Life-saving Interventions: The Importance of Epinephrine Auto-injectors

With over 20% of the UK’s population affected by at least one allergy, epinephrine auto-injectors are an important healthcare product used for those at risk of anaphylaxis and can save lives.

According to official government statistics, from 1998 to 2018, 101,891 people were hospitalised for anaphylaxis in the UK, with 30,700 cases attributed to food allergies. The most substantial rise in hospital admissions occurred among children under 15 years of age. For adults, anaphylaxis-related hospital admissions increased from 3,751 in 2019 to 4,756 in 2020. The number of adults admitted to hospitals due to allergies has more than doubled since 2013.

We can’t say for certain why allergy rates are increasing; however, researchers have some theories. One theory is that improved hygiene is to blame, as children are not getting as many infections, therefore with fewer parasites to fight, the immune system perceives a threat against things that should be harmless. Other theories are vitamin D deficiency, changes in diet including eating more processed foods, environmental factors and increased awareness and diagnosis. 

Allergy UK offers advice around living with allergies and still maintaining your quality of life.

The Role of Epinephrine Auto-injectors

An epinephrine auto-injector is a critical medical device used for the emergency treatment of severe allergic reactions, or anaphylaxis. Anaphylaxis can occur rapidly and is potentially life-threatening, making immediate administration of epinephrine crucial.

The administration of an epinephrine auto-injector, often referred to as an EpiPen, can be life-saving. The medical device is specifically designed to administer a controlled amount of the hormone epinephrine, also known as adrenaline. It is made to be small, portable and user-friendly. 

An EpiPen has a needle that automatically dispenses a predetermined epinephrine dosage when used. It works by reversing anaphylaxis symptoms by narrowing blood vessels, relaxing airway muscles, and enhancing the blood flow to essential organs.

Epinephrine works by stimulating alpha and beta-adrenergic receptors. This results in the narrowing of blood vessels, which increases blood pressure and reduces swelling. It also relaxes the muscles around the airways, helping to improve breathing, and inhibits further release of allergic mediators from mast cells and basophils.

The device is designed for ease of use, even by non-medical personnel. Epinephrine auto-injectors are portable and can be used in a variety of settings. The design typically includes clear instructions and a simple mechanism that allows for swift administration, often with just a single press against the thigh.

Prompt administration of epinephrine can be life-saving, as delayed treatment increases the risk of severe outcomes or fatality. It is recommended that individuals at risk of anaphylaxis carry an auto-injector at all times.

Patients prescribed an epinephrine auto-injector are usually educated on its use, including recognising the signs of anaphylaxis and how to administer the injection properly. Training often involves caregivers, family members and educators, especially in the case of children.

These devices are generally prescribed to individuals known to have severe allergies to specific triggers, such as foods, insect stings, medications or latex. 

After using an epinephrine auto-injector, it is critical to seek emergency medical care immediately, as symptoms can recur. Medical professionals can provide further treatment and monitoring.

Who Needs an Epinephrine Auto-injector?

Epinephrine auto-injectors are important medical devices which should be used if someone experiences anaphylaxis.

Anaphylaxis occurs when your body experiences a severe and life-threatening reaction to something which you are allergic to. Allergies involve your immune system responding to a typically harmless substance, known as an allergen. While the immune system’s usual role is to protect the body against bacteria and viruses, in cases of allergies, it mistakenly perceives the allergen as a threat and reacts to it. The severity of allergies can range from mild to severe, with symptoms varying from mild irritation to potentially life-threatening conditions.

Anaphylaxis can come on very quickly, highlighting the importance of knowing how to respond in an emergency. Immediate medical attention is crucial, as anaphylaxis prompts the immune system to release an excess of chemicals, leading to serious symptoms and the potential for the person to experience anaphylactic shock. This involves a sudden drop in blood pressure and the narrowing of the airways, making breathing difficult or impossible. Without urgent treatment, anaphylaxis may progress to anaphylactic shock, posing serious complications and, in some instances, this can be fatal.

The primary groups of people who need an epinephrine auto-injector include:

• Individuals with a history of anaphylaxis – anyone who has experienced anaphylaxis should carry an epinephrine auto-injector. Anaphylaxis is a severe, potentially life-threatening allergic reaction that can occur rapidly.
• People with severe allergies – individuals who are known to have severe allergies to specific triggers. Common food allergens include peanuts, tree nuts, shellfish, fish, milk, eggs, wheat and soy. Insect stings can include bees, wasps, hornets, yellow jackets and fire ants which can cause severe allergic reactions. Medications including antibiotics, aspirin and nonsteroidal anti-inflammatory drugs can be allergens. Some people have severe allergies to latex products.
• People with both asthma and allergies – those who have both asthma and severe allergies are at increased risk for anaphylaxis and should carry an auto-injector.
• Patients with idiopathic anaphylaxis – in cases where the cause of anaphylaxis is unknown, but the individual has experienced anaphylaxis, they should have an auto-injector on hand.
• Individuals with exercise-induced anaphylaxis – rarely, physical activity can trigger anaphylaxis, especially if combined with certain foods or environmental conditions.
• Children with severe allergies – parents of children diagnosed with severe allergies or a history of anaphylaxis should ensure their child has an epinephrine auto-injector available at all times, including at school and during activities.
• Individuals at risk due to occupational exposure – certain professions, such as healthcare workers or laboratory staff who handle allergens regularly, might be at increased risk of exposure and anaphylaxis.

