Epinephrine for anaphylaxis

Epinephrine auto-injector use in adolescents at risk of anaphylaxis: a qualitative study in Scotland, UK

BACKGROUND

Adolescents with severe allergies are at particular risk of severe and fatal anaphylactic reactions. Epinephrine (adrenaline) is known to be under-utilized by teenagers.

OBJECTIVE

We sought to gain knowledge of adolescents' attitudes towards and experience of epinephrine auto-injectors in order to inform improvements in patient education.

METHODS

A qualitative study of adolescents in Scotland, UK with a history of anaphylaxis and their parents. In-depth interviews explored adolescents' accounts of anaphylactic reactions, including issues related to using epinephrine auto-injectors. Focus groups with adolescents and parents were used to discuss interventions to improve adolescent self-management of anaphylaxis.

RESULTS

Twenty-six adolescents and 28 parents were interviewed. Eight adolescents and 10 parents participated in separate focus groups. Most adolescents had not used the auto-injector in an anaphylactic emergency. We identified multi-faceted barriers to use, including: failure to recognize anaphylaxis; uncertainty about auto-injector technique and when to administer it; fear of using the auto-injector. Most adolescents reported carrying auto-injectors some of the time, though several found this inconvenient due to the size; only one reported non-use of an auto-injector because it had not been carried.

CONCLUSION AND CLINICAL RELEVANCE

Adolescents and parents reported under-use of epinephrine auto-injectors. Carriage is insufficient to ensure that auto-injectors are used. Barriers to use are multiple and complex, and unlikely to be overcome using simple educational interventions. Auto-injector training currently offered is often inadequate preparation for an emergency. A more comprehensive approach is needed, addressing the psychosocial dimensions of anaphylactic emergencies as well as treatment. Training should ideally be provided by specialist allergists or nurses, but can also be provided and reinforced in primary care.

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.

Immediate-type allergy to drugs and related compounds: evaluation and management

Adverse drug reactions (ADR) constitute a major health issue in outpatient and inpatient clinical settings. An allergic drug reaction is an immunologically mediated adverse drug reaction that exhibits specificity and recurrence on re-exposure to the offending and/or cross-reactive compound(s). Diagnosis of drug allergy is difficult, as a broad spectrum of different drugs can elicit various immune-mediated diseases with distinct (sometimes unclear) pathomechanism, the exact structure (epitope) that causes the reaction is frequently unknown, the presence of an in vitro or in vivo test results might not be predictive of a clinical situation, and the gold standard or reference test for diagnosis, the drug challenge, is a complicated and sometimes dangerous endeavour. Nevertheless, during the past few years serious attempts have been made to standardise and validate in vitro and in vivo techniques for the diagnosis of drug allergy. New techniques, e.g. flow-assisted analysis of in vitro basophil activation, are replacing older ones like histamine release for immediate-type hypersensitivity reactions. However, additional comprehensive studies are required to further validate the technique and allow its entrance in mainstream diagnostic use, particularly for non-IgE-mediated hypersensitivity. This review attempts to summarize the major causes of immediate hypersensitivity reactions to drugs and related compounds. Special attention is paid to the diagnostic and therapeutic management of this common iatrogenic complication.