Autoinjector Prescription Research Articles

Socioeconomic factors and epinephrine prescription in children with peanut allergy

Epinephrine autoinjectors provide life-saving therapy for individuals with peanut allergies. OJECTIVE: To evaluate the association between socioeconomic status (SES) and epinephrine prescription among urban Canadian children with peanut allergy. Population-based survey data from school children in grades 1 and 2 participating in the Toronto Child Health Evaluation Questionnaire were used. Children with peanut allergy, their epinephrine autoinjector prescription status and their SES were identified by parental report. Between January and April 2006, 5619 completed questionnaires from 231 Toronto, Ontario, schools were returned. A total of 153 (2.83%) children were identified as having a peanut allergy, 68.6% of whom reported being prescribed an epinephrine autoinjector. Children from upper-middle and high-income homes (OR 8.35 [95% CI 2.72 to 25.61]) and with asthma (OR 4.74 [95% CI 1.56 to 14.47]) were more likely to report having an epinephrine prescription. A significant health disparity exists in the prescribing pattern of epinephrine autoinjectors for peanut-allergic children from families of differing SES.

Management of anaphylaxis in primary care: Canadian expert consensus recommendations

Anaphylaxis is often managed inadequately. We used findings from a systematic review of gaps in anaphylaxis management to develop evidence-based recommendations for gaps rated as clinically important by a panel of Canadian allergy experts. The nominal group technique (NGT) consensus methodology was used to develop evidence-based recommendations for the management of anaphylaxis in primary care. Physician-specific gaps from our systematic review were prioritized by consensus meeting participants in two rounds, which involved the rating, discussion, and re-rating of gaps. Using current anaphylaxis guidelines, recommendations were then developed for each category of gaps that were identified by the panel as clinically important. Thirty unique physician gaps from the systematic review were categorized according to gaps of knowledge and anaphylaxis practice behaviors. The panel rated diagnosis of anaphylaxis, and when and how to use epinephrine auto-injectors as clinically important knowledge gaps; and rated infrequent or delayed epinephrine administration, low rate of auto-injector prescription, and infrequent or no referrals to allergy specialists after a reaction as important practice behavior gaps. Evidence from four guidelines was used to support the consensus recommendation statements for three resulting categories of gap themes: anaphylaxis management, epinephrine use, and follow-up care. We used an NGT consensus methodology to develop an educational resource for primary care physicians and allergists to better understand how to manage patients with anaphylaxis. Next steps include testing our findings against observed data in primary care settings and to develop other strategies or tools to overcome gaps in anaphylaxis management.

Epinephrine and its use in anaphylaxis: current issues

Epinephrine is a life-saving medication in the treatment of anaphylaxis, in which it has multiple beneficial pharmacologic effects. Here, we examine the evidence base for its primary role in the treatment of anaphylaxis episodes in community settings. We review the practical pharmacology of epinephrine in anaphylaxis, its intrinsic limitations, and the pros and cons of different routes of administration. We provide a new perspective on the adverse effects of epinephrine, including its cardiac effects. We describe the evidence base for the use of epinephrine in anaphylaxis. We discuss the role of epinephrine auto-injectors for treatment of anaphylaxis in community settings, including identification of patients who need an auto-injector prescription, current use of auto-injectors, and advances in auto-injector design. We list reasons why physicians fail to prescribe epinephrine auto-injectors for patients with anaphylaxis, and reasons why patients fail to self-inject epinephrine in anaphylaxis. We emphasize the primary role of epinephrine in the context of emergency preparedness for anaphylaxis in the community. Epinephrine is the medication of choice in the first-aid treatment of anaphylaxis in the community. For ethical reasons, it is not possible to conduct randomized, placebo-controlled trials of epinephrine in anaphylaxis; however, continued efforts are needed towards improving the evidence base for epinephrine injection in this potentially fatal disease.

Epinephrine auto-injector use and demographics in a Veterans Administration population

The epinephrine auto-injector has been widely used over a long period of time. Certain aspects of this therapy and demographic data, however, have not been well studied. This study investigates patient use and understanding of epinephrine auto-injector use. As part of an ongoing quality assurance program, we evaluated 66 patients who had been given an epinephrine auto-injector and followed in the Allergy and Immunology Clinics at the West Los Angeles Veterans Medical Center. Data analyzed included patient demographics, medical indications for epinephrine auto-injector prescriptions, and the patient's understanding and use of the device. The mean age of our patients was 50 years. There were 44 men (66.7%) and 22 women (33%). Twenty-three patients were prescribed epinephrine auto-injector for adverse food reactions. Ninety-two percent (92%) of the patients knew how to use their epinephrine auto-injector properly, however, only 58% carried their device with them consistently. Of the patients, 91% understood why the auto-injector was prescribed. Of the total patients prescribed epinephrine auto-injector, 79% refilled their medication before the 1 year expiration date. Only 12% of the patients studied had required the use of their auto-injector. Most patients knew how and when to administer their epinephrine auto-injector. Despite detailed instructions in a specialty clinic only a slight majority carried it consistently. These data clearly indicate that further patient education or other measures are needed to improve compliance and effective use.

