Feature

5 questions patients may have about epinephrine shortage, how PCPs can answer

Janna Tuck
Janna Tuck

The last few weeks of summer can be an exceptionally difficult time to find an epinephrine auto-injector in some parts of the country, an allergist told Healio Primary Care.

“The epinephrine auto-injector has joined notebooks, pencils and folders as an item on many back-to-school shopping lists,” Janna Tuck, MD, an allergist in Santa Fe, New Mexico, and American College of Allergy, Asthma and Immunology spokesperson, said in an interview. 

“While most of the epinephrine auto-injector shortages this causes are only short-term, last year there were some New Mexico residents who couldn’t get any kind of epinephrine for 8 weeks,” she added.

The shortage in the southwestern U.S. is not an isolated one. Several reports suggest epinephrine is not always available even in places where it might be expected:

  • 36% of 433 summer camps that responded to an online questionnaire that was sent to members of three online summer camp directories in the summer of 2012 did not have epinephrine auto-injectors, according to a study in Pediatric Emergency Care.
  • 81.7% of 242 school nurses who responded to an electronic survey distributed at the 2016 National Association of School Nurses meeting and through the Allergy and Asthma Network listserv said their schools did not stock epinephrine, according to research that was published in Annals of Allergy, Asthma and Immunology.
  • 88% of 122 urgent care administrators that were also members of the American Academy of Urgent Care Medicine that responded to an electronic questionnaire did not have an IV form of epinephrine, according to a 2016 study in Pediatric Emergency Care.

The number of children diagnosed with food allergy grew from 8% in 2009-2010 to 9.3% in 2015-2016. This trend is expected to increase in the future, according to a study in the Internal Medicine Journal, and with this need, concern over the availability of epinephrine auto-injectors is likely to continue.

Below, Tuck and other published sources provide answers to five possible questions that primary care physicians can give to patients and their parents regarding these shortages. – by Janel Miller

How can I find an epinephrine auto-injector near me?

“Even if you personally don’t have these medical devices, encourage your patient to find, or help them find, a pharmacist or allergist that either has an epinephrine auto-injector or knows one that does,” Tuck said.

“If you don’t know the allergists in your area, the ACAAI’s website has a tool (https://acaai.org/locate-an-allergist) that can help find these details for allergists in every part of the United States,” she added.

 
The last few weeks of summer can be an exceptionally difficult time to find an epinephrine auto-injector in some parts of the country, an allergist told Healio Primary Care.

Source:Shutterstock

My epinephrine has expired and no allergist or pharmacist near me has one. What can I do?

Tuck said PCPs who encounter this question need to assure their patients that using an outdated auto-injector, while not ideal, is safe.

“Advise your patients that they should not throw their auto-injectors away until they have a replacement, because it’s better to use expired epinephrine than to have no epinephrine at all,” she said. “So long as the medication in the auto-injector’s window isn’t discolored, it can be used.”

Patients may also be reassured to know that in August 2018, the FDA extended the expiration date of certain lots of 0.3 mg products by 4 months. In addition, a study published in Annals of Internal Medicine found that EpiPens remain effective well beyond their expiration date.

Can I switch back and forth between the different types of epinephrine?

Unlike other medications, patients can switch between the name brands and generic versions of epinephrine without consequence, according to Tuck.

“Advise your patients that any auto-injector cleared by the FDA is just as good as another,” she said.

Another possible alternative that you can provide patients buying the supplies to make their own auto-injector — comes with a significant caveat, researchers wrote in the Journal of Allergy Clinical Immunology in Practice.

“The disadvantage of prescribing an epinephrine ampule with an empty syringe is that more skill is required to properly administer the medication in an emergency as compared with auto-injectors. Parents of patients with anaphylaxis take significantly longer to draw up epinephrine from an ampule as compared with emergency department nurses. The epinephrine content of doses drawn up by parents also ranged 40-fold as compared with twofold for emergency department nurses,” Amber N. Pepper, MD, division of allergy and immunology at the University of South Florida and colleagues wrote.

“Therefore, the training required to draw up the correct dose of epinephrine from an ampule may be too complicated for many patients. Although the ampule and syringe is a less reliable method for epinephrine self-administration, it is an option for health care professionals,” they added.

Why can’t I just use an antihistamine until epinephrine becomes available?

Doctors may realize the dangers of using an antihistamine to treat anaphylaxis but a survey indicates patients do not. The poll, which appeared in the Journal of Allergy and Clinical Immunology, showed 36% of 344 adults with a reported anaphylaxis incident and 37% of 261 adults with a confirmed anaphylaxis incident intended to take an antihistamine with their next attack.

Studies suggest patients with this mindset may be risking their lives.

