Value of a Second Dose of Epinephrine During Anaphylaxis: A Patient/Caregiver Survey

Song, T. Ted; Brown, Duncan; Karjalainen, M; Lehnigk, Ulrike; Lieberman, Phil

doi:10.1016/j.jaip.2018.01.019

Cited by 17 publications

(5 citation statements)

References 20 publications

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“…The study compared the following 3 strategies: (1) no school undesignated epinephrine supply, in which the only devices available are personal autoinjectors provided by students with an allergic condition; (2) school undesignated supplemental epinephrine supply, in addition to student-supplied devices (supplemental model); and (3) school undesignated universal epinephrine supply, in which school-based devices supplant the need for student-supplied devices (universal model). In the supplemental model, in addition to the school receiving an annual supply of 2 twin packs of undesignated stock epinephrine, children with peanut allergy attending school also received an additional annual prescription of an epinephrine twin pack dedicated for exclusive use at school (which is not available for at-home use and requires that an extra unit be dispensed as part of the prescription) per the current policy [11][12][13] ; after high school graduation, they received an annual prescription for a single twin pack (because colleges and universities do not have stock policies and because this is the typical management for peanut-allergic adults). The current practice in the 49 states with stock epinephrine law is the supplemental model; before the first stock legislation in 2011, no stock epinephrine was available, and allergic individuals provided their own units for school in every state.…”

Section: Undesignated School-based Epinephrine Strategies Comparedmentioning

confidence: 99%

Analysis of Value-Based Costs of Undesignated School Stock Epinephrine Policies for Peanut Anaphylaxis

Shaker

Greenhawt

2019

JAMA Pediatr

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IMPORTANCEChildren experiencing anaphylaxis at school may lack access to a personal epinephrine device, prompting recent legislation permitting undesignated (eg, non-student specific) stock epinephrine autoinjector units at school. However, epinephrine device costs vary, and the cost-effectiveness of undesignated school stock epinephrine is uncharacterized to date. OBJECTIVE To define value-based strategies for undesignated school stock epinephrine programs. DESIGN, SETTING, AND PARTICIPANTS Markov simulations of the Chicago Public Schools system were used over extended time horizons to model 2 school stock epinephrine autoinjector policies to provide access for at-risk students. The dates of the data used in the analysis were school year). MAIN OUTCOMES AND MEASURESThis study compared the following 3 strategies: no school undesignated epinephrine supply, school undesignated supplemental epinephrine supply (supplemental model), and school undesignated universal epinephrine supply (universal model). The base-case model assumed a 10-fold reduced fatality risk with having undesignated stock epinephrine units available vs not having undesignated stock epinephrine units available. Costs of school stock epinephrine units available for acquisition by schools were evaluated from a societal perspective. Quality-adjusted life-years (QALYs) and total epinephrine acquisition expenses were calculated. RESULTSBased on Markov simulations of the Chicago Public Schools system (371 382 students), the cost was $107 816 (95% CI, $107 382-$108 250) for no school undesignated epinephrine supply compared with $108 160 (95% CI, $107 725-$108 595) for the supplemental model and $100 397 (95% CI, $99 979-$100 815) for the universal model. Undesignated stock epinephrine improved outcomes, with 26.869 (95% CI, QALYs accrued as the model concluded compared with 26.867 (95% CI, 26.839-26.896) QALYs for the strategy without undesignated stock epinephrine. When comparing supplemental model stock epinephrine to the strategy without undesignated devices, the incremental cost-effectiveness ratio was high at $268 811 per QALY in the base-case simulation. However, the cost of the supplemental model fell below $100 000 per QALY when the annual undesignated epinephrine acquisition costs did not exceed $338 per school (compared with stock epinephrine unavailability). The universal model dominated all others and was associated with significant cost savings ($7419 per student at risk who would otherwise be prescribed an individual school epinephrine supply).CONCLUSIONS AND RELEVANCE Undesignated school stock epinephrine is cost-effective at device acquisition costs not exceeding $338 per school per year, although a universal model vs a supplemental model is associated with superior health and economic outcomes.

