Q: My son celebrated his birthday recently at a seafood restaurant. He experienced hives, itchiness, a tight throat, and some flushing of his face, probably as a result of something he ate. I am trying to see an allergist, but I was told that the wait time is more than 6 months. Should we be concerned that he will need an adrenaline kit?
A: Severe allergic reactions, known also as anaphylaxis, can be life-threatening. These events occur in children often enough to justify visits to an emergency room (ER). It is estimated that anaphylaxis accounts for 1 to 4 per 1000 visits to the ER (less than 1%).
A typical anaphylactic reaction involves the skin, respiratory tract, blood pressure, heart rate, and gastrointestinal tract (It was not that long ago when gastroenterologists identified an intriguing situation: patients who choke easily in restaurants due to a narrowing of the lower esophagus - all due to an allergic trigger.).
Of interest is the fact that of all the ER visits due to anaphylaxis, in only one-third of the cases is there an identifiable trigger. Of all the triggers, food is the main culprit, followed by stinging insects and then medications.
One of the world's top experts in the area of food-induced anaphylaxis is Dr. Hugh Sampson. According to extensive data compiled by Sampson and his colleagues, the foods most commonly implied are: peanuts, tree nuts, fish, shrimp, lobster, crab, scallops, and oysters.
The reality is that allergists are in short supply. The WHO (World Health Organization) estimates that the ideal number of allergists would be one allergist per 100,000 patients. In the whole of Canada, there are only approximately 150 allergists - about 50% of the ideal number.
Primary care doctors often see patients before they can be seen by allergists. These clinicians often have to educate patients about first aid treatment in the community; they also have to teach patients about the correct use of self-injectable adrenaline products.
Many studies have shown that the majority of primary care doctors are not skilled enough to teach patients how to use these epinephrine kits correctly; neither are some pharmacists. Even with education from the ideal teachers - allergists and their dedicated nursing staff who exclusively deal with allergies - patients still fall short in their ability to flawlessly administer their own adrenaline. Websites dedicated to improving knowledge have not helped much either. Even using a culturally popular venue such as YouTube has not improved the situation.
Speculation as to why this less-than-ideal situation prevails varies widely and there is no consensus. One popular theory is that when patients receive their education, they are relaxed and not under pressure. But when they are in the middle of a full blown emergency and they unexpectantly have to inject themselves in the thigh muscle, things suddenly become more stressful. Younger children typically are not fond of needles, and when a parent is stressed it may rub off onto a younger child.
The epinephrine market in Canada is lucrative. Recent data estimates it generates sales to the tune of $40 million annually, with 44% of the market in Ontario and 9% in B.C. and Alberta, respectively. The number of prescriptions has grown rapidly, probably because many patients ask to have multiple kits (i.e., some at school or work and some at home).
Prior to 2005, there was only one major supplier of self-injectable epinephrine. This product is known as an EpiPen kit. Its dominance was challenged by the launch of Twinject in 2005. The latter product has captured between 16-21% of the market.
Twinject, unlike its competition, delivers two dosages of epinephrine. The rationale for marketing such a device is the risk that some allergic patients experience a so-called biphasic allergic reaction, which is thought to occur in 6-12% of anaphylactic patients. This means that the first dose may wear off while there may be an ongoing allergic cascade in progress, thus requiring a second adrenaline dose prior to getting to an ER.
Some allergists object to using Twinject because its use requires extra teaching. Instead, these experts choose to prescribe two EpiPen kits, with the second one on standby in the event of a biphasic reaction. Furthermore, all allergists advise patients who have needed to use their epinephrine kit to go to an ER for further assessment and teaching prior to being allowed back into the community.
In the future, more products will be launched into Canada. For example, Anapen has already been available in Europe for some time. An easier way of administering epinephrine - under the tongue - may potentially simplify things greatly in future.
Meanwhile, in addition to both primary care doctors and patients not knowing how to use these kits correctly, two other challenges remain. Obese patients have become more prevalent; the extra layers of fat require the use of longer needles to reach through the fat and into the thigh muscle. Also, stunningly, a recent survey showed that only 28% of highly allergic individuals carry their epinephrine kits on their bodies at all times.
For more information, visit the Food Allergy and Anaphylaxis Network website at www.foodallergy.org.
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