Epinephrine as first-line therapy for anaphylaxis, says AAP

Recommendations also emphasize use of epinephrine auto-injectors in the community setting

New recommendations from the American Academy of Pediatrics (AAP) call for epinephrine in the treatment of an anaphylactic episode. AAP’s new clinical report, published in Pediatrics,1 updates a 2007 clinical report and is based on an extensive review of recent studies highlighting the safety and beneficial effects of epinephrine for anaphylaxis. It also emphasizes the use of epinephrine auto-injectors in the community setting.

“Given that many studies report underutilization, we updated the report to show more data on safe use and underscore benefits and use in the context of anaphylaxis plans,” said Scott H. Sicherer, MD, lead author of the report and professor of pediatrics, allergy, and immunology at Mount Sinai’s Icahn School of Medicine.

Included with the clinical report is a universal, yet customizable, anaphylaxis emergency plan (http://apha.us/2plLHH1) that should be used for an individual child during an anaphylactic episode. According to the summary of the AAP clinical report, epinephrine is best prescribed in the context of a written, personalized anaphylaxis emergency action plan, developed by the medical home with input from the child’s family.

The clinical report also urges patients and caregivers to be taught how to recognize anaphylaxis symptoms; when, why, and how to use an epinephrine auto-injector; and the rationale for calling 911.

While epinephrine is considered the primary initial treatment for anaphylaxis, the updated clinical report said that patients at risk for anaphylaxis should be prescribed an epinephrine auto-injector, especially for use in the community setting. This includes patients with a confirmed previous attack, those with idiopathic anaphylaxis, and patients with known food sensitivities who haven’t yet experienced anaphylaxis.

“Ensuring that these types of patients have ready access to an epinephrine auto-injector is imperative because prompt administration can be lifesaving for a large number of patients,” said Maria Miller Thurston, PharmD, BCPS, a clinical assistant professor at Mercer University College of Pharmacy.

She said she appreciates how the clinical report emphasized epinephrine as first-line therapy, too.

“Anything else like an antihistamine or an albuterol inhaler is considered adjunct management,” said Thurston. Albuterol can help with lower respiratory symptoms, but antihistamines are targeting only itching and hives and do not relieve life-threatening respiratory symptoms, hypotension, or shock. Epinephrine prevents or decreases upper airway mucosal edema, hypotension, and shock through narrowing the blood vessels. It also weakens the force of muscular contractions.

In the United States, epinephrine auto-injectors are available in two fixed doses: 0.15 mg and 0.3 mg.

According to Sicherer, the clinical report describes newer international guidelines suggesting that the fixed-dose auto-injector of 0.15 mg may be used in an infant weighing a minimum of 7.5 kg. That fixed dose represents double the ideal dose.

“Our report also discusses the impression that having only the two fixed doses of auto-injector epinephrine available is not ideal, especially for smaller infants,” said Sicherer.

According to Thurston, community pharmacists can play a role in this arena by confirming the weight of the patient to ensure that the proper dosage is being prescribed. And overall, pharmacists can make sure epinephrine auto-injectors are being prescribed to individuals who need them. 

Reference

Pediatrics 2017; DOI: 10.1542/peds.2016-4006

For the full article, please visit www.pharmacytoday.org for the May 2017 issue of Pharmacy Today.