Episode 5 -  How to Use Epinephrine for Anaphylaxis (A Step-by-Step Guide by Allergists)
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​Meagan: Today we are doing a how-to.

Kara: This is the first of our How-To series how to use Epinephrine. Welcome to allergy actually.

When we think about severe allergic reactions, epinephrine is the number one medication that we use to really treat, treat the root cause of what's going on.

Amber: We have this mantra, "epi epi, epi."

Meagan: Yeah. Or "When in doubt, use epi."

Amber: "Epi first." We have lots of epi statements. 

Kara: But the reality is that when push comes to shove and the proverbial, you know, what hits the fan, there often is hesitation. And I will say personally, I have hesitated to use epinephrine on myself when I needed it, even as an allergy fellow.

Amber: It's human nature and it's part of why the anaphylaxis guidelines have changed about. We can get into that later, but unless you want me to get into it now.

Meagan: Well, 

the, the new thing that occurred that we're talking about is that there is no longer advice that you have to go to a hospital or be observed by a medical provider if you use your epi. And that information was originally included because we thought anaphylaxis often would come in waves and come back, not because you used your epi, because the Epi's safe. That's the main thing I tell my patients. If you use it one to two times and it turns out you are not having an allergic reaction, you'll be fine. So that's important to know.

Kara: You might feel a little cruddy and a little exhausted afterwards 'cause it is a bit like you

Meagan: up a flight of stairs? 

Kara: Yeah. Big flight. Big.

Amber: it's adrenaline.

Yeah. 

Meagan: it's not going to hurt you as far as sending your blood pressure through the roof or your heart rate way too high that that minor dose that comes in an auto-injector, um, or an external delivery device is so small that that is not something that is going to cause a problem in most people, almost everyone. 

Amber: Yeah. 

And so because people are so afraid to use epinephrine, the 2023 anaphylaxis treatment guidelines were changed to say that if you have to use epinephrine to treat anaphylaxis, you can be observed at home. If your symptoms resolve quickly, like it does for many people, then you don't need to go to the ER or call 9-1-1 unless you feel the need to. And if you, if you feel the need to, then you should.

But if you end up needing a second dose, if five minutes in, your symptoms haven't completely melted away, you use your second dose, then you wanna activate EMS. And that's the new recommendation with the hope that people then don't have the thought of, "Oh, well if I'm not bad enough to have to go to the ER, I shouldn't use my Epi."

That's old thinking, the thinking should be, "Do I need my epi? If yes, use it."

Meagan: And worry about the EMS stuff later. I've had patients say, "I didn't wanna use my epi because I didn't wanna go to the hospital." And as an allergist, that's a heartbreaking statement to hear. So we want you to be able to use it with confidence.

So that leads us into talking about the different auto, external delivery devices that are available. Um, we used to just say auto-injector, but there are now some other therapies that don't involve an injection, which we're gonna briefly discuss as well, which is kind of cool.


How to Use: The Generic Auto-Injector (Adrenaclick-style)
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Meagan: So this right here is, um, Epinephrine, it used to be Adrenaclick and it's very easy to use. It also used to have numbers here as far as pulling the ends off. That's the first thing you're gonna do. They've stopped numbering it and you can pull off either way. So it's super simple to do like that. And this one suggests using a swinging motion and you do it into the muscle on your lateral thigh. This, uh, version, their package instructions still say to hold it in there for 10 seconds. Most research has shown that the medication ejects within three seconds. I often tell people, count out loud to five. That can also calm you down a little bit as well. And after you remove it, you're gonna wanna rub here. And I generally then give my patients instructions to try to lay back and get their legs up in the air to keep blood flowing to their heart. Um, and that's not because of the Epi use. 

Amber: Before we move on, can you show us what happens if you forget to take off one of the safeties? Because that device is unique in that it has a safety on each end. 

Kara: We've lost the cap.

Amber: will come back to that. 

