Anaphylaxis challenges on the front line: perspectives from community medicine

Update on the usage and safety of epinephrine auto-injectors, 2017

Anaphylaxis is a serious, potentially fatal allergic reaction. Guidelines recommend prompt intramuscular injections of epinephrine as the first-line therapy for anaphylaxis. Delayed epinephrine treatment may cause undesirable clinical outcomes, including death. In the community, epinephrine auto-injectors (EAIs) are commonly used to treat anaphylaxis. This literature review examines several recent concerns regarding the safety of EAIs that may prevent the timely administration of epinephrine. Reports of cardiovascular complications are linked with epinephrine administration, although recent studies suggest that these events are much more commonly associated with intravenous epinephrine rather than with EAIs. Recent studies have also highlighted accidental injections of EAIs in patients’ or caregivers’ fingers and lacerations associated with the use of EAI in children. However, the data suggest that both accidental injections and lacerations are rare and require limited medical intervention. In addition, patients may receive conflicting information on the safety and efficacy of using expired EAIs. Overall, it is believed that the benefits of using EAIs far outweigh the potential risks of not administering an EAI. Although legitimate safety concerns are associated with EAIs, adverse events are rare. Continued training of medical providers, caregivers, and patients may be beneficial to address these concerns and reduce EAI-associated injuries while ensuring that patients receive necessary medical care.

Anaphylaxis: underdiagnosed, underreported, and undertreated

Diagnostic criteria and administrative codes for anaphylaxis have evolved in recent years, partly reflecting the challenges in recognizing anaphylaxis and understanding its symptoms. Before the diagnostic criteria were disseminated by the National Institute of Allergy and Infectious Diseases and the Food Allergy and Anaphylaxis Network, several studies showed that a substantial proportion of anaphylaxis cases presenting to the emergency department (ED) were not recognized as such. Furthermore, epinephrine, the first-line treatment, was used in fewer than half of cases, especially if anaphylaxis was not diagnosed at the time. Although management practices may have improved since that time, anaphylaxis continues to be underrecognized and undertreated in the US. Of particular concern are findings that the majority of patients who visited the ED for an acute allergic reaction or anaphylaxis were not given a prescription for an epinephrine autoinjector, educated about avoiding the offending allergen, or advised to consult with an allergist. Improvements in the recognition and management of anaphylaxis have the potential to reduce the substantial burden that it currently places on the health care system. The articles in this supplement cover a wide range of issues surrounding anaphylaxis and seek to disseminate information helpful to health care professionals in general and primary care providers in particular.