Treating Anaphylactic Sticker Shock
What’s The Problem?
If you follow the news or spend much time on social media, you’ve seen a lot of consternation over the sky high cost of EpiPens- a brand name device that, once applied to the skin, automatically injects the correct dose of epinephrine into a patient suffering from a severe allergic reaction.
FIGURE 1: EpiPens. Source: Bioridgepaharma.com
That concern seems justified: according to widespread reporting, Mylan Pharmaceuticals has raised the price of an EpiPen two-pack from $94 to $608 over the last nine years- an increase of about 55% a year, even though general economic inflation has averaged just 1.8% a year during that same time period.
FIGURE 2: EpiPen Price Chart. Source listed on graphic.
Why Is This a Problem?
This is a big deal, because epinephrine is the first line treatment for the severe allergic reaction called anaphylaxis, during which the body has a massive systemic overreaction to an allergen that produces signs and symptoms such as airway swelling and critically low blood pressure. Anaphylaxis is a true life-threatening emergency, and epinephrine (the synthetic form of adrenalin) reverses those signs and symptoms.
But epinephrine isn’t a very stable drug. It expires fairly quickly, and its potency breaks down rapidly when exposed to prolonged heat. Given their maximum shelf life of 18 months and their tendency to be stored in glove boxes, gym bags, and backpacks, most people find that they need to replace their EpiPens frequently. And if you’re prone to anaphylaxis, you need to have epinephrine accessible wherever you go. For parents seeking to protect their children, this usually means ensuring that a set of EpiPens is present at home, at school, in their purses, and in the hands of coaches and supplemental caregivers. Ten years ago, it would have cost something like $400 to place a pack of EpiPens in each of those places. Today, it costs close to $2500. And $608 to replaced one that is used, of course.
It seems clear that brand name EpiPens are exorbitantly priced. What seems to have gotten lost in the conversation and outrage, though, is there are market competitors to the brand name Mylan-produced device.
One such alternative is the Adrenaclick autoinjector, produced by Amedra Pharmaceuticals. It sells for as low as $140 at retailers like Walmart and Rite Aid, once manufacturer coupons are applied. Another option is the generic epinephrine autoinjector, made by Lineage Therapuetics, which is similarly priced. Both devices are quite similar to the much more expensive EpiPen. Acquiring them is a matter of asking your physician to write a generic prescription, rather than one for the brand name devices, allowing your pharmacist to select the cheapest product of equal effectiveness. You also need to ensure that your insurance plan will cover any autoinjector, and not just the brand name EpiPen. But if it turns out they won’t and you have to pay out of pocket, the alternatives listed above won’t break the bank.
Yet another option is to ask your physician to prescribe you small ampules of generic epinephrine of the appropriate concentration, along with appropriately sized syringes and needles, and teach you how to give a manual intramuscular injection. These ampules, which contain roughly three doses, cost about $5 each. A syringe and needle costs about $1. Because you wouldn’t want to have to break open ampules and draw up specific dosages of epinephrine during an life-threatening anaphylaxis crises, you can do so before the dose is needed and simply carry some pre-filled syringes in a small pocket case. They might expire sooner than an autoinjector, but replacing $6 worth of epinephrine and syringes every few months (or even weeks) is clearly much cheaper than the alternative. And delivering an intramuscular injection to yourself or others really isn’t that much harder or different (with a few caveats) than using an autoinjector, once you’ve been trained.
In fact, this is pretty much how epinephrine for anaphylaxis used to be prescribed, before autoinjectors were popularized. It’s a somewhat trickier method of delivery, but it’s not significantly more complicated.
FIGURE 3: DIY Epi Kit. Credit: Fox45Now.com
FIGURE 4: Anakit. Credit: Allnurses.com
Impact on EMS
The high cost of EpiPens has had a large impact on EMS as well. In many states, EMTs are restricted to only using autoinjectors, and a quick Google search reveals that many agencies in such states are struggling to meet the rising cost of EpiPens. In states where EMTs are permitted to draw up and administer epinephrine by syringe, many agencies are quickly assembling “homemade” kits like the ones pictured above.
Fortunately, Kentucky has led the way on this front. Kentucky EMTs have been permitted to deliver epinephrine by syringe, by statute, since 2003. In fact, that same law (KRS 311A.195) directs every EMS agency in the Commonwealth to “Maintain an adequate supply of epinephrine and disposable sterile needles and syringes on every ambulance that it operates.” Here at EKU, we’ve been training our EMTs to draw up and administer epinephrine by syringe for the past 16 years.
FIGURE 5: Epi Statute
Clearly, some changes are needed. Changes to the way pharmaceutical companies and the FDA operates might be in order, and physicians might need to change the way they prescribe. Those changes are bit beyond what we do here in the EKU Emergency Medical Care program. But as educators, we can make some easy changes to reflect this dynamic.
As we do in Kentucky, all EMTs should learn how to use needles and syringes to draw up and safely administer epinephrine by the intramuscular route. It’s an easy skillset to teach and to learn, and would do much to promulgate more permissive regulations in the states that lack them.
As healthcare educators and members of the healthcare workforce, we (along with our colleagues who work in emergency and primary care) probably need to change the way we teach our students and patients to recognize anaphylaxis. Administration of epinephrine by needle and syringe is much easier to do when the patient is not in extremis; certainly this is true if one is contemplating self-administering a dose out of their homemade kit. Rather than waiting for the severe signs and symptoms that we current teach about- such as wheezing, swollen lips, and difficulty breathing- we should teach how to identify pending anaphylaxis much earlier- by identifying exposure to an allergen, changes in skin condition, moderately low blood pressure, and, very often, GI upset. In that paradigm of signs and symptoms, it is much more realistic to employ manually drawn up and injected epinephrine.
Epinephrine is a life-saving drug in anaphylaxis, and it doesn’t have to be so expensive or so dire to administer. A broader understanding of the alternatives would go a long way!
-David Fifer, WEMT, NRP
Published on September 01, 2016