By Jonathan Spergel, MD
Epinephrine auto-injectors have been in the news, recently. The rising cost over the last several years have surprised many families as they renew the prescription for back to school. The questions arise for many patients are 1) What are the options available to me? 2) Can we use an expired one? and 3) Do we need it?
Is there an alternative to EpiPen?
The quick answer is yes. There are two brands of epinephrine auto-injectors, called AdrenaClick and EpiPen®. Currently, only the generic version of the Adrenaclick is available. The price for each one depends on your insurance coverage, pharmacy coverage, co-pays and any offers that exist at the current time. More alternatives are being developed, including a generic version of the EpiPen. Two other pharmaceutical companies are working on their own auto-injector versions.
Can you make your own DIY kit, or just have a vial of epinephrine and syringe around?
Estelle Simons and colleagues examined the safety of vials of epinephrine. They examined the accuracy of parents, physicians, nurses and emergency department nurses drawing up epinephrine in an urgent setting. The parents took 4 times longer than physicians to draw it up. The amount of epinephrine drawn up ranged greatly with the parents in 40-fold compared 7-8 fold for physicians, general duty nurses’ doses (3-fold), and emergency department nurses’ doses (2-fold) (Simons et al, J Allergy Clin Immunol 2001; 108: 1040-4). In addition, the vials of epinephrine are very fragile and cannot be stored easily.
The other self-made idea is do-it-yourself kits (DIY). Besides the issues that are mentioned above, most folks (including school nurses) will not inject an unlabeled medication. Finally, the stability of epinephrine not in a FDA-reviewed product is unknown. In general, epinephrine in pre-filled syringe is stable for 3-4 months and at six months, it is only 50 percent of the original amount (Kelly and Dalm, Mil Med, 1985). The stability of epinephrine varies by temperature and storage conditions. This data means that DIYers would have be extra careful about dates, refilling, recycling on time and drawing up the correct amount.
Can we use an old Epipen?
A common complaint among families is, “I have never used my EpiPen or similar device. I am very careful. Why can I not use my old one?” The issue is that epinephrine is not very stable. As the stability study by Kelly and Dalm above found that 50 percent of epinephrine in pre-filled syringe decays in six months. However, Rachid and colleagues found that old epinephrine auto-injectors meet the United States Pharmacopeia standards of dose between 90-115 percent when they were within 24 months of the expiration date (Rachid et al, Annals Asthma Allergy Immunol 2015; 114;354-6). Therefore, maybe under ideal conditions, old epinephrine injectors might be ok to use. But, the conditions have to be right when epinephrine is stored beyond the recommended ranges of 68-77oF, it will lose potency.
Do we need our epinephrine auto-injector?
Many patients note that they have never need the epinephrine auto-injector and have only hives when they reacted to foods. Unfortunately, the previous reaction does not predict the next reaction. We have found this in several of our studies, whether done in supervised food challenges or real world exposures (Spergel et al. Ann Allergy Asthma Immunol. 2004 Feb; 92:217-24). The type and severity of reaction depends on the amount ingested, whether is done of full or empty stomach, associated with illness or exercise. It is not surprising that a worse reaction occurs when you have a larger amount of food compared to a small amount. It should be noted, however, that a potentially life-threatening reaction can occur even at very small amounts. Additionally, early administration of epinephrine in cases of suspected anaphylaxis are correlated with better outcomes and fewer hospital admissions.
Therefore, we still need our food allergy patients to carry their epinephrine auto-injectors at all times, and the prescription needs to be refilled at the expiration date.
Jonathan Spergel, MD is a professor of pediatrics at the University of Pennsylvania School of Medicine and chief of the Allergy Section at Children’s Hospital of Philadelphia. He is also a member of FARE’s Clinical Advisory Board executive committee.