Update on the usage and safety of epinephrine auto-injectors, 2017

Abstract

Anaphylaxis is a serious, potentially fatal allergic reaction. Guidelines recommend prompt intramuscular injections of epinephrine as the first-line therapy for anaphylaxis. Delayed epinephrine treatment may cause undesirable clinical outcomes, including death. In the community, epinephrine auto-injectors (EAIs) are commonly used to treat anaphylaxis. This literature review examines several recent concerns regarding the safety of EAIs that may prevent the timely administration of epinephrine. Reports of cardiovascular complications are linked with epinephrine administration, although recent studies suggest that these events are much more commonly associated with intravenous epinephrine rather than with EAIs. Recent studies have also highlighted accidental injections of EAIs in patients' or caregivers' fingers and lacerations associated with the use of EAI in children. However, the data suggest that both accidental injections and lacerations are rare and require limited medical intervention. In addition, patients may receive conflicting information on the safety and efficacy of using expired EAIs. Overall, it is believed that the benefits of using EAIs far outweigh the potential risks of not administering an EAI. Although legitimate safety concerns are associated with EAIs, adverse events are rare. Continued training of medical providers, caregivers, and patients may be beneficial to address these concerns and reduce EAI-associated injuries while ensuring that patients receive necessary medical care.

Keywords: allergy; anaphylaxis; asthma; pediatrics.

Figure 1

Criteria that increase the likelihood of anaphylaxis. Note: Adapted from Simons FE, Ardusso LR, Bilò MB, et al. World allergy organization guidelines for the assessment and management of anaphylaxis. World Allergy Organ J. 2011;4(2):13–37.

Figure 2

Pharmacological effects of epinephrine in the treatment of anaphylaxis.

Figure 3

Self-administration of an epinephrine auto-injector.

Figure 4

Comparison of the (A) old-look and (B) new-look (right) EpiPen^® Auto-Injector (Mylan Specialty L.P., Canonsburg, PA, USA). Note: The EpiPen Auto-Injector was redesigned in 2011 to include safety features such as the orange needle sheath.

Figure 5

Proposed child restraint options for the administration of an epinephrine auto-injector. Note: Reprinted from The Journal of Allergy and Clinical Immunology: In Practice, Volume 4/edition 3, Brown JC, Tuuri RE, Lacerations and embedded needles due to EpiPen use in children, Pages 549–551, Copyright 2016, with permission from Elsevier and Julie Brown, MD, MPH.