Kudos to Canada

This morning, SRxA’s Word on Health salutes the Canadian city of Hamilton, Ontario, for its pioneering lead in anaphylaxis safety. Hamilton is destined to become the first city in the world to require all food service outlets to have life-saving epinephrine auto-injectors on hand for people with severe food allergies.

The move is being led by Hamilton Councillor  – Lloyd Ferguson, in hopes of avoiding sudden and tragic deaths like one this past spring of a Stoney Creek girl.

Twelve-year-old Maia Santarelli-Gallo had what her doctor said was a mild allergy to eggs and milk that had only ever caused her a runny nose. But last March, while eating an ice cream cone at a Hamilton-area mall with her father and older sister, Maia experienced a sudden, severe allergic reaction.

Her sister found someone with an epinephrine injector, but by the time it was administered, it was too late. Emergency crews took Maia to hospital but she was pronounced dead.

When Councillor Ferguson heard about Maia’s death, he decided to draft a ground-breaking motion to get epinephrine auto-injectors in every restaurant and mall in the city.

He says it’s high time that food providers have access to medicines that could help their customers who develop allergic reactions. He says if automated external defibrillator (AEDs) are now being installed in arenas and other community centers, it makes sense to have epinephrine injectors in areas where food allergy reactions are most likely to occur.

“It took us about 40 years to get defibrillators into public facilities and they have been a great success. This is the next step,” he says.

Allergy specialist Dr. Mark Greenwald, Allergist, and Chief Medical Officer of EpiCenter Medical would like to go further and see public awareness campaigns that would train the public on how to use epinephrine injectors, just as there have been campaigns encouraging people to learn CPR.

Greenwald has developed an online course called EpiPenTraining.com, to offer training on how to recognize allergic reactions, and how to use the injectors. He says such training is vital because during anaphylaxis, seconds count.

And anaphylaxis isn’t rare.  Allergic disease is the 5th most prevalent chronic disease among all ages, and the 3rd most prevalent among children. Every 3 minutes in North America, a food allergic reaction sends someone to the Emergency Room. Every 6 minutes, that Emergency Room visit is for anaphylaxis, that’s 10 patients per hour!

In 25% of people requiring treatment, the reaction is their first episode, and they are completely unprepared.  And for 50% of the people who die from anaphylaxis, the victims had life-saving epinephrine, but it wasn’t used or it wasn’t used in time. The other 50% didn’t carry epinephrine despite their previous allergic episodes.

Participants in the online course become SAVE certified – Save Anaphylaxis Victims in an Emergency.

Debbie Bruce of the Canadian Anaphylaxis Initiative was part of a program this past spring to get epinephrine injectors on all fire trucks in Mississauga. She says that like Maia, up to one-third of people who have allergic reactions outside the home did not realize they had a severe allergy and didn’t carry an epinephrine injector. She is now petitioning politicians  to come up with a national allergy plan.

“I think it is a new reality,” she says. “Reactions happen and we need to be prepared.”

Maia’s mother, Leah Santarelli, backs all efforts to make the public more aware of anaphylaxis and hopes the Hamilton city council passes Ferguson’s motion.

“There’s no guarantee that an EpiPen will save your life 100 per cent of the time, just like a defibrillator won’t save you 100 per cent of the time, but it is there as a safety measure,” she says.

The motion is currently being reviewed by the city’s health team; if approved, it should go before Hamilton city council in October.

We certainly hope that it does and that this trend will rapidly spread across the borders.  As Greenwald says – every second counts!

Emergency! Epinephrine in Anaphylaxis: under-use and inappropriate use by EMS

Despite a decline in anaphylaxis deaths over the past 25 years, lack of epinephrine and incorrect administration of epinephrine still play a significant role in mortality.

According to a retrospective case study by researchers from McMaster University in Hamilton, Ontario only a quarter of patients received epinephrine prior to cardiac arrest, including those treated by emergency medicine personnel.

Of the 80 deaths recorded in Ontario from 1986 – 2011, 47 had a known or suspected allergy to the fatal allergen, but only 18 had been prescribed an epinephrine auto-injector and only 9 had their auto-injector at the time of the reaction. And at least 8 of these people received epinephrine that was either expired or administered incorrectly.

