Most Adults With Allergies Do Not Carry Epinephrine Injectors

Norra MacReady

June 21, 2018

Most people with life-threatening allergies do not use or carry the epinephrine autoinjectors (EAIs) that doctors prescribe for them, according to a new study of a large, representative sample of the US population.

Of 917 survey participants, roughly half (51%) reported having continuous access to an EAI, whereas 44% said they carried at least one with them all the time, researchers reported in an article published online June 21 in the Annals of Allergy, Asthma, and Immunology. Only 24% of the sample carried two or more EAIs, which is recommended.

This was despite the fact that 89% of all prescriptions for EAIs had been filled and 69% of the patients had experienced at least one allergic reaction within the last 12 months.

In the survey, 58% to 59% of the respondents said they knew how to use an EAI and could recognize the signs and symptoms of a severe allergic reaction. "Remarkably, over 50% of adults and 30% of children reported experiencing at least one severe allergic reaction where an EAI was not used but would have been beneficial," write Christopher M. Warren, PhD, from the University of Southern California Keck School of Medicine in Los Angeles, and colleagues.

"It's not enough to simply pick up your EAI prescription," senior author Ruchi Gupta, MD, MPH, from the Institute for Public Health and Medicine at Northwestern University Feinberg School of Medicine in Chicago, Illinois, said in a related press release. "You need to know how to use your EAI and always carry it, to be prepared for an allergy emergency. It could save your life."

For at least 40% of the respondents, no EAI was available during their most severe allergic reaction. This occurred more often among adults than children (44% vs 37%), which may reflect the increased availability of EAIs in schools, the authors add.

Identifying Barriers

The prevalence of serious allergy has risen significantly in recent decades and is currently estimated at 8% in children and 5% in adults, the authors note. There is already evidence that patients do not carry or use their EAIs as prescribed, which could have severe or even fatal consequences.

To learn more about the barriers for epinephrine carriage and usage, Warren and colleagues used a survey instrument developed by a multidisciplinary team of clinicians, patients, and parents of food-allergic children, with items drawn from validated population-level surveys whenever possible. Eligible participants were English-speaking adults 18 years of age or older who had been prescribed an EAI for themselves or for one of their children.

The final sample included information on 255 children aged 0 to 12 years, 212 adolescents aged 13 to 17 years, and 450 adults aged 18 to 65 years. Peanut allergy was the most common food allergy, reported by 30% of the sample, followed by shellfish (22%), and milk (21%).

Among adults who had not filled their EAI prescriptions, 47% cited cost as a reason, followed by the belief that their allergy was not that severe (23%) and no history of allergic reactions (20%). Among parents responding for children and adolescents, however, "the most commonly cited barriers were no history of previous reactions (28%), followed by perceptions that an EAI wasn't needed (25%)."

Participants who had a history of treatment with an EAI were more likely to carry them routinely; of those patients, 93% carried at least 1, compared with 62% of patients without that history (P < .001), and 29% carried multiple EAIs vs 16% of patients who had not previously been treated with an EAI (P < .001).

Although the vast majority of respondents had filled their prescriptions, 68% said that lowering EAI costs would improve anaphylaxis management, "with 50% of respondents reporting that their insurance co-pay or deductible presented a barrier to access," the authors write. Respondents also suggested that management could be improved by increasing stock supplies of epinephrine (50%) and raising public awareness about allergens (47%).

In addition, 61% of participants stated that more effective patient education during physician visits would help increase understanding of how and when to use an EAI.

"This highlights the important role that physicians play in counselling patients on allergy management and the need for more effective clinical counselling strategies," the authors write. They suggest that "routine preventive visits" might present the best opportunities for this education to take place.

Study limitations include its cross-sectional survey design, which limits causal inference, the authors note. Other limitations include the use of parent-proxy reporting for individuals younger than 18 years, the possibility of recall bias, and use of only an English-speaking population.

Overall, the survey findings suggest that "practices among allergic patients are suboptimal and may be improved through reducing EAI-related out-of-pocket costs and facilitating patient education efforts aimed at increasing knowledge and self-efficacy regarding how/when to effectively use EAIs," the authors conclude.

Mylan provided funding for the study. Gupta receives grant support from the Allergy and Asthma Network, National Institutes of Health/National Institute of Allergy and Infectious Diseases, Melchiorre Family Foundation, and Sean N. Parker Center for Allergy & Asthma Research, UnitedHealth Group, Thermo Fisher Scientific, Rho Inc, and Aimmune Therapeutics. She serves as a consultant for DBV Technologies, Kaleo Inc, and BEFOREBrands. Another coauthor serves as a consultant for DBV Technology and GlaxoSmithKline; receives grant support from DBV Technology, Aimmune Therapeutics, and Food Allergy Research & Education; receives payments for lectures from Meeting Events International and Rockpointe; receives payment for development of educational presentations from Rockpointe; holds stock options with DBV Technology; and serves on the advisory boards for the National Eczema Association, Food Allergy Research & Education, and the International Association for Food Protein Induced Enterocolitis. The other authors have disclosed no relevant financial relationships.

Ann Allergy Asthma Immunol. Published online June 21, 2018.

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