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Wassenberg S, Rau R, Klopsch T, Plenske A, Jobst J, Klaus P, Meng T, Löschmann PA. Etanercept is Effective and Halts Radiographic Progression in Rheumatoid Arthritis and Psoriatic Arthritis: Final Results from a German Non-interventional Study (PRERA). Rheumatol Ther 2023; 10:117-133. [PMID: 36251174 PMCID: PMC9931988 DOI: 10.1007/s40744-022-00491-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 08/31/2022] [Indexed: 10/24/2022] Open
Abstract
INTRODUCTION Etanercept (ETN) has been shown to slow radiographic progression of rheumatoid arthritis (RA) and psoriatic arthritis (PsA) in clinical trials. This real-world, non-interventional study assessed radiographic progression in patients with RA or PsA treated with ETN for ≤ 36 months in outpatient care in Germany (NCT01623752). METHODS Patients with RA or PsA attended ≤ 10 visits across two study phases (phase 1: seven visits, baseline to month 18; phase 2: three visits until month 36). Radiographs were taken at baseline (Rx1), months 12-18 (Rx2), and/or months 30-36 (Rx3). Historic radiographs (Rx0) taken 12-48 months pre-baseline were also evaluated (if available). The primary endpoint was the change in modified total Sharp score (mTSS). The erosion score (ES) and joint space narrowing score (JSN) were also evaluated. RESULTS Overall, 1821 patients were enrolled (RA: n = 1378; PsA: n = 440). In patients with Rx1 and Rx2 (RA: n = 511; PsA: n = 167), the mean mTSS remained stable for both disease groups, and the annualized median change in mTSS was 0. In patients with Rx0, Rx1, and Rx2 (RA: n = 180; PsA: n = 47), annualized radiographic progression in mTSS, ES, and JSN was larger in the pre-ETN treatment phase than during ETN treatment in both disease groups. The percentage of patients with radiographic non-progression was higher during ETN treatment versus pre-ETN. Improvement in clinical disease activity and patient-reported outcomes was also observed. CONCLUSIONS This was the first real-world, non-interventional study to report systematically collected radiographic data in a large cohort of patients with RA or PsA under treatment with a biologic. In patients with available radiographic data, mean radiographic progression was lower and the proportion of patients without progression was greater during ETN treatment than in the pre-ETN period.
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Dreborg S, Walter G, Kim H. International recommendations on epinephrine auto-injector doses often differ from standard weight-based guidance: a review and clinical proposals. Allergy Asthma Clin Immunol 2022; 18:102. [PMID: 36471385 PMCID: PMC9724388 DOI: 10.1186/s13223-022-00736-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 10/25/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND In anaphylaxis, the dosing of injectable epinephrine in medical settings has been arbitrarily recommended to be 0.01 mg/kg of body weight. For ethical reasons, there have been no dose-response studies or double-blind studies performed on patients with active anaphylaxis. Intramuscular delivery of epinephrine has been the standard. Auto-injectors for use in the treatment of anaphylaxis are available in four strengths (0.1, 0.15, 0.3, and 0.5 mg). However, in many countries, only the 0.15 and 0.3 mg strengths are available. Consequently, many adult, heavy patients are prescribed the 0.3 mg dose, which may result in only one-fifth to one-third of the recommended weight-based dose being administered in heavy patients experiencing anaphylaxis. Underdosing may have therefore contributed to mortality in anaphylaxis. OBJECTIVE To review the doses of epinephrine recommended for the treatment of anaphylaxis in the community, and assess whether recommendations should be made to increase dosing for heavy adult patients in hopes of avoiding future deaths from anaphylaxis. METHODS We reviewed multiple national and international recommendations for the dosing of epinephrine. We also reviewed the literature on adverse drug reactions from epinephrine, lethal doses of epinephrine, and epinephrine dose-finding studies. RESULTS The majority of national and regional professional societies and authorities recommend epinephrine delivered by auto-injectors at doses far lower than the generally accepted therapeutic dose of 0.01 mg/kg body weight. Furthermore, we found that the recommendations vary even within regions themselves. CONCLUSIONS We suggest prescribing more appropriate doses of epinephrine auto-injectors based on weight-based recommendations. There may be some exceptions, such as for patients with heart disease. We hypothesize that these recommendations will lead to improved outcomes of anaphylaxis.
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Affiliation(s)
- Sten Dreborg
- grid.8993.b0000 0004 1936 9457Department of Child and Adolescent Allergology, Women’s and Children’s Health, University of Uppsala, Uppsala, Sweden
| | - Graham Walter
- grid.39381.300000 0004 1936 8884Department of Medicine, Western University, London, ON Canada ,grid.39381.300000 0004 1936 8884Division of Clinical Immunology and Allergy, Western University, London, ON Canada
| | - Harold Kim
- grid.39381.300000 0004 1936 8884Department of Medicine, Western University, London, ON Canada ,grid.39381.300000 0004 1936 8884Division of Clinical Immunology and Allergy, Western University, London, ON Canada ,grid.25073.330000 0004 1936 8227Department of Medicine, McMaster University, Hamilton, ON Canada
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Spataru A, van Dommelen P, Arnaud L, Le Masne Q, Quarteroni S, Koledova E. Use of machine learning to identify patients at risk of sub-optimal adherence: study based on real-world data from 10,929 children using a connected auto-injector device. BMC Med Inform Decis Mak 2022; 22:179. [PMID: 35794586 PMCID: PMC9261072 DOI: 10.1186/s12911-022-01918-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 05/31/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Our aim was to develop a machine learning model, using real-world data captured from a connected auto-injector device and from early indicators from the first 3 months of treatment, to predict sub-optimal adherence to recombinant human growth hormone (r-hGH) in patients with growth disorders. METHODS Adherence to r-hGH treatment was assessed in children (aged < 18 years) who started using a connected auto-injector device (easypod™), and transmitted injection data for ≥ 12 months. Adherence in the following 3, 6, or 9 months after treatment start was categorized as optimal (≥ 85%) versus sub-optimal (< 85%). Logistic regression and tree-based models were applied. RESULTS Data from 10,929 children showed that a random forest model with mean and standard deviation of adherence over the first 3 months, infrequent transmission of data, not changing certain comfort settings, and starting treatment at an older age was important in predicting the risk of sub-optimal adherence in the following 3, 6, or 9 months. Sensitivities ranged between 0.72 and 0.77, and specificities between 0.80 and 0.81. CONCLUSIONS To the authors' knowledge, this is the first attempt to integrate a machine learning model into a digital health ecosystem to help healthcare providers to identify patients at risk of sub-optimal adherence to r-hGH in the following 3, 6, or 9 months. This information, together with patient-specific indicators of sub-optimal adherence, can be used to provide support to at-risk patients and their caregivers to achieve optimal adherence and, subsequently, improve clinical outcomes.
