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Half of Adults Not Using Epinephrine in Reactions, Study Finds

Dr. Moshe Ben-ShoshanDr. Moshe Ben-Shoshan

Adults and children who experience anaphylaxis do not always receive live-saving epinephrine, according to findings from a three-year Canadian study.

“In adults, our study indicates that almost 50 percent of severe reactions are not treated with epinephrine in or outside of the hospital,” says Dr. Moshe Ben-Shoshan, a pediatric allergist at Montreal Children’s Hospital and a key researcher behind the Cross-Canada Anaphylaxis Registry.

Started in 2011, the registry, known as C-CARE, has collected data from approximately 1,500 allergic adults and children who visited emergency departments in British Columbia, Ontario and Quebec hospitals. The goal was to gain insights into the triggers and management of anaphylaxis.

In a related research paper from the C-CARE data, the rates of epinephrine use in children having reactions proved to be better than the adult patients, but could still stand improvement. Data collected from the Montreal Children’s Hospital emergency department showed that the most common triggers for reactions were peanut and tree nuts, and that nearly 1 in 3 children experiencing reactions did not receive epinephrine. Almost all of these children had been prescribed auto-injectors.

The children not receiving epinephrine were given either antihistamines or corticosteroids to bring a reaction under control. “Antihistamines and steroids are not established as primary management of anaphylaxis and further,” Ben-Shoshan said in an interview. “The only drugs that stops the progression of anaphylaxis is epinephrine.”

Antihistamines and steroids may treat visible symptoms such as hives, they do not tackle the systemic symptoms such as cardiac or breathing issues. Therefore, the allergist says, not using epinephrine right away can actually make a person’s condition worse.

Ben-Shoshan cites the case of one allergic teenager who ate a cookie she was handed as a store sample. She quickly realized the cookies contained peanut butter, and her mouth began to itch. She did not have her epinephrine auto-injector with her, so a friend drove her to the emergency department. When she arrived, she was walking, talking and had only minor symptoms. Within a few minutes, she collapsed. She received CPR and an epinephrine drip to stabilize her condition, and was admitted to intensive care where she later recovered.

“Had she injected [epinephrine] promptly, all the studies indicate that she is not likely to have deteriorated the way she did,” says Ben-Shoshan. The C-CARE data found that the prompt use of epinephrine may also prevent the need for additional doses of the drug in the emergency department.

The low rate of epinephrine use among adults experiencing anaphylaxis is a growing concern. Ben-Shoshan suggests the trend likely relates to concern about side effects, a common misconception. (In fact, the C-CARE data reveals that most of the adults who used the drug experienced no side effects.) The researcher says that it’s also not uncommon for patients to make a “distorted link” between giving epinephrine and having to go to the hospital, believing that if they don’t administer epinephrine, the reaction is less severe and they can stay home.

“On the contrary, if you don’t give epinephrine, you’re more likely to deteriorate and end up at the hospital,” he says. The registry data also show that nearly half of the adult patients with moderate-to-severe reactions did not own a prescribed auto-injector.

C-CARE, funded in part by AllerGen, is the world’s first registry to track anaphylaxis occurrences as they are reported, and the researchers plan to publish the four-year findings in 2015.

The medical guidelines state that any serious allergic reaction requires epinephrine. “It’s clearly indicated. It’s the educational programs that need to be distributed and implemented,” says Ben-Shoshan.

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