“Although histamine is involved in anaphylaxis, treatment with antihistamines does not relieve or prevent all of the pathophysiological symptoms of anaphylaxis, including the more serious complications such as airway obstruction, hypotension, and shock,” Stanley M. Fineman, MD, an adjunct associate professor at the Emory University School of Medicine, wrote in Postgraduate Medicine.

Tuck and Larissa S. Dudley, MD, of the Newark Beth Israel Medical Center, and colleagues, provided more rationale for not using antihistamines during anaphylaxis.

“These products can take upwards of an hour to work, and your patient may be dead in that amount of time if they are having a very severe reaction. Tell your patients to use the epinephrine and go to the nearest emergency room immediately,” Tuck said.

“Administration of an antihistamine may mask the cutaneous symptoms of anaphylaxis, potentially delaying treatment with epinephrine,” Dudley, et al, added in a Western Journal of Emergency Medicine article.

I am only finding name brands of auto-injectors, and they are too expensive. Why can’t I just go without one until the shortage is over?

Data in Current Opinion in Pediatrics indicating the number of anaphylaxis-related ED visits among U.S. children doubled from 5.7 to 11.7 per 10,000 visits from 2009 to 2013.

Tuck said that point alone should provide enough incentive for parents to find a way to get epinephrine auto-injectors regardless of cost, but if not, she suggested that PCPs remind patients of the financial assistance programs that many pharmaceutical companies offer. 

References:

Dudley LS, et al. West J Emerg Med. 2015;doi:10.5811./westjem.2015.3.25337.

Farbman KS, Michelson KA. Curr Opin Pediatr. 2016;doi:10.1097/MOP.0000000000000340.

Fineman SM. Postgrad Med. 2014;doi:10.3810/pgm.2014.07.2785.

Kao LM, et al. Ann Allergy Asthma Immunol. 2018;doi:10.1016/j.anai.2017.12.019.

Olympia RP, et al. Pediatr Emerg Care. 2015;doi:10.1097/PEC.000000000000379.

Pepper AN, et al. J Allergy Clin Immunol Pract, 2017;doi:10.1016/j.jaip.2016.12.018.

Tang ML, Mullins RJ. Intern Med J. 2017;doi:10.1111/imj.13362.

Wilkinson R. Pediatr Emerg Care. 2016;doi:10.1097/PEC.0000000000000698.

Wood RA, et al. J Allergy Clin Immunol. 2013;doi:08.016.

Disclosures: Tuck reports no relevant financial disclosures. Please see the cited studies for those authors’ relevant financial disclosures.

Janna Tuck
Janna Tuck

The last few weeks of summer can be an exceptionally difficult time to find an epinephrine auto-injector in some parts of the country, an allergist told Healio Primary Care.

“The epinephrine auto-injector has joined notebooks, pencils and folders as an item on many back-to-school shopping lists,” Janna Tuck, MD, an allergist in Santa Fe, New Mexico, and American College of Allergy, Asthma and Immunology spokesperson, said in an interview. 

“While most of the epinephrine auto-injector shortages this causes are only short-term, last year there were some New Mexico residents who couldn’t get any kind of epinephrine for 8 weeks,” she added.

The shortage in the southwestern U.S. is not an isolated one. Several reports suggest epinephrine is not always available even in places where it might be expected:

  • 36% of 433 summer camps that responded to an online questionnaire that was sent to members of three online summer camp directories in the summer of 2012 did not have epinephrine auto-injectors, according to a study in Pediatric Emergency Care.
  • 81.7% of 242 school nurses who responded to an electronic survey distributed at the 2016 National Association of School Nurses meeting and through the Allergy and Asthma Network listserv said their schools did not stock epinephrine, according to research that was published in Annals of Allergy, Asthma and Immunology.
  • 88% of 122 urgent care administrators that were also members of the American Academy of Urgent Care Medicine that responded to an electronic questionnaire did not have an IV form of epinephrine, according to a 2016 study in Pediatric Emergency Care.

The number of children diagnosed with food allergy grew from 8% in 2009-2010 to 9.3% in 2015-2016. This trend is expected to increase in the future, according to a study in the Internal Medicine Journal, and with this need, concern over the availability of epinephrine auto-injectors is likely to continue.

Below, Tuck and other published sources provide answers to five possible questions that primary care physicians can give to patients and their parents regarding these shortages. – by Janel Miller

How can I find an epinephrine auto-injector near me?

“Even if you personally don’t have these medical devices, encourage your patient to find, or help them find, a pharmacist or allergist that either has an epinephrine auto-injector or knows one that does,” Tuck said.

“If you don’t know the allergists in your area, the ACAAI’s website has a tool (https://acaai.org/locate-an-allergist) that can help find these details for allergists in every part of the United States,” she added.

 
The last few weeks of summer can be an exceptionally difficult time to find an epinephrine auto-injector in some parts of the country, an allergist told Healio Primary Care.

