKGROUND

Little is known about the frequency of and the features associated with recurrent anaphylaxis in pediatric populations. During 1994 to 1996, we enrolled 76 children affected by anaphylaxis in a prospective study to analyze their clinical and allergic features.

OBJECTIVE

To undertake a follow-up study of these children to ascertain how many experienced a recurrence of anaphylaxis.

METHODS

After a mean interval of 7 years, a pediatric allergist conducted a telephone interview of patients who had been enrolled in our 1994-1996 study.

RESULTS

A telephone interview was successfully completed in 46 (61%) of the 76 patients who had been enrolled in our 1994-1996 study. Of these 46 patients, 14 (30%) had experienced a recurrence of anaphylaxis. Children with atopic dermatitis either during 1994 to 1996 (64% vs 34%; P = .04) or at the time of the current study (43% vs 16%; P = .03) and those with urticaria-angioedema at the time of the current study (93% vs 31%; P = .0002) were found to be at a significantly higher risk for recurrent anaphylaxis. Furthermore, those children who were sensitive to at least 1 food allergen during 1994 to 1996 were more likely to have experienced a recurrence of anaphylaxis (93% vs 56%; P < .04).

CONCLUSIONS

This study suggests that patients may have a greater risk of recurrence of anaphylaxis if they have atopic dermatitis, urticaria-angioedema, or at least 1 positive result of skin prick tests to food allergens.

Influence of a multidisciplinary paediatric allergy clinic on parental knowledge and rate of subsequent allergic reactions

BACKGROUND

Studies have demonstrated that families of children with food allergy have significant deficiencies in their knowledge of how to avoid allergen exposure and how to manage allergic reactions. This study aims to assess the impact of a multidisciplinary paediatric allergy clinic consultation on parental knowledge of food allergy and to determine the rate of subsequent allergic reactions.

METHODS

Sixty-two subjects (<17 years) referred with food allergy were prospectively enrolled. Parental knowledge was assessed by questionnaire and EpiPen trainer. Families saw a paediatric allergist, clinical nurse specialist and dietician. Knowledge was reassessed after 3 months and rate of allergic reactions after 1 year.

RESULTS

After one visit to the paediatric allergy clinic, there was a significant improvement in parental knowledge of allergen avoidance (26.9%, P < 0.001), managing allergic reactions (185.4%, P < 0.0001) and EpiPen usage (83.3%, P < 0.001). Additionally, there was a significant reduction in allergic reactions (P < 0.001). Children with egg, milk or multiple food allergies were more likely to suffer subsequent reactions.

CONCLUSIONS

A single visit to a multidisciplinary allergy clinic considerably improves families' abilities to manage allergic reactions to foods with an accompanying reduction in allergic reactions. Young children with egg, milk or multiple food allergies were at greatest risk of further reactions.

Anaphylaxis: risk factors for recurrence

BACKGROUND

There are few studies on the incidence or recurrence of anaphylaxis.

OBJECTIVE

To examine the incidence of anaphylaxis and risk factors for recurrence.

METHODS

A prospective study of 432 patients referred to a community-based specialist practice in the Australian Capital Territory with anaphylaxis, followed by a survey to obtain information on recurrence.

RESULTS

Of 432 patients (48% male, 73% atopic, mean 27.4 years, SD 19.5, median 26) with anaphylaxis, 260 patients were seen after their first episode; 172 experienced 584 previous reactions. fifty-four percent of index episodes were treated in hospital. Aetiology was identified in 91.6% patients: food (61%), stinging insects (20.4%) or medication (8.3%). The minimum occurrence and incidence of new cases of anaphylaxis was estimated at 12.6 and 9.9 episodes/100,000 patient-years, respectively. Follow-up data were obtained from 304 patients (674 patient-years). One hundred and thirty experienced further symptoms (45 serious), 35 required hospitalization and 19 administered adrenaline. Accidental ingestion of peanut/tree nut caused the largest number of relapses, but the highest risk of recurrence was associated with sensitivity to wheat and/or exercise. Rates of overall and serious recurrence were 57 and 10 episodes/100 patient-years, respectively. Of those prescribed adrenaline, 3/4 carried it, 2/3 were in date, and only 1/2 patients faced with serious symptoms administered adrenaline. Five patients each developed new triggers for anaphylaxis, or re-presented with significant psychiatric symptoms.

