Epinephrine Autoinjectors: New Data, New Problems
2017; Elsevier BV; Volume: 5; Issue: 5 Linguagem: Inglês
10.1016/j.jaip.2017.06.027
ISSN2213-2201
AutoresSusan Waserman, Ernie Avilla, Moshe Ben‐Shoshan, Lana Rosenfield, Andrea Burke Adcock, Matthew Greenhawt,
Tópico(s)Contact Dermatitis and Allergies
ResumoEpinephrine is the first-line treatment for anaphylaxis. Despite this, there have been identified gaps in the management of anaphylaxis including infrequent or delayed use of epinephrine for acute allergic reactions, as well as inadequate epinephrine autoinjector (EAI) training, and prescription rates of these devices for patients at risk. This paper reviews new data, and new problems in recently published literature on EAIs. A database search was conducted for publications between January 2015 and February 2017 using keywords related to EAIs including their functionality and features, carriage, prescription rates, barriers, and side effects. Eligibility criteria included patients at risk for anaphylaxis, caregivers, and health care professionals. Experimental studies and observational studies were included. Of 1,737 potentially relevant articles, 19 were used for analysis. These articles addressed specific aspects of an EAI, including (1) information on features and functionality; (2) prescriptions; (3) training on their use; and (4) carriage and use at the time of reaction by patients, schools, camps, emergency departments, and paramedics. Our review highlights that existing gaps in anaphylaxis management remain unaddressed. Patient needs are largely unmet, and very few studies are being designed to clarify and instill best practice, and to determine how to increase adherence to existing anaphylaxis guidelines through integrated knowledge translation strategies. Epinephrine is the first-line treatment for anaphylaxis. Despite this, there have been identified gaps in the management of anaphylaxis including infrequent or delayed use of epinephrine for acute allergic reactions, as well as inadequate epinephrine autoinjector (EAI) training, and prescription rates of these devices for patients at risk. This paper reviews new data, and new problems in recently published literature on EAIs. A database search was conducted for publications between January 2015 and February 2017 using keywords related to EAIs including their functionality and features, carriage, prescription rates, barriers, and side effects. Eligibility criteria included patients at risk for anaphylaxis, caregivers, and health care professionals. Experimental studies and observational studies were included. Of 1,737 potentially relevant articles, 19 were used for analysis. These articles addressed specific aspects of an EAI, including (1) information on features and functionality; (2) prescriptions; (3) training on their use; and (4) carriage and use at the time of reaction by patients, schools, camps, emergency departments, and paramedics. Our review highlights that existing gaps in anaphylaxis management remain unaddressed. Patient needs are largely unmet, and very few studies are being designed to clarify and instill best practice, and to determine how to increase adherence to existing anaphylaxis guidelines through integrated knowledge translation strategies. Information for Category 1 CME CreditCredit can now be obtained, free for a limited time, by reading the review articles in this issue. Please note the following instructions.Method of Physician Participation in Learning Process: The core material for these activities can be read in this issue of the Journal or online at the JACI: In Practice Web site: www.jaci-inpractice.org/. The accompanying tests may only be submitted online at www.jaci-inpractice.org/. Fax or other copies will not be accepted.Date of Original Release: September 1, 2017. Credit may be obtained for these courses until August 31, 2018.Copyright Statement: Copyright © 2017-2019. All rights reserved.Overall Purpose/Goal: To provide excellent reviews on key aspects of allergic disease to those who research, treat, or manage allergic disease.Target Audience: Physicians and researchers within the field of allergic disease.Accreditation/Provider Statements