Source:Shutterstock

My epinephrine has expired and no allergist or pharmacist near me has one. What can I do?

Tuck said PCPs who encounter this question need to assure their patients that using an outdated auto-injector, while not ideal, is safe.

“Advise your patients that they should not throw their auto-injectors away until they have a replacement, because it’s better to use expired epinephrine than to have no epinephrine at all,” she said. “So long as the medication in the auto-injector’s window isn’t discolored, it can be used.”

Patients may also be reassured to know that in August 2018, the FDA extended the expiration date of certain lots of 0.3 mg products by 4 months. In addition, a study published in Annals of Internal Medicine found that EpiPens remain effective well beyond their expiration date.

Can I switch back and forth between the different types of epinephrine?

Unlike other medications, patients can switch between the name brands and generic versions of epinephrine without consequence, according to Tuck.

“Advise your patients that any auto-injector cleared by the FDA is just as good as another,” she said.

Another possible alternative that you can provide patients buying the supplies to make their own auto-injector — comes with a significant caveat, researchers wrote in the Journal of Allergy Clinical Immunology in Practice.

“The disadvantage of prescribing an epinephrine ampule with an empty syringe is that more skill is required to properly administer the medication in an emergency as compared with auto-injectors. Parents of patients with anaphylaxis take significantly longer to draw up epinephrine from an ampule as compared with emergency department nurses. The epinephrine content of doses drawn up by parents also ranged 40-fold as compared with twofold for emergency department nurses,” Amber N. Pepper, MD, division of allergy and immunology at the University of South Florida and colleagues wrote.

“Therefore, the training required to draw up the correct dose of epinephrine from an ampule may be too complicated for many patients. Although the ampule and syringe is a less reliable method for epinephrine self-administration, it is an option for health care professionals,” they added.

Why can’t I just use an antihistamine until epinephrine becomes available?

PAGE BREAK

Doctors may realize the dangers of using an antihistamine to treat anaphylaxis but a survey indicates patients do not. The poll, which appeared in the Journal of Allergy and Clinical Immunology, showed 36% of 344 adults with a reported anaphylaxis incident and 37% of 261 adults with a confirmed anaphylaxis incident intended to take an antihistamine with their next attack.

Studies suggest patients with this mindset may be risking their lives.

“Although histamine is involved in anaphylaxis, treatment with antihistamines does not relieve or prevent all of the pathophysiological symptoms of anaphylaxis, including the more serious complications such as airway obstruction, hypotension, and shock,” Stanley M. Fineman, MD, an adjunct associate professor at the Emory University School of Medicine, wrote in Postgraduate Medicine.

Tuck and Larissa S. Dudley, MD, of the Newark Beth Israel Medical Center, and colleagues, provided more rationale for not using antihistamines during anaphylaxis.

“These products can take upwards of an hour to work, and your patient may be dead in that amount of time if they are having a very severe reaction. Tell your patients to use the epinephrine and go to the nearest emergency room immediately,” Tuck said.

“Administration of an antihistamine may mask the cutaneous symptoms of anaphylaxis, potentially delaying treatment with epinephrine,” Dudley, et al, added in a Western Journal of Emergency Medicine article.

I am only finding name brands of auto-injectors, and they are too expensive. Why can’t I just go without one until the shortage is over?

Data in Current Opinion in Pediatrics indicating the number of anaphylaxis-related ED visits among U.S. children doubled from 5.7 to 11.7 per 10,000 visits from 2009 to 2013.

Tuck said that point alone should provide enough incentive for parents to find a way to get epinephrine auto-injectors regardless of cost, but if not, she suggested that PCPs remind patients of the financial assistance programs that many pharmaceutical companies offer. 

References:

Dudley LS, et al. West J Emerg Med. 2015;doi:10.5811./westjem.2015.3.25337.

Farbman KS, Michelson KA. Curr Opin Pediatr. 2016;doi:10.1097/MOP.0000000000000340.

Fineman SM. Postgrad Med. 2014;doi:10.3810/pgm.2014.07.2785.

Kao LM, et al. Ann Allergy Asthma Immunol. 2018;doi:10.1016/j.anai.2017.12.019.

Olympia RP, et al. Pediatr Emerg Care. 2015;doi:10.1097/PEC.000000000000379.

Pepper AN, et al. J Allergy Clin Immunol Pract, 2017;doi:10.1016/j.jaip.2016.12.018.

Tang ML, Mullins RJ. Intern Med J. 2017;doi:10.1111/imj.13362.

Wilkinson R. Pediatr Emerg Care. 2016;doi:10.1097/PEC.0000000000000698.

Wood RA, et al. J Allergy Clin Immunol. 2013;doi:08.016.

Disclosures: Tuck reports no relevant financial disclosures. Please see the cited studies for those authors’ relevant financial disclosures.