Epinephrine auto-injector pandemic

Unintentional Epinephrine Auto-Injector Maxillofacial Injury in a Pediatric Patient

Case Presentation

A four-year-old female patient presented to the emergency department with an epinephrine auto-injector that had unintentionally discharged into her mandible. There was difficulty removing the auto-injector at bedside. Images we acquired noted needle curvature not present in an off-the-shelf model. She was sedated, and the auto-injector was removed by retracing the angle of discharge, with care taken not to inject epinephrine into the patient.

Discussion

Epinephrine auto-injector accidental discharges are an unusual injury pattern, but the incidence of such events is increasing in the United States. The emergency clinician should be cognizant of complicating factors with discharges, such as bent needles. Here we discuss a case of discharge into the maxillofacial region (lower jaw), with approaches to treatment.

Self-injectable epinephrine: doctors' attitude and patients' adherence in real-life

PURPOSE OF REVIEW

Epinephrine is the only life-saving treatment of anaphylaxis. Prescription and administration rates of self-injectable epinephrine are generally low. It is unclear whether this is because of availability, low prescription rates, fear of using epinephrine, or a combination of these issues.

RECENT FINDINGS

This review focuses on what self-injectable epinephrine devices (SIED), such as auto-injectors and prefilled syringes, are preferred by patients and healthcare professionals (HCP). Our findings suggest that a device's ease to use, proper and frequent training on its operability, and availability have an impact on preferences and adherence to treatment with SIEDs. After prescribing a patient with a SIED, clinicians should emphasize its use in anaphylaxis, educate patients/caregivers to identify anaphylaxis and on how to use the SIED, and encourage constant practicing with training devices.

SUMMARY

Epinephrine is the sole recommended anaphylaxis treatment and SIEDs are of critical usefulness in the community setting. Further studying of these devices is needed to optimize education for HCPs and patients and their accessibility to SIEDs.

Bee Updated: Current Knowledge on Bee Venom and Bee Envenoming Therapy

Honey bees can be found all around the world and fulfill key pollination roles within their natural ecosystems, as well as in agriculture. Most species are typically docile, and most interactions between humans and bees are unproblematic, despite their ability to inject a complex venom into their victims as a defensive mechanism. Nevertheless, incidences of bee stings have been on the rise since the accidental release of Africanized bees to Brazil in 1956 and their subsequent spread across the Americas. These bee hybrids are more aggressive and are prone to attack, presenting a significant healthcare burden to the countries they have colonized. To date, treatment of such stings typically focuses on controlling potential allergic reactions, as no specific antivenoms against bee venom currently exist. Researchers have investigated the possibility of developing bee antivenoms, but this has been complicated by the very low immunogenicity of the key bee toxins, which fail to induce a strong antibody response in the immunized animals. However, with current cutting-edge technologies, such as phage display, alongside the rise of monoclonal antibody therapeutics, the development of a recombinant bee antivenom is achievable, and promising results towards this goal have been reported in recent years. Here, current knowledge on the venom biology of Africanized bees and current treatment options against bee envenoming are reviewed. Additionally, recent developments within next-generation bee antivenoms are presented and discussed.

Epinephrine Autoinjector Prescribing Trends: An Outpatient Population-Based Study in Olmsted County, Minnesota

BACKGROUND

The prescribing pattern of epinephrine over time is an indicator of the secular trend of anaphylaxis. However, it is not well known in a population level in the United States.

OBJECTIVE

To evaluate the trend of prescriptions for epinephrine autoinjectors in Olmsted County, Minn, residents.

METHODS

Outpatient prescriptions for epinephrine were identified among residents of Olmsted County, Minn, between January 1, 2004, and December 31, 2010. We used the first prescription per patient per year, and the first prescription per patient during the study period to calculate incidence rates. Incidence rates per 100,000 person-years were calculated using patients prescribed epinephrine per year as the numerator and age- and sex-specific counts of the population of Olmsted County as the denominator. The relationships of age group, sex, and year of prescription with incidence rates were assessed by fitting Poisson regression models using the SAS procedure GENMOD.

RESULTS

The overall incidence rate of epinephrine autoinjector prescriptions during the study period was 757 per 100,000 person-years (95% confidence interval: 740-774). The prescription rates per patient per year increased over time, with an annual rate of increase of 8% (P < .001), but the rates per patient remained stable (P = .077). For each year, incidence rates overall were higher in women compared with men (P < .001). From ages 0 to 19, incidence rates were higher in boys compared with girls. At age 20 and above, incidence rates were higher in women compared with men.

CONCLUSIONS

The overall rate of epinephrine autoinjector prescriptions increased, but the rate of first-time prescriptions was stable from 2005 to 2010. In childhood, boys were more likely to receive a prescription than girls, but this reversed in later ages.

Anaphylaxis: a payor's perspective on epinephrine autoinjectors

The scope of expenditures due to anaphylaxis likely is underestimated by health care payors because anaphylaxis is underdiagnosed and, when reported, most costs of anaphylaxis borne by payors relate to direct medical expenses. Direct costs of anaphylaxis have been estimated at $1.2 billion per year, with direct expenditures of $294 million for epinephrine, and indirect costs of $609 million. More accurate diagnostic coding will allow payors to improve their understanding of the full impact of anaphylaxis on health care plans, employers, patients, and their families. Similarly, more accurate diagnosis and treatment of anaphylaxis should have a direct effect on overall cost savings achieved in this disease state. This includes savings in both direct costs, such as emergency department visits, and indirect costs, such as lost productivity of patients and caregivers. Educating medical personnel on treatment guidelines regarding the specific use of appropriate epinephrine autoinjectors will contribute to cost savings. Even though the cost of autoinjectors has been increasing, evidence indicates that the cost of improper response to, and treatment of, anaphylaxis outweighs that increase. At this time, there are several branded epinephrine autoinjectors and one generic equivalent for one of these branded products available on the US market; the branded autoinjectors are not considered equivalents for substitution. Barriers to coverage and access, such as managed care organization tier classification, medication copay, and socioeconomic status of specific patients, need to be examined more closely and addressed. Education in the proper use of epinephrine autoinjectors, including regular checking of medication expiration dates, is critical for proper management of anaphylaxis and minimizing the costs of anaphylactic events. Managed care organizations can play a role in educational initiatives.