CONCLUSION

In any 1 year, 1/12 patients who have suffered anaphylaxis will experience recurrence, and 1/50 will require hospital treatment or use adrenaline. Compliance with carrying and using adrenaline is poor. Occasional patients develop new triggers or suffer psychiatric morbidity.

An audit of the use of self-administered adrenaline syringes in patients with angio-oedema

BACKGROUND

Self-administered adrenaline syringes may be prescribed for patients at risk of life-threatening episodes of angio-oedema or anaphylaxis.

OBJECTIVES

To determine whether patients are able to use these syringes appropriately and adequately.

METHODS

Twenty-nine consecutive patients who had been prescribed self-administered adrenaline syringes for severe angio-oedema were recruited. All completed a questionnaire (unsupervised), and were asked to demonstrate how to use a dummy syringe.

RESULTS

Three of 29 (10%) patients had been prescribed syringes in the absence of severe angio-oedema or collapse. Seventeen of 29 (59%) patients had been prescribed two syringes, and 21 of 29 (72%) kept a syringe with them at all times. Twenty of 28 (71%) patients had had the use of a syringe demonstrated to them with the initial prescription, but two of 29 (7%) had never been shown how to use it. Only six of 26 (23%) patients had been told to telephone for an ambulance after using a syringe. Only seven of 29 (24%) patients would use a syringe for an episode of collapse, whereas eight of 28 (29%) would use one for an episode of lip swelling. Nine of 21 (43%) patients had not been warned about adverse effects, although 13 of 20 (65%) given adrenaline had had at least one adverse effect. Of the 25 patients asked to demonstrate their use of a syringe, only 14 (56%) were able to perform all steps correctly, and three (12%) were unable to perform any of the steps. Despite this, all 29 patients felt confident about giving themselves an injection, and most felt more secure having been prescribed syringes.

CONCLUSIONS

As self-administered adrenaline syringes are prescribed for life-threatening events, it is vital that they are given to appropriate patients with adequate written instructions and proper demonstration at the time of the initial prescription. As a result of this study we have developed a more detailed patient information leaflet, and all patients are shown how to use a syringe for a second time when attending the clinic for follow-up.

An Internet-based survey of anaphylactic reactions to foods

BACKGROUND

A favorable outcome of anaphylaxis depends on the rapidity of adequate initial management and epinephrine injection. However, few data on the management of anaphylactic reactions are available. The aim of this study was to investigate the management and awareness of anaphylaxis to foods by mean of an Internet-based survey.

METHODS

Visitors to a website with information on food allergy were invited to join the survey. Items in the survey included the management of anaphylactic reactions, investigations done by the diagnosing physician, and information given to the responder in anticipation of a new anaphylactic reaction.

RESULTS

Almost all of the 264 responders were from North America, Europe, Australia, or New Zealand (263/264). The most recent reaction was treated by epinephrine injection in 68.7% (180/262) of cases, or by antihistamines in 14.1% (37/262). Epinephrine was the first treatment for the most severe reaction in only 43.9% (101/230), while antihistamines were given first in 43.5% (100/230). One-third (62/210 = 29.5%) of the responders diagnosed by a physician received neither a diagnostic blood test nor a skin test. Responders diagnosed by an allergist were more often investigated (91/105 = 86.7%) than those diagnosed by a pediatrician or an internist (29/44 = 65.9%), a general practitioner (22/45 = 48.9%), or another physician (6/16 = 37.5%) (P < 0.001). Most responders had received instructions on how to deal with a new episode of anaphylaxis (244/263 = 92.8%). Responders instructed by an allergist were most frequently satisfied with the instructions (115/131 = 87.8%).

CONCLUSION

A large number of responders did not receive epinephrine for treatment of their most severe, or most recent anaphylactic reaction, and did not undergo allergy tests. The conventional management of anaphylaxis might still be improved.

Epinephrine dispensing for the out-of-hospital treatment of anaphylaxis in infants and children: a population-based study

BACKGROUND

Epinephrine is life-saving in the treatment of anaphylaxis. A limited number of fixed-dose epinephrine formulations are available for out-of-hospital treatment of this disorder.

OBJECTIVE

To examine dispensing patterns for epinephrine formulations over 4 consecutive years in a population of 279,638 infants, children, and adolescents (from birth up to but not including the 17th birthday).

