Epinephrine for Anaphylaxis

In this episode, TRC Healthcare editor, Vickie Danaher, PharmD, explains how the recently approved epinephrine nasal spray compares to the injectable products for treating anaphylaxis. 

This is an excerpt from our October 2024 Pharmacy Essential Updates continuing education webinar series.

The clinical resources mentioned during the podcast are part of a subscription to Pharmacist’s Letter, Pharmacy Technician’s Letter, and Prescriber Insights: 

• Article: Explain How Epinephrine Nasal Spray Compares to Injectables
• FAQ: Emergency Epinephrine Devices
• FAQ: Managing Anaphylaxis

Don’t miss out! Subscribe to Pharmacist’s Letter today to stay ahead with trusted insights and tools. 

If you're a student, good news—students can access a free version of Pharmacist’s Letter. 

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Transcript

This transcript is automatically generated.  

00:00:04 Narrator

Welcome to Clinical Capsules, where we bring you the same evidence-based insights you trust from TRC Healthcare, now in podcast form. This year, we’re celebrating 40 years of keeping healthcare professionals ahead of critical medication updates and guidelines.

00:00:22 Narrator

Every 2nd and 4th Tuesday, our expert editors from Pharmacist’s Letter, Prescriber Insights, and Pharmacy Technician’s Letter will break down the most impactful clinical developments - giving you clear, actionable takeaways in just minutes.

00:00:36 Narrator

Today, you’ll hear an excerpt from our October 2024 Pharmacy Essential Updates continuing education webinar series. In this segment, Associate Editor and Pharmacist Vickie Danaher explains how the recently approved epinephrine nasal spray compares to the injectable products for treating anaphylaxis.

00:00:55 Narrator

With that, let's get started.

00:01:03 Vickie Danaher

When we talk about epinephrine, many people usually think of a traditional EpiPen or autoinjector that needs to be injected.

00:01:12 Vickie Danaher

But now, like our article says, you'll hear buzz about Neffy, the first epinephrine nasal spray for treating severe allergic reactions, including anaphylaxis.

00:01:24 Vickie Danaher

O this is a pretty big deal since we know that injectable epinephrine products have been the go-to for decades, so it needs to be ready to answer patient questions about the different options and how they stack up.

00:01:36 Vickie Danaher

And we can start to think about this with.

00:01:38 Vickie Danaher

Patient case.

00:01:40 Vickie Danaher

So this is.

00:01:42 Vickie Danaher

She's a three-year old patient at your pharmacy.

00:01:45 Vickie Danaher

Rose is allergic to peanuts and she's been prescribed an epinephrine auto injector, which her family has had to use in the past.

00:01:53 Vickie Danaher

But Rose's mom?

00:01:54 Vickie Danaher

He recently heard there's now an epinephrine nasal spray available. She wants to know if Rose can or should get that nasal spray version instead.

00:02:04 Vickie Danaher

So would you do in this situation? What would you want to know to help determine whether the nasal spray could be an?

00:02:10 Vickie Danaher

For rose.

00:02:14 Vickie Danaher

And it's probably not too surprising that many patients will be interested in getting an epinephrine nasal spray instead of an injectable.

00:02:21 Vickie Danaher

You know that any patients and their caregivers, needles or they don't feel comfortable giving epinephrine.

00:02:28 Vickie Danaher

Or when they do use these products, they use them incorrectly and we know this is a big problem since it can delay or prevent patients from getting lifesaving treatment.

00:02:39 Vickie Danaher

None of our problems with actually having the med on hand, for example, due to high costs or ongoing shortages.

00:02:47 Vickie Danaher

And another issue is that people often wait too long to give epinephrine.

00:02:51 Vickie Danaher

Because they don't recognize symptoms of anaphylaxis.

00:02:56 Vickie Danaher

Is that we, as pharmacists or technicians, can help address many of these barriers, for example, more states are following the trend, allowing pharmacists to furnish epinephrine under a protocol or standing order, similar to how many pharmacies now provide naloxone or contraceptives.

