Anaphylaxis and Epinephrine—You've Got to Get It Right
I attended a session at the American Academy of Allergy Asthma & Immunology conference in Philadelphia about food allergy and anaphylaxis led by the highly esteemed Dr. F. Estelle Simons of the University of Manitoba and the former president of the AAAAI.
Her portion of the seminar focused on epinephrine as the cornerstone of treatment for anaphylaxis. She emphasized that epinephrine is on the WHO's worldwide approved list of drugs because there is no alternative. However, epinephrine delivery is fraught with error on all levels of treatment: from doctors, nurses and hospitals to us, the consumers. Dr. Simons asserted that if there is any so-called failure of this treatment, it is usually because of human error.
Epinephrine Often Delivered Incorrectly
Some people don't use epinephrine when they should. Why? Sometimes they don't recognize the symptoms of anaphylaxis, as they can be very subjective.
Problem 1: Novel triggers — According to a study conducted by Dr. Simmons and published in the Journal of Clinical Immunology in February 2006 (JACI), sometimes anaphylaxis happens in response to a novel trigger, i.e. a previously unrecognized trigger. Sometimes, "...an allergen might be novel in one population but not in another, depending on geographic location, age, and occupation, and the clinical importance of an allergen might increase over time (e.g., allergic reactions to sesame are increasing in the ''developed'' world)"... In this case, a patient might not know what to look for.
Problem 2: Missed Symptoms — Even in hospitals, some doctors are only looking for symptoms of shock. Shock, as defined by the NIH, occurs when the body is not getting enough blood flow and includes symptoms such as rapid or weak pulse, fainting, light-headedness or dizziness. Another example: skin symptoms (itching, hives, redness, swelling) appear 80% to 90% of the time during anaphylaxis, but are often overlooked.
Problem 3: Previous mild occurrences — Dr. Simons said, "Spontaneous recovery can happen from a mild anaphylactic response; the body has a way of fighting off a mild episode." Perhaps someone had a previously mild occurrence that went away without medication, so they believe medication is not necessary. On the contrary, everyone should still discuss their allergy action plan with their doctor and make sure they understand what to do for any form and any level of anaphylactic response.
Other Reasons Epinephrine May Not Seem To Work
The delivery devices (such as the EpiPen) need a design update. There is an inadequate range of doses for different ages, weights etc. and often the needle in the auto injector is either too low or too short.
For example, Dr. Simons presented an unrelated study that showed that the fat layer on many women's thigh muscles, the optimal auto-injection site, is thicker than previously believed. This fat layer is often thicker than the needle is long. This means that if a person is in an environment (restaurant, school, office, street) where they feel they can't remove their clothing, the needle in the current injector might not penetrate deep enough past their clothing and past the layer of thigh fat (in many women) to get into the muscle and deliver the lifesaving dose of epinephrine.
Additionally, doctors and laypeople often don't know how to administer the auto injector correctly. There have been several cases, especially with parents trying to inject children, when someone accidentally injected themselves, usually puncturing their own finger, thus needing a trip to the hospital for the damaged digit and the lost of the much-needed dose.
At Dr. Simon's session, participants had an opportunity to inject an orange with an empty, but fully functional, auto injector. She wanted session participants not only to know how to administer the medication properly, but to highlight how many health professionals do not know how to use the auto-injectors properly.
This goes to show that everyone needs practice on how to properly administer the auto injector. Also, as this medicine is labile (meaning that even with preservatives, it expires within a year and half of production), Dr. Simons suggested that people could use their outdated EpiPens to practice on an orange to get a feel of how to get the optimal medicine delivery in the quickest time, should you ever need to. However, MAKE SURE YOUR FINGERS ARE OUT OF THE WAY!
If you have been given a prescription for epinephrine but do not know how to use it, talk with your health care provider, go over the need for it, go over your allergy action plan and make sure that everyone in your household, school or office knows the plans and how to administer the medication.
The Future of Epinephrine Delivery
Future plans exist to increase the availability and usability of epinephrine. Teams are working on a sublingual tab, an easy-to-use red button on the auto injectors and oral inhalation and intranasal inhalation devices.
Dr. Simons main point was to stress that receiving a therapeutic dose of epinephrine quickly in response to any level of an allergic anaphylaxis can mean the difference between life and death.