Dr. Sharma:  The ability of epinephrine to treat the many signs of anaphylaxis is rather amazing.

It acts on a number of receptors in the body to exert its effects. First, it causes constriction, or tightening, of the blood vessels, which decreases swelling and also helps to increase blood pressure.

It also increases the heart’s contraction and heart rate, which can help to prevent or reverse cardiovascular collapse. Epinephrine relaxes the muscles around the airways in the lungs, helping the airways to open up.

Finally, it prevents the release of additional allergic chemicals, which aids in stopping further progression of the reaction. No other medicine acts on so many body systems, which is why epinephrine is the drug of choice for anaphylaxis.

Dr. Sharma is an allergist, clinical researcher and Assistant Professor of Pediatrics. He is Associate Chief of the Division of Allergy and Immunology at Children’s National Medical Center in Washington D.C. and Director of the Food Allergy Program. He co-authors “The Food Allergy Experts” column in the American Edition of Allergic Living magazine. Questions submitted below will be considered for answer in the magazine.

Epinephrine works best when injected directly into muscle, as opposed to fat, as it absorbs into the bloodstream faster this way. Using ultrasound results, researchers from the U.K. measured the distance between the surface of the thigh and the inner muscle of 93 children. It was discovered that this distance was greater than the length of the auto-injector’s needle in 82 percent of the obese children studied.

At three-quarters down the thigh, the distance was reduced so that only 17 percent still had their muscle out of reach.  This suggests that the lower thigh could be a more effective location for giving an epinephrine shot to any obese individual.

Heights, weights, waistline measurements and body mass index data were gathered in order to determine which children would be considered obese.

See more news from the AAAAI 2013 conference here.

The following article is from the Winter 2013 of Allergic Living magazine.

Michael Saffioti’s mom Rose thought her 22-year-old son was doing the right thing by turning himself into police after a missed court date last July. But for the Washington state man, who had a life-threatening allergy to dairy, one night in jail turned into a death sentence.

The young man had landed in the court system on a misdemeanor marijuana possession charge – he spoke of using pot to curb crippling anxiety about his food allergy and asthma – and then a legal technicality led to him spending a night in the county prison.

Under normal circumstances, he would have gone before a judge then been released, but Saffioti never made it past breakfast. According to witness testimony from fellow inmates, the young man was given a meal that included a pancake and oatmeal, and when he reminded staff of his dairy allergy, they removed the pancake and told him the oatmeal was safe.

After a few spoonfuls, Saffioti began having difficulty breathing and asked for his asthma medication. Soon after, the prisoners were locked into their cells and the guards changed shifts. Saffioti’s reaction continued to worsen. According to Anne Bremner, the Seattle lawyer representing the family, Saffioti pressed his emergency button and called for medical help, but his emergency light got turned off; as his breathing grew more labored, Saffioti pleaded for someone to call 911.

Other inmates say they began pressing their emergency buttons and yelling for help, making clear that this guy was not faking. Their calls were ignored.

Saffioti was supposed to be housed in the prison’s medical ward, and his mother had made sure that corrections staff had his asthma medication, EpiPen auto-injector and medical records, and yet no help came for at least 20 minutes. A prison trustee (an inmate who has work privileges) said he watched in horror as Saffioti finally collapsed in his cell. By the time paramedics arrived, it was too late.

“The trustee is a tough guy, but he said it’s the worst thing he’s ever seen,” says Bremner. “They let this guy die, and he was begging for help.”

Next: Mother’s Actions

According to a new 2012 Leger Marketing survey commissioned by Sanofi Canada, an alarming number of Canadians at risk of anaphylaxis do NOT always carry or have immediate access to an epinephrine auto-injector. And many are uncertain about how to correctly use the device.

Low level of compliance

The national survey of adults and parents of children at risk of anaphylaxis found that 57% overall do NOT always carry an epinephrine auto-injector as recommended by physicians.

By group, a surprising 63% of adult patients and 51% of parents with children at risk do NOT have an auto-injector immediately available at all times.

Research shows that most deaths associated with anaphylaxis have resulted from not having epinephrine readily available or delaying its use. 1

“At risk individuals should have an epinephrine auto-injector immediately available at all times,” explains Dr. Susan Waserman, a Canadian allergist and researcher. “But this survey tells us there are serious gaps. These individuals need to be better prepared.”