00:03:13 Vickie Danaher

Plus, as pharmacists, we can help patients and their caregivers recognize what anaphylaxis is and how to manage it.

00:03:22 Vickie Danaher

For example, we can educate that some of the red flag symptoms of anaphylaxis to be aware of include things like swelling of the lip or tongue.

00:03:29 Vickie Danaher

Tightness or hoarseness in the throat or shortness of breath, coughing or trouble swallowing.

00:03:36 Vickie Danaher

Sometimes the skin can also be involved, including itching, hives, redness or swelling.

00:03:42 Vickie Danaher

I think most people do tend to expect these types of reactions, but there's others to be aware of too.

00:03:48 Vickie Danaher

For example, a weak pulse dizziness, pale skin color, severe vomiting, diarrhea or cramps can also be a symptom of anaphylaxis.

00:03:57 Vickie Danaher

Or these may occur in combination with other symptoms.

00:04:01 Vickie Danaher

Of the key things people should be keeping an eye out for, especially if someone's been in contact with a known allergen.

00:04:09 Vickie Danaher

And if a patient is having symptoms of severe allergic reaction, we know that giving epinephrine can reduce or reverse these symptoms quickly and help save their life. 

00:04:19 Vickie Danaher

In terms of injectables, we know that most products come in several strengths and are dispensed based on the patient's weight.

00:04:26 Vickie Danaher

And as a refresher, the different devices include autoinjector, such as EpiPen or EpiPen Junior Adrenocllick, as well as generics and Auvi-Q, which has audio cues to talk the user through administration.

00:04:41 Vickie Danaher

There's also Symjepi which is a prefilled epinephrine syringe, or in rare cases, patients may get kits which are preassembled with files of epinephrine, needles and syringes.

00:04:55 Vickie Danaher

And again, now we have the first epinephrine nasal spray, Neffy, which is being touted as the first and only FDA approved needle free epinephrine product.

00:05:07 Vickie Danaher

Evidence suggests that epinephrine 2MG nasal spray achieved similar blood levels as injectable epinephrine as well as similar increases in blood pressure and heart rate.

00:05:19 Vickie Danaher

But we want to be aware that these studies are in healthy patients who are not experiencing anaphylaxis.

00:05:28 Vickie Danaher

And real world use of the nasal spray is limited.

00:05:32 Vickie Danaher

Each carton of epinephrine nasal spray comes with two nasal spray devices and each device is single use only and contains enough medication for one dose.

00:05:43 Vickie Danaher

Want to point out that the epinephrine 2 milligram nasal spray is only approved for patients who weigh 30 kilograms, which is about 66 lbs. Or more.

00:05:54 Vickie Danaher

So this particular strength won't be an option for many young children.

00:05:59 Vickie Danaher

But a 1 milligram dose for children who weigh 15 to 30 kilograms, or 33 to 66 lbs, is being reviewed by FDA.

00:06:08 Vickie Danaher

We'll have to stay tuned for that.

00:06:12 Vickie Danaher

Plus absorption of the nasal spray may be impacted by a history of nasal conditions such as nasal polyps or surgery.

00:06:18 Vickie Danaher

So these particular patients should discuss risks and benefits with their prescriber.

00:06:25 Vickie Danaher

But overall, we want to keep in mind that the best emergency epinephrine device is the one that patients and their caregivers are willing to use. Carry with them at all times and are able to use correctly.

00:06:38 Vickie Danaher

And this sometimes will boil down to what's in stock and what patients can afford.

00:06:44 Vickie Danaher

So he has pharmacists can continue to recommend an emergency epinephrine device based on patient preference, availability and cost.

00:06:54 Vickie Danaher

O we can exlain that a 2 pack costs about $710 for Neffy nasal spray.

00:07:01 Vickie Danaher

$620 for the talking Auvi-Q injector $300.00 for generic EpiPen, or $250 for Symjepi prefilled syringes.