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Affiliation(s)
- Amalia Spataru
- Swiss Data Science Center, ETH Zürich and EPFL, Zürich, Switzerland
| | - Paula van Dommelen
- The Netherlands Organization for Applied Scientific Research TNO, P.O. Box 2215, 2301 CE, Leiden, The Netherlands.
| | - Lilian Arnaud
- Connected Health and Devices, Global Healthcare Operations, Ares Trading S.A., An Affiliate of Merck KGaA, Eysins, Switzerland
| | - Quentin Le Masne
- Connected Health and Devices, Global Healthcare Operations, Ares Trading S.A., An Affiliate of Merck KGaA, Eysins, Switzerland
| | | | - Ekaterina Koledova
- Global Medical Affairs Cardiometabolic & Endocrinology, Merck Healthcare KGaA, Darmstadt, Germany
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Morgan K, Van Dommelen P, Batista AR, Koledova E. Observed High Adherence to Recombinant Human Growth Hormone Treatment Using a Multi-Component Approach to Improve Adherence in Individuals with Growth Disorders. Stud Health Technol Inform 2022; 294:817-818. [PMID: 35612215 DOI: 10.3233/shti220595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
We explored whether a multi-component approach - using a digital health device, the easypod™ auto-injector, the 'MySupport' patient support programme (PSP) and a Patient Activation Measure® (PAM®) - could improve adherence in patients receiving recombinant human growth hormone (r-hGH). A 13-item PAM was used to assess caregiver self-reported knowledge, resulting in two PAM scores for 88 patients at four UK hospitals after an average of 5.6 months. Most patients improved their PAM score by ≥1 level (43%) or maintained it (>-1 and <1; 21%). In parallel, 74% of patients maintained (-5 to +5%) or improved (≥5%) their adherence. Further studies are required to evaluate a multi-component approach to adherence in a larger population and for a longer duration.
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Affiliation(s)
- Kate Morgan
- Merck Serono Ltd., Feltham, UK, an affiliate of Merck KGaA
| | - Paula Van Dommelen
- The Netherlands Organization for Applied Scientific Research TNO, Leiden, The Netherlands
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Zhang W, Tyrrell H, Ding HT, Pulley J, Boruvka A, Erickson R, Abouhossein M, Ravanello R, Tang MT. Comparable Pharmacokinetics, Safety, and Tolerability of Etrolizumab Administered by Prefilled Syringe or Autoinjector in a Randomized Trial in Healthy Volunteers. Adv Ther 2021; 38:2418-2434. [PMID: 33778929 PMCID: PMC8107163 DOI: 10.1007/s12325-021-01661-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 02/10/2021] [Indexed: 11/24/2022]
Abstract
Introduction Etrolizumab is a novel, dual-action anti-β7 integrin antibody studied in phase 3 trials in patients with inflammatory bowel disease. An autoinjector (AI) is being developed in parallel to complement the prefilled syringe with needle safety device (PFS-NSD) for subcutaneous (SC) administration in these trials. Here we demonstrate the comparable pharmacokinetics, tolerability, and safety of both devices. Methods This randomized, open-label, two-part study in healthy participants evaluated the comparability of etrolizumab exposure between the AI and the PFS-NSD. Part 1 (pilot) involved a small number of participants, and initial results were used to finalize the design of the larger part 2 (pivotal) study. In both parts, participants were randomly assigned to receive a single SC dose of etrolizumab 105 mg by AI or PFS-NSD. Randomization was stratified by body weight. Primary pharmacokinetic outcomes were Cmax, AUClast, and AUC0–inf. Results One hundred and eighty healthy participants (part 1, n = 30; part 2, n = 150) received a single SC dose of etrolizumab by AI or PFS-NSD. Primary pharmacokinetic results from part 1 supported modification of the part 2 study design. Results from part 2 demonstrated that etrolizumab exposure was equivalent between devices, with geometric mean ratios (GMRs) between AI and PFS-NSD of 102% (90% confidence interval [CI] 94.2–111) for Cmax, 98.0% (90% CI 89.3–107) for AUClast, and 97.6% (90% CI 88.6–107) for AUC0–inf. Median tmax and mean terminal t1/2 were also similar between devices. GMRs and 90% CIs of all primary pharmacokinetic parameters were fully contained within the predefined equivalence limits (80–125%). Conclusion This pharmacokinetic study demonstrated that single SC injections of etrolizumab 105 mg using an AI or a PFS-NSD resulted in equivalent etrolizumab exposure and similar safety and tolerability in healthy participants. Taken together, these results support the use of an AI for etrolizumab administration. Trial Registration NCT02996019.
