Epinephrine Autoinjector Prescription Research Articles

Prevalence, Management, and Anaphylaxis Risk of Cold Urticaria: A Systematic Review and Meta-Analysis

Cold urticaria is a subtype of chronic inducible urticaria (CIndU) associated with significant morbidity and a risk for anaphylaxis. Few studies have assessed the prevalence, management, and prevalence of associated anaphylaxis of cold urticaria. To evaluate the prevalence of cold urticaria among CIndU and chronic urticaria (CU) cases, to assess the management of cold urticaria, and to determine the prevalence of associated anaphylaxis. We searched PubMed and EMBASE for studiespertaining to cold urticaria and/or CIndU published in the past 10 years. We conducted meta-analyses to evaluate theprevalence of cold urticaria among CIndU and CU cases,the management of cold urticaria with H1-antihistamines andomalizumab, and the prevalence of associated anaphylaxis. Twenty-two studies were included in the systematicreview and 14 in the meta-analysis. The pooled prevalence of cold urticaria among patients with CU and CIndU was 7.62% (95% confidence interval [CI], 3.45% to 15.99%; I2=98%) and 26.10% (95% CI, 14.17% to 43.05%; I2= 97%), respectively. Cold urticaria was managed by H1-antihistamines in 95.67% (95% CI, 92.47% to 97.54%; I2= 38%) of patients and omalizumab in 5.95% (95% CI , 2.55% to 13.27%; I2= 83%) of patients. The pooled prevalence of anaphylaxis among patientswith cold urticaria was 21.49% (95% CI, 15.79% to 28.54%; I2= 69%). Cold urticaria constitutes an appreciable proportion of CIndU and CU cases and is predominantly managed with H1-antihistamines; few patients receive omalizumab. Anaphylaxis is common, and an epinephrine autoinjector prescription may be considered.

Access barriers to epinephrine autoinjectors for the treatment of anaphylaxis: A survey of practitioners

Epinephrine is the first-line treatment for systemic allergic reactions including anaphylaxis and commonly prescribed for self-administration as an epinephrine autoinjector (EAI).1 More EAI prescriptions have been written during the past decade, with an annualized growth of 8% between 2004 and 2010.2 The 2016 U.S. congressional hearings reported considerable EAI price hikes coupled with increased demand.3 Although the U.S. Food and Drug Administration first noted EAI shortages in May 2018, shortages are ongoing, directly impacting patient care.

Evaluation of anaphylaxis recurrence and adrenaline autoinjector use in childhood.

Introduction: Limited data are available on recurrent anaphylaxis in childhood. Delayed adrenaline administration is the major cause of deaths due to anaphylaxis. As well as prescribing the adrenaline autoinjector (AAI), it is important to make sure that the patient carries the device at all times and uses it correctly for the appropriate indication. Objective: The aim of our study was to evaluate the recurrence of anaphylaxis and AAI use in childhood. Methods: Pediatric patients who were evaluated for anaphylaxis and prescribed AAI between January 2015 and December 2018, in the pediatric allergy and immunology clinic of our hospital were screened retrospectively. A telephone-based survey was conducted with the parents of the patients to investigate the recurrence of anaphylaxis in patients and the use of AAI by their parents for the management of anaphylaxis. Results: A total of 148 patients (64.9% boys) were prescribed an AAI for anaphylaxis. The telephone survey could be conducted with 111 parents (75%) with an AAI prescription. Of these patients, 23.4% (n = 26) of the parents reported that their children experienced recurrent episodes of anaphylaxis. In the recurrent anaphylaxis cases, the triggers were foods in 77%, venoms in 11.5%, drugs in 3.8%, and idiopathic anaphylaxis in 7.7% of the patients. AAI use at the time of anaphylaxis was reported by 42.3% of the parents. The reasons cited by the parents for not using AAI during an episode of anaphylaxis included the preference to have adrenaline administered at a health care facility because of its proximity (60%), fear of using the device (13.3%), hesitation (6.7%), not having the device with them (13.3%), and unavailability of the device (6.7%). Conclusion: Educating the patients and families about the importance of using AAI is crucial, and training on how to use the device should be repeated at each clinic visit and every opportunity.

