Artículo original Anaphylaxis. How often patients carry epinephrine

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Revista Alergia México 2013;60:168-171
México
Artículo original
Anaphylaxis. How often patients carry epinephrine in real life?
Jorge Sánchez
RESUMEN
ABSTRACT
Antecedentes: la epinefrina es un tratamiento importante en
los pacientes con anafilaxia.
Objetivo: evaluar cuántos pacientes con antecedentes de
anafilaxia portaban la epinefrina durante la consulta médica.
Material y métodos: estudio observacional efectuado en la
Unidad de Alergología de la Universidad de Antioquia, Medellín,
Colombia, entre agosto de 2012 y junio de 2013. Preguntamos
a los pacientes con antecedente de reacción anafiláctica en los
últimos 18 meses si portaban, o tenían en su casa, epinefrina
para autoaplicación en caso de sufrir anafilaxia.
Resultados: de 120 pacientes con antecedente de anafilaxia,
sólo 69 (57.5%) tenían adrenalina en la casa o en el lugar de
trabajo, y 33 (27.5%) portaban la adrenalina durante la consulta, luego de seis meses de haber sido prescrita.
Conclusiones: la mayoría de los pacientes con antecedente
de anafilaxia no portan epinefrina para autoinyección, y consideramos necesario mejorar el apego al tratamiento en este
grupo de pacientes.
Background: Epinephrine is an important life-saving treatment
in patients with anaphylaxis.
Objective: To evaluate how many patients with a history
of anaphylaxis, carry epinephrine with them during medical
consultation.
Material and methods: A prospective study was done in the
Allergy Unit of the University of Antioquia (Medellin, Colombia),
we recruited patients, of all ages, from August 2012 to June
2013, who were referred with suspected anaphylactic reaction for the last 18 months, and were asked about carrying
epinephrine with them.
Results: Among 120 patients with a history of anaphylaxis,
only 69 (57.5%) had epinephrine in their house or office, and
33 (27.5%) carried it in the medical consultation after 6 months
of being prescribed.
Conclusion: Most patients with a history of anaphylaxis do not
carry epinephrine with them all the time, and it is necessary to
advise the patients, to improve their compliance to treatment.
Palabras clave: adrenalina, anafilaxia, apego, alergia, epinefrina, histamina.
Key words: anaphylaxis, compliance, allergy, epinephrine,
histamine.
Grupo de Alergia Clínica y Experimental. IPS Universitaria,
Universidad de Antioquía, Medellín, Colombia. Fundación para
el Desarrollo de Ciencias Médicas y Biológicas (FUNDEMEB),
Cartagena, Colombia. Instituto para Investigaciones Inmunológicas, Universidad de Cartagena, Cartagena, Colombia
Correspondence to: Dr. Jorge Sánchez
Carrera 42 n 7A Sur 92, Apto. 1710, Bloque 3,
Medellín, Colombia
[email protected]
Received: November 25, 2013
Accepted: December 10, 2013
This article must be quoted: Sánchez J. Anaphylaxis. How often
patients carry epinephrine in real life? Revista Alergia México
2013;60:168-171.
www.nietoeditores.com.mx
168
A
naphylaxis is a serious, life-threatening,
syndrome that can occur by different
mechanisms. Among clinical manifestations multiple organs can be affected at
the same time, most frequently the skin and bronchial
tract, but skin signs can be absent in up to 20% of cases.
Epinephrine is an important life-saving treatment in
patients with anaphylaxis. Nevertheless, despite medical
recommendations, many patients remain hesitant to use
it, and little is known about how many patients carry
epinephrine with them all the time. The aim of this study
was to evaluate how many patients carry epinephrine as
well as medals or bracelets, identifying them as patients
Revista Alergia México Volumen 60, Núm. 4, octubre-diciembre, 2013
Anaphylaxis. How often patients carry epinephrine in real life?
with history of anaphylactic reactions during medical
care, as an indirect measure of how often they carry
them in real life.
MATERIAL AND METHODS
An observational study was done in the Allergy Unit
of the University of Antioquia, Medellin, Colombia, in
which we recruited patients, of all ages, from August
2012 to June 2013, who were referred to us with suspected anaphylactic reaction for the past 18 months. Ethics
approval was obtained from the Ethics Committee of
the institution.
Patients with anaphylaxis history, who required
carry epinephrine as part of outpatient management,
were included. Inclusion criteria for initial enrollment
were according to one of the three Word Allergy Organization (WAO) criteria for anaphylaxis.1,2 Taking into
consideration WAO recommendation that anaphylaxis
diagnosis can be made in some specific cases, when
symptoms suddenly develop even in only one organ.1,2
We also included a second group of patients (possible
anaphylaxis) who did not comply strictly with one of the
three criteria, but history of anaphylaxis was considered
possible and the patient could benefit from carrying
epinephrine.
For each patient, a structured data sheet was completed in the first, second (three months) and third (six
months) clinical appointment. Data sheet included
reactions features, clinical managements and treatments
compliance.
In the first appointment, it was explained to each patient, verbally and through a brochure, that they should
carry epinephrine with them and how to use it, and to
consult the service in case of doubts on how to use it.
All patients were asked to bring their epinephrine in
the following clinical appointment. A list of possible
anaphylaxis triggers that each patient ought to avoid,
was supplied.