Meagan: I found it. Okay, here we are. Sorry about that. I think I sat on it for a bit. Okay. So if you just pull one, clearly, you know the medication isn't gonna come out. It's going to be stopped. So the needle isn't going to hit the end of this. 

Amber: What if you leave the other one on and you pull?

Meagan: If you do this, it's not gonna deploy. 

Yeah. 

Amber: You have to take both off?

Meagan: Yeah, so it's kind of foolproof and I like that it no longer has numbers because the numbers to me indicated that there was an order you needed to do that And, um, I found that too complicated. 

Kara: I want to point out one other thing though, which is how you're holding it. And that is really important. You wanna hold it like a baton or like a microphone. Um, because if you put your thumb over one end or the other, you could inject your thumb rather than your thigh.

You 

Amber: And 

Kara: that. 

Meagan: that 

happens.

Yeah, that does actually happen. 


How to Use: The EpiPen ("Blue to the sky, orange to the thigh")
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Meagan: So this is, um, another device and the brand name for this, um, is EpiPen. It's one that a lot of people are familiar with, and at, at least in the past, a lot of large, um, family entertainment centers, amusement parks, things like that would have centers where they would keep these. And so we hope to keep that going with all these types of epinephrine.

But this comes in a plastic case typically. Typically they're grouped as two, and that's an important tip as well. You always want to have two, because, one, you might need a second one. And then two, you can accidentally deploy it into some other portion of your body or just, um, in the air, which I actually did one day when I was a fellow. I thought it was the trainer and I was looking to see if I could see the needle and it ejected and I went and it flew by my face, so that could happen as well. And no one saw that. Yeah. And I was like, no one saw that. I mean that, that was amazing. And I, you know, quick dodge action.

So anyway, the way you use this, you take the top off and you, again, hold like a baton, swing onto your lateral thigh. This one now says to hold for three seconds. So again, if you are needing to, you know, count out loud or you just freak out and can't remember, count out loud to five and then pull it directly out. Rub a little bit, lay back with your legs up in the air. 

Kara: I wanna share my, I can't take credit for this. I heard it from the epi folks, but blue to the sky, orange to the thigh.

Amber: Ooh, 

I that. 

like it. 

Kara: So that cap on the top was blue, the orange, which is where the needle is, goes towards your thigh and you have a nice little rhyme to go along with it.

Yeah. The third, um, version that you may see, and this is actually, um, my, my middle child, Josie, um, at about nine months of age ate scrambled eggs and ended up with hives and threw up. Anaphylaxis. I think that's another important point to bring up, that the definition of anaphylaxis, the reason you should use epinephrine is more than one system of your body is affected. So in her case, she had her GI symptoms, she threw up and she had hives, her skin. Um, if she would've had wheezing, that would've also, you know, or coughing, um, that would've been another consideration.

You do not have to have skin findings, you do not have to have hives or swelling to have anaphylaxis in about, is 20%? 10-20% do not. And that, um, that is really important. The other organ system, we think about our cardiovascular system or nervous system. If you pass out, that is also a big problem. Use Epi.


How to Use: The Auvi-Q (The Talking Auto-Injector)
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Kara: Alright, so this is called Auvi-Q. Um, it is again an injection based, um, device. What I liked about this as a parent, and especially as a parent of a kiddo who could not speak for themselves quite yet, um, and in a daycare situation, was that this is pretty foolproof in that this is the trainer, but we're gonna listen to it. You take it out of the case.

"This trainer contains no needle or drug. if you are ready to use, pull off red safety guard. To inject, place black end against outer thigh then press firmly and hold in place for 5 seconds. 5, 4 , 3 , Injection Complete. This trainer may be reused for trainer 

trainer quiet.

Um, yes, but you could see where, you know, if it was someone who is not as confident that that might help, um, help ease that situation. 

Amber: Yeah. 

Kara: Um, and I will say from a, you can kind of, the shape is a little different, so it is a little more amenable to putting in a pocket. Um, often really the reality is though with the cost of these that your insurance coverage often is going to determine, determine

Amber: Mm-hmm. Yeah. 