and Credit Designation: The American Academy of Allergy, Asthma & Immunology (AAAAI) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The AAAAI designates this journal-based CME activity for 1.00 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.List of Design Committee Members: Susan Waserman, MSc, MDCM, FRCPC, Ernie Avilla, MBA(c), Moshe Ben-Shoshan, MD, MSc, Lana Rosenfield, MD, Andrea Burke Adcock, MD, and Matthew Greenhawt, MD, MBA, MSc (authors); Scott H. Sicherer, MD (editor)Learning objectives:1.To understand the features and functionality of epinephrine autoinjectors (EAIs).2.To illustrate the current gaps in anaphylaxis management by health care professionals.3.To illustrate the current utilization of EAIs by patients and caregivers in schools or camps.Recognition of Commercial Support: This CME has not received external commercial support.Disclosure of Relevant Financial Relationships with Commercial Interests: S. Waserman has received research support and lecture fees from Pfizer Canada. M. Greenhawt has received research support from AHRQ (1K08HS024599-01, Career Development Award); has received travel support from NIAID and the Joint Taskforce on Allergy Practice Parameters; is an unpaid member of the National Peanut Board Scientific Advisory Council; has received consultancy fees from the Canadian Transportation Agency, Nutricia, Nestle, Aimmune, Kaleo Pharmaceutical, Monsanto, and Intrommune Pharmaceutical; is an Associate Editor for Annals of Allergy, Asthma, and Immunology; and has received lecture fees from ACAAI, Reach MD, Thermo Fisher Scientific, New York Allergy and Asthma Society, Swineford Allergy Society, Medscape, Aspen Allergy Society, EAACI, Canadian Society of Allergy and Clinical Immunology. The other authors declare they have no relevant conflicts of interest. S. H. Sicherer disclosed no relevant financial relationships. Credit can now be obtained, free for a limited time, by reading the review articles in this issue. Please note the following instructions. Method of Physician Participation in Learning Process: The core material for these activities can be read in this issue of the Journal or online at the JACI: In Practice Web site: www.jaci-inpractice.org/. The accompanying tests may only be submitted online at www.jaci-inpractice.org/. Fax or other copies will not be accepted. Date of Original Release: September 1, 2017. Credit may be obtained for these courses until August 31, 2018. Copyright Statement: Copyright © 2017-2019. All rights reserved. Overall Purpose/Goal: To provide excellent reviews on key aspects of allergic disease to those who research, treat, or manage allergic disease. Target Audience: Physicians and researchers within the field of allergic disease. Accreditation/Provider Statements and Credit Designation: The American Academy of Allergy, Asthma & Immunology (AAAAI) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The AAAAI designates this journal-based CME activity for 1.00 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. List of Design Committee Members: Susan Waserman, MSc, MDCM, FRCPC, Ernie Avilla, MBA(c), Moshe Ben-Shoshan, MD, MSc, Lana Rosenfield, MD, Andrea Burke Adcock, MD, and Matthew Greenhawt, MD, MBA, MSc (authors); Scott H. Sicherer, MD (editor) Learning objectives:1.To understand the features and functionality of epinephrine autoinjectors (EAIs).2.To illustrate the current gaps in anaphylaxis management by health care professionals.3.To illustrate the current utilization of EAIs by patients and caregivers in schools or camps. Recognition of Commercial Support: This CME has not received external commercial support. Disclosure of Relevant Financial Relationships with Commercial Interests: S. Waserman has received research support and lecture fees from Pfizer Canada. M. Greenhawt has received research support from AHRQ (1K08HS024599-01, Career Development Award); has received travel support from NIAID and the Joint Taskforce on Allergy Practice Parameters; is an unpaid member of the National Peanut Board Scientific Advisory Council; has received consultancy fees from the Canadian Transportation Agency, Nutricia, Nestle, Aimmune, Kaleo Pharmaceutical, Monsanto, and