Having two epipens has become more difficult for patients due to recent shortages, rising prices and manufacturing difficulties. Anaphylaxis is a life-threatening allergic reaction characterized by skin, respiratory and gastrointestinal allergy symptoms with a rapid onset. Anaphylaxis affects both adults and children and it can occur up to 2% of the population. Among pediatrics, the most common trigger is food and in adults, medication and insect venom.
Anaphylaxis requires immediate medical treatment with epinephrine for stabilization of symptoms until the patient can reach an emergency room. The first line treatment is epinephrine, however it is only used 50% of the time. A second dose of epinephrine is required in 16% to 36% of patients who experience anaphylaxis. People who are more prone to needing a second dose of epinephrine are those who have asthma and food allergy. Approximately 30% of patients do not carry any epinephrine auto injectors, and about 10% of those devices have passed expiration dates.
Epinephrine auto injectors are relatively easy to use, but now with multiple devices on the market and new ones coming out, caregivers may not know how to use them immediately. Education of patients on the correct use of their epinephrine auto injectors is a key factor in the management of anaphylaxis.
A recent study published in The Journal of Allergy and Clinical Immunology: In Practice, took a survey of nearly 1000 respondents to see how they followed management guidelines.
- 82% of respondents did not carry two epipens (or 2 of any autoinjectors), the main reason given was to have 1 in another location.
- 84% keep 1 auto injector at home.
- most people had only 1 auto injector available to them at a specific location (home 22%, work 2%, caregivers 27%, school 10%).
- half of respondents reported needing to use a second epinephrine dose in a previous event.
- 45% of respondents who sought emergency care did so because of unavailability of a second dose.
The Joint Task Force on Practice Parameters guidelines recommend that patients at risk carry two epipens at all times (or any auto injector). A substantial proportion of children (33%) did not have any Epi at school. This finding suggests that it would be beneficial to keep an unassigned stock of devices in school settings.
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Early epinephrine administration has been associated with a decreased risk of hospitalization. It is important to ensure access to more than 1 device across all locations.
Unfortunately with rising prices of epinephrine auto injectors, shortages, lack of insurance coverage, may make it difficult for patients to have two epinephrine auto injectors available at all locations.
Update July 15, 2022
A recent study published in JACI, showed that nearly 8% of anaphylactic reactions need more than 1 dose of epinephrine. This study reviewed literature from 1946 to 2020 and involved a total of 36,557 events. 7.7% of anaphylaxis from any cause required multiple doses. 3 more doses were used in 2.2% of reactions overall. Repeat doses are more frequently needed for reactions to venom compared with foods. It is important for patients to carry 2 autoinjectors and recognize anaphylaxis signs and administer epinephrine as soon as possible. Repeat the dose every 5 to 15 minutes, if the response is inadequate and to avoid subcutaneous and deltoid administration.
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