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Ring J, Beyer K, Biedermann T, Bircher A, Fischer M, Fuchs T, Heller A, Hoffmann F, Huttegger I, Jakob T, Klimek L, Kopp MV, Kugler C, Lange L, Pfaar O, Rietschel E, Rueff F, Schnadt S, Seifert R, Stöcker B, Treudler R, Vogelberg C, Werfel T, Worm M, Sitter H, Brockow K. Guideline (S2k) on acute therapy and management of anaphylaxis: 2021 update: S2k-Guideline of the German Society for Allergology and Clinical Immunology (DGAKI), the Medical Association of German Allergologists (AeDA), the Society of Pediatric Allergology and Environmental Medicine (GPA), the German Academy of Allergology and Environmental Medicine (DAAU), the German Professional Association of Pediatricians (BVKJ), the Society for Neonatology and Pediatric Intensive Care (GNPI), the German Society of Dermatology (DDG), the Austrian Society for Allergology and Immunology (ÖGAI), the Swiss Society for Allergy and Immunology (SGAI), the German Society of Anaesthesiology and Intensive Care Medicine (DGAI), the German Society of Pharmacology (DGP), the German Respiratory Society (DGP), the patient organization German Allergy and Asthma Association (DAAB), the German Working Group of Anaphylaxis Training and Education (AGATE). Allergo J Int 2021; 30:1-25. [PMID: 33527068 PMCID: PMC7841027 DOI: 10.1007/s40629-020-00158-y] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Johannes Ring
- Department Dermatology and Allergology Biederstein, Technical University Munich, Biedersteiner Straße 29, 80802 Munich, Germany
| | - Kirsten Beyer
- Department of Pediatrics, Division of Pulmonology, Immunology and Critical Care Medicine, Charité—University Hospital Berlin, Berlin, Germany
| | - Tilo Biedermann
- Department Dermatology and Allergology Biederstein, Technical University Munich, Biedersteiner Straße 29, 80802 Munich, Germany
| | - Andreas Bircher
- Department of Dermatology, University Hospital of Basel, Basel, Switzerland
| | - Matthias Fischer
- Clinic for Anaesthesiology, Intensive Care Medicine, Emergency Medicine and Pain Therapy, ALB FILS Hospitals Göppingen, Göppingen, Germany
| | - Thomas Fuchs
- Department of Dermatology, University Hospital Göttingen, Göttingen, Germany
| | - Axel Heller
- Department of Anesthesiology and Operative Intensive Care Medicine, Medical Faculty, University of Augsburg, Augsburg, Germany
| | - Florian Hoffmann
- Dr. von Hauner Children’s Hospital, Ludwig Maximilians University, Munich, Germany
| | - Isidor Huttegger
- Department of Pediatrics, University Hospital Salzburg, Salzburg, Austria
| | - Thilo Jakob
- Department of Dermatology and Allergology, University Medical Center Gießen (UKGM), Justus-Liebig-University Gießen, Gießen, Germany
| | - Ludger Klimek
- Center of Rhinology and Allergology, Wiesbaden, Germany
| | - Matthias V. Kopp
- Pediatric Respiratory Medicine, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Claudia Kugler
- Department Dermatology and Allergology Biederstein, Technical University Munich, Biedersteiner Straße 29, 80802 Munich, Germany
| | | | - Oliver Pfaar
- Section of Rhinology and Allergy, Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Marburg, Philipps-University Marburg, Marburg, Germany
| | - Ernst Rietschel
- Department of Pediatrics, University Hospital Cologne, Cologne, Germany
| | - Franziska Rueff
- Department of Dermatology and Allergology, Hospital of the Ludwig Maximilians University, Munich, Germany
| | - Sabine Schnadt
- German Allergy and Asthma Association, Mönchengladbach, Germany
| | - Roland Seifert
- Institute of Pharmacology, Hannover Medical School, Hannover, Germany
| | - Britta Stöcker
- Medical practice for pediatrics and youth medicine, Poppelsdorfer Allee, Bonn, Germany
| | - Regina Treudler
- Department of Dermatology, Venereology, and Allergology, Leipzig Interdisciplinary Allergy Center, University Hospital Leipzig, Leipzig, Germany
| | - Christian Vogelberg
- Department of Pediatric Pneumology and Allergology, University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany
| | - Thomas Werfel
- Immunodermatology and Experimental Allergology Unit, Department of Dermatology, Allergology, and Venereology, Medical University Hannover, Hannover, Germany
| | - Margitta Worm
- Department of Dermatology, Venereology, and Allergology, Charité—University Hospital Berlin, Berlin, Germany
| | - Helmut Sitter
- Institute for Surgical Research, Philipps-University Marburg, Marburg, Germany
| | - Knut Brockow
- Department Dermatology and Allergology Biederstein, Technical University Munich, Biedersteiner Straße 29, 80802 Munich, Germany
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Blanco-López A, Antillón-Ferreira C, Saavedra-Castillo E, Barrientos-Pérez M, Rivero-Escalante H, Flores-Caloca O, Calzada-León R, Rosas-Guerra CC, Koledova E, Chiquete E, Ayala-Estrada A. Adherence to treatment in children with growth hormone deficiency, small for gestational age and Turner syndrome in Mexico: results of the Easypod™ connect observational study (ECOS). J Endocrinol Invest 2020; 43:1447-1452. [PMID: 32239476 PMCID: PMC7481146 DOI: 10.1007/s40618-020-01218-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 03/05/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Assessing adherence to growth hormone (GH) is challenging. The Easypod™ connect device delivers pre-set doses of recombinant human GH (r-hGH) and stores a digital record of adherence that can be shared with healthcare provider. We assessed adherence to r-hGH delivered with Easypod™ according to the approved pediatric indications for r-hGH: growth hormone deficiency (GHD), born small for gestational age (SGA) who failed to show catch-up growth and Turner syndrome (TS). METHODS ECOS (NCT01555528) was a multicenter (24 countries), 5-year, longitudinal, observational study, which aimed to evaluate country-specific adherence to r-hGH therapy prescribed via the Easypod™ electronic injection device. The primary endpoint was yearly adherence. Secondary endpoints were height velocity, height velocity standard deviation scores (SDS), height, height SDS and IGF-1 concentrations. Clinical and auxological data were obtained from medical records and adherence from Easypod™ logs. RESULTS This study included 147 Easypod™-naïve Mexican children assessed during 3 years (mean age: 9.96 ± 3.41 years, 56.8% boys, mean height SDS at baseline: - 2.17 ± 0.97): 118 with GHD, 24 SGA and 5 with TS. A total of 105 (71.4%) patients were GH naïve. Overall median adherence was > 90% over the first year of treatment and > 80% at 3 years. Adherence was not different by r-hGH indication or between GH-naïve or experienced patients. At 1-year follow-up, mean change in height SDS was 0.57 ± 0.34, whereas mean height velocity SDS was 2.85 ± 2.51. In all, 84.7% patients had normal IGF-1 concentrations at 1-year follow-up. Adherence was associated with change in height SDS (r = 0.239, p = 0.005) and height velocity SDS (r = 0.194, p = 0.027). CONCLUSION Adherence rates with the Easypod™ device are high and maintained over time in GHD, SGA and TS Easypod™-naïve Mexican patients. High adherence is associated with better outcomes. Easypod™ assists physicians in monitoring adherence to r-hGH.
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Affiliation(s)
- A Blanco-López
- Hospital Ángeles Interlomas and Hospital Español, Mexico City, Mexico
| | | | | | | | | | | | - R Calzada-León
- Servicio de Endocrinología, Instituto Nacional de Pediatría, Mexico City, Mexico
| | - C C Rosas-Guerra
- Merck Biopharma Distribution S.A. de C.V, Naucalpan de Juárez, Mexico
| | - E Koledova
- Merck Healthcare KGaA, Darmstadt, Germany
| | - E Chiquete
- Departamento de Neurología y Psiquiatría, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Delegacion Tlalpan, C.P. 14080, Ciudad de Mexico, México.
| | - A Ayala-Estrada
- Servicio de Pediatría, Hospital ISSEMyM, Toluca, Estado de México, México.