How to Use: Neffy (The Needle-Free Nasal Spray Option)
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Amber: So the, yeah, the newest FDA approved epinephrine product on the market is needle free. So it's the first of the non auto-injectors, and this product is called Neffy. It, uh, comes with, in this plastic device, there's no needle. It goes in your nose. So you, I'm not going to put this in my nose, but you slide the nozzle up in the nose. You don't have to worry about any certain direction. Just put it up there as far as you can.

And some people have said, well, that's pretty big. Will that fit in a child's nose? Because it's now approved down to age four, down to 15 kilograms. Um, you know, we've all seen kids put fingers up their nose, other things up their nose. Trust us, it fits. So you put it up the nose and then you push the plunger. And this demo is kinda like a fidget, but the real one, you really have to use some pressure. So you push with pressure until you hear it pop, and that's your dose. Similar to the auto-injectors, if after five minutes you're not seeing improvement, you're using a second dose, so you should always keep two together.

Meagan: One thing about the second dose that I think is interesting is that for Neffy, it's in the same nostril. For the auto-injectors, it's in the opposite leg.

Now, again, in the grand scheme of things, during the heat of the moment, it's probably going to be okay if you don't follow that, but I did find that interesting. 

Amber: Yep. And the Neffy data does show if you do one dose, one nostril, one dose the other, you still get effective dosing. But to your point, you get even better effectiveness with using it in the same nostril.

So, um, this is a, a new option for you if you're needle-phobic or, um. The other thing, this has a longer expiration, 30 months after manufacturing, which if you add in time that it sits at the pharmacy, you know, maybe two years for most people. And it's not heat sensitive or temperature sensitive. So it's been tested up to hundred 22 degrees Fahrenheit. If you leave it in the car accidentally, it's gonna be okay and in freezing conditions. if it freezes, you can thaw it within 20 minutes and it still, uh, is effective.

And it's tiny. It could be in your pocket.

Kara: In your little clutch.

Meagan: Yeah, on a tiny little clutch, you can take it. Even fitting two of them in there is easy. 


Future Technology: Anaphylm (The Under-the-Tongue Film)
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Meagan: And, uh, finally there's another needle free, um, delivery, uh, method that is under review for the FDA and the conditional name that the FDA has given conditional consent for is Anaphylm and it is a little film, it looks like a Listerine, uh, I never remember what to call 'em a little. Blistering breath strip, the things that we put on our tongue that, you know, we all loved when they came out.

Um, but it is in a little package that almost looks like a little Aquaphor sample. It's, um, and it's foil and you literally, yeah, you just tear it, but the, the width, it's literally like this wide and that tall. So we are hopeful that that will even be able to like, be put in a wallet or something like that, that you don't have to carry that and be aware of it, um, at all. So as far as the stability data and all of that, that stuff is still coming, but we're very excited about the possibility of another delivery device.


What If My Epinephrine is Expired?
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Kara: I think one of the questions I've been asked really frequently is, you know, what if it's expired, what if it was left in the car? And you know, my advice has been, you know, one on the, depends. Often there is a little window, um, the trainer there is not, but you wanna make sure that the medication looks, um, clear. It doesn't look cloudy. Um, as long as that looks fine, you're better off to use what you have. You may be more prone to call EMS, but when in doubt, use it. It's the medication itself is not necessarily going bad. It just may not be as effective. And so, you know, ideally you have something that is not expired and, but when in doubt.

Meagan: And if I were, I mean, being a mom, I always think to myself, even if I had chunks in it, I'm gonna go ahead and I'm gonna use it. We're gonna worry about that muscle later. It's fine. But, um, the, the point is you do you, this is not straight up medical advice, I'm telling you personally as a mom. Um, but we just want you to be comfortable using epinephrine, know that it is safe and it can save your life.

So join us next time on 

Allergy actually.

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