The Psychosocial Burden of Food Allergy Among Adults: A US Population-Based Study

Food allergy (FA) affects >25 million US adults, resulting in substantial health care utilization. Data suggest that patients with FA suffer impairments in FA-related quality of life (FAQoL); however, little is known regarding psychosocial impacts of FA among US adults. To characterize FAQoL among a large, nationally representative adult sample, and its determinants, including sociodemographic characteristics, severity, comorbid conditions, allergic symptoms, number and type of allergens, and health care utilization. A survey was administered between October 2015 and September 2016 to a nationally representative sample of US households. Survey constructs included the Food Allergy Independent Measure (FAIM), which was developed to quantify adverse impacts of living with FA on patient quality of life. FAIM responses were analyzed from adults reporting current FA (N= 6207). Linear regression models examined associations with sociodemographic and FA characteristics. The overall estimated mean FAIM score was 2.87 (95% confidence interval: 2.83-2.90). FAIM scores (range= 1-7) in adjusted models were invariant by race/ethnicity, private/public insurance status, and census division. Significant differences (P < .05) by lower household income, lower age, and greater education emerged, resulting in higher FAIM scores indicating FAQoL impairment. Among major food allergens, wheat, soy, and milk allergies were each associated with the greatest increases in adjusted FAIM scores. Reporting a current epinephrine autoinjector (EAI) prescription, severe allergic reaction history, history of EAI use, FA-related emergency department visits, or more FAs were also associated with significantly higher FAIM scores. The population-level psychosocial burden of adults with FA is substantial, broadly distributed, and differs by demographic and allergic disease characteristics.

Prevalence of Food-Hypersensitivity and Food-Dependent Anaphylaxis in Colombian Schoolchildren by Parent-Report.

Background and objectives: The epidemiology of food allergy (FA) and food-dependent anaphylaxis remains unknown in Colombia. Our aim was to estimate by parent-report the prevalence of FA and food-dependent anaphylaxis in a Colombian population of schoolchildren. Materials and methods: A printed questionnaire was sent to parents of schoolchildren aged 5–12 years old from Medellín, Colombia in order to collect FA-related data. Results: Nine hundred and sixty-nine (969) parents returned the questionnaire with valid responses (response rate, 52.5%). The estimated prevalence rates (95% CI) were: adverse food reactions 12.79% (10.76–15.07), “perceived FA, ever” 10.93% (9.08–13.08), “physician-diagnosed FA, ever” 4.33% (3.14–5.81), “immediate-type FA, ever” 6.81% (5.30–8.58), “immediate-type FA, current” 3.30% (2.26–4.63), and food-dependent anaphylaxis 1.85% (1.10–2.92). The most frequently reported food allergens were milk (1.44%), fruits (0.41%), meat (0.41%), and peanut (0.3%). Sixty-one percent of “food-dependent anaphylaxis” cases sought medical attention, but only eleven percent of the cases reported the prescription of an epinephrine autoinjector. Conclusions: FA and food-dependent anaphylaxis are not uncommon among schoolchildren from Colombia. The prescription of epinephrine autoinjectors should be encouraged among health personnel for the optimal management of suspected cases of food-dependent anaphylaxis.

Panel of Unintended Consequences

Food Allergy Panels are increasingly accessible. Indiscriminate food allergen testing is not sensitive, and has high false-positive rates. Inaccurate diagnosis of food allergy, and subsequent food avoidance, often results in deleterious physical, psychosocial, and economic effects. Unclear results may lead to inappropriate management of true IgE mediated food allergy. We hypothesized that food allergy panel orders would be associated with unnecessary food avoidance, as well as decreased Epinephrine auto-injector prescriptions in patients with immediate food reactions.

