Study: Epinephrine Management in Children and Adults

Epinephrine is the first-line treatment for anaphylaxis, a severe and potentially life-threatening allergic reaction most commonly triggered by food, latex, medication or insect venom. Delayed administration of epinephrine is a risk factor for fatal anaphylaxis to food. To stay safe, individuals with food allergies (or their caregivers) must have ready access to epinephrine, be able to recognize the symptoms of anaphylaxis, and be willing to use epinephrine to treat those symptoms.

To test how personal experiences and social circumstances might influence a patient’s willingness to acquire, carry and use epinephrine, researchers from several institutions analyzed 597 survey responses representing 917 patients who had been prescribed epinephrine auto-injectors. Survey questions were answered by the patients themselves or by parents of younger patients, with some surveys including responses for multiple individuals. After determining that little additional information would be gained by considering children and adolescents separately, data from those groups were merged, allowing the comparison of adults ages 18 and older and children ages 0-17. The results were recently published online in the Annals of Allergy, Asthma and Immunology.

Four epinephrine-related behaviors were assessed: (1) filling the auto-injector prescription, (2) carrying at least one auto-injector, (3) carrying multiple auto-injectors and (4) using an auto-injector to treat a severe allergic reaction. About 90 percent of respondents filled their epinephrine prescriptions, but only half reported always being within five minutes of access to epinephrine, and fewer than half (44 percent) carry at least one auto-injector at all times. One-third of the children carry their own auto-injector, while parents carry an auto-injector for another third of the child respondents. Only one patient in four follows the recommended practice of always carrying multiple auto-injectors, and half of the patients and parents indicated that their insurance co-pay or deductible was a barrier to epinephrine access.

Roughly 70 percent of respondents reported a reaction within the past year, and 40 percent had more than one reaction during that time. Adults were more likely to report recent reactions than children. A child’s most severe food allergy reaction was most commonly triggered by peanut, milk or shellfish, in that order. The food that most frequently triggered an adult’s most severe reaction was shellfish, followed by peanut.

Nearly 90 percent of adults and 70 percent of children reported at least one hospital visit to treat a reaction, but only 65 percent of respondents had ever been treated with an epinephrine auto-injector. More than half of the adults (52 percent) and 30 percent of the children had at least one severe reaction that was not treated with epinephrine but in retrospect should have been. Among individuals who were given epinephrine for their most severe reaction, 6 percent received stock epinephrine and another 7 percent received epinephrine prescribed to someone else.

Five factors were tested for association with epinephrine carriage and use:

• knowledge: understanding how and when to use epinephrine
• supportive environment: social support from friends and extended family and access to stock epinephrine
• positive patient attitude toward epinephrine: sense that carrying epinephrine improves safety and quality of life
• reaction history: frequency of recent reactions and experience with severe reactions requiring a hospital visit
• allergy-related quality of life: impact of allergies on family and social activities as well as respondent’s comfort level with managing food allergies

Among respondents of all ages, greater likelihood of acquiring epinephrine was associated with more positive patient attitudes toward epinephrine, more severe reaction history and more supportive environment. The likelihood that a patient would routinely carry at least one auto-injector increased with higher scores for each of the five factors above, regardless of age.

For children, higher scores for each factor – including peer and family support – were associated with greater likelihood of carrying multiple auto-injectors and using an auto-injector to treat the patients’ most severe reaction. For adults, by contrast, higher scores regarding auto-injector knowledge were not associated with greater likelihood of using an auto-injector during the patient’s most severe reaction. Likewise for adults, routinely carrying multiple auto-injectors was associated with more positive patient attitudes toward epinephrine, more severe reaction history, and higher quality-of-life scores; this recommended practice was not significantly associated with an adult’s peer and family support or auto-injector knowledge.

The researchers note that food allergy education provided by clinicians during office visits mays be an effective means to promote the routine carrying of multiple auto-injectors, which is consistently associated with higher scores for allergy-related quality of life. Effective interventions to increase the number of patient who carry multiple auto-injectors may not only make patients safer, but may also make their lives better.

The survey was conducted by telephone in English. About three-quarters of the respondents were white, non-Hispanic. The study received funding from Mylan Specialty LP.