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Rekaya N, Vicik SM, Hulesch BT, McDonald LL. Enhancement of an Auto-Injector Device for Self-Administration of Etanercept in Patients With Rheumatoid Arthritis Confers Emotional and Functional Benefits. Rheumatol Ther 2020; 7:537-552. [PMID: 32500508 PMCID: PMC7410887 DOI: 10.1007/s40744-020-00216-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Indexed: 11/30/2022] Open
Abstract
Introduction Etanercept is effective in the management of rheumatoid arthritis (RA) and can be self-administered via an auto-injector. While these devices are generally well accepted, some patients are not comfortable with the process of self-administration; this has been cited as a reason for discontinuation of biologic treatment. Alternative routes of administration (e.g., infusion) are more resource intensive. The aim of this analysis was to explore the attributes of auto-injection devices that impact patient confidence and ability to self-administer. Methods Patients with RA (n = 168) and healthcare providers (n = 82) in Belgium, Germany, Japan, Spain, and the UK were interviewed (n = 250 overall). Mock injection procedures were carried out using an auto-injector device with the addition of a sleeve with a wider rubber grip. Importance of and performance of the device against a range attributes were captured using a Likert scale (1–7). Disease severity was captured using the Cochin hand function scale. Results Device attributes reported by patients to be most important were ‘use without assistance’ ‘ease of administration’, ‘ease of operation’, and ‘ease of grip’. The device with additional sleeve performed strongly against these attributes, scoring 6.9 (out of 7), 6.8, 6.8, and 6.6, respectively with no difference observed between countries. Nurses and physicians reported similar responses. Qualitatively, patients reported that stability and grip provided a sense of control and reduced anxiety. Similar overall ‘ease of operation’ was reported between patients with mild (n = 89) or moderate/severe (n = 71) disease (score 6.4 vs. 6.5, respectively). Conclusions The auto-injector plus sleeve performed strongly against key attributes even in patients with moderate/severe RA and patients with reduced grip strength. The robust grip improved patient confidence and reduced injection-related anxiety. This may be beneficial in patients who are anxious about self-administration, those new to self-administration, and potentially in patients with reduced hand dexterity as a result of either advanced disease or a painful day. Electronic Supplementary Material The online version of this article (10.1007/s40744-020-00216-5) contains supplementary material, which is available to authorized users. Etanercept is a medicine used to treat rheumatoid arthritis that is given by injection. It can be delivered by patients themselves, in their own homes, using an auto-injection device that looks like a pen. Some patients are not comfortable with the process of self-injecting. Other patients have severe arthritis in their hands that stops them from carrying out self-injection. One auto-injection device (MyClic) has been enhanced by the addition of a sleeve that fits over the top of the pen. This was shown to 168 patients with rheumatoid arthritis, who already use the MyClic ‘pen’ and 82 doctors and nurses in five countries (Belgium, Germany, Japan, Spain, and the UK). Patients, nurses, and doctors said what they believed to be the most important features of a self-injection device. Generally, patients, nurses, and doctors from the different countries had similar views. Next, the participants scored the modified auto-injection device against those features. The device plus sleeve scored highly, meaning that patients, nurses, and doctors believed it would work well for the patient population tested. Many patients said that with the added sleeve, the self-injection device was more stable and they were able to grip it better. This helped to make patients feel in control and reduced any anxiety or fear they were feeling about their self-injection. This suggests that the sleeve is a useful addition and may be particularly useful for patients who are nervous about self-injection or have difficulty gripping self-injection devices because of their arthritis.
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Dreborg S, Tsai G, Kim H. Epinephrine auto-injector needle length: The impact of winter clothing. Allergy Asthma Clin Immunol 2020; 16:24. [PMID: 32322286 PMCID: PMC7160976 DOI: 10.1186/s13223-020-00422-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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Xing L, Li Y, Li T. Local Concentrating, Not Shear Stress, That May Lead to Possible Instability of Protein Molecules During Syringe Injection: A Fluid Dynamic Study with Two-Phase Flow Model. PDA J Pharm Sci Technol 2019; 73:260-275. [PMID: 30651339 DOI: 10.5731/pdajpst.2018.009357] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
A two-phase flow computational fluid dynamic (CFD) model was developed to study the hydrodynamic forces and the protein concentration changes of a protein solution in a syringe injector. Proteins were assumed to be nanosized solid spheres commensurate with their molecular weight and suspended in an aqueous environment, passing through the rapidly constricted sections of the syringe. Interaction between the solid and the liquid phase was taken into account, and four laminar flow cases were studied under the extensional flow. Profiles of pressure, velocity, and shear stress of the different cases were examined and compared. Hydrodynamic forces on a single protein particle were further analyzed. Our results indicate that the hydrodynamic forces are too small to affect significant conformational changes in proteins. The plunger rate showed limited impact on the distribution of protein particles inside the syringe. Nonetheless, the larger velocity gradient at the connection section of the hub toward the needle resulted in considerable accumulation of proteins. Such a concentrating effect may lead to protein aggregation and subsequent structural changes and will be examined in future studies.LAY ABSTRACT: Concentrated protein in the liquid form has become a preferred formulation strategy for delivering protein products, but it suffers from a high possibility of aggregation and precipitation, which may trigger a structural change and denaturation of the protein molecules and eventually cause the loss of the therapeutic functions of the protein products. To understand the effect of hydrodynamic forces on the change in local protein concentration in a syringe injector, we developed a two-phase flow computational fluid dynamic (CFD) model in this work. It was found that the local concentration of protein strongly depends on the velocity gradient of the fluid. A higher amount of proteins accumulates at the connection section of the hub toward the needle where the maximum velocity gradient is exhibited. The model results also imply a limited effect by hydrodynamic forces on possible unfolding of protein molecules. The local concentrating effect may enhance the possibility of molecular collision, resulting in aggregation and structural change.
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Affiliation(s)
- Lei Xing
- Department of Industrial and Physical Pharmacy, Purdue University, 575 Stadium Mall Drive, West Lafayette, IN 47907
| | - Yue Li
- Department of Industrial and Physical Pharmacy, Purdue University, 575 Stadium Mall Drive, West Lafayette, IN 47907
| | - Tonglei Li
- Department of Industrial and Physical Pharmacy, Purdue University, 575 Stadium Mall Drive, West Lafayette, IN 47907
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Saraux A, Hudry C, Zinovieva E, Herman-Demars H; Self-I Investigators group. Use of Auto-Injector for Methotrexate Subcutaneous Self-Injections: High Satisfaction Level and Good Compliance in SELF-I Study, a Randomized, Open-Label, Parallel Group Study. Rheumatol Ther 2019; 6:47-60. [PMID: 30547379 DOI: 10.1007/s40744-018-0134-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Indexed: 02/07/2023] Open
Abstract
Introduction The objective of the study was to compare compliance and acceptability of a new auto-injector (AI) versus syringe for administration of methotrexate (MTX) in patients with rheumatoid arthritis (RA). Methods We conducted a randomized, open-label, parallel group study comparing AI to pre-filled syringe (PFS). Adult patients with RA (ACR/EULAR 2010) receiving MTX (orally or by injection) for at least 3 months were allocated to AI or PFS for 6 months and then were allocated to AI for 6 further months. Two co-primary endpoints were defined at M6: percentage of patients with compliance at least 80%; change in functional capacity assessed by Health Assessment Questionnaire (HAQ). Secondary endpoints included quality of life (RaQoL), RA activity (DAS28), and acceptability. Local safety at injection site was assessed at each visit. Results Two-hundred and sixty-five patients were randomized. The main analysis was conducted on per protocol set (99 AI and 98 PFS). Compliance was 96.2% in AI and 98.9% in PFS. Good complier rates were 89.9% and 94.9%, thus a difference of − 5.0% (− 18.9%; 8.9%). HAQ remained stable in both groups. No difference was found on RaQoL, change in RA activity, and safety profile. Autonomy, acceptability, and patient satisfaction were better with AI, and patients having had the experience of both AI and PFS preferred AI (p < 0.001). Conclusions Although this study did not demonstrate non-inferiority of AI versus PFS, compliance was excellent in the two groups, and AI, which was preferred by patients, is a valuable alternative to PFS for administration of MTX. Trial Registration ClinicalTrials.gov identifier, NCT02553018. Funding Nordic Pharma SAS.
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Järvinen E, Multanen J, Atula S. Subcutaneous Interferon β-1a Administration by Electronic Auto-injector is Associated with High Adherence in Patients with Relapsing Remitting Multiple Sclerosis in a Real-life Study. Neurol Int 2017; 9:6957. [PMID: 28286627 PMCID: PMC5337756 DOI: 10.4081/ni.2017.6957] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 01/15/2017] [Indexed: 11/23/2022] Open
Abstract
The objective was to investigate adherence measured by an electronic auto-injector device, and self-reported adherence and treatment convenience in subjects with relapsing remitting multiple sclerosis (RRMS), using an electronic auto-injector Rebismart® to self-inject interferon β-1a. Thirty one patients with RRMS using the electronic auto-injector Rebismart® for self-injecting interferon β-1a subcutaneously three times weekly were included in a real-life clinical multicenter study for 24 weeks in Finland. Mean adherence reported by the device and mean self-assessment of adherence were studied. Reasons for missing injections and treatment convenience were assessed. Association between adherence and gender and age were studied. The mean adherence calculated from the device data was 93.5%. The mean self-assessment of adherence was 96.6%. The most common reason for missing an injection was forget-fulness. Adherence (measured by the device) was not changed over time. In the high adherence group there were more females and young patients (<30 years of age). The auto-injector was found to substantially ease the treatment by 90% of the patients. The electronic auto-injector was associated with high adherence to treatment. The device was found to ease the patient’s treatment and it was perceived as easy to use. It is a convenient tool to assess patient’s adherence to treatment.
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Affiliation(s)
| | | | - Sari Atula
- Helsinki University Central Hospital , Helsinki, Finland
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Raffa RB, Taylor R, Pergolizzi JV, Nalamachu S, Edwards ES, Edwards ET. Application of human factors engineering (HFE) to the design of a naloxone auto-injector for the treatment of opioid emergencies. Drug Deliv Transl Res 2017; 7:1-10. [PMID: 27562292 PMCID: PMC5222905 DOI: 10.1007/s13346-016-0323-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The increased use of opioids for chronic treatment of pain and the resulting epidemic of opioid overdoses have created a major public health challenge. Parenteral naloxone has been used since the 1970's to treat opioid overdose. Recently, a novel naloxone auto-injector device (EVZIO, kaleo, Inc., Richmond, VA) was approved by the Food and Drug Administration. In this article, we review the Human Factors Engineering (HFE) process used in the development and testing of this novel naloxone auto-injector currently used in nonmedical settings for the emergency treatment of known or suspected opioid overdose. HFE methods were employed throughout the product development process for the naloxone auto-injector including formative and summative studies in order to optimize the auto-injector's user interface, mitigate use-related hazards and increase reliability during an opioid emergency use scenario. HFE was also used to optimize the product's design and user interface in order to reduce or prevent user confusion and misuse. The naloxone auto-injector went through a rigorous HFE process that included perceptual, cognitive, and physical action analysis; formative usability evaluations; use error analysis and summative design validation studies. Applying HFE resulted in the development of a product that is safe, fast, easy and predictably reliable to deliver a potentially life-saving dose of naloxone during an opioid overdose emergency. The naloxone auto-injector may be considered as a universal precaution option for at-risk patients prescribed opioids or those who are at increased risk for an opioid overdose emergency.
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Affiliation(s)
- Robert B Raffa
- Temple University School of Pharmacy, Philadelphia, PA, USA
| | | | - Joseph V Pergolizzi
- NEMA Research, Bonita Springs, FL, USA
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Bardou M, Luu M, Walker P, Auriel C, Castano X. Efficacy of a Novel Prefilled, Single-Use, Needle-Free Device (Zeneo ®) in Achieving Intramuscular Agent Delivery: An Observational Study. Adv Ther 2017; 34:252-60. [PMID: 27928757 DOI: 10.1007/s12325-016-0452-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Indexed: 10/26/2022]
Abstract
BACKGROUND It is recognized that, as a result of variation in tissue anatomy, current auto-injectors may have insufficient needle length to achieve successful intramuscular agent delivery in a number of patients. The Zeneo® auto-injector is a novel prefilled, single-use, needle-free device currently in development for intradermal, subcutaneous, and intramuscular agent delivery across a variety of clinical indications. We aimed to evaluate delivery depth of the device calibrated at pressure appropriate for intramuscular (IM) administration. METHODS This was a prospective single-center study in healthy adult volunteers, in whom each received a single injection of saline into the anterolateral thigh. Using sequential MRI scans, we measured skin-to-muscle distance (STMD) agent delivery depth, and the success of IM agent penetration. Device dynamic pressure measurements were also recorded. RESULTS Results are reported for 37 subjects with evaluable MRI scans; 19 men, 18 women; mean age 38 years (range 20-58); mean BMI 27.0 kg/m2 (range 21.2-30.8 kg/m2). Mean STMD values were 18.6 mm (range 13.4-23.6 mm) in women and 10.0 mm (range 5.0-21.7 mm) in men, with gender differences due primarily to greater subcutaneous thickness in women. A trend for greater STMD in subjects with BMI greater than 25 kg/m2 was seen. Mean injectate penetration depths of 30.1 mm (range 20.2-45.6 mm) were observed with values similar in male and female subjects. Successful IM delivery was reported in 95% of subjects. When failure occurred, this was not due to inadequate injection depth. Device pressure (P max) had the greatest influence on injectate muscle penetration. CONCLUSION Use of the Zeneo® auto-injector achieves delivery depth that ensures intramuscular delivery in both men and women, regardless of BMI. Consistent with other reported data, STMD is greater in women. FUNDING Crossject.
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Abstract
Anaphylaxis is a life-threatening condition, with at-risk individuals remaining at chronic high risk of recurrence. Anaphylaxis is frequently underrecognized and undertreated by healthcare providers. The first-line pharmacologic intervention for anaphylaxis is epinephrine, and guidelines uniformly agree that its prompt administration is vital to prevent progression, improve patient outcomes, and reduce hospitalizations and fatalities. Healthcare costs potentially associated with failure to provide epinephrine (hospitalizations and emergency department visits) generally exceed those of its provision. At-risk patients are prescribed epinephrine auto-injectors to facilitate timely administration in the event of an anaphylactic episode. Despite guideline recommendations that patients carry 2 auto-injectors at all times, a significant proportion of patients fail to do so, with cost of medicine cited as one reason for this lack of adherence. With the increase of high-deductible healthcare plans, patient adherence to recommendations may be further affected by increased cost sharing. The recognition and classification of epinephrine as a preventive medicine by both the US Preventive Services Task Force and insurers could increase patient access, improve outcomes, and save lives.
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Affiliation(s)
- Leonard Fromer
- Family Medicine, UCLA School of Medicine, Los Angeles, Calif; The Group Practice Forum, New York, NY.
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Elzey MJ, Fudin J, Edwards ES. Take-home naloxone treatment for opioid emergencies: a comparison of routes of administration and associated delivery systems. Expert Opin Drug Deliv 2016; 14:1045-1058. [PMID: 27606669 DOI: 10.1080/17425247.2017.1230097] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Naloxone reversal of opioid-induced respiratory depression outside of medical facilities has become more prevalent because of the escalating opioid epidemic in the USA. Take-home naloxone for treatment of opioid emergencies is now being recommended by numerous federal, state, and professional organizations. Areas covered: The scope of the opioid overdose epidemic is reviewed along with practical, clinical, regulatory, and usability considerations for take-home naloxone routes of administration currently available and associated delivery systems. Specific opioid-related factors are discussed in detail with emphasis placed on life-threatening respiratory depression and naloxone antagonism. A clinical overview, including pharmacokinetic and FDA approval information for each take-home naloxone product is discussed in detail as well as the impact of take-home naloxone in the community. Finally, given these products are to be used in a panic-stricken, life-threatening opioid emergency, an analysis of available usability data is provided with proposed directions for further study. Expert opinion: Based on the available clinical evidence, auto-injectable naloxone should be the preferred administration route for take-home naloxone treatment until additional safety, efficacy, and comparative outcomes data are available for unconventional routes of administration that unequivocally provide equal or superior results.
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Affiliation(s)
- Mark J Elzey
- a Medical Affairs , kaleo, Inc ., Richmond , VA , USA
| | - Jeffrey Fudin
- b Scientific and Clinical Affairs at Remitigate, LLC , Delmar , NY , USA.,c PGY2 Pharmacy Pain Management, Stratton VA Medical Center , Albany , NY , USA.,d Albany College of Pharmacy & Health Sciences , Albany , NY , USA.,e Western New England University College of Pharmacy , Springfield , MA , USA
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Ridolo E, Montagni M, Bonzano L, Savi E, Peveri S, Costantino MT, Crivellaro M, Manzotti G, Lombardi C, Caminati M, Incorvaia C, Senna G. How far from correct is the use of adrenaline auto-injectors? A survey in Italian patients. Intern Emerg Med 2015; 10:937-41. [PMID: 25990486 DOI: 10.1007/s11739-015-1255-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2015] [Accepted: 05/01/2015] [Indexed: 11/29/2022]
Abstract
Self-administered adrenaline through an auto-injector is the main out-of-hospital treatment for anaphylaxis, and patients should be trained to promptly and correctly use the device. The aim of the study was to verify the proper use of the device and the correct drug administration, and to identify possible misuse by patients. In seven Italian Allergy clinics, patients who were previously provided with self-injectable adrenaline were recruited at the follow-up visit required for the renewal of their prescription. All patients completed a questionnaire covering details of their allergic reactions, and knowledge of the device. The correct use was verified by the physician using a trainer with a four-step examination. 242 patients were included; 46 patients (18 %) did not always carry the auto-injector, and 35 patients (14 %) reported situations in which they were doubtful about whether to use adrenaline. Only 39 % of patients properly managed the device, while some patients (6 %) failed in all four steps. The majority of patients considered it appropriate to use adrenaline at the onset of respiratory symptoms (56 %). The factor most closely related to proper use of the device was the education of the patient (p = 0.03), while age and the time from first prescription did not affect the ability to properly use the auto-injector. Even though accurate training is conducted, many patients are still unable to properly use the adrenaline auto-injector in case of anaphylaxis. Allergists should review the instructions provided to the patients every time a renewal of the auto-injector is prescribed.
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Affiliation(s)
- Erminia Ridolo
- Department of Clinical and Experimental Medicine, University of Parma, via Gramsci 14, 43126, Parma, Italy.
| | - Marcello Montagni
- Department of Clinical and Experimental Medicine, University of Parma, via Gramsci 14, 43126, Parma, Italy
| | - Laura Bonzano
- Department of Clinical and Experimental Medicine, University of Parma, via Gramsci 14, 43126, Parma, Italy
| | - Eleonora Savi
- Allergy Unit, G. da Saliceto Hospital, Piacenza, Italy
| | - Silvia Peveri
- Allergy Unit, G. da Saliceto Hospital, Piacenza, Italy
| | | | - Mariangiola Crivellaro
- Allergology Service, Department of Medicine and Public Health, University of Padua, Padua, Italy
| | | | - Carlo Lombardi
- Allergy and Immunology Unit, Department of Internal Medicine, Sant'OrsolaPoliambulanza Hospital, Brescia, Italy
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Simons FER, Ebisawa M, Sanchez-Borges M, Thong BY, Worm M, Tanno LK, Lockey RF, El-Gamal YM, Brown SG, Park HS, Sheikh A. 2015 update of the evidence base: World Allergy Organization anaphylaxis guidelines. World Allergy Organ J 2015; 8:32. [PMID: 26525001 PMCID: PMC4625730 DOI: 10.1186/s40413-015-0080-1] [Citation(s) in RCA: 313] [Impact Index Per Article: 34.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 09/25/2015] [Indexed: 11/10/2022] Open
Abstract
The World Allergy Organization (WAO) Guidelines for the assessment and management of anaphylaxis provide a unique global perspective on this increasingly common, potentially life-threatening disease. Recommendations made in the original WAO Anaphylaxis Guidelines remain clinically valid and relevant, and are a widely accessed and frequently cited resource. In this 2015 update of the evidence supporting recommendations in the Guidelines, new information based on anaphylaxis publications from January 2014 through mid- 2015 is summarized. Advances in epidemiology, diagnosis, and management in healthcare and community settings are highlighted. Additionally, new information about patient factors that increase the risk of severe and/or fatal anaphylaxis and patient co-factors that amplify anaphylactic episodes is presented and new information about anaphylaxis triggers and confirmation of triggers to facilitate specific trigger avoidance and immunomodulation is reviewed. The update includes tables summarizing important advances in anaphylaxis research.
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Affiliation(s)
- F Estelle R Simons
- Department of Pediatrics & Child Health and Department of Immunology, College of Medicine, Faculty of Health Sciences, The University of Manitoba, Room FE125, 820 Sherbrook Street, Winnipeg, R3A 1R9 MB Canada
| | - Motohiro Ebisawa
- Department of Allergy, Clinical Research Center for Allergy & Rheumatology, Sagamihara National Hospital, Sagamihara, Kanagawa Japan
| | - Mario Sanchez-Borges
- Allergy and Clinical Immunology Department, Centro Medico-Docente La Trinidad, Caracas, Venezuela
| | - Bernard Y Thong
- Department of Rheumatology, Allergy & Immunology, Tan Tock Seng Hospital, Singapore, Singapore
| | - Margitta Worm
- Allergie-Centrum-Charite, Klinik fur Dermatologie, Venerologie und Allergologie, Campus Charite Mitte, Universitatsmedizin, Berlin, Germany
| | - Luciana Kase Tanno
- Department of Allergy and Clinical Immunology, Hospital Servidor Publico Estadual de Sao Paulo and Hospital Sirio-Libanes, Sao Paulo, Brazil
| | | | - Yehia M El-Gamal
- Pediatric Allergy and Immunology Unit, Children's Hospital, Ain Shams University, Cairo, Egypt
| | - Simon Ga Brown
- Royal Hobart Hospital, Tasmania, and University of Western Australia and Royal Perth Hospital, Perth, Western Australia
| | - Hae-Sim Park
- Department of Allergy & Clinical Immunology, Ajou University School of Medicine, Seoul, South Korea
| | - Aziz Sheikh
- Allergy & Respiratory Research Group, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, UK
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Song TT. Letter to the editor for the article " Auto-injector needle length may be inadequate to deliver epinephrine intramuscularly in women with confirmed food allergy". Allergy Asthma Clin Immunol 2014; 10:54. [PMID: 25685163 PMCID: PMC4326436 DOI: 10.1186/1710-1492-10-54] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 10/15/2014] [Indexed: 11/10/2022] Open
Abstract
Letter to the Editor for "Auto-injector needle length may be inadequate to deliver epinephrine intramuscularly in women with confirmed food allergy" by Tsai et al. There are limitations of this study note mentioning such as method of compression, role of propulsion, defining those patients who are at risk of prophylaxis and future studies.
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Affiliation(s)
- T Ted Song
- Division of Allergy and Infectious Diseases, University of Washington, School of Medicine, Seattle, WA USA
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Topal E, Bakirtas A, Yilmaz O, Karagol IHE, Arga M, Demirsoy MS, Turktas I. When should we perform a repeat training on adrenaline auto-injector use for physician trainees? Allergol Immunopathol (Madr) 2014; 42:472-5. [PMID: 24176470 DOI: 10.1016/j.aller.2013.07.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Revised: 06/22/2013] [Accepted: 07/06/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND Studies demonstrate that both doctors and patients may use adrenaline auto-injector improperly and the usage skills are improved by training. In this study, we aimed to determine the appropriate frequency of training to maintain skills for adrenaline auto-injector use. METHODS We invited all interns of 2011-2012 training period. At baseline, all participants were given theoretical and practical training on adrenaline auto-injector use. The participants were randomly assigned into two groups. We asked those in group 1 to demonstrate the use of adrenaline auto-injector trainer in the third month and those in group 2 in the sixth month. RESULTS One hundred and sixty interns were enrolled. Compared with the beginning score, demonstration of skills at all the steps and total scores did not change for the group tested in the third month (p=0.265 and p=0.888, respectively). However; for the group examined in the sixth month; the demonstration of skills for proper use of the auto-injector at all steps and the mean time to administer adrenaline decreased (p=0.018 and p<0.001, respectively). Besides, the group which was tested in the third month was better than the group which was tested in the sixth month in terms of demonstrating all steps (p=0.014), the total score (p=0.019), mean time of change to administer adrenaline (p<0.001) and presumptive self-injection into thumb (p=0.029). CONCLUSIONS Auto-injector usage skills of physician trainees decrease after the sixth month and are better in those who had skill reinforcement at 3 months, suggesting continued education and skill reinforcement may be useful.
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Affiliation(s)
- E Topal
- Department of Pediatric Allergy and Asthma, Gazi University Faculty of Medicine, Ankara, Turkey.
| | - A Bakirtas
- Department of Pediatric Allergy and Asthma, Gazi University Faculty of Medicine, Ankara, Turkey
| | - O Yilmaz
- Department of Pediatric Allergy and Asthma, Gazi University Faculty of Medicine, Ankara, Turkey
| | - I H E Karagol
- Department of Pediatric Allergy and Asthma, Gazi University Faculty of Medicine, Ankara, Turkey
| | - M Arga
- Department of Pediatric Allergy and Asthma, Gazi University Faculty of Medicine, Ankara, Turkey
| | - M S Demirsoy
- Department of Pediatric Allergy and Asthma, Gazi University Faculty of Medicine, Ankara, Turkey
| | - I Turktas
- Department of Pediatric Allergy and Asthma, Gazi University Faculty of Medicine, Ankara, Turkey
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Kim L, Nevis IF, Tsai G, Dominic A, Potts R, Chiu J, Kim HL. Children under 15 kg with food allergy may be at risk of having epinephrine auto-injectors administered into bone. Allergy Asthma Clin Immunol 2014; 10:40. [PMID: 25110478 PMCID: PMC4126643 DOI: 10.1186/1710-1492-10-40] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Accepted: 07/16/2014] [Indexed: 01/01/2023] Open
Abstract
Background The Epipen® Jr and Allerject® 0.15 mg are currently the most commonly prescribed epinephrine auto-injectors (EAIs) for the management of anaphylaxis in pediatric patients in North America and Canada. To ensure rapid absorption, it should be administered intramuscularly into the anterolateral aspect of the thigh. We examined whether the 12.7-mm needle length of the Epipen® Jr and Allerject® 0.15 mg is adequate for delivering epinephrine intramuscularly in pediatric patients who weighed <15 kg. Methods Consecutive pediatric patients with food allergy weighing <15 kg who required an EAI were included. Ultrasounds of the mid-anterolateral thigh were performed under minimal (min) and maximal (max) pressure. Skin-to-muscle depth (STMD) and skin-to-bone depth (STBD) measurements were completed. Baseline characteristics were compared between patients with a STBDmax <12.7 mm vs. ≥12.7 mm. Linear regression including variables such as age, sex, body mass index (BMI) and race was performed. The proportion of patients with a STBDmax <12.7 mm was compared in those weighing <10 kg vs. 10–14.9 kg. Results One hundred patients were included; 29 (29%) had STBDmax <12.7 mm. Height (p = 0.02) and weight (p = 0.0002) differed significantly between the two groups. Approximately 19% of those weighing 10–14.9 kg and 60% of those <10 kg had a STBDmax <12.7 mm. In the multivariable regression analysis, BMI was found to be a significant predictor of STBDmax. Conclusions A large proportion of children <15 kg prescribed an EAI is at risk of having the auto-injector administered into bone. Since alternative EAIs with shorter needle lengths are not currently available, EAIs should be prescribed with appropriate counselling in this population.
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Affiliation(s)
- Laura Kim
- Department of Anatomy and Cell Biology, McGill University, Montreal, Quebec, Canada
| | - Immaculate Fp Nevis
- Michael D. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada ; Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Gina Tsai
- Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Arunmozhi Dominic
- Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Ryan Potts
- Department of Biology, University of Waterloo, Waterloo, Ontario, Canada
| | - Jack Chiu
- Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Harold L Kim
- Michael D. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada ; Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada ; 525 Belmont Avenue West, Suite 205, Kitchener N2M 5E2, Ontario, Canada
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Tsai G, Kim L, Nevis IF, Dominic A, Potts R, Chiu J, Kim HL. Auto-injector needle length may be inadequate to deliver epinephrine intramuscularly in women with confirmed food allergy. Allergy Asthma Clin Immunol 2014; 10:39. [PMID: 25071856 PMCID: PMC4112615 DOI: 10.1186/1710-1492-10-39] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Accepted: 07/11/2014] [Indexed: 01/09/2023] Open
Abstract
Background Epinephrine auto-injectors are the standard first aid treatment for anaphylaxis. Intramuscular delivery into the anterolateral aspect of the thigh is recommended for optimal onset of action of epinephrine. The most frequently prescribed auto-injector in North America and Canada is the EpiPen®, which has a needle length of 15.2 mm. Currently, it is unknown whether this needle length is adequate for intramuscular delivery of epinephrine in adult patients at risk of anaphylaxis. Methods One hundred consecutive adult patients with confirmed food allergy requiring an epinephrine auto-injector were recruited. Skin to muscle depth (STMD) at the right mid-anterolateral thigh was measured using ultrasound under minimal (min) and maximum (max) pressure. The EpiPen® needle length was considered adequate if STMDmax was ≤15.2 mm. Baseline characteristics including age, gender, ethnicity, and body mass index (BMI) were compared in patients with STMDmax ≤15.2 mm vs. >15.2 mm. Results The EpiPen® needle length of 15.2 mm was inadequate for intramuscular delivery in 19 of the 100 enrolled patients (19%), all of whom were female; 28% of women had a STMDmax >15.2 mm. The mean STMDmax in the ≤15.2-mm and >15.2-mm groups were 9 ± 4 mm and 20 ± 4 mm, respectively (p = 0.0001). Linear regression analysis found BMI to be significantly associated with STMDmax after adjusting for age (p < 0.001). Conclusions The needle length of the epinephrine auto-injectors may not be adequate for intramuscular delivery of epinephrine in a large proportion of women with food allergy; this may impact morbidity and mortality from anaphylaxis in this patient population.
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Affiliation(s)
- Gina Tsai
- Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Laura Kim
- Department of Anatomy and Cell Biology, McGill University, Montreal, Quebec, Canada
| | - Immaculate Fp Nevis
- Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada ; Michael D. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Arunmozhi Dominic
- Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Ryan Potts
- Department of Biology, University of Waterloo, Waterloo, Ontario, Canada
| | - Jack Chiu
- Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Harold L Kim
- Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada ; Michael D. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada ; 525 Belmont Avenue West, Suite 205, Kitchener, Ontario N2M 5E2, Canada
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