The Ability to Use Epinephrine Autoinjector in Patients Who Receive Prescription Immediately after Anaphylaxis

Background: Epinephrine autoinjector (EAI) is prescribed to prevent a fatal outcome in the case of a repeated anaphylactic reactions. We wanted to determine how adult patients who received their first prescription as part of an urgent treatment of an anaphylactic reaction or at their family physician were instructed on the use of EAI. Methods: Nurses assessing patients’ knowledge asked the patient to demonstrate how to use the EAI training device. Patients who performed the critical steps correctly in 1 min were labelled as competent. Results: Forty-one patients (24% women, 46 ± 5 years) came for the allergy examination 116 ± 145 days after receiving a prescription for EAI. When prescribing, the doctor or nurse explained the instructions for the use of EAI to 63.4% patients, and 31.7 patients practiced the use of EAI using a training device. At the pharmacy, 22% received explanation and 7% also practiced using a training device. Fifty-four percent of patients were able to effectively administer EAI adrenaline within 1 min. Higher education level was associated with sufficient knowledge about the use of EAI (p = 0.026). At the time of the visit to the allergy specialist clinic, 61% of patients had EAI with them. The shelf life of EAI was known to 63% of patients. Conclusions: The activities to increase the prescription rate of EAI immediately after treatment of anaphylactic episode are not sufficient to prevent severe outcome after the repeated episodes of anaphylaxis as nearly a half of patients are not able to use EAI correctly.

Guideline-informed care among Medicaid-enrolled children with food allergy.

To describe food allergy (FA)-related service utilization and identify factors associated with guideline-informed care among Medicaid-enrolled US children with FA. Retrospective cohort study. We used the 2012 Medicaid Analytic eXtract files to identify children with an FA diagnosis. FA-related services including outpatient allergist visits, emergency department (ED) visits, epinephrine autoinjector prescription fills, and diagnostic testing were identified. Factors associated with services were assessed using logistic regression. Kaplan-Meier survival curves evaluated the time to guideline-informed care, and proportional hazard models determined associated socioeconomic characteristics. There were 64,276 Medicaid-enrolled children younger than 20 years who had at least 1 claim with an FA diagnosis in 2012. Minority children and those living in a high-poverty county were less likely to have visited an allergist for FA or received diagnostic testing but more likely to have an FA-related ED visit compared with White children and those not living in a high-poverty county. Survival analyses found that of children seen for FA-related primary care or an ED visit, rates of allergist follow-up visits were 21% and 17%, respectively, and rates of epinephrine autoinjector prescription fills were 39% and 41%. Significant associations with guideline-informed care were found by race/ethnicity, dense population, and high-poverty counties. Although guideline-informed FA care includes follow-up with an allergist and epinephrine autoinjector prescription, this study finds low probabilities of timely service utilization after medical visits, as well as socioeconomic disparities in care.

Increasing incidence of anaphylaxis in Hong Kong from 2009 to 2019\u2014discrepancies of anaphylaxis care between adult and paediatric patients

BackgroundAnaphylaxis has been increasing in developed countries but there is very little published data on the burden of anaphylaxis and the pattern of adrenaline autoinjector (AAI) prescription from Asia. We aim to determine the incidence rates of anaphylaxis and prescription rates of AAI over the past decade in Hong Kong.MethodsUsing a centralized electronic database of Hong Kong’s sole public-funded healthcare provider, we obtained and analysed all patients between 2009 and 2019 with physician-reported diagnosis of anaphylaxis. Incidence rates were calculated using population statistics as the denominator. Patients’ prescriptions on discharge were collected to determine the AAI prescription rates.ResultsThe overall 10-year estimated incidence rate of anaphylaxis was 3.57 per 100,000 person-years. An increasing trend over time across both paediatric and adult populations from 2009 to 2014 was found, which remained stable until 2019. This was more marked among the paediatric population (paediatric vs adult incidence rate ratio in 2019: 3.51 [95% CI 1.12–2.66] vs 1.82 [95% CI 1.05–1.60]). There was an overall increasing rate of AAI prescription for patients admitted for anaphylaxis, but the overall AAI prescription rate was less than 15% and was significantly less likely to be prescribed for the adult compared to paediatric patients (36.5% vs. 89.4%, p < 0.001).ConclusionsAn increasing trend of anaphylaxis incidence rates over the past decade is evident in Asian populations, with a discrepantly low rate of AAI prescription, particularly in the adult patients.

