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Prevention of Anaphylaxis: The Role of the Epinephrine Auto-Injector

  epi-pen-stockAnaphylaxis is a life-threatening condition, with at-risk individuals remaining at chronic high risk of recurrence. Anaphylaxis is frequently underrecognized and undertreated by healthcare providers. The first-line pharmacologic intervention for anaphylaxis is epinephrine, and guidelines uniformly agree that its prompt administration is vital to prevent progression, improve patient outcomes, and reduce hospitalizations and fatalities. Healthcare costs potentially associated with failure to provide epinephrine (hospitalizations and emergency department visits) generally exceed those of its provision. At-risk patients are prescribed epinephrine auto-injectors to facilitate timely administration in the event of an anaphylactic episode. Despite guideline recommendations that patients carry 2 auto-injectors at all times, a significant proportion of patients fail to do so, with cost of medicine cited as one reason for this lack of adherence. With the increase of high-deductible healthcare plans, patient adherence to recommendations may be further affected by increased cost sharing. The recognition and classification of epinephrine as a preventive medicine by both the US Preventive Services Task Force and insurers could increase patient access, improve outcomes, and save lives.

Allergies are the sixth leading cause of chronic illness in the United States, affecting more than 50 million Americans and costing the healthcare system more than $18 billion annually.1 Individuals in hyperallergic states are at chronic high risk for the occurrence of acute anaphylactic episodes, and as many as 49 million individuals are thought to be at risk in the United States.2 Annual direct costs of anaphylaxis are estimated at $1.2 billion.2Anaphylactic episodes are serious, multisystem, life-threatening, and generalized or systemic hypersensitive or allergic reactions that are rapid in onset and potentially fatal.345 Anaphylaxis may be immunologic (immunoglobulin E mediated or non–immunoglobulin E mediated) or nonimmunologic; both forms are referred to as “anaphylaxis” in this review, in line with international guidelines and consensus statements.3 Risk factors for anaphylaxis include age,56 comorbidities (eg, asthma7), and certain medications (eg, beta-blockers and angiotensin-converting enzyme inhibitors).56

Anaphylaxis occurs on a continuum and can begin with relatively minor symptoms before progressing, in an unpredictable manner, to a life-threatening condition.3 The most common signs and symptoms include changes in the skin (eg, itching, erythema, pruritus, urticaria, angioedema) and respiration (including bronchospasm, laryngeal edema, cough, respiratory arrest); effects on the gastrointestinal, cardiovascular, and central nervous systems also may be evident.35 Anaphylaxis often is underrecognized by healthcare professionals both in general practice and in emergency care,6 particularly if cutaneous signs and symptoms are not present (these are absent in 10%-20% of patients).5

International guidelines concur that anaphylaxis is a medical emergency and requires rapid intervention.56Prompt treatment with epinephrine, the only first-line intervention for anaphylaxis, is recommended to prevent the progression of an anaphylactic episode.4568 For patients experiencing an anaphylactic event, epinephrine is the only medication proven to prevent hospitalization and fatalities.6 Because the onset of anaphylaxis symptoms often occurs in the community setting,3 at-risk patients should be prescribed epinephrine auto-injectors to provide rapid intramuscular administration of epinephrine.479 However, a large number of patients prescribed epinephrine auto-injectors do not have access to one at the time of an allergen exposure, leading to delayed medication administration and increased risk of progression to severe anaphylaxis.10111213

Currently, many high-deductible healthcare plans include epinephrine auto-injectors among those medications to which the plan’s deductible applies rather than as a preventive medicine exempt from cost sharing. Because high deductibles and high cost sharing, such as those in high-deductible healthcare plans, may lead to decreased use of medical care,14151617 the recognition and classification of epinephrine as a preventive medicine could improve patient access. Recommended preventive services or medications (ie, those graded A or B by the US Preventive Services Task Force [USPSTF]) are not subject to any cost-sharing requirements for the patient, (eg, deductibles, copayments) (as discussed next), as per the Patient Protection and Affordable Care Act 2010.18 The role of epinephrine auto-injectors in the prevention of anaphylaxis progression and their potential classification as preventive by the USPSTF and inclusion on healthcare plan preventive medication lists are reviewed.


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-Leonard Fromer, MD

This article originally appeared in the December 2016 issue of The American Journal of Medicine.

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