We’re in the midst of an epidemic of allergies in the U.S., and severe allergic reactions like anaphylaxis could be life threatening. Epinephrine is used For the emergency treatment of allergic reactions to stinging or biting insects, foods, drugs, and other allergens, as well as exercise-induced anaphylaxis; yes, you can be allergic to exercise, but don’t use that as an excuse to be a couch potato!
Epinephrine is most commonly used these days in an autoinjector that’s fast and easy to use. In the United States, one brand of autoinjector, the EpiPen, manufactured by a subsidiary of Pfizer pharmaceuticals, and marketed by Mylan corporation, is considered the gold standard. Annual sales of all epinephrine autoinjectors were about $200M; EpiPen had around 90% of the market; in 2015 the market size grew to $1.5B and epipen still has the lion’s share. Well, in a move that some might describe as profiteering, Mylan raised the U.S. price from around $100 for a package of two EpiPens in 2007 to around $600 in 2016, although it’s still less expensive in the UK and Canada. The devices, by the way, deliver about $1 worth of drug.
In a public relations move, Mylan made savings cards worth up to $300 available to some patients to purchase EpiPens, Unfortunately, these can only be used by a small number of people who need the drug, and doesn’t seem to include people on Medicaid. The high prices paid by insurers, however, haven’t changed and they pass the cost onto consumers in the form of higher and higher health insurance premiums every year.
(update: Mylan recently released a half-price generic version of the Epi-pen in response to the widespread resistance to their price increase.)
So what’s your best option if the Epipen is now outside of your financial reach? It might be using vials or ampules of epinephrine, small syringes, and some antiseptic wipes. The 1:1000 epinephrine ampules are 1 ml and contains enough for a one-time use of up to 2 doses. The same concentration vials are usually 30 ml and made for multiple uses. Here’s how to use epinephrine that’s packaged this way :
1:1000 epinephrine solution contain 1mg of drug per milliliter or cc of solution. For a person weighing 30 kg, 66 pounds, or greater, give 0.3 to 0.5 mg (0.3 to 0.5 mL) into the anterolateral thigh about the level of the bottom of your Jeans pocket. Repeat the dose every 5 to 10 minutes, alternating left and right thighs until improvement is noted. Remember that epinephrine will cause a fast heartbeat, nervousness and, perhaps, a number of other side effects. Of course, in normal times, get the victim to modern medical care as soon as possible, especially if more than 2 doses were needed.
For children weighing less than 66 pounds, the formula for anaphylaxis is 0.01 mg/kg, so a small child weighing 10 kg, or 22 pounds, would receive 0.2 mg, that’s .2 ml if you use 1:1000 epinephrine solution. The maximum pediatric dose is up to 0.3 mg, that’s 0.3 ml of epinephrine (1:1000).
This might seem complicated, and indeed, it does take longer to deliver the product than with an autoinjector like the Epipen unless you keep some small syringes prefilled with the medication. In a 2010 article in the ASIAN PACIFIC JOURNAL OF ALLERGY AND IMMUNOLOGY, manually prefilled syringes were recommended as a way to keep ready to use epinephrine available at all times, and it appears that the medication remains potent and uncontaminated by bacteria or fungus for 3 months. After that, it changes color and all bets are off. This also assumes that the syringes are stored at room temperature, as high temperatures will affect potency considerably over time.
(This article can be viewed in video form HERE)
Joe Alton, MD
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