00:07:12 Vickie Danaher

And remind patients that most manufacturers have copay cards or patient assistance programs. So most patients will pay less than these prices with savings or discounts.

00:07:23 Vickie Danaher

We also want to point out other differences that patients they want to consider when taking a product.

00:07:28 Vickie Danaher

For example, epinephrine 2MG nasal spray has a shelf life of 30 months from the data manufacturer.

00:07:36 Vickie Danaher

But most epinephrine injection devices are labeled with an expiration date of 15 to 20 months.

00:07:44 Vickie Danaher

So the nasal spray is longer.

00:07:46 Vickie Danaher

Something to keep in mind, especially since we know that many up and up and devices expire before a patient needs to use them.

00:07:54 Vickie Danaher

The nasal spray is also less sensitive to temperature excursions compared to other products, including EpiPen and Symjepi.

00:08:01 Vickie Danaher

The nasal spray can withstand temperatures up to 122°F for a few days, or be thought in inadvertently frozen.

00:08:11 Vickie Danaher

When you dispense epinephrine, spray want to train patients and caregivers on proper use.

00:08:17 Vickie Danaher

The single use device is the same design as Narcan, naloxone or Imitrex nasal spray, and again, it contains enough Med for one dose.

00:08:28 Vickie Danaher

So my patients that the nasal device should not be primed or tested as this will discharge that dose.

00:08:36 Vickie Danaher

Educate to hold the device with a thumb on the bottom of the plunger and a finger on each side of the nozzle.

00:08:42 Vickie Danaher

Insert the nozzle fully into one nostril. Either nostril can be used, and then press the plunger to give a dose.

00:08:52 Vickie Danaher

Advise giving a second dose of the nasal spray in the same nostril 5 minutes after the first dose if needed.

00:09:01 Vickie Danaher

Now we don't have time in today's session to walk through each injectable epinephrine device.

00:09:06 Vickie Danaher

But we.

00:09:06 Vickie Danaher

That there's brands and generics and they're all a little different.

00:09:10 Vickie Danaher

But you be aware that these devices are often used incorrectly, so this is a good reminder to train patients and caregivers on proper administration of any device.

00:09:19 Vickie Danaher

Especially if they're.

00:09:20 Vickie Danaher

From a product than what they've used before.

00:09:23 Vickie Danaher

And if you have a training or demo device available, that's really a great way to walk through the process and have patience practice.

00:09:30 Vickie Danaher

And also remind patients and caregivers to always call 911 if a dose of epinephrine is given.

00:09:38 Vickie Danaher

And part of the reason to call 911 is because of the risk of recurrence. Some patients have what's known as a biphasic anaphylactic reaction. As the name suggests, there can be two peaks to the reaction at the beginning, the person is exposed to an antigen like.

00:09:55 Vickie Danaher

Insect sting.

00:09:57 Vickie Danaher

There's this acute initial phase where they may get epinephrine and the symptoms resolve.

00:10:02 Vickie Danaher

But then with biphasic anaphylaxis, symptoms can recur, and this can occur anywhere from within one to about 72 hours after that first initial reaction.

00:10:14 Vickie Danaher

Symptoms can be as bad as the first reaction, possibly better, possibly worse.

00:10:19 Vickie Danaher

And this can be a really big concern, especially if patients don't make it to the emergency department.

00:10:26 Vickie Danaher

These biphasic reactions can occur in up to one in five patients, but it's really hard to predict which patients will have these recurrent episodes.

00:10:34 Vickie Danaher

So again, it's really important for patients to be aware of this.

00:10:38 Vickie Danaher

And this is one reason why we want to recommend having two epinephrine doses available, especially if patients have a prior severe or hard to treat reaction. These patients may be at a higher risk of having a biphasic reaction.

00:10:53 Vickie Danaher

Having two doses on hand is also important in other situations, such as if the person lives far from the hospital.

