EpiPens should be used more for allergic reactions: study
Children treated with the epinephrine auto-injector, or EpiPen, for sudden and life-threatening allergic reactions before getting to the hospital do better than children treated with antihistamines alone and significantly better than children treated with steroids, according to a new study by Canadian researchers involving nearly 3,500 patients in five provinces.
The study, published in the Journal of Allergy and Clinical Immunology: In Practice, shows clearly for the first time that epinephrine in a pre-hospital setting is superior to antihistamines, lead author Dr. Moshe Ben-Shoshan, a pediatric allergist and immunologist at the Montreal Children’s Hospital, said in an interview Thursday.
In most cases, antihistamines are used in place of epinephrine, “but epinephrine should always be first.”
Ben-Shoshan was part of a team at the Research Institute of the McGill University Health Centre that analyzed data from nine emergency departments in five provinces between 2011 and 2017 as part of the AllerGen Cross-Canada Anaphylaxis Registry project, which he heads.
The majority of the anaphylactic reactions — 79 per cent — were caused by food, with peanuts, tree nuts, eggs and milk as the most common food triggers.
The study found only 31 per cent of those reactions were treated with epinephrine before arrival at the hospital. Antihistamines, such as Benadryl, were used in 46 per cent of cases, steroids in two per cent of cases. The majority of the reactions “of moderate severity” most commonly happened at home.
Those who did not get epinephrine before getting to hospital were found to be five times more likely to need two or more doses of epinephrine in the emergency room to control the allergic reaction, he said. Antihistamines helped — but not nearly as much. And the researchers found that admission to hospital, including intensive care, was nearly three times more likely when the anaphylaxis was treated with steroids before the child got to hospital.
The results, said the researchers, suggest that treatment guidelines for managing anaphylaxis in children should be modified, at least in the pre-hospital setting, to exclude steroids and to include antihistamines only when used in conjunction with epinephrine.
Parents and others need to know “that anaphylaxis can progress very fast,” Ben-Shoshan said.
Seven-year-old Yohan-Thomas Sénéchal, who has a severe wheat allergy, usually carries two EpiPens with him. The people around him are vigilant and he always brings his own lunch to school, said his mother, Yolaine Paul. Before April, he had not had an anaphylactic reaction since 2016. But that day, he took a couple of small bites of a pizza containing wheat — a pizza that had been purchased in error. He felt his throat starting to close and quickly developed hives.
He started to run around, panicked, and his mother could not get hold of him to give him an EpiPen injection. The paramedics, when they arrived, were unwilling to give him the injection, even though his mother implored them.
In the hospital, as his heart rhythm and breathing became unstable, Sénéchal grabbed onto a member of the team treating him and said “I’m going to die.” He went into cardiorespiratory arrest and needed to be intubated. Eventually, after multiple doses of epinephrine, he rallied.
Families that have used the EpiPen before are less reluctant to administer it because they see how simple the process is, BenShoshan said.
Growing up, Benjamin Znoi, who has several food allergies, ate lunch alone at the allergy table. Now 17, he grew up “pretty much brainwashed to not touch anyone’s food … and to be suspicious and alert.”
He has had a few allergic reactions as a teenager, but injected himself with his EpiPen only once — at a party this past winter with friends. Several minutes after the first injection, he gave himself another. Friends insisted that he go to the hospital — there was one a couple of blocks away — and he did. He was given medication, kept under observation and then sent home.
“With these reactions, you never know what the next second will bring,” he said. Were he to have another allergic reaction, “I would be leaning more toward using the EpiPen earlier,” he said. “It’s simple and, also, I don’t know where the reaction will go. You also earn that hospital is not that scary a place.”
In Canada, the EpiPen costs between $90 and $100. Ben-Shoshan believes that EpiPens should be stocked in schools and public places like airports and restaurants — but said that only legislation will guarantee this. schwartz@postmedia.com
It’s simple and, also, I don’t know where the reaction will go. You also earn that hospital is not that scary a place.