Economic considerations in the treatment of systemic allergic reactions

Pharmacoequity in Allergy-Immunology: Disparities in Access to Medications for Allergic Diseases and Proposed Solutions in the United States and Globally

Pharmacoequity is the principle that individuals should have access to high-quality medications regardless of race and ethnicity, socioeconomic status, or availability of resources. In this review, we summarize access to therapeutics for allergic diseases in the United States and other selected countries. We focus on domains of health care access (health insurance coverage, medication availability, and specialist access) as well as system-level factors and clinician- and patient-level factors such as interpersonal racism and cultural beliefs, and how they can affect timely access to appropriate therapy for allergic diseases. Finally, we propose how pharmacoequity in allergy-immunology can be achieved by highlighting solutions to factors limiting access to medications for allergic diseases, and identify potential future research directions.

Anaphylaxis: A 2023 practice parameter update

This practice parameter update focuses on 7 areas in which there are new evidence and new recommendations. Diagnostic criteria for anaphylaxis have been revised, and patterns of anaphylaxis are defined. Measurement of serum tryptase is important for diagnosis of anaphylaxis and to identify underlying mast cell disorders. In infants and toddlers, age-specific symptoms may differ from older children and adults, patient age is not correlated with reaction severity, and anaphylaxis is unlikely to be the initial reaction to an allergen on first exposure. Different community settings for anaphylaxis require specific measures for prevention and treatment of anaphylaxis. Optimal prescribing and use of epinephrine autoinjector devices require specific counseling and training of patients and caregivers, including when and how to administer the epinephrine autoinjector and whether and when to call 911. If epinephrine is used promptly, immediate activation of emergency medical services may not be required if the patient experiences a prompt, complete, and durable response. For most medical indications, the risk of stopping or changing beta-blocker or angiotensin-converting enzyme inhibitor medication may exceed the risk of more severe anaphylaxis if the medication is continued, especially in patients with insect sting anaphylaxis. Evaluation for mastocytosis, including a bone marrow biopsy, should be considered for adult patients with severe insect sting anaphylaxis or recurrent idiopathic anaphylaxis. After perioperative anaphylaxis, repeat anesthesia may proceed in the context of shared decision-making and based on the history and results of diagnostic evaluation with skin tests or in vitro tests when available, and supervised challenge when necessary.

Meat Allergy: A Ticking Time Bomb

Food allergies are relatively prevalent, but mammalian meat allergy remains uncommon and represents an important, potentially acute healthcare risk. This risk is partly because both clinicians and the public lack awareness of this serious allergy, which is unique in three important ways: it incurs a delayed reaction, it is induced by a carbohydrate rather than a protein, and it is linked to tick bites. Although various symptoms are possible, its unique presentation means that mammalian meat allergy is often presented to the dermatologist. We review this challenging subject, which is particularly salient considering the unique connection between ticks and mammalian meat allergy, the expanding tick territory, and the dependency by so many on meat products, not only in the diet but also in medications and medical devices.

Wilderness Medical Society Clinical Practice Guidelines on Anaphylaxis

The Wilderness Medical Society convened a panel to review the literature and develop evidence-based clinical practice guidelines on the treatment of anaphylaxis, with an emphasis on a field-based perspective. The review also included literature regarding the definition, epidemiology, clinical manifestations, and prevention of anaphylaxis. The increasing prevalence of food allergies in the United States raises concern for a corresponding rise in the incidence of anaphylaxis. Intramuscular epinephrine is the primary treatment for anaphylaxis and should be administered before adjunctive treatments such as antihistamines, corticosteroids, and inhaled β agonists. For outdoor schools and organizations, selecting a method to administer epinephrine in the field is based on considerations of cost, safety, and first responder training, as well as federal guidelines and state-specific laws.

Food allergy: how expensive are they?