Prevalence of Physician-Reported Food Allergy in Canadian Children

Food allergy prevalence data have largely been derived from self-report, and estimates vary. Determine the prevalence of physician-reported food allergy in children using electronic medical record data from the Canadian Primary Care Sentinel Surveillance Network (CPSSN). This was a retrospective cohort study using the CPCSSN repository, Canada's only primary care practice-based surveillance system. Machine learning algorithms were applied to assess for food allergy documentation. Demographic information, chronic diseases of interest, prescribed medications, and health behaviors from the CPCSSN repository were identified. The prevalence of physician-reported food allergy in Canadian children was 2.53% (95% CI, 2.48%-2.59%). The most common food allergies documented were peanut (0.8% of children), tree nut (0.6%), cow's milk (0.4%), egg (0.3%), fruit (0.2%), finned fish (0.2%), and shellfish (0.2%). Among children with food allergy, only 33.7% had an epinephrine autoinjector prescription. In logistic regression analysis, children with food allergy were more likely to have an atopic comorbidity (odds ratio [OR], 2.20; 95% CI, 2.06-2.35) and less likely to be obese than children without food allergies (OR, 0.84; 95% CI, 0.78-0.90). In the age- and sex-adjusted models, patients with food allergy were significantly more likely to have a psychiatric morbidity, specifically: attention deficit/hyperactivity disorder (OR, 1.81; 95% CI, 1.66-1.96), autism (OR, 1.89; 95% CI, 1.63-2.19), and depression (OR, 1.17; 95% CI, 1.02-1.35). Our study is the first to estimate national physician-reported prevalence of food allergy, and demonstrates a lower rate than that based on self-report. Further studies into the association of food allergy and psychiatric comorbidities (attention deficit/hyperactivity disorder, autism, depression) and the association of food allergy and obesity are needed.

Epinephrine autoinjector prescription patterns for severe anaphylactic patients in Japan: A retrospective analysis of health insurance claims data

BackgroundCurrent guidelines recommend that any patient who has experienced anaphylaxis should be prescribed one or more epinephrine autoinjectors (EAI) for immediate self-treatment. However, the etiology of anaphylaxis and prescription patterns of EAI have not been widely examined in Japan. MethodsThis was a retrospective cohort study using a large Japanese claims database (JMDC, Tokyo, Japan). We included patients with severe anaphylaxis who received epinephrine in a hospital or outpatient clinic from 2011 to 2016. We extracted patients who were prescribed EAIs and examined the annual trend of EAI prescription rates and refill patterns. ResultsWe identified 1255 eligible patients. Among them, 361 patients (28.8%) were prescribed EAIs within 30 days after their initial severe anaphylactic episode. In patients who were prescribed EAIs, 65.9% were prescribed EAIs from the same facility in which initial treatment was given for severe anaphylaxis. The prescription rates of EAI significantly increased from 11.1% in 2011 to 30.9% in 2016. Among patients with initial EAI prescriptions, 97.3% refilled their EAI prescriptions at least once and 40.5% refilled their prescriptions annually during the 3 year follow up period. ConclusionsEAI prescription rates were relatively low in patients who experienced severe anaphylaxis in Japan. Physicians should prescribe EAIs to all patients who were treated for anaphylaxis under their care and avoid delegating the responsibility of prescribing EAIs to other facilities. Initial prescription of EAIs can result in improved regular refill and dissemination practices.