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Section: Undesignated School-based Epinephrine Strategies Comparedmentioning

confidence: 99%

Analysis of Value-Based Costs of Undesignated School Stock Epinephrine Policies for Peanut Anaphylaxis

Shaker

Greenhawt

2019

JAMA Pediatr

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“…Third, in the base case, we assumed a 12% rate of needing a 2 nd dose of epinephrine based on history; however, sensitivity analyses of rising rates showed a universal strategy becomes more cost-effective. (34) Patients may require a 2 nd device for either device failure (a rare but recognized occurrence), incorrect use of device during administration or for anaphylaxis that is not responsive to a first dose of epinephrine, and our model accounted for a fatality risk reduction of up to 10,000-fold. Fourth, we did not explicitly consider the effect of epinephrine device shortages in the model though this impact is lessened by a risk-stratified approach.…”

Section: Discussionmentioning

confidence: 99%

A Cost-Effectiveness Analysis of Epinephrine Autoinjector Risk Stratification for Patients with Food Allergy—One Epinephrine Autoinjector or Two?

Shaker

Turner

Greenhawt

2021

The Journal of Allergy and Clinical Immunology: In Practice

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“…Grabenhenrich et al (2) recently evaluated the epinephrine usage in anaphylaxis patients and concluded that, even in this state of the art drug, significant discrepancies between recommended use and actual treatment practice exist. Similarly, US studies documented poor adherence in patients and caregivers to anaphylaxis guidelines recommending more than one adrenaline autoinjector available at all times (33). Therefore, more effort needs to be dedicated to promote and develop consensus guidelines as practically as possible in order to increase adherence.…”

Section: Discussionmentioning

confidence: 99%

Refractory Anaphylaxis: Data From the European Anaphylaxis Registry

Francuzik

Dölle‐Bierke

Knop³

et al. 2019

Front. Immunol.

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Refractory anaphylaxis (unresponsive to treatment with at least two doses of minimum 300 μg adrenaline) is a rare and often fatal hypersensitivity reaction. Comprehensive data on its definition, prevalence, and risk factors are missing. Using the data from the European Anaphylaxis Registry (11,596 cases in total) we identified refractory anaphylaxis cases (n = 42) and analyzed these in comparison to a control group of severe anaphylaxis cases (n = 4,820). The data show that drugs more frequently elicited refractory anaphylaxis (50% of cases, p < 0.0001) compared to other severe anaphylaxis cases (19.7%). Cases elicited by insects (n = 8) were more often due to bees than wasps in refractory cases (62.5 vs. 19.4%, p = 0.009). The refractory cases occurred mostly in a perioperative setting (45.2 vs. 9.05, p < 0.0001). Intramuscular adrenaline (as a first line therapy) was administered in 16.7% of refractory cases, whereas in 83.3% of cases it was applied intravenously (significantly more often than in severe anaphylaxis cases: 12.3%, p < 0.0001). Second line treatment options (e.g., vasopression with dopamine, methylene blue, glucagon) were not used at all for the treatment of refractory cases. The mortality rate in refractory anaphylaxis was significantly higher (26.2%) than in severe cases (0.353%, p < 0.0001). Refractory anaphylaxis is associated with drug-induced anaphylaxis in particular if allergens are given intravenously. Although physicians frequently use adrenaline in cases of perioperative anaphylaxis, not all patients are responding to treatment. Whether a delay in recognition of anaphylaxis is responsible for the refractory case or whether these cases are due to an overflow with mast cell activating substances—requires further studies. Reasons for the low use of second-line medication (i.e., methylene blue or dopamine) in refractory cases are unknown, but their use might improve the outcome of severe refractory anaphylaxis cases.

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Value of a Second Dose of Epinephrine During Anaphylaxis: A Patient/Caregiver Survey

Abstract: Our study suggests poor adherence in patients and caregivers to anaphylaxis guidelines recommending more than 1 EAI available at all times and implies that this can result in adverse outcomes.

Cited by 17 publications

References 20 publications

Analysis of Value-Based Costs of Undesignated School Stock Epinephrine Policies for Peanut Anaphylaxis

Analysis of Value-Based Costs of Undesignated School Stock Epinephrine Policies for Peanut Anaphylaxis

A Cost-Effectiveness Analysis of Epinephrine Autoinjector Risk Stratification for Patients with Food Allergy—One Epinephrine Autoinjector or Two?

Refractory Anaphylaxis: Data From the European Anaphylaxis Registry

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