METHODS

We used the Drug Programs Information Network, an administrative claims database for prescriptions dispensed in ambulatory care settings, developed from real-time computer links with retail pharmacies in the province of Manitoba, Canada. We studied the specific epinephrine formulation dispensed and the precise age of the infant or child at the time it was dispensed.

RESULTS

Epinephrine formulations were dispensed for 1.2% of the pediatric population (3,340 children). Boys comprised 59.5% of the recipients. Of all epinephrine formulations, 38.6% were dispensed as EpiPen Jr (0.15 mg), and 57.4% were dispensed as EpiPen (0.3 mg). EpiPen Jr was dispensed for patients ranging in age from 2 months to 16 years, 10 months, inclusive. EpiPen was dispensed for patients ranging in age from 1 year, 8 months to 16 years, 11 months, inclusive. During the 4 years studied, a subgroup of children transitioned from EpiPen Jr to EpiPen auto-injectors at a mean age of 6 years, 6 months +/- 2 years, 8 months (range 1 year, 10 months to 16 years, 11 months).

CONCLUSIONS

Both EpiPen Jr and EpiPen auto-injectors were dispensed over almost the entire age range of the pediatric population. Physicians should consider a child's age more carefully when prescribing these auto-injectors. Additional concentrations of epinephrine are needed in these fixed-dose formulations.

Diagnosis and management of childhood food allergy

The pediatrician plays a pivotal role in the initial diagnosis of food allergy. Alternative diagnoses are considered as a careful history, physical examination, and directed laboratory tests determine the type of adverse reaction and the responsible food. Through elimination diets in infants, appropriately selected tests for specific IgE, and, in some cases, supervised oral food challenges, a diagnosis is secured. Treatment consists of strict dietary elimination with provisions for emergency management of accidental ingestions. Referral to an allergist and dietitian is made as warranted by the severity and type of allergy and for follow-up for possible resolution of the allergy. The pediatrician also provides information to the family for the prevention of allergy in at-risk newborns. Future diagnostic tests and treatment modalities are likely to simplify the management of the food allergic child.

[Anaphylactic shock in the infant]

Anaphylactic shock is a life-threatening allergic reaction with cardiovascular collapse. The cardiovascular collapse may occur suddenly without warning signs or may be preceded by symptoms such as pruritus, wheezing, dyspnea, urticaria, pallor, digestive symptoms, and weakness. Food allergens, injected drugs and hymenoptera stings are the main etiologies. Anaphylactic shock requires an emergency treatment with immediate intramuscular or subcutaneous epinephrine injection. Subsequent avoidance of the inciting allergens is mandatory together with the availability of a first aid kit including ready-to-use epinephrine syringes. Besides its absolute necessity in any doctor's office, such first aid kits should be available in any children's group.

Can epinephrine inhalations be substituted for epinephrine injection in children at risk for systemic anaphylaxis?

BACKGROUND

For out-of-hospital treatment of anaphylaxis, inhalation of epinephrine from a pressurized metered-dose inhaler is sometimes recommended as a noninvasive, user-friendly alternative to an epinephrine injection.

OBJECTIVE

To determine the feasibility of administering an adequate epinephrine dose from a metered-dose inhaler in children at risk for anaphylaxis by assessing the rate and extent of epinephrine absorption after inhalation.

METHODS

We performed a prospective, randomized, observer-blind, placebo-controlled, parallel-group study in 19 asymptomatic children with a history of anaphylaxis. Based on the child's weight, 10, 15, or 20 carefully supervised epinephrine or placebo inhalations were attempted. Before dosing, and at intervals from 5 to 180 minutes after dosing, we monitored plasma epinephrine concentrations, blood glucose, heart rate, blood pressure, and adverse effects.