Anaphylaxis Attended in Emergency Departments: a Reliable Picture of Real-world Anaphylaxis

The aim of this document is to review the epidemiology of anaphylaxis in the emergency departments (EDs) (burden and temporal trends), the generally deficient management of anaphylaxis in the ED, and the measures and interventions tested in different settings to improve management of anaphylaxis in the ED. The population attended for anaphylaxis episodes is low (0.009 to 0.4%). Recent studies report an increase in anaphylaxis episodes attended in the ED. Discordance has been observed between the diagnosis of anaphylaxis in the ED and the diagnosis confirmed in allergy units; this can reach 45%. Management of anaphylaxis is not consistent with international guidelines, and the lack of adherence to guidelines affects the use of epinephrine in the ED, prescription of epinephrine autoinjectors, initial advice on avoidance, and referral to an allergist. Measures to improve the management of anaphylaxis have proven effective. The low burden of anaphylaxis in the ED and the disappointing landscape of management of this syndrome in the ED should drive strategies aimed at providing staff with key concepts and measures that enable them to manage episodes of anaphylaxis effectively.

Development of a model care pathway for the management of Hymenoptera venom allergy: evidence-based key interventions and indicators

BackgroundHymenoptera venom allergy (HVA) is an underestimated condition representing an important cause of morbidity and mortality worldwide. Preventing future allergic reactions in patients who have already developed a systemic reaction is based on the correct management of the acute phase of the reaction followed by a correct diagnosis and, where indicated, prescription of adrenaline autoinjectors and VIT. A possible strategy to optimize care processes and to improve outcomes is the implementation of a Diagnostic and Therapeutic Care Pathways, also known as Integrated Care Pathways or Clinical Pathways (CPWs). The aim of the care pathway is to enhance the quality of care by improving risk‐adjusted patient outcomes, promoting patient safety, increasing patient satisfaction, and optimizing the use of resources. To our knowledge, currently in Italy as well as in Europe, there is no CPWs codified for the management of HVA patients. This paper describes the development of the clinical content of a care pathway for the management of HVA.MethodsThe methodology applied is based on the eight step method to build the clinical content of an evidence-based care pathway suggested by Lodewijckx et al.ResultsThree hundred and seventeen different clinical activities were extracted from the selected literature. The expert panel was involved in their evaluation, expressing a judgment of relevance through the Delphi study. As a result, 126 clinical activities were appraised to be valid and feasible. The final recommendations (126) were translated into 123 key interventions. Six indicators were produced by the clinical activities.ConclusionA set of 123 key interventions and of six process indicators were found to be appropriate for the development and standardization of the clinical content of the Hymenoptera venom allergy care pathway.

Allergy immunotherapy for inhalant allergens: Strategies to minimize adverse reactions.

Background: Allergy immunotherapy (AIT), both subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT), is an effective and safe treatment for allergic rhinitis and allergic asthma due to inhalant allergens. However, there are many variables in how it is administered. Objective: To review the evidence that suggests the optimal practice(s) to minimize adverse reactions to AIT. Methods: Articles that reported the results of various approaches to the practice of AIT and evidence-based guidelines were consulted for guidance about approaches that would minimize adverse reactions to AIT. Results: Evidence is presented that supports care in the preparation of allergy extracts for treatment; use of modified extracts; location for administration of SCIT and SLIT; risk factors for systemic reactions; AIT in patients on adrenergic blocking agents and angiotensin-converting enzyme inhibitors; use of premedication; the need for prescription of epinephrine autoinjectors; adjustments in dose for pollen seasons, interruptions in treatment, and for local and systemic reactions; and the safety in patients with autoimmune diseases and during pregnancy. Conclusion: Although some of these variables have not been adequately studied, there are many studies that indicate practices that minimize the risk of adverse reactions for both SCIT and SLIT.