Intrommune Pharmaceutical; is an Associate Editor for Annals of Allergy, Asthma, and Immunology; and has received lecture fees from ACAAI, Reach MD, Thermo Fisher Scientific, New York Allergy and Asthma Society, Swineford Allergy Society, Medscape, Aspen Allergy Society, EAACI, Canadian Society of Allergy and Clinical Immunology. The other authors declare they have no relevant conflicts of interest. S. H. Sicherer disclosed no relevant financial relationships. Anaphylaxis is a serious allergic reaction that is rapid in onset and may be associated with fatality.1Sampson H.A. Muñoz-Furlong A. Campbell R.L. Adkinson Jr., N.F. Bock S.A. Branum A. 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: 391-397Abstract Full Text Full Text PDF PubMed Scopus (1649) Google Scholar Current guidelines recommend prompt use of intramuscular (IM) epinephrine as first-line treatment.1Sampson H.A. Muñoz-Furlong A. Campbell R.L. Adkinson Jr., N.F. Bock S.A. Branum A. 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: 391-397Abstract Full Text Full Text PDF PubMed Scopus (1649) Google Scholar, 2Simons F.E. Ebisawa M. Sanchez-Borges M. Thong B.Y. Worm M. Tanno L.K. et al.2015 update of the evidence base: World Allergy Organization anaphylaxis guidelines.World Allergy Organ J. 2015; 8: 32Crossref PubMed Scopus (366) Google Scholar, 3Boyce J.A. Assa'ad A. Burks A.W. Jones S.M. Sampson H.A. Wood R.A. et al.Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID-Sponsored Expert Panel.J Allergy Clin Immunol. 2010; 126: S1-S58Abstract Full Text Full Text PDF PubMed Scopus (1176) Google Scholar, 4Sheikh A. Simons F.E. Barbour V. Worth A. Adrenaline auto-injectors for the treatment of anaphylaxis with and without cardiovascular collapse in the community.Cochrane Database Syst Rev. 2012; : CD008935PubMed Google Scholar Currently, anaphylaxis has been defined by multiple guidelines, all of which emphasize cardiorespiratory symptoms or involvement of 2 or more organ systems as key identifying features. Administration via the IM route is known to provide faster and higher peaks of plasma concentration compared with the subcutaneous route.5Lane R.D. Bolte R.G. Pediatric anaphylaxis.Pediatr Emerg Care. 2007; 23: 49-56Crossref PubMed Scopus (17) Google Scholar Despite its pivotal role, utilization of epinephrine in the management of anaphylaxis remains suboptimal. Previous studies have identified gaps in anaphylaxis management by health care professionals, patients, and their caregivers (including schools and other key stakeholders in the community). Findings included infrequent use of epinephrine in the treatment of acute allergic reactions6Kastner M. Harada L. Waserman S. Gaps in anaphylaxis management at the level of physicians, patients, and the community: a systematic review of the literature.Allergy. 2010; 65: 435-444Crossref PubMed Scopus (107) Google Scholar, 7Xu Y.S. Kastner M. Harada L. Xu A. Salter J. Waserman S. Anaphylaxis-related deaths in Ontario: a retrospective review of cases from 1986 to 2011.Allergy Asthma Clin Immunol. 2014; 10: 38Crossref PubMed Scopus (86) Google Scholar; significant delay in the timing of epinephrine administration after the occurrence of a reaction6Kastner M. Harada L. Waserman S. Gaps in anaphylaxis management at the level of physicians, patients, and the community: a systematic review of the literature.Allergy. 2010; 65: 435-444Crossref PubMed Scopus (107) Google Scholar, 7Xu Y.S. Kastner M. Harada L. Xu A. Salter J. Waserman S. Anaphylaxis-related deaths in Ontario: a retrospective review of cases from 1986 to 2011.Allergy Asthma Clin Immunol. 2014; 10: 38Crossref PubMed Scopus (86) Google Scholar; low prescription rates for epinephrine autoinjectors (EAIs) across different settings including hospital, outpatient clinics, or emergency departments (EDs); and inappropriate prescription of antihistamines and corticosteroids during and in the aftermath of treated reactions.6Kastner M. Harada L. Waserman S. Gaps in anaphylaxis management at the level of physicians, patients, and the community: a systematic review of the literature.Allergy. 