RESULTS

Eleven children (mean +/- standard error of the mean: 9 +/- 1 years and 33 +/- 3 kg) in the epinephrine group were able to inhale 11 +/- 2 (range: 3-20) puffs, equivalent to 74% +/- 7% of the precalculated dose or 0.078 +/- 0.009 mg/kg. They achieved a mean peak plasma epinephrine concentration of 1822 +/- 413 (range: 230-4518) pg/mL at 32.7 +/- 6.2 minutes. Eight children (10 +/- 1 years of age and 33 +/- 5 kg) in the placebo group were able to inhale 12 +/- 2 (range: 8-20) puffs, 89% +/- 3% of the precalculated dose, and had a peak endogenous plasma epinephrine concentration of 1316 +/- 247 (range: 522-2687) pg/mL at 44.4 +/- 16.7 minutes. In the children receiving epinephrine compared with those receiving placebo, mean plasma epinephrine concentrations were not significantly higher at any time, mean blood glucose concentrations were significantly higher from 10 to 30 minutes, mean heart rate was not significantly different at any time, and mean systolic and diastolic blood pressures were not significantly increased at most times. After the inhalations of epinephrine or placebo, the children complained of bad taste and many experienced cough or dizziness. After inhaling epinephrine, 1 child developed nausea, pallor, and muscle twitching.

CONCLUSIONS

Despite expert coaching, because of the number of epinephrine inhalations required and the bad taste of the inhalations, most children were unable to inhale sufficient epinephrine to increase their plasma epinephrine concentrations promptly and significantly. Therefore, we urge caution in recommending epinephrine inhalation as a substitute for epinephrine injection for out-of-hospital treatment of anaphylaxis symptoms in children.

Lessons for management of anaphylaxis from a study of fatal reactions

BACKGROUND

The unpredictability of anaphylactic reactions and the need for immediate, often improvised treatment will make controlled trials impracticable; other means must therefore be used to determine optimal management.

OBJECTIVES

This study aimed to investigate the circumstances leading to fatal anaphylaxis.

METHODS

A register was established including all fatal anaphylactic reactions in the UK since 1992 that could be traced from the certified cause of death. Data obtained from other sources suggested that deaths certified as due to anaphylaxis underestimate the true incidence. Details of the previous medical history, the reaction and necropsy were sought for all cases.

RESULTS

Approximately half the 20 fatal reactions recorded each year in the UK were iatrogenic, and a quarter each due to food or insect venom. All fatal reactions thought to have been due to food caused difficulty breathing that in 86% led to respiratory arrest; shock was more common in iatrogenic and venom reactions. The median time to respiratory or cardiac arrest was 30 min for foods, 15 min for venom and 5 min for iatrogenic reactions. Twenty-eight per cent of fatal cases were resuscitated but died 3 h-30 days later, mostly from hypoxic brain damage. Adrenaline (epinephrine) was used in treatment of 62% of fatal reactions but before arrest in only 14%.

CONCLUSIONS

Immediate recognition of anaphylaxis, early use of adrenaline, inhaled beta agonists and other measures are crucial for successful treatment. Nevertheless, a few reactions will be fatal whatever treatment is given; optimal management of anaphylaxis is therefore avoidance of the cause whenever this is possible. Predictable cross-reactivity between the cause of the fatal reaction and that of previous reactions had been overlooked. Adrenaline overdose caused at least three deaths and must be avoided. Kit for self-treatment had proved unhelpful for a variety of reasons; its success depends on selection of appropriate medication, ease of use and good training.

First aid anaphylaxis management in children who were prescribed an epinephrine autoinjector device (EpiPen)

BACKGROUND

Epinephrine for first aid use by parents and other caregivers and in the form of an autoinjector device (EpiPen, Center Laboratories) is often prescribed for children who have had previous anaphylactic reactions. It is not known whether the EpiPen device is used appropriately during subsequent reactions and whether its use is able to prevent the complications of anaphylaxis.

OBJECTIVE

Our purpose was to determine parental knowledge and practice concerning first aid anaphylaxis management, the frequency of recurrent generalized allergic reactions, the first aid measures taken, and the subsequent outcome of these reactions.

METHODS

A retrospective survey was performed with a telephone questionnaire of all children with a history of anaphylaxis who attended a specialist allergy service and were prescribed an EpiPen autoinjector device.

RESULTS

Recurrent generalized allergic reactions occurred with a frequency of 0.98 episodes per patient per year and were more common in those with food compared with insect venom anaphylaxis. The EpiPen device was only used in 29% of recurrent anaphylactic reactions. Parental knowledge was deficient in recognition of the symptoms of anaphylaxis and use of the EpiPen device, and adequate first aid measures were not in place for the majority of children attending school. Those children in whom the EpiPen device was used were less likely to be given epinephrine in hospital and to require subsequent hospital admission.

