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ASCIA Guidelines for adrenaline autoinjector prescription

Proforma - Script Examples

Examples of documents that can be used to handle requests for adrenaline autoinjectors (EpiPen or Anapen) on PBS Authority prescription

pdfRequest for adrenaline autoinjectors (EpiPen, EpiPen Jr) 164.76 KB

pdfRequest for adrenaline autoinjectors (Anapen, Anapen Jr)158.13 KB

pdfASCIA Guidelines for adrenaline autoinjector prescription Dec 2013281.83 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 tree 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.
    • Systemic stinging insect allergy (bees, wasps, jumper ants) in adults.
  • Co-morbid conditions - Asthma (concurrent or past history), history of ischaemic heart disease or 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 some remote residential 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 alone - in patients with asthma without previous anaphylaxis or generalised allergic reactions.
  • If known allergen can be successfully avoided - e.g. drug allergy (medical identification jewellery should be worn).
  • Elevated specific IgE only (positive blood or skin allergy test) without a history of clinical reactivity. 
    A positive test alone is not equivalent to allergy since false positive results may occur. 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 autoinjector dose recommendations

In Australia, two adrenaline autoinjector devices can be prescribed per patient (children and adults) per authority prescription.

Adrenaline autoinjectors available in Australia and New Zealand include EpiPen Jr (0.15 mg), EpiPen (0.3 mg) and Anapen 150 (0.15 mg) and Anapen 300 (0.3 mg)

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

Children 10-20kg**
EpiPen Jr (0.15 mg) or Anapen 150 (0.15 mg) are recommended for children between 10 and 20kg**

Children over 20kg and adults**
EpiPen (0.3 mg) or Anapen 300 (0.3 mg) are recommended for adults and children over 20kg**

* Refer to definitions below
** 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: Adrenaline ampoules and syringes are unsuitable for non-medical settings such as schools, childcare and workplaces.

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

Anaphylaxis management plan

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

1. 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; and
  • Advise on specific management in community setting.

2. Identification of anaphylaxis trigger(s)
This should include a comprehensive history, clinical examination, appropriate use and interpretation of allergy testing and under some circumstances, deliberate challenge to prove or disprove allergy.

3. Education on the avoidance of trigger(s)
This is particularly important with food induced anaphylaxis.

4. 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; and
  • Doctor's name and signature.

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

5. Appropriate follow-up
Yearly review by a patient's general practitioner should occur to:

  • Provide re-education on adrenaline autoinjector use (using a trainer device);
  • Renew ASCIA Action Plan;
  • Provide ASCIA Travel Plan if required;
  • Ensure the adrenaline autoinjector has not expired; and
  • Determine whether specialist review is required to ascertain if the allergy persists, new allergies have developed or review is required.
Definitions
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 include:

Respiratory
Difficult/noisy breathing 
Swelling of tongue
Swelling/tightness in throat 
Difficulty talking and/or hoarse voice 
Wheeze or persistent cough

Cardiovascular:
Loss of consciousness/collapse
Persistent dizziness
Pale and floppy (in young children)
Hypotension

Generalised allergic reaction

A generalised allergic reaction is a characterised by one or more symptoms or signs of skin and/or
gastrointestinal tract involvement without respiratory and/or cardiovascular involvement:

Skin: 
Generalised pruritus 
Urticaria/erythema 
Angioedema 

Gastrointestinal:
Abdominal pain
Vomiting
Loose stools

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

Adrenaline autoinjector

Adrenaline rapidly to reverses the effects of anaphylaxis and should be considered first line treatment for anaphylaxis.

Adrenaline autoinjectors are spring-loaded automatic injector devices for emergency/first aid treatment of anaphylaxis. Adrenaline autoinjectors contain a single fixed dose of adrenaline to be administered intramuscularly for safer, rapid absorption of adrenaline.

Adrenaline autoinjectors should be administered into the outer mid-thigh muscle and can be administered through a single layer of clothing (not pockets or seams).

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

©ASCIA 2013

Content updated December 2013

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