2010; 65: 435-444Crossref PubMed Scopus (107) Google Scholar, 8Tsuang A. Wang J. Childcare and school management issues in food allergy.Curr Allergy Asthma Rep. 2016; 16: 83Crossref PubMed Scopus (13) Google Scholar Findings also revealed inadequate training of patients and/or caregivers (including school teachers) on when and how to use an EAI correctly.6Kastner M. Harada L. Waserman S. Gaps in anaphylaxis management at the level of physicians, patients, and the community: a systematic review of the literature.Allergy. 2010; 65: 435-444Crossref PubMed Scopus (107) Google Scholar, 9Gaeta T.J. Clark S. Pelletier A.J. Camargo C.A. National study of US emergency department visits for acute allergic reactions, 1993 to 2004.Ann Allergy Asthma Immunol. 2007; 98: 360-365Abstract Full Text Full Text PDF PubMed Scopus (123) Google Scholar It has been previously noted that many patients do not carry an EAI or did not have one available at the time of a reaction, particularly in cases of documented fatal anaphylaxis6Kastner M. Harada L. Waserman S. Gaps in anaphylaxis management at the level of physicians, patients, and the community: a systematic review of the literature.Allergy. 2010; 65: 435-444Crossref PubMed Scopus (107) Google Scholar, 7Xu Y.S. Kastner M. Harada L. Xu A. Salter J. Waserman S. Anaphylaxis-related deaths in Ontario: a retrospective review of cases from 1986 to 2011.Allergy Asthma Clin Immunol. 2014; 10: 38Crossref PubMed Scopus (86) Google Scholar, 8Tsuang A. Wang J. Childcare and school management issues in food allergy.Curr Allergy Asthma Rep. 2016; 16: 83Crossref PubMed Scopus (13) Google Scholar, 10Pumphrey R.S. Gowland M.H. Further fatal allergic reactions to food in the United Kingdom, 1999-2006.J Allergy Clin Immunol. 2007; 119: 1018-1019Abstract Full Text Full Text PDF PubMed Scopus (438) Google Scholar, 11Bock S.A. Muñoz-Furlong A. Sampson H.A. Further fatalities caused by anaphylactic reactions to food, 2001-2006.J Allergy Clin Immunol. 2007; 119: 1016-1018Abstract Full Text Full Text PDF PubMed Scopus (782) Google Scholar an outcome that many view as almost entirely preventable. The objective of this paper is to present a succinct review of the evidence from recently published literature (January 1, 2015, to February 6, 2017) focused on new data and new challenges related to EAIs. A database search (Ovid MEDLINE(R) Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily, Ovid MEDLINE, and Versions(R)) for articles (up to February 6, 2017) was conducted using the following key words: "epinephrine," AND-ed "hypersensitivity or food hypersensitivity or anaphylaxis or epinephrine autoinjectors or self administration" AND-ed "features or functionality or needle length or injection pressure or rapid onset of activity or doses or IM or subcutaneous or storage or expiry date or carriage or prescription or dispensing rates, accidental injections, barriers, fear, side effects or stock epinephrine or preparedness or anaphylaxis action plan or training, laws or epinephrine tablets or needle-less devices." Search terms were generated using known terms and synonyms suggested by allergy specialists. For article inclusion, the following eligibility criteria were used: Population: Included were patients at risk for anaphylaxis and their caregivers (including schools and other community settings) and health care professionals involved in their care. Intervention: Included were any approaches or protocols that incorporated a strategy for EAI use. Comparator: Included were any studies for inclusion irrespective of whether there was a comparator included in the study design. Outcomes: Included were any related to treatments, prescription rates, EAI training/education, and carriage. Study design: Included were experimental studies (eg, randomized controlled trials [RCTs]), other experimental designs (eg, nonrandomized methods of assignment, controlled before-after studies, and interrupted time series), and observational studies (eg, prospective or retrospective cohort studies, cross-sectional studies, and case-control studies). Per an agreed on a priori decision of the authors, we excluded case reports, opinion-based reports (ie, editorials, letters, and nonsystematic or narrative reviews), as well as basic science or animal (non-human) studies. All included studies were agreed on by author consensus after review in an iterative process. The analysis involved summarizing the data, and presenting results in a narrative synthesis. We prepared descriptive tables to give an overview of the included study characteristics. This manuscript was not designed to carry out quantitative analysis, meta-analysis, or assess risk of bias. Of 1,737 potentially relevant articles identified by our search, 1,412 did not meet the inclusion/exclusion criteria or were duplicates and removed from the review. Of 325 citations that were screened for relevance, 37 were selected for full-text review (including 2 articles identified by experts in the field) and 32 met the inclusion criteria. Of the 32 full-text articles, 19 were included in the analysis (Fig 1). The majority of the studies (Table I) were epidemiological in nature, consisting of retrospective cohort studies (n = 6); cross-sectional surveys (n = 5); prospective studies (n = 5); case-control study (n = 1); pretest/posttest (n = 1); and retrospective chart review (n = 1). More than 80% of the studies involved hospital- or clinic-based populations (n = 12) or community settings (n = 4), and these populations varied widely across studies with respect to participant age and gender. No controlled studies of any type were identified in the literature search.Table ICharacteristics of included studiesStudyStudy objectiveSetting/durationPopulationDesignBardou et al 201712Bardou M. Luu M. Walker P. Auriel C. Castano X. Efficacy of a novel prefilled, single-use, needle-free device (Zeneo) in achieving intramuscular agent delivery: an observational study.Adv Ther. 2017; 34: 252-260Crossref PubMed Scopus (10) Google ScholarTo evaluate the functional performance of the Zeno device in the setting of IM delivery to the lateral thighClinic center, FranceJune and December 2015Adult healthy volunteers aged between 18 and 60 y and body mass index (BMI) 20-30 kg/m2N = 37 subjects with evaluable MRI scans included analysisProspective cohort studyCampbell et al 201613Campbell R.L. Bellolio M.F. Motosue M.S. Sunga K.L. Lohse C.M. Rudis M.I. Autoinjectors preferred for intramuscular epinephrine in anaphylaxis and allergic reactions.West J Emerg Med. 2016; 17: 775-782Crossref PubMed Scopus (15) Google ScholarTo examine health care providers' preferences and perceptions about the optimal mode of epinephrine delivery (safety, effectiveness, ease of administration, convenience, and cost)Emergency department, Mayo Clinic HospitalApril and June 2011Emergency department personnel N = 172Cross-sectional surveyCivelek et al 201614Civelek E. Erkoçoğlu M. Akan A. Özcan C. Kaya A. Vezir E. et al.The etiology and clinical features of anaphylaxis in a developing country: a nationwide survey in Turkey [e-pub ahead of print].Asian Pac J Allergy Immunol. 2016; http://dx.doi.org/10.12932/ap0752PubMed Google ScholarTo determine etiology and clinical features of anaphylaxis patients prescribed adrenaline autoinjectors within a certain periodPediatric allergy clinicJanuary 2008 and December 2011N = 843 anaphylaxis patientsCross-sectional surveyColleti et al 201615Colleti Jr., J. de Carvalho W.B. Anaphylaxis knowledge among pediatric intensivists in Brazil: a multicenter survey [e-pub ahead of print].J Intensive Care Med. 2016; https://doi.org/10.1177/0885066616659866Google ScholarTo assess the knowledge of pediatric intensivists regarding the first-line drug and the route of administration for the treatment of anaphylaxisPediatric ICUs, Sao Paulo State, BrazilMarch to June 2015N = 43 pediatric intensivistsCross-sectional surveyDreborg et al 201616Dreborg S. Wen X. Kim L. Tsai G. Nevis I. Potts R. et al.Do epinephrine auto-injectors have an unsuitable needle length in children and adolescents at risk for anaphylaxis from food allergy?.Allergy Asthma Clin Immunol. 