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.”