PURPOSE OF REVIEW

Food allergy remains a disease of global public health significance well known to impact social, emotional, and financial well being. This review aims to summarize the existing literature focused on the direct, indirect, and intangible costs of food allergy at the household and healthcare system levels, and begin to discuss how emerging treatment and prevention strategies may be leveraged to comprehensively care for the food allergic population with the efficient use of health resources.

RECENT FINDINGS

Food allergy imposes significant costs to multiple stakeholders and largely impact families at the household level. Recent studies elucidate the need to balance the household management of food allergy with the efficient use of health resources. Overall, it remains critical that safe foods and medications remain affordable while further exploring the cost-effectiveness of early introduction, emerging food allergy therapies, and the wider use of stock epinephrine to adequately meet the public health needs of the food-allergic community.

SUMMARY

Better understanding how the cost of food allergy impacts populations will help to inform more progressive policies aimed at lessening socioeconomic disparities and ultimately improve quality of life for children and adults with food allergies.

Penicillin Allergy Testing Is Cost-Saving: An Economic Evaluation Study

BACKGROUND

Having a penicillin allergy label is associated with the use of less appropriate and more expensive antibiotics and increased healthcare utilization. Penicillin allergy testing results in delabeling most allergy claimants and may be cost-saving. This study aimed to project whether penicillin allergy testing in patients reporting a penicillin allergy is cost-saving.

METHODS

In this economic evaluation study, we built decision models to project the economic impact of 2 strategies for a patient with a penicillin allergy label: (1) perform diagnostic testing (drug challenges, with or without skin tests); and (2) do not perform diagnostic testing. The health service perspective was adopted, considering costs with penicillin allergy tests, and with hospital bed-days/outpatient visits, antibiotic use, and diagnostic testing. Twenty-four base case decision models were built, accounting for differences in the diagnostic workup, setting (inpatient vs outpatient) and geographic region. Uncertainty was explored via probabilistic sensitivity analyses.

RESULTS

Penicillin allergy testing was cost-saving in all decision models built. For models assessing the performance of both skin tests and drug challenges, allergy testing resulted in average savings (in United States [US] dollars) of $657 for inpatients (US: $1444; Europe: $489) and $2746 for outpatients (US: $256; Europe: $6045). 75% of simulations obtained through probabilistic sensitivity analysis identified testing as the less costly option.

CONCLUSIONS

Penicillin allergy testing was projected to be cost-saving across different scenarios. These results are devised to inform guidelines, supporting the adoption of policies promoting widespread testing of patients with a penicillin allergy label.

Epinephrine autoinjector prescription filling after pediatric emergency department discharge

Background: There are known racial and socioeconomic disparities in the use of epinephrine autoinjectors (EAI) for anaphylaxis. Objective: To measure the rates of EAI prescription filling and identify patient demographic factors associated with filling rates among patients discharged from the pediatric emergency department. Methods: This was a retrospective observational cohort study of all patients discharged from a pediatric emergency department who received an outpatient prescription for an EAI between January 1, 2018, and October 31, 2019. The rates of prescription filling were calculated, and multivariable logistic regression was performed to identify sociodemographic factors associated with prescription filling. Results: Of 717 patients included in the analysis, 54.8% (95% confidence interval {CI}, 51.1%-58.5%) filled their prescription. There were no significant associations between EAI fill rates and patient age or sex. In bivariable analysis, non-Hispanic white patients were more likely to fill EAI prescriptions compared with non-Hispanic Black patients (odds ratio [OR] 1.89 [95% CI, 1.11-3.20]), and patients with in-state Medicaid were significantly less likely to fill EAI prescriptions compared with those patients with private insurance (OR 0.69 [95% CI, 0.48-0.98]). However, after multivariable adjustment, there was no significant difference in filling by age, insurance status, or race or ethnicity. Conclusions: Only approximately half the patients had their EAI prescriptions filled after discharge. Filling rates did not vary by sociodemographic characteristics.

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.