Q:

1/14/2014
I believe that the current recommendations for allergy immunotherapy includes the option of a patient having an adrenaline injector available for a systemic reaction to immunotherapy after the recommended 30 minutes of observation. Literature reports a 5-10% risk of anaphylaxis for a large local reaction that occurs in some patients with insect stings, but I don’t believe patient availability of epinephrine is recommended? Am I correct and if so should not this recommendation with such a greater chance of systemic reaction i.e. 5-10% VS .02%?

A:

Thank you for your inquiry.

The decision to give a patient an automatic epinephrine injector in the two situations you mentioned in your inquiry is best answered by a quote from the most recent Joint Council Parameters on Insect Sting Anaphylaxis, by David Golden and colleagues (1). This quote is copied for you directly below:

"In patients who have had large local reactions, it is optional to prescribe injectable epinephrine for use if the patient experiences a systemic reaction in the future."

The quote can be applied equally well to patients receiving aeroallergen immunotherapy. The decision as to whether or not to prescribe an automatic epinephrine injector in these situations therefore remains an option left entirely to the physician caring for the patient in question, as discussed previously on entries posted to our "Ask the Expert" website.

In this regard, a reference analyzing the percentage of allergists who do give such an injector to patients on immunotherapy would be of interest to you. It is the Gupta reference cited under the reference list below (2). As you can see when you read this reference, there are great differences of opinion as to whether such a prescription is necessary, and some allergists prescribe it to some patients receiving immunotherapy but not to others.

In summary, for both situations you mentioned, the prescription of such injectors remain optional and at the discretion of the patient's personal physician. Thus, you are correct in that there is no mandate or specific recommendation to prescribe automatic epinephrine injectors in these situations.

The second question you posed - that is, should there be such a recommendation? - is one that can only be approached philosophically. There are many situations we deal with where questions remain as to the advisability of the institution of specific treatments. For example, if one argues that an automatic epinephrine injector be mandated for a patient with a large local reaction, who may be at a 5 to 10% risk for anaphylaxis, could one not argue also that venom immunotherapy, which has been shown to be highly effective as a preventive, also be instituted?

Another situation where a question arises is whether or not a patient with oral allergy syndrome (who may be at increased risk for a systemic reaction) should be given an automatic epinephrine injector.

In these situations, the issue of whether recommendations or mandates be applied or whether these decisions be left up to the individual physician is philosophical. I believe that one can cogently argue both sides of this issue. I cannot, therefore, comment on whether or not, as you asked, you are "correct" that a recommendation for an automatic epinephrine injector be given to a patient with a large local reaction. I can simply say to you that there are others who feel just as strongly that encroachments on a physician's prerogative to utilize his/her clinical judgment in such situations can sometimes do more harm than good.

For the present time, however, any physician who wishes to prescribe automatic epinephrine injectors in these situations is certainly welcome to do so. Whether it would be mandated to do so by virtue of a specific recommendation remains an issue of debate.

Thank you again for your inquiry and we hope this response is helpful to you.

References:
1. Golden D, et al. Stinging Insect Hypersensitivity: A Practice Parameter Update 2011. J Allergy Clin Immunol 2011; 127(4):852-854.

2. Gupta P, et al. Current Practices Among Allergists on Writing Self-Injectable Epinephrine Prescriptions for Immunotherapy Patients. J Allergy Clin Immunol 2012 (February); 129(2):571-572.

3. Cox L, Nelson H, Lockey R, et al. Allergen immunotherapy: a practice parameter, third update. Journal of Allergy and Clinical Immunology, January 2011; Volume 127 (1), Supplement, page S1-S55.

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology