Q&A: What Is Responsible for the Underuse of Epinephrine?
Allergies, whether to food, medications, latex, or another source, are the 6th leading cause of chronic illness in the United States, with more than 50 million Americans experiencing reactions each year, according to the Centers for Disease Control and Prevention.1
Although epinephrine auto-injectors (EAIs) are a first-line treatment for anaphylaxis, recommended for use at the first sign of allergic reaction, a new study has found that emergency use and daily carriage of EAIs is inadequate.2
Consultant360 spoke with study authors Christopher M Warren, PhD(c), from the University of Southern California Keck School of Medicine, Justin Zaslavsky from the Tufts University Department of Community Health, and Ruchi S Gupta, MD, MPH, who is a Professor of Pediatrics and Medicine at Northwestern University Feinberg School of Medicine, about their findings and how these trends could be improved.
Consultant360: What is the effect on outcomes and care when patients without an available EAI go into anaphylaxis and are treated by emergency services?
Authors: With respect to care, the primary medication one would receive from emergency services to stop an anaphylactic reaction is the same as the medication in an EAI. But, what an auto-injector offers that emergency services does not is time. Amidst an anaphylactic event, time is of the essence, and the ability to safely wait for an ambulance might not exist. This is why it is important for individuals to have their own epinephrine on hand. This is the same reason why stock epinephrine is so important. Additionally, to more specifically answer your question about the care provided, any delay in epinephrine might mean that the patient will need more acute care in treating the reaction. This can impact both the type and cost of care received.
Overall, the most important message is this: A person at risk for anaphylaxis should always have epinephrine close by, epinephrine should be used in a timely way when a person is experiencing a severe allergic reaction, and he/she/they should always seek emergency services after epinephrine is used.
C360: The US Food and Drug Administration (FDA) recently updated the status of the EpiPen supply shortage that first occurred in 2017. How can healthcare providers reassure patients in areas with limited availability of auto-injectors? What other options are available to these patients?
Authors: One way to reassure patients is to ensure they know that there are other alternative epinephrine products besides the EpiPen that can be used safely and effectively. For example, other FDA-approved devices include the Auvi-Q and Adrenaclick. Regarding the shortages mentioned, it is important to note that there was a shortage of EpiPen devices, not epinephrine itself, which remains widely available.
C360: How do you think the potential future introduction of intranasal epinephrine could affect the rates you observed in your study?
Authors: This is an interesting question, and we are as curious to know the answer as you are! Thinking about the effect of intranasal epinephrine, one important piece is going to be cost, as the majority of our sample (68%) said that reducing cost would improve access to epinephrine. Thus, if it were provided as an equally effective, less expensive option, it might be able to improve the rates we observed. More anecdotally, we see that another barrier to epinephrine use is fearing the needle within the device. Intranasal epinephrine might mitigate this barrier. All clinicians and educators need to help dissipate these fears, since most people who have used an epinephrine auto-injector in their life report not feeling or barely feeling the needle, and you never actually see the needle. Making people feel more comfortable knowing when and how to use epinephrine is critical.
C360: Besides the factors laid out in your study and the fear of needles, are there any other notable barriers to epinephrine use? If so, how can these barriers be overcome?
Authors: Because anaphylaxis management practices must be tailored to each patient’s individual lifestyle, there exist many potential barriers to proper anaphylaxis management. Patients and families at risk of anaphylaxis must learn how to identify and overcome these specific barriers as they prepare for—and react to—an anaphylactic emergency. However, in addition to barriers, it is also important to think about factors that facilitate effective anaphylaxis management.
One important facilitator that we identified in our study was perceived social support. Patients who felt that their friends and extended family supported them in the management of their allergy, were significantly more likely to fill their EAI prescription, report routinely carrying it, and more likely to use it during their most severe allergic reaction. We also found that knowledge of how and when to effectively use an epinephrine auto-injector was an important facilitator of effective allergy management. Specifically, patients who felt that they could effectively use an auto-injector to treat a severe reaction, patients who knew how to recognize the signs/symptoms of a severe allergic reaction, and patients who knew the steps to use an auto-injector were also significantly more likely to fill their EAI prescription, to report routinely carrying it, and to use it during a severe allergy emergency. Finally, patient empowerment also appears to be an important facilitator of effective allergy management. Specifically, patients endorsing the following beliefs were significantly more likely to adhere to recommended management practices than those who did not: Carrying epinephrine makes me feel safer in social situations involving my allergen, and Carrying epinephrine improves my quality of life.
Each of the aforementioned facilitators can be bolstered through timely, effective patient education efforts. Educational resources can be provided by physicians and nurses during clinical visits, through food allergy support groups, and/or via online resources, such as the peer educational videos available on our website. Given how important it is to ensure that patients are educated and empowered to effectively manage their allergies, our team is constantly working to develop tools and messages to more effectively educate patients and their families about anaphylaxis management.3
—Michael Potts
References:
1. Allergies. Centers for Disease Control and Prevention. Page last updated on September 15, 2017. https://www.cdc.gov/healthcommunication/toolstemplates/entertainmented/tips/Allergies.html. Accessed June 26, 2018.
2. Warren CW, Zaslavsky JM, Kan K, et al. Auto-injector carriage and use practices among US children, adolescents, and adults [published online June 21, 2018]. Annals of Allergy, Asthma Immunology. doi: 10.1016/j.anai.2018.06.010.
3. Visit teamsoaar.com for more.