CONCLUSION

The EpiPen autoinjector device is infrequently used in children with recurrent episodes of anaphylaxis; the reasons for this require further research. It is likely that parents and other caregivers will require continuing education and support in first aid anaphylaxis management. When the EpiPen device is used appropriately, it appears to reduce subsequent morbidity from anaphylaxis.

Outdated EpiPen and EpiPen Jr autoinjectors: past their prime?

BACKGROUND

EpiPen and EpiPen Jr autoinjectors are often recommended for prehospital treatment of anaphylaxis. When these units become outdated, there may be a delay in replacing them.

OBJECTIVES

Our purpose was to evaluate unused, outdated EpiPen and EpiPen Jr autoinjectors, obtained from patients at risk for anaphylaxis, for epinephrine bioavailability and epinephrine content.

METHODS

We conducted a prospective, randomized, cross-over study of epinephrine bioavailability after injection from outdated autoinjectors in rabbits; controls included EpiPen and EpiPen Jr autoinjectors that had not expired ("in-date" autoinjectors) and intramuscular injection of 0.9% saline solution. In addition, the epinephrine content of the outdated EpiPen and EpiPen Jr autoinjectors was measured by a spectrophotometric method and an HPLC-UV method.

RESULTS

Twenty-eight EpiPen and 6EpiPen Jr autoinjectors were studied 1 to 90 months after the stated expiration date. Most were not discolored and did not contain precipitates. Epinephrine bioavailability from the outdated EpiPen autoinjectors was significantly reduced (P <.05) compared with epinephrine bioavailability from the in-date autoinjectors. The inverse correlation between the decreased epinephrine content of the outdated autoinjectors, assessed with an HPLC-UV method, and the number of months past the expiration date was 0.63.

CONCLUSIONS

For prehospital treatment of anaphylaxis, we recommend the use of EpiPen and EpiPen Jr autoinjectors that are not outdated. If, however, the only autoinjector available is an outdated one, it could be used as long as no discoloration or precipitates are apparent because the potential benefit of using it is greater than the potential risk of a suboptimal epinephrine dose or of no epinephrine treatment at all.

Use assessment of self-administered epinephrine among food-allergic children and pediatricians

BACKGROUND AND OBJECTIVES

Food allergy is a common cause of anaphylaxis, and early treatment with epinephrine can be life-saving. We sought to determine the ability of families with food allergic children and pediatricians to properly use self-injectable epinephrine.

METHODS

We enrolled families of consecutive, food-allergic pediatric patients newly referred to our allergy practice but previously prescribed epinephrine and a sampling of pediatricians. Parents or teenage patients answered a structured questionnaire concerning use of self-injectable epinephrine and demonstrated the use of devices with which they were familiar. Demonstrations were scored in a standard manner.

RESULTS

One hundred one families of food-allergic children (mean age of patients, 6.4 years) were enrolled. Self-injectable epinephrine was prescribed (mean of 2.7 years previously) primarily by pediatricians (n = 46) and allergists (n = 49). Patients were prescribed EpiPen (n = 93), EpiE-Z Pen (n = 11), and Ana-Kit (n = 3). Eighty-six percent of the families responded that they had the device with them "at all times," but only 71% of this group had epinephrine at the visit. Among those with the epinephrine, 10% had devices beyond the labeled expiration date. Thus, only 55% of the 101 families had unexpired epinephrine on-hand at the time of the survey. Among children in school, 77% had the medication available in school, and 81% stated that the school knew the indications for administration. Only 32% of the participants correctly demonstrated the use of the device. Twenty-nine attending pediatricians were enrolled (mean 14 yrs in practice; mean 4 epinephrine prescriptions/year). Familiarity with the devices was as follows: EpiPen (86%), EpiE-Z Pen (17%) and Ana-Kit (7%). Only 24% generally gave patients written materials concerning indications. Overall, 18% were familiar with and able to demonstrate correct use of at least 1 device (21% correctly demonstrated Epi-Pen). Seventeen pediatric residents were enrolled; 65% were familiar with the EpiPen; 36% demonstrated it correctly and only 1 resident was familiar with Ana-Kit.

CONCLUSIONS

Many parents of severely food-allergic children, and food-allergic teenagers cannot correctly administer their self-injectable epinephrine and may not have the medication readily available. Pediatricians are not familiar with these devices and may fail to review their use with patients. Improved patient and physician education is needed to ensure proper use of this life-saving medication.