2016; 12: 11Crossref PubMed Scopus (30) Google ScholarTo evaluate whether children and adolescents who are at risk of anaphylaxis from food allergy weighing 15-30 kg and >30 kg would receive epinephrine into the intramuscular space, the bone, or subcutaneous spaceWestern University, London, Ontario, CanadaJuly 2012 to June 2014Patients less than 18 y of age, with diagnosed food allergyN = 202(102 weighed 5-30 kg; 100 weighed >30 kg)Prospective cohort studyFoster et al 201517Foster A.A. Campbell R.L. Lee S. Anderson J.L. Anaphylaxis preparedness among preschool staff before and after an educational intervention.J Allergy (Cairo). 2015; 2015: 231862PubMed Google ScholarTo assess anaphylaxis preparedness among preschool staff members before and after an educational interventionPreschoolsSeptember 2011 and May 2012N = 10 preschoolsN = 171 staff membersPre/posttest in a convenience sampleHogue et al 201618Hogue S.L. Goss D. Hollis K. Silvia S. White M.V. Training and administration of epinephrine auto-injectors for anaphylaxis treatment in US schools: results from the EpiPen4Schools pilot survey.J Asthma Allergy. 2016; 9: 109-115Crossref PubMed Scopus (29) Google ScholarTo describe the occurrence of anaphylactic reactions and the training and personnel resources available to manage these eventsSchools, USAMay 2014 and July 2014N = 6,019 schoolsCross-sectional surveyKawano et al 201719Kawano T. Scheuermeyer F.X. Stenstrom R. Rowe B.H. Grafstein E. Grunau B. Epinephrine use in older patients with anaphylaxis: clinical outcomes and cardiovascular complications.Resuscitation. 2017; 112: 53-58Abstract Full Text Full Text PDF PubMed Scopus (29) Google ScholarTo compare the frequency of epi nephrineadministration and the subsequent documented cardiovascular complications in patients with anaphylaxisEmergency department, Vancouver, British Columbia, CanadaApril 2007 to March 2012N = 492 patients with anaphylaxisRetrospective cohort studyKimchi et al 201520Kimchi N. Clarke A. Moisan J. Lachaine C. La Vieille S. Asai Y. et al.Anaphylaxis cases presenting to primary care paramedics in Quebec.Immun Inflamm Dis. 2015; 3: 406-410Crossref PubMed Scopus (15) Google ScholarTo assess anaphylaxis cases managed by paramedicsEmergency medical services/paramedicsMay 2013 and May 2014N = 104 anaphylaxis casesProspective cohort studyKo et al 201621Ko B.S. Kim J.Y. Seo D.-W. Kim W.Y. Lee J.H. Sheikh A. et al.Should adrenaline be used in patients with hemodynamically stable anaphylaxis? Incident case control study nested within a retrospective cohort study.Sci Rep. 2016; 6: 20168Crossref PubMed Scopus (15) Google ScholarTo investigate whether adrenaline use in hemodynamically stable patients can prevent the in-hospital occurrence of hypotension in hemodynamically stable patients with anaphylaxisEmergency department, Tertiary Care, Seoul, KoreaJanuary 2004 and December 2013Adult (≥16 y) patients with anaphylaxisN = 340 hemodynamically stable patients; 300 no hypotension; 40 hypotensionRetrospective cohort studyLee et al 201622Lee A.Y. Enarson P. Clarke A.E. La Vieille S. Eisman H. Chan E.S. et al.Anaphylaxis across two Canadian pediatric centers: evaluating management disparities.J Asthma Allergy. 2016; 10: 1-7Crossref PubMed Scopus (25) Google ScholarTo compare the percentage, triggers, and management of anaphylaxis between 2 Canadian tertiary hospitalsEmergency department, British Columbia and Montreal2014 and 2016N = 977 children with anaphylaxisProspective cohort studyLee et al 201623Lee S. Hess E.P. Lohse C. Souza D.L. Campbell R.L. Epinephrine autoinjector prescribing trends: an outpatient population-based study in Olmsted County, Minnesota.J Allergy Clin Immunol Pract. 2016; 4: 1182-1186.e1Abstract Full Text Full Text PDF PubMed Scopus (13) Google ScholarTo determine the trends of epinephrine autoinjector prescriptions in Olmsted County residentsOlmsted County residents over a 7-y period, 2004-2010All Olmsted County residents identified by REP censusRetrospective cohort studyPourang et al 201624Pourang D. Batech M. Sheikh J. Samant S. Kaplan M. Anaphylaxis in a health maintenance organization: International Classification of Diseases coding and epinephrine auto-injector prescribing.Ann Allergy Asthma Immunol. 2017; 118: 186-190.e1Abstract Full Text Full Text PDF PubMed Scopus (16) Google ScholarTo quantify the accuracy of anaphylaxis-related ICD-9 codes in the Southern California Permanente Medical GroupHMO— Kaiser Permanente, Southern CaliforniaJanuary 2008 and December 2012N = 2,531,563 patients were included in the analysisRetrospective cohort studyRachid et al 201625Rachid O. Simons F.E. Rawas-Qalaji M. Lewis S. Simons K.J. Epinephrine doses delivered from auto-injectors stored at excessively high temperatures.Drug Dev Ind Pharm. 