Although the precise number of people at risk of anaphylaxis is unknown, a recent publication found that approximately 7% (or about 2.5 million Canadians) self-report a food allergy. 2

Next: Uncertain about how to use
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1. Bock et al, Journal of Allergy and Clinical Immunology 2001 Jan v107 p 191

2. L. Soller et al, “Overall Prevalence of Self-reported Food Allergy in Canada”, JACI (2012). doi: 10.1016/j.jaci.2012.06.029

Also of concern, 51 percent of parents of children at risk of this life-threatening form of allergic reaction do not have epinephrine available at all times, says the study released on Nov. 1. Anaphylactic reactions can come on very swiftly and incapacitate the allergic individual.

Because of this, allergist Dr. Susan Waserman notes that people at-risk of anaphylaxis are always meant to have an auto-injector with them. “But this survey tells us there are serious gaps,” she says. “These individuals need to be better prepared.”

The findings are from an online survey of 1,089 individuals who are either at risk of anaphylaxis or have a child who is at risk. The study, commissioned by the pharmaceutical company Sanofi Canada, has other interesting results about attitudes toward using auto-injectors in an emergency.

Read the press release here.

Dr. Scott Sicherer: Being able to recognize the need for epinephrine and to actually self-inject in an emergency are beyond the capability of most children your son’s age. The readiness to self-administer requires the appropriate developmental level, understanding about symptoms of a reaction, and then the willingness to inject the epinephrine.

Before you consider the readiness of your child, speak with your allergist to be sure you are comfortable with recognizing symptoms and understand when and how to inject epinephrine. Since barriers to using the auto-injector include “needle phobia” and unfounded worries about side effects, have a discussion with the allergist about the safety of epinephrine, and perhaps practice with an old injector and an orange. Achieving your own comfort is the first step in preparing the right message to give to a child who will eventually take on this responsibility.

The notion of self-treatment can be taught early on, but granting full independence is a much more gradual process. For all children, I generally instruct that a responsible adult should be available to make treatment decisions and ultimately inject epinephrine. For teenagers, having their friends aware of the food allergy and how to inject epinephrine can add another layer of safety.

Gradually include your child in allergy management, with guidance from your doctor. Having him practice with an epinephrine self-injection trainer is a good first step. The road toward independence also includes having him play a part in reading labels on packaged foods, speaking up about allergy at restaurants, and eventually discussing when epinephrine would be required.

Dr. Sicherer is a practicing allergist, clinical researcher and Professor of Pediatrics. He is Chief of the Division of Allergy and Immunology, Jaffe Food Allergy Institute, at the Mount Sinai Medical School of Medicine in New York. He is also a member of the FAAN medical advisory board. Together with Dr. Hemant Sharma, Associate Chief of the Division of Allergy and Immunology at Children’s National Medical Center in Washington, he writes “The Food Allergy Experts” column in the American Edition of Allergic Living magazine.

To submit a question, write to ask@allergicliving.com. Write “The Food Allergy Experts” in the subject field, and keep your question brief.

Little Amarria was the wakeup call. We have the tool, the auto-injector, to stop the senseless allergy deaths like hers. Now we have to use it.

On the first day of school after Christmas of 2011, 7-year-old Amarria Johnson and her Grade 1 classmates in Richmond, Virginia bounced outside of Hopkins Road Elementary after lunch to play. You could usually hear Amarria before you saw her: she loved to sing, in church, for the video camera, in the car, at school. She would sing for anyone, and she had big plans to be a star on the Disney Channel.

For this first day back to school, Amarria’s mother had carefully rolled her daughter’s long hair in a bun. The girl was excited to be going back. “She loved everything,” her mother Laura Pendleton told Allergic Living. “The world was an awesome, innocent place.”

Then a child in the playground gave her a peanut. Amarria had always avoided the peanut butter and jam sandwiches that the school offered for lunch every day because she had an allergy to peanuts. But this time, for reasons no one knows, she popped the peanut into her mouth.

Amarria knew right away she was in trouble. She asked the teacher outside to help. That was exactly what she was supposed to do. But then the system failed her.

