They are the life-saving devices that people with severe allergies reach for in an emergency — but now doctors are warning that people may not be using EpiPens correctly.
Around 358,000 Britons regularly carry adrenaline auto-injectors or AAIs, as they’re called, relying on them to deliver a vital shot of adrenaline to counter the potentially fatal effects of a severe allergic reaction to food, medicines or insect stings.
Under official guidelines these should be prescribed to people who have had an anaphylactic reaction or who are allergic to ‘high-risk allergic triggers’ such as nuts, although AAIs (which are also known by the brand names EpiPen, Jext and Emerade) may also be prescribed in other cases.
Doctors and activists are concerned that AAIs may be not being used optimally by thousands of patients, making them less efficient.
Anaphylaxis happens when the body is overreacts to something to which it’s allergic. This can be common with foods like peanut butter and milk as well as medicines such as chemotherapy and antibiotics.
Around 358,000 Britons regularly carry adrenaline auto-injectors or AAIs, as they’re called, relying on them to deliver a vital shot of adrenaline to counter the potentially fatal effects of a severe allergic reaction to food, medicines or insect stings
The allergen sends the body’s immune system into overdrive, releasing chemicals such as histamine to attack it, and causing symptoms including swelling of the lips, tongue and throat, breathing difficulties, wheezing, and a drop in blood pressure.
Hospital admissions for food-induced anaphylaxis — the most common cause — increased three-fold between 1998 and 2018 according to figures from Imperial College London, published earlier this year in the BMJ.
AAIs are the only treatment for anaphylaxis — prescriptions for these devices have risen four-fold over the past two decades as the number of people with allergies increased, according to the study.
Sometimes, only one dose of adrenaline will be sufficient. However, severe reactions may require two.
This is why the UK’s medicine’s watchdog, the Medicines and Healthcare products Regulatory Agency, recommends that people with severe allergies carry two AAIs at all times, with parents and carers also trained to help in an emergency.
According to Anaphylaxis Campaign, around 10% of the population may only have one AAI.
Concerns are being raised now about its administration.
AAIs are the only treatment for anaphylaxis — prescriptions for these devices have risen four-fold over the past two decades as the number of people with allergies increased, according to the study
New advice issued last month from the Commission on Human Medicines, which advises the Government on the safety, quality and effectiveness of medicines, states an AAI should be administered at the first sign of anaphylaxis — but does not recommend where the injection should be given.
According to past guidelines, the injection should only be performed on the outside part of the thigh.
The question is whether the second dose — administered five minutes after the first if needed — should be in the same or a different leg.
Adrenaline narrows blood vessels. Anaphylaxis is a condition in which the adrenaline helps restore blood pressure and heart function.
There is concern that adrenaline may not be able to work if it is administered twice into one leg. The blood vessels have already narrowed and the first dose won’t have any effect.
This issue was raised at the inquest of Natasha Ednan-Laperouse, the teenager from London, who died aged 15 from anaphylaxis in 2016, after eating a Pret A Manger baguette that didn’t list the ingredient sesame, to which she was highly allergic.
This issue was raised at the inquest of Natasha Ednan-Laperouse, the teenager from London, who died aged 15 from anaphylaxis in 2016, after eating a Pret A Manger baguette that didn’t list the ingredient sesame, to which she was highly allergic
When Natasha had the anaphylactic reaction while travelling on a plane to Nice, her father Nadim administered two doses of adrenaline via an AAI, both in her right outer thigh, but the drug didn’t work.
Alex Croom (a consultant allergist) was asked by her jury in 2018, why she didn’t believe the AAIs worked.
Natasha’s mother Tanya, who with Nadim set up The Natasha Allergy Research Foundation to raise awareness of food allergies, says: ‘We are very concerned that there is no official advice about where to administer a second AAI in the event of a severe allergic reaction. This is a life-threatening situation where every second counts, so it’s crucial to make the most of AAIs.
‘Yet we know from people with food allergies that many who are prescribed AAIs receive no information about where they should inject the second dose.
‘Clarity on their use is urgently needed to prevent more avoidable deaths from severe allergic reaction.’
The concern was also expressed by Dr Mark Porter (a Cotswold GP and television presenter) on social media.
He says: ‘The second dose should not be given in the same spot, as adrenaline causes vasoconstriction (reduced blood flow) which could impair absorption of the second dose.
‘So always use a different site. Using the opposite thigh is a simple way to ensure this.’
Some others believe this opinion is solely based upon understanding adrenaline’s workings and that there has been no research published to support the idea.
New advice this year from Resuscitation Council UK, which publishes guidelines on life-saving for healthcare workers, acknowledges a different leg could be helpful — but the evidence is ‘uncertain’.
Dr Paul Turner, a reader in paediatric allergy and immunology at Imperial College Healthcare NHS Trust, who oversaw these latest guidelines, says he believes this advice is ‘appropriate’ as ‘there is no clear evidence that administration into the same leg is a problem’.
He adds: ‘Our experience of advising patients and training them is that people tend to use their dominant hand and may misuse the device if forced to inject into the opposite thigh.
‘Therefore, the bottom line is if it’s easy to use the opposite thigh and you remember, great. But otherwise don’t worry about it. Get another dose of medication and ensure that 999 is called.
‘There is a real concern that if the focus becomes injecting into another leg, then what is well-intentioned advice might actually end up causing confusion and risk delaying correct and appropriate administration of a second dose — which would clearly be the more important issue.’
In a separate announcement, the Government last month announced that EpiPens will soon be made available at restaurants, stations on trains, and in other public locations in an effort to reduce deaths from severe allergies.