The essential measures to improve the management of anaphylaxis

Studies of anaphylaxis in humans is scarce. It has been proven that the frequency of anaphylactic reactions is in increase and its management is not adequate and/or below an acceptable level. The prescription of auto-injectable epinephrine for use outside the hospital, which is the treatment of choice for an anaphylactic reaction, and its correct administration is drastically low. The proper management of anaphylaxis involves improving the training of patient's behaviors to allow both (i) prevention (avoiding known triggers of anaphylaxis) and (ii) effective treatment (adherence to a self-care plan and training to apply epinephrine with an auto-injector). Therefore, it is necessary to ensure and monitor the correct prescription of adrenaline auto-injectors as well as the training of health professionals in such use.

Physicians prescribe adrenaline autoinjectors, do parents use them when needed?

BackgroundAnaphylaxis is a sudden, severe, and potentially life-threatening allergic reaction, affecting a portion of allergic patients. Adrenaline is the first-line medication for anaphylaxis and available in many parts of the world as adrenaline autoinjectors (AAIs). ObjectiveAim of this study was to determine attitudes and knowledge levels of patients/parents regarding the use of AAIs, frequency, and rate of appropriate AAI use and to give a standardized and better education by improving on mistakes during administration. Method190 patients aged 1–18 years who were prescribed AAIs for any reason between 2012 and 2017 in Hacettepe University Pediatric Allergy Unit. Demographic data were collected during face-to-face interview or by telephone. Parents completed a mini-survey regarding use, carriage, and storage of AAI. ResultsSome 190 patients (64.7% male) aged 7.83 (4.99–12.08) years, median (inter-quartile), were included in the study. The indications for AAI prescription were food allergy (78.9%); venom allergy (14.2%); idiopathic anaphylaxis (3.7%); mastocytosis (2.1%); and drug allergy (1.0%). One-fourth of AAI-prescribed patients experienced anaphylaxis requiring the use of AAI within the past five years. However, only 30% of the patients dared to use AAI; only three-quarters of whom had managed to use it correctly. ConclusionAfter prescription of AAI and initial training, patients and parents’ concerns and fears should be taken into consideration and necessary support should be provided. At every opportunity and each clinical visit, not only should training sessions be repeated but also the patients and parents should be psychologically supported.

Clinical aspects of hymenoptera venom allergy and venom immunotherapy.

Hymenoptera venom allergy (HVA) is the most frequent cause of anaphylaxis in Europe, accounting for most of the severe reactions occurring in adults, and being the second cause of anaphylaxis in children. Prevention of further episodes in patients who developed a systemic reaction (SR) is based on the correct management of the allergic emergency, the referral to an allergist for a correct diagnosis, prescription of adrenaline auto-injectors (AAI) and specific venom immunotherapy (VIT), if recommended. Diagnosis is based on the classification of the type of reaction, confirmation of an IgE-mediated pathogenesis and the identification of the offending insect. The use of component resolved diagnostics may be helpful in case of poly-sensitization or negative allergy tests with a proven history of previous SRs. When a severe SR occurs, baseline serum tryptase levels should always be assessed. The prescription of AAI is recommended or suggested for untreated patients, patients undergoing VIT and after discontinuation of treatment, according to multiple evidence. VIT is the most effective treatment available for HVA patients, as confirmed by recent European guidelines. VIT has an early, sustained and persistent protective effect and modifies the natural course of the disease. Moreover, VIT proved to be safe and well tolerated. According to a recent systematic review, no treatment-related fatalities were recorded to date. Compared to AAI, VIT significantly improves the quality of life of HVA patients by reducing the anxiety and limitations in daily activities caused by the fear of stinging insects. The memory of a life-threatening experience is the most likely reason why adherence to VIT is higher compared to immunotherapy with inhalant allergens. Several risk factors in HVA have been identified that can influence not only the severity of sting reactions in untreated patents, but also the occurrence of side effects, treatment effectiveness and the risk of relapse after discontinuation of VIT. Patient and treatment-related risk factors must be considered while selecting the best candidates for VIT, the type and duration of treatment. In this paper we address the most important issues related to HVA and VIT that may have an impact on daily clinical practice.

