ASCIA Guidelines for adrenaline autoinjector prescription

ASCIA Guidelines for adrenaline autoinjector scripts 2012275.52 KB 

1. Recommended

History of anaphylaxis* (if patient is considered to be at continuing risk)

2. May be recommended

History of a generalised* allergic reaction with one or more of the following factors:

• Age
  - Adolescents and young adults have a greater risk of fatal food anaphylaxis.
  - The majority of recorded fatal reactions to foods (~90%) occur in children over the age of 5 years.
  - Adults have a greater risk of fatal stinging insect anaphylaxis than children.
• Specific allergic triggers
  - Nut allergy (to peanuts or other nuts) - most deaths from food anaphylaxis occur from nuts.
  - Generalised allergic reactions can be triggered by exposure to trace or small amounts of nuts, which can be difficult to avoid. Subsequent allergic reactions to nuts may be unpredictable.
  - Stinging insect allergy (bees, wasps, jumper ants) in adults
• Co-morbid conditions
  - Asthma (concurrent or past history), history of arrhythmia.
  This list is not comprehensive and if there is a concern, patients should be referred to a clinical immunology/allergy specialist for assessment.
• Limited access to emergency medical care
  - In remote locations early administration of adrenaline may not be possible unless an adrenaline autoinjector is provided to the patient for self administration.

These factors should be considered when deciding whether an adrenaline autoinjector is prescribed, as they are known risk factors for more severe or fatal reactions.

3. Not normally recommended

• Asthma
  - in patients with asthma without anaphylaxis or generalised allergic reactions.
• Elevated specific IgE only (positive RAST and/or skin test) without a history of clinical reactions.
  Positive test results alone do not necessarily mean there is allergic disease. These patients may be referred to an allergy specialist for assessment of their risk of allergy and anaphylaxis. This may include further investigations such as challenge testing.
• Family (rather than personal) history of anaphylaxis or allergy
  Whilst the risk for allergic disease is in part inherited, the risk of anaphylaxis is not inherited.
• Local reactions to insect stings in adults and children
• Generalised skin rash (only) to bee or wasp stings in children
  Prospective follow-up studies of subsequent bee stings in children presenting with local reactions or generalised skin rash (only) show that these children are at a very low risk of experiencing anaphylaxis with subsequent stings.
• Resolved food allergy.
  This should be established by a medical practitioner.

Adrenaline autoinjectors

Adrenaline autoinjectors available in Australia and New Zealand include EpiPen Jr (0.15mg), EpiPen (0.30mg) and Anapen (0.15mg, 0.30mg and 0.50mg)

Children less than 10kg
Adrenaline autoinjectors are not usually recommended for children less than 10kg

Children 10-20kg**
EpiPen Jr (0.15mg) or Anapen 0.15mg are recommended for children between 10 and 20kg**

Children over 20kg and adults**
EpiPen 0.30mg or Anapen 0.30mg are recommended for adults and children over 20kg**

For Anapen 0.50mg:

• Initial prescription
  Consideration may be given for initial prescription for any patient over 60kg^{#
  #}Assessment of need for a higher dose (0.5mg) to be undertaken by prescribing physician, taking into account risk factors for anaphylaxis and the presence of comorbidities.
• Prescription renewal
  Consideration may be given to changing existing patients to a 0.5mg device when their weight is over 60kg^{#
  #}Assessment of need for a higher dose (0.5mg) to be undertaken by prescribing physician, taking into account risk factors for anaphylaxis, the presence or absence of comorbidities and patient's ability to learn to use a new device if prescribed a different device previously.
  For paediatric patients, also consider patient age and the ability of patient/carers/school staff to learn to use a new device if prescribed a different device previously.

** These dosage recommendations are based on expert opinion, which is currently at variance with the product information leaflet

EpiPen and Anapen are:

• not brand substitutable
• available on PBS authority prescription in Australia
• not currently Pharmac funded in New Zealand
• available without prescription in Australia and New Zealand

IMPORTANT: An adrenaline autoinjector should only be prescribed within the context of a comprehensive Anaphylaxis Management Plan (see below).

Anaphylaxis Management Plan

An adrenaline autoinjector should only be prescribed within the context of a comprehensive anaphylaxis management plan that includes the following:

A. Referral to a Clinical Immunology/Allergy Specialist

Review by a clinical immunology/allergy specialist should occur to:

• Ascertain if the correct trigger(s) have been identified
• Determine whether the allergy persists

B. Identification of the Anaphylaxis Trigger(s)

This should include a comprehensive history, clinical examination, appropriate use and interpretation of allergy testing.

C. Education on the avoidance of trigger(s)

This is particularly important with food anaphylaxis.

D. Provision of an ASCIA Action Plan for Anaphylaxis

This should document the following;

• Name of child/adult
• Confirmed allergens
• Carer contact details
• Symptoms and signs indicating when to use the adrenaline autoinjector
• Instructions on how to use the adrenaline autoinjector

ASCIA Action Plans for Anaphylaxis for both adrenaline autoinjectors brands are available from www.allergy.org.au and contain electronic fields to allow online completion of patient information.

E. Appropriate follow-up

Yearly review by a patient's general practitioner should occur to;

• Provide re-education on adrenaline autoinjector use
• Renew action plan
• Ensure the adrenaline autoinjector has not expired.
• Determine whether specialist review if required to ascertain if the allergy persists

*Definitions

1. Anaphylaxis

Any acute onset of hypotension or bronchospasm or upper airway obstruction where anaphylaxis is considered possible, even if typical skin features are not present

OR

Any acute onset illness with typical skin features (urticarial rash or erythema/flushing, and/or angioedema), PLUS involvement of respiratory and/or cardiovascular and/or persistent severe gastrointestinal symptoms (particularly for insect allergy)

Symptoms/signs of respiratory/cardiovascular involvement are:

2. Generalised allergic reaction

A generalised allergic reaction is a characterized by one or more symptoms or signs of skin and/or

gastrointestinal tract involvement without respiratory and/or cardiovascular involvement.

NOTE: Vomiting and abdominal pain are signs of a severe allergic reaction to insect stings and bites.

3. Adrenaline autoinjector

• Adrenaline autoinjectors are pre-loaded injector devices containing a single fixed dose of adrenaline.
  Adrenaline rapidly to reverses the effects of anaphylaxis and should be considered first line treatment for anaphylaxis.

ASCIA is the peak professional body of clinical immunology and allergy specialists in Australia and New Zealand – www.allergy.org.au

©ASCIA 2012

Content updated February 2012