“The low proportion of patients who received epinephrine correctly may indicate that more information is needed by both patients and first responders regarding indications and techniques for administering epinephrine and auto-injectors,” said lead investigator, Ya Sophia Xu, MD

Most of the fatalities were caused by food allergy (n = 37), insect sting (n = 27), or medication (n = 11).  But in 5 patients, death occurred with no known allergen.

More than half (59%) of the food-related fatalities involved food eaten away from home – at public places including school, camp, or another person’s home.

“Patients with food allergies should be especially vigilant when eating outside of the home,” added Dr. Xu “restaurants need to improve the labeling and disclosure of potential allergens to the public.”

The study also revealed that Coroners’ reports are sometimes lacking information about the severity of previous allergic reactions, level of asthma control, time of administration of the first epinephrine dose, body mass index of patients, and anatomical location of the epinephrine injection.

Ryan Jacobsen, MD, EMT who is associate emergency medical services director for the Kansas City Fire Department in Missouri commented “there seems a perception among pre-hospital personnel that the administration of epinephrine is dangerous.”  He and his colleagues recently published a study with very similar results.

Dr. Jacobsen’s team surveyed 3,500 nationally registered paramedics in the United States and found that 36.2% of responders felt there were contraindications to the administration of epinephrine for a patient in anaphylactic shock. And 40% of paramedics (incorrectly) believed that diphenhydramine was the first-line medication for a patient suffering from anaphylactic shock.

“They also had challenges in the recognition of atypical presentations of anaphylaxis and determining the correct location and route of epinephrine administration,” he said.

Only 2.9% correctly identified atypical presentation of anaphylaxis, while less than half (46.2%) identified epinephrine as the initial drug of choice. Equally concerning, only 38.9% correctly chose the intramuscular route of administration, while 60.6% incorrectly identified the deltoid, rather than the anterolateral thigh as the preferred injection site location.

As an EMS educator I spend much of my time, discussing the 5 Rights of Administration: right patient, right time, right drug, right route, right dose.

Yet, according to this study, it seems as if emergency medical personnel are routinely failing on all 5 when it comes to anaphylaxis.

“Basically, we have the same issues in the United States that were found in the Canadian study,” says Jacobsen. “There needs to be an aggressive educational campaign geared toward emergency personnel in both the safety of epinephrine and its importance as the first-line therapy for anaphylaxis.  The benefits of epinephrine almost always outweigh the risks, but there’s a reluctance to use it. Patients get palpitations, they might get a headache, their heart rate goes up, but it’s a potentially life-saving treatment.

Amen to that.

Doctors Deficient in Anaphylaxis Care

Having just returned from the American College of Allergy, Asthma and Immunology (ACAAI) annual meeting, we’re spoiled for choice of news. But among all the science there was one stand out shocker.  In a session on Sunday, physicians presented the results of a survey, sponsored by the Asthma and Allergy Foundation of America (AAFA). During this, they revealed that a disturbingly high proportion of primary care and emergency physicians don’t know how to treat anaphylaxis.

Interviews with 318 physicians indicated that:

• substantial numbers do not always provide epinephrine to patients – even those  they believe are having anaphylactic reactions
• they often fail to refer anaphylaxis patients for follow-up care
• they believe incorrectly that some patients should not receive epinephrine auto-injectors

Myron Zitt, MD, says the results reveal “likely deficiencies in physician knowledge,” and corroborate results from earlier chart review studies.

In the telephone-based survey, researchers conducted interviews lasting an average of 19 minutes with approximately 100 emergency room physicians, 100 allergists, 50 adult primary care physicians, and 50 pediatricians.

82% to 99% of respondents in each group said they had treated at least one anaphylaxis case.

Although epinephrine is supposed to be given to all patients having such reactions, about 10% of emergency room physicians and 20% of primary care and pediatric physicians said they had done something else.  These “something else’s” included prescribed another drug, sending the patient to a hospital, or an “other” action.

Prescribing of auto-injectors for patients to take home also was far from universal. Barely 60% of emergency room physicians said they did. In fact, emergency physicians were generally bad at all phases of follow-up care. They rarely referred patients for diagnostic tests, they almost never demonstrated use of an auto-injector, and seldom explained that auto-injectors have an expiration date.

Another disturbing finding from the survey, Zitt said, was that many physicians of all types – even the allergists – mistakenly believed that some patients should never receive epinephrine.

In the same session, Akhil Chouksey, MD, reported that anaphylaxis care in a major teaching hospital usually failed to meet guidelines established by a consortium of allergy societies including the ACAAI.  In a 10-year review of anaphylaxis cases only 15% met the standards of care recommendations i.e. that epinephrine be administered within 30 minutes of triage, that auto-injectors be prescribed at discharge, and that patients be referred to an allergist or immunologist for follow-up investigations and treatment.

The review also found that in 26% of cases in which anaphylaxis was definitively confirmed, the patients never received epinephrine.  Antihistamines, such as benadryl (diphenhydramine), were given in nearly all cases but epinephrine was omitted in one-quarter. In fact, epinephrine was only the third most commonly administered medication, with corticosteroids such as methylprednisolone, taking the second spot after antihistamines.

During the question-and-answer period, an audience member suggested that, when patients present with relatively mild symptoms, the treating physicians may decide that epinephrine isn’t needed at that point.  Zitt countered, that this was a very dangerous approach.

The national guidelines state explicitly that there are no absolute contraindications to epinephrine. Nevertheless, 16% of the pediatric allergists and 32% of the other allergists said there were such contraindications, as did 38% of adult primary care and emergency physicians.

Also common were beliefs that schools, restaurants, and ambulances always stock epinephrine. In fact, Zitt said, there are no general requirements for schools or restaurants to do so, and approximately half of all ambulances do not have epinephrine on hand.

Clearly there is much work still to be done in terms of education.  SRxA’s Word on Health suggests a first step would be to instill a healthy fear of anaphylaxis into doctors and the general public while simultaneously removing the fear of epinephrine.

Or as Dr Zitt says, “Give epinephrine first, ask questions later.”

Allergic to Running?

Earlier this week I posted on facebook, asking if any of my friends wanted to join me in an Iron Girl Triathlon this fall, So far, there has been a distinct lack of takers. Or to be more precise, nobody, not one single solitary person, has taken me up on the challenge.

I did, however, hear a lot of reasons why people didn’t want to swim, bike and run with me at 7am on a September morning.  Among the best of these: “I’d love to, but I think I’m allergic to sport.”

I think she was trying to be funny – though with my friends you never can tell!

You see, not only do most of my friends have a wicked sense of humor, most are also involved one way or another with healthcare, and maybe, just maybe, she who will remain nameless, really is allergic to running.

While it may sound like the perfect excuse, people can in fact suffer an anaphylactic reaction to exercise.  But, before you cancel your gym membership and start justifying your life as a couch potato, I should point out that it’s generally pretty rare.

People usually associate working out with an increased heart rate and a nice endorphin rush — not hives, or shock. But it can happen.

Cholinergic urticaria, a common type of heat rash, can occur when there’s an increase in body temperature and when mast cells in the skin break down right before releasing sweat. Studies suggest up to 11% of adults experience post-exercise hive attacks, men, more commonly than women.

Even worse is exercise-induced anaphylaxis.  Like the name suggests, it’s triggered by exercise, especially running. Anaphylaxis, is more commonly seen after insect stings or eating shellfish and peanuts.  And just as with food allergies, those affected by exercise can experience symptoms including vomiting, hives, difficulty breathing, collapse and even death…although fewer than 1,000 cases and only one exercise-related fatality have been reported since the 1970s.

So while running (or Iron Girl Triathlons) may not be everyone’s favorite fitness activity, the “I’m allergic” excuse is reserved for those (un)lucky few.

And even then, most cases can be avoided.

Usually, it’s triggered by eating certain foods before exercise. But this isn’t just your average food allergy says allergist Jacqueline Eghrari-Sabet MD – a spokeswoman for the American Academy of Allergy, Asthma and Immunology.  “Eating shellfish and sitting there? Nothing. But eating shellfish and exercising? For these people, it’s bad news.”

As you exercise and your heart rate speeds up, your blood starts whizzing through organs much faster than it normally does. With every trip your blood takes to your stomach, it’s picking up more, of say, the peanuts. For those with exercise-induced anaphylaxis, the normal amount of peanut antigens picked up by the blood isn’t enough to bother them. But while exercising, the extra peanuts their blood is picking up causes an allergic reaction.

So next time you are convinced that if you spend even one more minute on the treadmill, you will die? Maybe it’s not all in your head.

Who’s to blame for your allergies?

Are you one of the 35 million Americans who suffer from seasonal allergies? If so you’re probably not cheering the official end of winter.  But before you start blaming Persephone – goddess of Spring, for your symptoms you may want to look a little closer to home.

Many of the everyday things you’re doing, from what you eat to how you clean your home may be interfering with relief from your stuffy nose, sneezing, sniffling or other symptoms.

“People with spring allergies often don’t realize how many things can aggravate their allergy symptoms so they just muddle along and hope for an early end to the season,” says allergist Myron Zitt, M.D.“But there’s no reason to suffer. A few simple adjustments in habits and treatment can make springtime much more enjoyable.”

The American College of Allergy, Asthma and Immunology (ACAAI) advises people with spring allergies to be on the lookout for five things that can aggravate suffering.

1. Eating fruits and vegetables – Many people with seasonal allergies also suffer from pollen food allergy syndrome (also called oral allergy syndrome), a cross-reaction between the similar proteins in certain types of fruits, vegetables and the allergy-causing pollen. 1:5 people with grass allergies and as many as 70% of people with birch tree allergies suffer from the condition, which can make your lips tingle and swell and your mouth itch.

If you’re allergic to birch or alder trees, you might have a reaction to celery, cherries or apples. If you have grass allergies, tomatoes, potatoes or peaches may bother you. Usually the reaction is simply annoying and doesn’t last long. But up to 9% of people have reactions that affect a part of their body beyond their mouth and almost 2% can suffer a life-threatening anaphylactic reaction.

2. Using the wrong air filter – Using an air filter to keep your home pollen-free is a good idea, but be sure it’s the right kind. Studies show inexpensive central furnace/air conditioning filters and ionic electrostatic room cleaners aren’t helpful – and in fact the latter releases ions, which can be an irritant. Whole-house filtration systems do work, but change the filters regularly or you could be doing more harm than good.

3. Opening your windows – When your windows are open, the pollen can drift inside, settle into your carpet, furniture and car upholstery and continue to torture you. So keep your house and car windows shut during allergy season.

4. Procrastinating – You may think you can put off or even do without medication this spring, but the next thing you know you’re stuffed up, sneezing and downright miserable. Instead, get the jump on allergies by taking your medication before the season gets under way.

5. Self medicating – Perhaps you’re not sure exactly what’s making you feel awful so you switch from one medication to the next hoping for relief.

This spring, your best bet is to see an allergist, who can determine just what’s triggering your symptoms and suggest the most appropriate treatment.

Survey Reveals Unmet Needs Among Patients with Allergic Rhinitis

SRxA’s Word on Health team spent the last week attending the American Academy of Allergy Asthma & Immunology Annual Meeting in San Francisco. In addition to spending quality time with many of our KOL Allergy Advisors and pharmaceutical clients, we were able to catch up with some of the latest research on allergic rhinitis (AR).

Allergic rhinitis is an allergic reaction that happens when the immune system overreacts to inhaled, such as pollen. This causes release of a type of antibody, known as IgE, into the nasal passages, along with inflammatory chemicals such as histamines. The two types of allergic rhinitis are seasonal allergic rhinitis (hay fever) and perennial allergic rhinitis, which occurs year-round. Hay fever is caused by outdoor allergens. Perennial allergic rhinitis is caused by indoor allergens such as dust mites, pet dander, and mold.