Improvement in Epinephrine Auto-injector Prescription Rate in Patients Having Had a Systemic Reaction to Immunotherapy

Improvement in Epinephrine Auto-injector Prescription Rate in Patients Having Had a Systemic Reaction to Immunotherapy

Regional variation in epinephrine autoinjector prescriptions in Australia: more evidence for the vitamin D–anaphylaxis hypothesis

There is little information on the regional distribution of anaphylaxis in Australia. To examine the influence of latitude (a marker of sunlight/vitamin D status) as a contributor to anaphylaxis in Australia, with a focus on children from birth to the age of 4 years. Epinephrine autoinjector (EpiPen) prescriptions (2006-2007) in 59 statistical divisions and anaphylaxis hospital admission rates (2002-2007) in 10 regions were used as surrogate markers of anaphylaxis. EpiPen prescription rates (per 100,000 population per year) were higher in children from birth to the age of 4 years (mean, 951) than in the overall population (mean, 324). In an unadjusted model of children from birth to the age of 4 years, decreasing absolute latitude was associated with a decrease in EpiPen prescription rates, such that rates were higher in southern compared with northern regions of Australia (beta, -44.4; 95% confidence interval, -57.0 to -31.8; P < .001). Adjusting for age, sex, ethnicity, indexes of affluence, education, or access to medical care (general, specialist allergy, or pediatric) did not attenuate the finding (beta, -51.9; 95% confidence interval, -71.0 to -32.9; P < .001). Although statistical power was limited, anaphylaxis admission rates (most prominent in children aged 0-4 years) showed a similar south-north gradient, such that admission rates were higher in southern compared with northern regions of Australia. EpiPen prescription rates and anaphylaxis admissions are more common in southern regions of Australia. These data provide additional support for a possible role of vitamin D in the pathogenesis of anaphylaxis.

Epinephrine auto-injector prescriptions as a reflection of the pattern of anaphylaxis in an Asian population

This study surveyed the prescription patterns of adrenaline auto-injectors (AAs) in Singapore to examine the frequency, triggers, and demographic pattern of anaphylaxis requiring such prescriptions. A 6-year retrospective review of 417 consecutive patients prescribed AAs in Singapore from January 1999 to December 2004, as identified from hospital pharmacy records. There were 417 patients identified, consisting of 295 (70.7%) Singaporeans with the remaining being non-Singaporean residents. Based on population census, the frequency of AA prescriptions was estimated at 1 per 10,000 Singaporeans. Demographic factors associated with AA prescriptions were male gender (OR = 1.361; p = 0.002); minority ethnic groups, which included Eurasians, Caucasians, Koreans, and Japanese (OR = 15.873; p < 0.001); and children <15 years of age (OR = 2.593; p < 0.001). The most common food allergens resulting in AA prescriptions were peanut (41.9%) and shellfish allergy (28.5%). Multiple logistic regression analysis showed that peanut allergy was independently associated with Eurasian ethnicity (OR = 5.045; p = 0.021); and shellfish allergy with Indian ethnicity (OR = 2.757; p = 0.034). The estimated frequency of AA prescriptions in Singapore is relatively low at 0.01%. The incidence of peanut and shellfish allergy in the Asian population appears to differ from that seen in Western populations.

Treatment of anaphylaxis in the outpatient setting

Rationale To identify how anaphylaxis is treated in the outpatient setting, what patient instruction is provided at time of diagnosis and what follow-up is arranged. Methods Records over the last 2 years with the primary diagnosis of anaphylaxis, angioedema, or urticaria were examined. Parameters evaluated included the dose, route, and time to administration of epinephrine. Epinephrine autoinjector prescriptions, instruction on use, and allergy referral were also evaluated. Results 181 records were reviewed with 28 patients having 31 episodes of anaphylaxis. 84% of episodes were evaluated in the emergency department and 13% in primary care clinics. Average age was 36 years, female:male ratio was 1.6:1.0, and 50% were atopic. 87% of patients had evidence of urticaria and/or angioedema during the episode. Other end organ effects included 87% of patients with respiratory, 65% with cardiovascular, and 35% with gastrointestinal symptoms. Epinephrine was administered in 52% of episodes and given subcutaneously in 75% of these cases. None received intramuscular administration. The dose range of epinephrine was 0.1–0.5mg with 0.3mg given in 66% of cases. Average time to first dose was 18 min. An autoinjector prescription was given in 32% with documented instruction in 16% of encounters. Allergy referral was provided in 35% of cases. Conclusions In our review, epinephrine was utilized in only 52% of anaphylaxis cases and was administered by the subcutaneous route. Educational efforts are needed regarding the importance of intramuscular epinephrine for the treatment of anaphylaxis. Improvement in providing autoinjectors with instructions on use and referral to an allergist is imperative.