FDA announced that epinephrine prefilled auto-injections (EpiPen—Mylan 0.15 mg/0.15 mL, 0.3 mg/0.3 mL, and the authorized generic) were placed on the drug shortage list in May because of manufacturing delays.1www.accessdata.fda.gov/scripts/drugshortages/dsp_ActiveIngredientDetails.cfm?AI=Epinephrine%20Injection,%20Auto-Injector&st=cGoogle Scholar Many immunizing pharmacists rely on the availability of prefilled epinephrine injections to manage potential cases of anaphylaxis associated with immunizations, other medication administration, and other causes of allergic reactions. Understanding and being trained on proper use of alternative epinephrine formulations, such as ampules, is essential. All medication administration, including vaccinations, have a risk of potential adverse reactions—some severe. Severe allergic reactions are the least frequent, with anaphylaxis following vaccines occurring at a rate of approximately 1 per 1 million doses for many vaccines, but immunizing practitioners need to be prepared to manage these emergency situations.2www.cdc.gov/vaccines/hcp/acip-recs/general-recs/adverse-reactions.html#ref-11Google Scholar Anaphylaxis symptoms can vary and may include a sudden or gradual onset of generalized itching, erythema, or urticaria; angioedema; severe bronchospasm, including wheezing; shortness of breath; shock; abdominal cramping; and/or cardiovascular collapse. CDC’s Advisory Committee on Immunization Practices (ACIP) recommends that epinephrine be available if needed to manage severe reactions.2www.cdc.gov/vaccines/hcp/acip-recs/general-recs/adverse-reactions.html#ref-11Google Scholar ACIP noted that for respiratory or cardiovascular symptoms, immediate I.M. epinephrine is the treatment of choice. For infants and children, the recommended dose is epinephrine 0.01 mg/kg injected I.M. in the middle to outer thigh. Tabled 1Epinephrine dosing for anaphylaxisChildren0.01 mg/kg up to 0.5 mg I.M. repeated as needed every 5–15 minAdults0.3–0.5 mg I.M. repeated as needed every 5–15 min Open table in a new tab For children who weigh more than 50 kg (110 lbs), the maximum epinephrine dose is 0.5 mg. For patients who fail to respond to the initial dose, the I.M. injection can be repeated every 5 to 15 minutes as needed. For adults, the recommended dose of epinephrine is 0.3 mg to 0.5 mg I.M., also in the middle to outer thigh. As with children, the dose can be repeated every 5 to 15 minutes as needed, but patients generally respond to the initial one to two doses. The Immunization Action Coalition’s guidance for medical management of vaccine reactions in adult patients recommends that community immunization clinics have epinephrine in stock.3www.immunize.org/catg.d/p3082.pdfGoogle Scholar The organization noted that clinics can stock epinephrine, aqueous 1:1000 (i.e., 1 mg/mL) dilution, in ampules, vials of solution, or prefilled syringes, including epinephrine auto-injectors. If auto-injectors are stocked, the organization noted that at least three should be available. In addition, they noted that 1-cc and 3-cc syringes and needles (i.e., 22 and 25 ga, 1”, 1½”, and 2”) should be available for epinephrine injections, and that filtered needles should be used for medications taken from ampules. Epinephrine is a high-alert medication that may cause significant patient harm if used incorrectly.4www.ismp.org/alerts/epinephrine-pre-filled-syringe-shortageGoogle Scholar One associated issue is dose miscalculations between the 1:1000 and 1:10,000 strengths. Another is no option for bulk compounding by pharmacy departments because the medication is sensitive to light, air, and pH, with a short stability time when extemporaneously prepared. To minimize errors with epinephrine, the Institute for Safe Medication Practices (ISMP) has several safety tips that focus on ensuring that concentrations and dosing conversions are done correctly and that medications are labeled properly.4www.ismp.org/alerts/epinephrine-pre-filled-syringe-shortageGoogle Scholar If a patient experiences an anaphylactic reaction, the pharmacist should administer epinephrine, call 911, and then monitor the patient until help arrives. The patient’s blood pressure and pulse should be monitored every 5 minutes. Immunizing pharmacists have been trained to keep epinephrine prefilled auto-injectors in stock in cases of emergency. Given the current shortage, however, alternative forms of epinephrine need to be available in the pharmacy. Ampules of epinephrine can be used to prepare emergency doses of epinephrine. Pharmacies should have procedures in place to guide proper preparation of syringes if needed. All immunizing pharmacists—and technicians, if appropriate—should be trained on proper dosing of epinephrine for children and adults (see chart) and how to prepare epinephrine injections from ampules. The specific procedures should cover proper dose calculation; preparation, including drawing up epinephrine from a glass ampule and using a filter needle; handling precautions; and appropriate needle length for an I.M. injection.
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Aug 25, 2024
S Moiseev + 3
Open Access