00:11:01 Vickie Danaher

And we want to clarify that antihistamines or corticosteroids do not treat anaphylaxis.

00:11:08 Vickie Danaher

So patients should rely on these instead of epinephrine.

00:11:13 Vickie Danaher

And one reason is that antihistamines or steroids work more slowly than epinephrine.

00:11:19 Vickie Danaher

And they also do not prevent bipolar.

00:11:25 Vickie Danaher

But then antihistamine or steroid is OK to add after a dose of epinephrine.

00:11:30 Vickie Danaher

If needed to treat hives, itching, or other continued symptoms.

00:11:37 Vickie Danaher

On top of that, some data suggests that about one in three kids who go to the emergency department with anaphylaxis leave the emergency department without a prescription for epinephrine.

00:11:48 Vickie Danaher

So patients are discharged for anaphylaxis.

00:11:51 Vickie Danaher

We want to verify that they are prescribed epinephrine.

00:11:54 Vickie Danaher

And also ensure they have an anaphylaxis emergency action plan to help them remember or to help inform caregivers or other people such as the patients’ teachers, about how to respond to allergic reactions.

00:12:07 Vickie Danaher

These action plans lay out the red flag symptoms, walk patients through the steps of what to do so that the patient or their caregiver can act promptly.

00:12:18 Vickie Danaher

And this type of plan should be kept on hand, right along with the patient's epinephrine.

00:12:23 Vickie Danaher

One thing to call it here is that the caregiver or patient should not hesitate to give epinephrine for these red flag symptoms and make sure to give it promptly. If they do suspect a severe allergic reaction.

00:12:38 Vickie Danaher

Now a few reminders when you get epinephrine prescriptions, ask for and document the patient's weight and double check doses, especially as children grow.

00:12:48 Vickie Danaher

For example, we know that most injectable epinephrine devices come in 0.3 or 0.15 milligram doses that 0.3 milligram dose is usually for patients who weigh 30 kilograms or more and the 0.15 milligram doses for lighter weight kids.

00:13:07 Vickie Danaher

But if doses aren't increased as the children grows, that dose may be too low.

00:13:14 Vickie Danaher

Remind patients to check the expiration date of their device and make a note on their calendar or in their phones to refill it before it expires.

00:13:24 Vickie Danaher

In general, we want to advise not to rely on expired epinephrine, but a recently expired product could be tried in a pinch if no other option is available.

00:13:35 Vickie Danaher

And we in the pharmacy can also continue to follow good inventory control practices such as checking expiration dates and rotating stock so that most patients get a product that will last at least a year or more before expiration.

00:13:49 Vickie Danaher

And for more on how the different epinephrine products stack up and to order demo devices for patients to practice with, you can see our resource emergency epinephrine devices.

00:14:01 Vickie Danaher

Also check out our managing anaphylaxis resource.

00:14:04 Vickie Danaher

It has tips on recognizing symptoms.

00:14:07 Vickie Danaher

Performing follow up and the role of other medications in treating allergic reactions.

00:14:15 Narrator

We hope you enjoyed and gained practical insights from listening to this presentation! 

Be sure to follow or subscribe, rate, and review this show in your favorite podcast app. Or find the show on YouTube by searching for ‘TRC Healthcare’ or clicking the link in the show notes. While you’re there, check out our other TRC podcasts like Medication Talk and Rumor vs Truth.

00:14:38 Narrator

Also in the show notes, we’ve linked directly to a few of the excellent resources mentioned today available to subscribers of Pharmacist’s Letter, Pharmacy Technician’s Letter, or Prescriber Insights. On those websites you’ll also find a lot more evidence-based, concise, yet comprehensive resources on this and other medication therapy topics. 

00:15:01 Narrator

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00:15:15 Narrator

And if you're a student, good news—students can access a free version of Pharmacist’s Letter, we’ve linked to that directly in the show notes as well… Check it out!

00:15:26 Narrator

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00:15:39 Narrator

Thanks for listening to Clinical Capsules!