AL: What are the signs that it’s time to inject?
SW: There are signs where it’s undebatable: dizziness, shortness of breath, difficulty swallowing, loss of consciousness, drop in blood pressure, tongue swelling, severe abdominal pain, profuse vomiting. But it’s hard to use those signs of fairly advanced symptoms to say at the start of a reaction that it won’t progress. The idea is to prevent those symptoms from happening.
AL: But there is a tendency to wait for significant symptoms before using the auto-injector.
SW: I know. Yet, everything that you read in the medical literature points to too little epinephrine being given – by patients, by the community, by the emergency room. Still, there’s no question that there’s a trend that people do want this mild-severe type of spectrum where antihistamine is enough.
But there’s a downside to that, as seen with young Natalie. Somebody can always say, “The signs must have been there, somebody missed them” – well, people don’t judge severity very well; it’s not that straightforward. Most of us [allergists] are fairly convinced that we don’t know that every mild reaction stays a mild reaction, and that’s the danger.
AL: Is there anything else you would add to this discussion?
SW: As sad and tragic as Natalie’s death is, I think it reinforces really basic principles about treatment, about how reactions can advance very quickly and you’re not aware of it. Now that there is much discussion around this issue of antihistamine use for mild reactions, which many of us are uncomfortable with, I think this reinforces why it’s not a good idea.
[In Natalie’s case], even if they’d used epinephrine early, you have no idea what the outcome would have been. One cannot go back in time and address those issues – you can only try to stack the deck in your favor in future situations.
If you’d like to comment on this discussion, please do so on Allergic Living’s Facebook page. Thanks to Dr. Wood and Dr. Waserman for participating in these interviews.