RESULTS
Of 989 new patients, 78 (7.8%) had a definite diagnosis
of anaphylaxis. Other 42 (4.2%) had a history of possible anaphylaxis with a high risk of a new event. We
did not observe significant differences according to age
and gender between groups. 30% of participants were
age <18 years. Patient’s characteristics are summarized
in Table 1. In the second appointment, of a total of 120
patients who were indicated to carry epinephrine all the
time, 27 (22.5%) had the epinephrine at home or office,
and only 10 (8.3%) carried epinephrine with them at
the time. In the third appointment, 69 (57.5%) had the
epinephrine and 33 (27.5%) carried it in the medical
consultation (10 of them were the same that carried it in
the second consultation). Among 51 patients who never
carried epinephrine, the main reasons for not carrying
it were: could not get it (23%), forgot it (34%), did not
remember how to use it (15%), feared its use (12%),
and other reasons (16%). At six months, 71% of patients
carried an identification object of anaphylaxis causes
and possible triggers, but only 51% carried it in a visible
place. Patients with loss of consciousness or requiring
ICU (Intensive Care Unit) because severe reactions,
carried epinephrine more frequently than patients with
less severe reactions (Table 2).
DISCUSSION
The use of epinephrine is a critical step in the management
of patients with anaphylactic reactions.3,4 Some studies have
shown that the delay in its use is associated with increased
mortality and morbidity; all patients with anaphylactic reaction and a high risk of recurrence should carry epinephrine
at all times. Ben-Shoshan et al, observed that almost all
outpatients with history of moderate or severe anaphylactic
reactions received an epinephrine autoinjector, nevertheless
more than 50% did not have autoinjector at the time of a
new reaction.5 In our study, 39 patients had a history of a
severe episode with loss of consciousness or requiring ICU;
four of them had a new episode during the six months of
follow up that required emergency management, but none
of them carried epinephrine during the episode, nor in the
next medical appointment; however during follow up, most
patients with severe reactions had the epinephrine at home,
office or car, that was a little higher than patients with less
severe symptoms.
Independent of the severity of the reaction, most
patients did not carry epinephrine at the time of the
medical consultation, even after explicit medical indi-
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Sánchez J
Table 1. Causes, symptoms and comorbidities of anaphylaxis and possible anaphylaxis
Features
Anaphylaxis
Possible anaphylaxis
Total
p
Patients
Age (media)
Female
# reactions (media)
Cause
Foods
Venoms
Medications
Unknown
Other
2 o more triggers
Symptoms
Skin
Gastrointestinal
Respiratory
Cardiovascular
Comorbidities
Asthma
Urticaria
78 (100%)
1 to 56 (30)
46 (59)
1 to 4 (1.8)
42 (100%)
1 to 54 (29)
24 (57)
1 to 7 (2.1)
120 (100%)
1 to 56 (30)
70 (58)
1 to 7 (1.9)
>0.05
>0.05
>0.05
33 (42)
6 (7)
15 (19)
18 (23)
18 (23)
12 (15)
21 (50)
0
8 (19)
15 (36)
12 (28)
18 (43)
54 (45)
6 (5)
23 (19)
33 (27)
30 (25)
30 (25)
>0.05
<0.05
>0.05
<0.05
>0.05
<0.05
74 (95)
12 (15)
65 (83)
12 (15)
36 (86)
5 (12)
32 (76)
8 (19)
110 (92)
17 (14)
97 (81)
20 (17)
>0.05
>0.05
>0.05
>0.05
23 (29)
20 (26)
15 (36)
20 (48)
38( 32)
40 (33)
>0.05
<0.05
p was evaluated between anaphylaxis and systemic reaction groups. p <0.05 statistically significant.
Table 2. Carrying of epinephrine and anaphylaxis identification objects, according to severity of reactions
Features
Patients
Had epinephrine
3 months
6 months
Carried epinephrine
3 months
6 months
Identification objects
3 months
6 months
Visible identification objects
3 months
6 months
Mild/moderate
reaction
Severe
reaction
Total
p
81 (100%)
39 (100%)
120 (100%)
-
14 (17)
43 (53)
13 (33)
26 (67)
<0.05
>0.05
6 (7)
21 (26)
4 (10)
12 (31)
27 (22)
69 (57)
(100%)
10 (8)
33 (27)
>0.05
>0.05
47 (58)
58 (72)
23 (59)
27 (69)
70 (58)
85 (71)
>0.05
>0.05
19 (23)
41 (51)
10 (26)
20 (51)
29 (24)
61 (51)
>0.05
>0.05
p was evaluated between mild/moderate and severe reaction groups. p <0.05 statistically significant.
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Anaphylaxis. How often patients carry epinephrine in real life?
cations, which implies a low compliance and need of
constant reinforcement during consultations. There are
no epinephrine autoinjectors for sale in Colombia, so
we recommend patients to wear epinephrine prefilled
syringes, and we explain them how to store and use it.
Prefilled syringes involve a risk of infection or epinephrine degradation, yet it was observed that even under
controlled conditions, it may take more than 5 minutes
for the patient to load the syringe with epinephrine,
which could be fatal.3 These devices have the advantage
of being very cheap (less than one dollar per epinephrine
ampule + syringe), however, among the main causes for
not carrying epinephrine, were the lack of supply by
the health service, which reflects a remarkable lack of
knowledge about the high risk of this health problem for
both, the patient and healthcare institutions.
noted that repeating instructions has a positive impact,
therefore it is advisable to implement periodical patient
education to improve compliance.
CONCLUSIONS
5.
We observed a low compliance in patients with a history of anaphylaxis to carry epinephrine, but we also
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