Proper Epipen Use
Epinephrine is a medication that is used for anaphylaxis related to various causes. We most commonly prescribe it for treatment of food or bee sting allergies. Epinephrine temporarily increased blood pressure, which helps ensure blood is delivered to vital organs and decreased mucosal swelling in the skin, throat and bronchioles. It also acts as a bronchodilator, which opens of the bronchioles and decreases activation of mast cells, which are responsible for releasing histamine, a key component in anaphylaxis. There are no absolute contraindications to the use of epinephrine for anaphylaxis [1]. Therefore, all patients who are at risk for anaphylaxis should have access to epinephrine for self-treatment.
We prescribe two types of epinephrine devices:
• Auvi-Q: containing 0.15mg or 0.3 mg per dose(provides audible directions to guide user)
• Epipen: containing 0.15mg or 0.3 mg per dose
Anaphylaxis Reactions
Anaphylaxis is highly unpredictable [2]. One exposure to an allergen may result in mild symptoms, like hives and/or slight swelling, while the next causes a life-threatening reaction. It is not fully understood why reactions in the same patient can be so different. Anaphylaxis can sometime occur in two phases, called biphasic. Retrospective studies of anaphylaxis have found that a second dose was necessary in up to 35 percent of cases due to this biphasic reaction [3].
Epinephrine is the most effective treatment available for anaphylaxis and having an autoinjector enables patient to safely treat themselves immediately. Studies that have looked into reasons for fatal anaphylaxis show an association with lack of availability of epinephrine or failure to inject it at the onset of anaphylaxis symptoms [4]. Antihistamines and albuterol cannot reverse throat swelling or hypotension and are too slow-acting to be effective in anaphylaxis that develops quickly [5]. It is vital that epinephrine autoinjectors be carried at all times so the medication is available when the drug is needed. Autoinjectors should be taken everywhere, without exception.
In the setting of an allergic reaction, patients should use the epinephrine autoinjector immediately if they:
Are having trouble breathing or asthma symptoms
Feel tightness in the throat or difficulty swallowing
Feel lightheaded, dizzy or think they might pass out
If treating a child with an allergic reaction, also use the autoinjector if the child:
Is not improving or has a decrease in consciousness during an allergic reaction
Has food allergies and is vomiting repeatedly shortly after eating, especially if these symptoms are accompanied by flushing or hives
Is coughing repeatedly during an allergic reaction (indicating bronchospasm)
Had previous anaphylaxis and develops widespread hives after a suspected or known ingestion of the allergen.
Administering Epinephrine
Epinephrine is most effective when given within the first few minutes of an allergic reaction and should be injected into the mid-outer part of the thigh, into the underlying muscle [2]. The autoinjector should be held with a closed fist (like a baton, with fingers away from either end) [6]. The autoinjector can be used through clothes, as the needles are designed to penetrate clothing. A second dose may be needed if symptoms do not appear to be stabilizing or improving, and this may be given 5 to 15 minutes after the first injection [2]. If patients become lightheaded they should lie down with their legs elevated, if possible, in order to increase blood flow to vital organs. Patients should never be propped up during anaphylaxis.
Patients should stay with other people if possible during an allergic reaction. If alone, epinephrine should be self-administered first, and then the patient should call for help and be transported to the nearest emergency department as soon as possible, in case the symptoms of anaphylaxis worsen or recur without further exposure to the trigger (biphasic reaction). The reason for proceeding to the emergency department is because of the possibility of worsening or recurrent symptoms. It is important to inform and educate appropriate friends, family, colleagues, and food providers about their allergic condition.
Storing Epinephrine
Epinephrine autoinjectors have a limited shelf life and need to be replaced annually. It is recommended to use an out-of-date autoinjector, if that is all that is available, rather than not injecting epinephrine at all [7]. Autoinjectors should not be refrigerated. They should be stored in locations with neutral temperatures (work bag, purse, cabinets) rather than locations where the unit may overheat or freeze (glove compartment of a car, in an uninsulated bag on the beach).
References
1. Lieberman P, Nicklas RA, Oppenheimer J, et al. The diagnosis and management of anaphylaxis practice parameter: 2010 update. J Allergy Clin Immunol 2010; 126:477.
2. Sampson HA, Muñoz-Furlong A, Campbell RL, et al. Second symposium on the definition and management of anaphylaxis: summary report--Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium. J Allergy Clin Immunol 2006; 117:391.
3. Korenblat P, Lundie MJ, Dankner RE, Day JH. A retrospective study of epinephrine administration for anaphylaxis: how many doses are needed? Allergy Asthma Proc 1999; 20:383.
4. Bock SA, Muñoz-Furlong A, Sampson HA. Further fatalities caused by anaphylactic reactions to food, 2001-2006. J Allergy Clin Immunol 2007; 119:1016.
5. Simons FE. Anaphylaxis: evidence-based long-term risk reduction in the community. Immunol Allergy Clin North Am 2007; 27:231.
6. Simons FE, Lieberman PL, Read EJ Jr, Edwards ES. Hazards of unintentional injection of epinephrine from autoinjectors: a systematic review. Ann Allergy Asthma Immunol 2009; 102:282.
7. Simons KJ, Simons FE. Epinephrine and its use in anaphylaxis: current issues. Curr Opin Allergy Clin Immunol 2010; 10:354.
8. Simons FE, Gu X, Simons KJ. Outdated EpiPen and EpiPen Jr autoinjectors: past their prime? J Allergy Clin Immunol 2000; 105:1025.
Psoriasis is an autoimmune disease that typically affects the outside of the elbows, knees or scalp, however it may appear on any location. One of the most common forms of psoriasis is called plaque psoriasis. It causes raised, red patches covered with a silvery white layer of dead skin cells. Some people report that psoriasis itches, burns and stings .
It is reported that at least 10 percent of the general population inherits one or more of the genes that create a predisposition to psoriasis. However, only 2 percent to 3 percent of this population develops the disease. Researchers believe that for a person to develop psoriasis, the individual must have a combination of the genes that cause psoriasis and be exposed to specific external factors known as "triggers". These triggers can include; stress, injury or trauma to the skin and some types of medications. Psoriasis can also flare following a strep throat infection, earache, bronchitis, tonsillitis or a respiratory infection. Basically, anything that can affect the immune system can affect psoriasis[1].
The severity of psoriasis is not only measured by how much area of the body is affected, but also by how psoriasis affects a person's quality of life. There are a variety of ways to treat psoriasis, including; topical medications, systemic medications, biologic drugs, phototherapy treatment and alternatives therapies1.
The Baker Research Center is currently offering a study to research a topical medication that has been found to be beneficial in the treatment of psoriasis in adults 18 years or older. If you or someone you know has had psoriasis for over 6 months and would like more information regarding this study please notify Emily Widen, Erin Flamiatos, FNP or Angie Johnson at 503 534-2622.
References
1. National Psoriasis Foundation (n.d.). Retrieved November 26, 2013 from https://www.psoriasis.org/about-psoriasis