Hymenoptera Venom Allergy: Management of Children and Adults in Clinical Practice

Hymenoptera venom allergy is an epidemiologically underestimated condition and a major cause of morbidity worldwide. Preventing future allergic reactions in patients who experience a systemic reaction is based on the correct management of the emergency followed by an accurate diagnosis, prescription of adrenaline autoinjectors, and, where indicated, specific venom immunotherapy. Some epidemiological studies highlight our poor knowledge of this disease and the frequent inadequacy of its management. Moreover, they emphasize the importance of such a life-saving treatment as specific immunotherapy. The availability of high-quality hymenoptera venom extracts for diagnostic and therapeutic use has dramatically improved the prognosis and quality of life of allergic patients. Subcutaneous venom immunotherapy is currently the most effective form of allergen-based immunotherapy, with a carry-over effect lasting up to several years after its interruption. This report on the management of hymenoptera venom-allergic children and adults was prepared by a panel of Italian experts. The main objective of this consensus document is to review the scientific evidence related to diagnosis, therapy, and management of patients allergic to hymenoptera venom. Thus, we can improve our knowledge of the disease and promote good clinical practices. The present document provides practical suggestions for correct diagnosis, prescription of emergency therapy and immunotherapy, and strategies for patient care.

THE ANALYSIS OF ANAPHYLAXIS DIAGNOSED AT DERMATOLOGY OF TOKYO MEDICAL UNIVERSITY HOSPITAL

There are few epidemiological reports of anaphylaxis since childhood. We herein examined cases of anaphylaxis diagnosed in our department. One hundred-thirty-two patients who were examined at the Dermatology Department of Tokyo Medical University Hospital between January 2011 and March 2017 and were prescribed epinephrine autoinjector (EpiPen®) for treatment were enrolled. The referral institution if any, severity of anaphylaxis, diagnostic method, causative antigen, and recurrence rate was examined. The referral rate was 54% while 46% of patients requested examination of their own accord. Anaphylaxis severity was mild to moderate in 75% of cases. Food allergy accounted for 71% of the symptoms, with wheat as the most common causative antigen, followed by Anisakis allergy. After diagnosis only 37% of patients continued periodic consultations, and 16 patients recurred anaphylaxis of the diagnosis. Wheat and WDEIA were the most frequent causes of anaphylaxis diagnosed in our department. We also found that as many as 15% of patients had Anisakis allergy, suggesting that it may be an important item in antigen testing.

Under Prescription of Epinephrine to Medicaid Patients in the Pediatric Emergency Department.

Objective. To describe pediatric Medicaid patients with pediatric emergency department (PED) visits for anaphylaxis who received epinephrine auto-injector (EAI) prescriptions in the ED versus those who did not; and to compare patients who filled their prescriptions versus those who did not. Methods. We conducted a cross-sectional study of Medicaid patients aged 0 to 21 years presenting to 2 PEDs, with symptoms meeting the National Institute of Allergy and Infectious Diseases criteria for anaphylaxis, between July 2012 and July 2014. Results. We identified 86 patients across the 2 hospitals with a confirmed diagnosis of anaphylaxis in the PED. Of these, 55 (64%, 95% confidence interval [CI] = 53% to 74%) received a prescription for an EAI during their ED visit. Forty-two (68%; 95% CI = 56% to 80%) received a prescription for EAI in Hospital 1 versus 13 (54%; 95% CI = 33% to 74%) in Hospital 2. Medicaid prescription fill rates were available for Hospital 1. Of the 42 who received an EAI prescription, 36 (86%; 95% CI = 75% to 96%) filled these prescriptions with Medicaid. Of the 20 (32%) out of 62 patients with anaphylaxis who did not receive prescriptions for an EAI, only 5 had previously filled prescriptions for epinephrine. Conclusion. Previous Medicaid patient prescription adherence data suggested that these patients would have a low EAI prescription fill rate. We found Medicaid patients who received prescriptions for an EAI after the ED visit for anaphylaxis filled them; however, a considerable proportion of anaphylaxis visits had no EAI prescription provided at discharge.