Results from a recent pivotal AR satisfaction survey assessing patient and healthcare provider perspectives on AR reveal that symptoms like nasal congestion and post-nasal drip continue to impact patients’ daily activities.

Findings from the Nasal Allergy Survey Assessing Limitations (NASL) 2010, highlight the continued unmet need for more effective treatment options to help reduce symptoms and overall disease burden of AR.

The prevalence of AR in the U.S. has increased during the past three decades.  It is now estimated that 20% of the general adult population and almost 40% of children have the condition.  Of the estimated 60 million Americans affected with AR, approximately 20% have seasonal allergic rhinitis (SAR), 40% have perennial allergic rhinitis (PAR), and 40% have a combination of the two (i.e., PAR with seasonal exacerbations) depending on the allergen sensitivity.

In other words, one in 5 adults and almost half of children suffer from symptoms including:

• Stuffy, runny nose
• Sneezing
• Post-nasal drip
• Red, itchy, and watery eyes
• Swollen eyelids
• Itchy mouth, throat, ears, and face
• Sore throat
• Dry cough
• Headaches, facial pain or pressure
• Partial loss of hearing, smell, and taste
• Fatigue
• Dark circles under the eyes

According to NASL 2010, nasal congestion, post-nasal drip and repeated sneezing continue to be the most frequently reported nasal allergy symptoms among patients. Beyond physical symptoms, AR patients experience emotional burdens, like feeling tired and miserable. When assessing the impact nasal allergies have on productivity, the survey revealed that patients are less productive when their nasal allergies are at their worst, limiting them from doing well at work.

“It’s clear from the NASL 2010 findings that the estimated 60 million people living with allergic rhinitis in the U.S. are still significantly affected, both physically and emotionally, by symptoms,” said Gary Gross, M.D. FAAAAI, Dallas Allergy & Asthma Center, Dallas, Texas. “This is a continuing trend we’re seeing in patients having allergic rhinitis as these findings are similar to those released in a past survey evaluating disease burden on patients. The NASL survey results further support the need for more effective treatment options that address these specific issues for patients living with allergic rhinitis.”

Nasal allergies can make it difficult for people to take part in both indoor and outdoor activities if their symptoms are not well controlled. According to NASL 2010, less than 20% of surveyed patients felt their nasal allergies were completely controlled over a one week time period. The vast majority of allergists, otolaryngologists and primary care providers interviewed in the survey stated intranasal corticosteroid sprays as their preferred treatment of choice for adults with moderate to severe persistent nasal allergies.

Because of its prevalence and health effects, AR is associated with considerable direct and indirect costs.  Latest estimates suggest that AR alone results in a staggering  $11.2 billion in healthcare costs, 12 million physician office visits, 2 million days of school absences and 3.5 million lost work days per year. In addition, the presence of co-morbidities such as asthma and sinusitis further increase AR-related treatment costs.

Word on Health will be bringing you more from AAAAI in the coming days, including some exciting new treatment options being developed for allergic rhinitis.

Allergy Aid is just a click away

For many people the arrival of spring is a time for celebration marking, as it does, the end of winter and the coming of summer. But for the 50 million Americans with allergies, spring heralds the arrival of pollen and a long season of misery.  However, this year, there is hope.  The American Academy of Allergy, Asthma and Immunology (AAAAI) has teamed up with Rite Aid to bring help to allergy sufferers.

Visitors to www5.riteaid.com/health/allergies can:

• learn about allergens
• download a free allergy relief guide
• sign up for email, iTunes or cell phone alerts on daily pollen levels
• take advantage of rewards programs and savings on allergy products
• create a personal, customized guide for managing allergies

Rite Aid’s focus on allergy awareness is part of its yearlong commitment to health and wellness.

Additional resources for allergy sufferers can be found on the AAAAI website including an allergist locator, a pollen monitoring database and The Virtual Allergist, an interactive tool to help patients better understand their symptoms before consulting with a board-certified allergist.

Whether you suffer from allergies, treat allergy sufferers, or manufacture allergy relief products, SRxA’s Word on Health would love to hear your tips for coping with spring allergy season.