MedPageToday: Many allergic kids who need epinephrine don’t get it

One in three prescribed an epinephrine injector didn't have it when needed

Only about one in three children with anaphylaxis presenting to a busy pediatric hospital emergency department (ED) or urgent care center (UCC) received epinephrine before arrival, even though the life-saving medication had been previously prescribed to about half of them, researchers report.

Just 50% of the children received epinephrine upon arrival for treatment, while about 65% had experienced a previous anaphylactic reaction, according to a retrospective review of medical records from Nationwide Children's Hospital in Columbus, Ohio.

The review, published online in Annals of Allergy, Asthma & Immunology, included 408 cases of anaphylaxis treated at the hospital between 2009 and 2013.

The children and teens who received epinephrine prior to arrival at the hospital's ED or UCC were less likely to be treated with epinephrine once they arrived, and they were also more likely to be sent home without hospital admittance.

"Allergists want parents, caregivers, and emergency responders to know epinephrine should always be the first line of defense when treating anaphylaxis. Our study found that only two-thirds of those who had an epinephrine prescription had their auto-injector available at the time of their allergic reaction," the senior researcher, David Stukus, MD, of Nationwide Children's, said in a press statement.

He and his colleagues noted that despite guidelines calling for the use of epinephrine for anaphylaxis management, it is often not used as promptly as it should be or at all.

"Treatment with epinephrine is often delayed or avoided and may be substituted with other treatment options, such as antihistamines," the team wrote. "Survey research has shown poor understanding of indications for the use of epinephrine among families with food allergic children, school nurses, and emergency responders, likely contributing to the underuse of epinephrine before the arrival at the ED."

In an effort to better understand issues associated with anaphylaxis management before hospital ED or UCC arrival, the researchers performed a retrospective review of electronic medical records for all patients (age range of 0 to 25) presenting with anaphylaxis at the pediatric academic referral center between 2009 and 2013.

The mean age of the 408 patients included in the analysis was 7.25, and 62% were male. A total of 264 patients (64.7%) had a known history of prior anaphylactic reactions, and 195 (47.9%) had been previously prescribed self-injectable epinephrine before the event that brought them to the hospital.

Just over two-thirds (69.7%) of patients who had been previously prescribed epinephrine had access to it at the time of the event, and 86% of these patients received epinephrine before arrival at the ED or UCC.

Among the other findings:

  • The odds of receiving epinephrine before ED or UCC arrival were four times higher (OR, 3.9, 95% CI 1.7-8.9) among patients with multiple food allergies compared with those with single food allergies
  • Allergic reactions occurring at home were less likely to be treated with epinephrine before arrival than reactions occurring at school (OR, 0.29, 95% CI, 0.15-0.59)
  • Patients who did not receive epinephrine before arrival were significantly less likely to be discharged to home (OR, 0.56, 95% CI 0.37-0.86; P=0.01)

Most patients (92.6%) reported cutaneous symptoms (flushing, urticaria, angioedema), and three out of four (74.8%) had documentation of respiratory symptoms. Gastrointestinal symptoms were reported in 36%. The odds of receiving epinephrine before arrival at the ED or UCC were significantly lower when two or three organ systems were involved, compared with just one organ system.

"The reasons for this were beyond the scope of this study, and, admittedly, this is a very ominous and illogical finding, considering a marked campaign in recent years specifically identifying multi-organ system reactions and reactions beyond 'just hives' as prime indications for epinephrine administration," the researchers wrote.

They added that while the implications of the finding are not clear, it may reflect "regional preferences or advice for treatment, regional emergency medical services practices, or a failure at the patient level to simply implement anaphylaxis management plans."

The researchers concluded that studies examining barriers to anaphylaxis use are needed.