2016; 42: 131-135Crossref PubMed Scopus (14) Google ScholarTo simulate the effects of constant or cyclic thermal heat stress greatly exceeding the recommendations of the manufacturer for optimal EAI storage on the epinephrine doses delivered from the EAIUniversity of ManitobaN = 25 EpiPens 0.3 mg, lot number 3GU006, labeled to deliver 0.3 mL of epinephrine USP 1:1000Case-control studyRidolo et al 201526Ridolo E. Montagni M. Bonzano L. Savi E. Peveri S. Constantino M.T. et al.How far from correct is the use of adrenaline auto-injectors? A survey in Italian patients.Intern Emerg Med. 2015; 10: 937-941Crossref PubMed Scopus (15) Google ScholarTo verify the proper use of the device, the correct administration of drug, and to identify possible misuse by patients at risk of anaphylaxisAllergy clinics, ItalyJuly and December 2013N = 242 patients who had been prescribed an adrenaline autoinjector for at least 1 yProspective cohort studySaleh-Langenberg et al 201527Saleh-Langenberg J. Dubois A.E. Groenhof F. Kocks J.W. van der Molen T. Flokstra-de Blok B.M. Epinephrine auto-injector prescriptions to food-allergic patients in primary care in The Netherlands.Allergy Asthma Clin Immunol. 2015; 11: 28Crossref PubMed Scopus (8) Google ScholarTo describe and evaluate practice in EAI prescriptions by GPs to food-allergic patientsGeneral practice, the NetherlandsFrom 2001 to 2012N = 148 patients aged 12-23 y who consulted their GP for allergic symptoms due to food from 2001 to 2012Retrospective cohort studySchellpfeffer et al 201628Schellpfeffer N.R. Leo H.L. Ambrose M. Hashikawa A.N. Food allergy trends and epinephrine autoinjector presence in summer camps.J Allergy Clin Immunol Pract. 2017; 5: 358-362Abstract Full Text Full Text PDF PubMed Scopus (14) Google ScholarTo estimate the prevalence of food allergies among otherwise healthy campers in a large number of summer camps throughout the United States and CanadaSummer camps, USA and CanadaOctober 2011N = 3,055 campersRetrospective cohort studySheikh et al 201529Sheikh A. Dhami S. Regent L. Austin M. Sheikh A. Anaphylaxis in the community: a questionnaire survey of members of the UK Anaphylaxis Campaign.JRSM Open. 2015; 6: 1-6Crossref Google ScholarTo examine the circumstances, features, and management of anaphylaxis in children and adultsAnaphylaxis campaign, UK-wide patient charityMay 2001-September 2013N = 243 unique subjectsCross-sectional surveySidhu et al 201630Sidhu N. Jones S. Perry T. Thompson T. Storm E. Melquizo Castro M.S. et al.Evaluation of anaphylaxis management in a pediatric emergency department.Pediatr Emerg Care. 2016; 32: 508-513Crossref PubMed Scopus (34) Google ScholarTo assess the adherence to the guidelines in the EDEmergency department, Arkansas Children's HospitalJanuary 2004 and January 2006 (preguideline period) and those from July 2007 and July 2011 (postguideline period)N = 187 patients presenting with anaphylaxisRetrospective chart reviewEAI, Epinephrine autoinjector; ED, emergency department; GP, general practitioner; HMO, Health Maintenance Organization; ICD-9, International Classification of Diseases, Ninth Revision; ICU, intensive care unit; IM, intramuscular; MRI, magnetic resonance imaging; REP, Rochester Epidemiology Project. Open table in a new tab EAI, Epinephrine autoinjector; ED, emergency department; GP, general practitioner; HMO, Health Maintenance Organization; ICD-9, International Classification of Diseases, Ninth Revision; ICU, intensive care unit; IM, intramuscular; MRI, magnetic resonance imaging; REP, Rochester Epidemiology Project. An analysis of the studies revealed 4 major themes addressing aspects of an EAI (Table IIA-D ), including (1) information on features and functionality; (2) prescriptions; (3) training on their use; and (4) carriage and use at the time of reaction by patients, schools, camps, EDs, and paramedics.Table IISummary of theme
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