The teacher walked Amarria to the school’s health clinic, where an aide searched for an epinephrine auto-injector with Amarria’s name on it. An auto-injector shoots epinephrine, also known as adrenaline, into the body. The drug can stop a severe allergic reaction outright or buy enough time for paramedics to arrive. Amarria desperately needed that shot of life; in the minutes after she arrived at the clinic, she was struggling to breathe. But the clinic did not have an auto-injector prescribed for Amarria.

A Child Runs Out of Breath

Over the next few minutes, the girl ran out of breath, right there in the clinic. Just before 2:30 p.m., the school called 911, but by the time firefighters and police arrived, Amarria’s heart was failing. The rescuers tried CPR; they tried to restart her heart with a defibrillator. They rushed her to Chippenham Hospital, but it was too late. Amarria was pronounced dead shortly after she arrived. The cause of death: anaphylaxis and cardiac arrest.

It is such a senseless, heartbreaking loss of a little girl so full of life. But beyond the tragedy, this disturbing issue has emerged: there were likely auto-injectors prescribed to other students in the Hopkins Road Elementary clinic. (Allergic Living has learned this was likely the case, though the school board declines to comment on specifics.) If an auto-injector was there, however, the aide was not allowed to use it. Why?

“Many of our students [in Chesterfied County] have EpiPens at school,” acknowledged Shawn Smith, the board’s spokesman. “It’s illegal to give a prescription drug to someone else,” he said.

The staff at the county’s public schools are instructed that they are only allowed to use an epinephrine auto-injector if it is specifically prescribed by a doctor for the child in question and if the school has the child’s written action plan for allergy emergencies. “Absent those two,” Smith said, “we’re unable to carry out the doctor’s [verbal] orders.”

Next page: Why we can stop the tragedies – now

Allergic Living asked Dr. Phil Lieberman, clinical professor of medicine and pediatrics at the University of Tennessee’s College of Medicine (and father and grandfather to food-allergic children), for answers to nine food allergy questions you’ve been wondering about but haven’t had a chance to ask.

1. What are the typical hallmarks of severe allergic reaction?

Reactions that involve the respiratory tract system (upper and lower areas) and the cardiovascular system. For example, coughing, wheezing, shortness of breath, inability to breathe because of upper airway swelling, cardiac arrhythmias, fall in blood pressure with shock, and even a heart attack typify a severe allergic reaction.

2. What do the new food allergy guidelines produced by the National Institute of Health/National Institute of Allergy and Infectious Diseases say constitutes an anaphylactic reaction to food?

If any two of the following body organ systems (skin, GI tract, cardiovascular, airway or central nervous) are affected, this automatically requires the use of an auto-injector of epinephrine. If a known allergen is ingested and there is a single manifestation of any reaction in any of those bodily systems, this also automatically requires use epinephrine. For a deeper explanation, the National Institute of Allergy and Infectious Diseases has patient guidelines that can be downloaded for free.

3. What is the best course of action in the event of an anaphylactic reaction?

Immediately inject epinephrine and then call 911.  A second dose should be available and it should be administered in 10 minutes if there has been no improvement and/or if an emergency medical facility has not been reached. To prevent threatening falls in blood pressure, you can lie down and elevate your legs as well, if this posture does not make it difficult to breathe.

4. What exactly is epinephrine and how does it work in the body? What does it do to a severe reaction?

Epinephrine is a hormone the body makes itself: the “fight or flight” hormone. It is designed to increase blood flow to muscles, strengthen contractions of the heart and increase alertness. Its other name is adrenaline because it is manufactured in the adrenal gland.

5. Are there any side effects or risks of using an autoinjector of epinephrine?

In general, there are no severe side effects from the administration of epinephrine. Because it is the “fight or flight” hormone, it can make you jittery, raise your blood pressure and in some patients, cause tremors. In a healthy individual, this is uncomfortable but is not a threat. In some patients who have high blood pressure or heart disease, more severe side effects can occur.  Still, in a case of anaphylaxis, the risk/benefit ratio favors the administration of the drug since anaphylaxis is a life-threatening condition.

Next page: “Is there a difference between different manufacturers of epinephrine?”