There are certain risk factors for someone experiencing anaphylaxis; these include:

• Experiencing anaphylaxis before – if you have already experienced anaphylaxis, this makes it more likely that you will experience it again in the future. Future episodes may also be more severe.
• A family history of anaphylaxis – having a close family member who has experienced anaphylaxis makes it more likely that you will experience it also.
• Having allergies – having allergies makes it more likely that you will experience anaphylaxis.
• Your age – children and young adults may be at a higher risk of anaphylaxis, though it can occur at any age.
• Having asthma – the combination of asthma and anaphylaxis can lead to more serious respiratory symptoms.
• Having multiple allergen sensitivities – people with multiple allergies may be at an increased risk of anaphylaxis.
• A delay in administering an adrenaline auto-injector – there should be no delay in giving this if anaphylaxis is suspected. It is recommended that anyone at risk of anaphylaxis carries two EpiPens with them at all times.

Young people between 16-24 years old are the group recognised as being most at risk of anaphylaxis. At this age they become more independent from their parents and are more likely to experiment with new, unfamiliar foods, they are more likely to travel alone or with friends, and may be reluctant to carry two EpiPens with them at all times, which is necessary when you have a serious allergy.

Symptoms of anaphylaxis happen very quickly and include:

• Swelling of the throat and tongue.
• Difficulty breathing or breathing very fast.
• Wheezing, coughing or noisy breathing.
• Difficulty swallowing or tightness in the throat.
• Feeling faint, dizzy or fainting.
• Feeling tired or experiencing confusion.
• Skin that feels cold to touch.
• Blue, grey or pale lips or face.
• A drop in blood pressure.
• Becoming unconscious.

If you suspect someone is experiencing anaphylaxis, you should follow these steps:

• Call an ambulance immediately.
• Administer an adrenaline auto-injector, if available. This is sometimes called an EpiPen. You should use it as directed, which usually involves injecting the person into the outer thigh and holding it in place for 10 seconds.
• If their symptoms have not improved after 5 minutes, use a second adrenaline auto-injector.
• Lie the person down and elevate their legs.
• Stay with the person and monitor their breathing.
• Do not offer any food or drinks as this could potentially make their condition worse.
• Do not ask the person to stand or walk at any time, even if they feel better.
• If the person has been stung by an insect, try to remove the sting if it’s still in the skin.
• Administer CPR if the person has stopped breathing or their heart has stopped.

You should stay with the person at all times and try to keep them calm. Reassure them and encourage them to lie down. Monitor their vital signs such as breathing, pulse and blood pressure. Be prepared to perform CPR if necessary. CPR is a life-saving medical procedure which is given to someone who is in cardiac arrest. It helps to pump blood around their body when their heart is unable to do this.

The British Heart Foundation offers an online CPR course. It is recommended that everyone knows CPR in the event of an emergency situation; it could save a life.  

Anaphylaxis needs to be treated in hospital straight away. Treatment may include oxygen, adrenaline given by an injection or drip into your vein and fluids given by a drip in your vein.

Allergy UK offers a helpful factsheet about anaphylaxis.

How to Use an Epinephrine Auto-injector

Using an epinephrine auto-injector correctly is crucial in an emergency situation, especially during a severe allergic reaction. There are general steps for using an epinephrine auto-injector, but always follow the specific instructions provided with your device, as different brands may have slightly different procedures. 

Steps to use an epinephrine auto-injector include:

• Recognise the symptoms – symptoms of anaphylaxis can include swelling, hives, difficulty breathing, a rapid heartbeat, or a feeling of doom.
• Prepare the auto-injector – remove the auto-injector from its protective case.
• Remove the safety cap – the cap is usually at one end of the device.
• Position the auto-injector – hold the auto-injector in your dominant hand, with your thumb not touching either end of the device.
• Position the auto-injector about halfway down the outer thigh – the injection site should be on the outer thigh, halfway between the hip and knee.
• Administer the injection – firmly press the auto-injector against the outer thigh until you hear a click. This means the needle has been deployed and the medication is being injected.
• Hold the auto-injector in place for about 3 seconds – some devices recommend holding it for up to 10 seconds; you should check the specific instructions for your device.
• Remove and dispose – remove the auto-injector and massage the injection site for about 10 seconds to help disperse the medication. Place the used auto-injector back in its case and dispose of it according to local guidelines.
• Seek emergency medical help – call emergency services immediately, even if symptoms seem to improve. Anaphylaxis can be a biphasic reaction, meaning symptoms can return after the initial treatment.
• Monitor and record – if you have a second dose, as some prescriptions include two auto-injectors, you may need to use it if symptoms persist or return after 5 to 15 minutes.
• Note the time of injection and any changes in symptoms – this is to inform medical personnel when they arrive.

You should practise with a trainer device if available. Trainer devices do not contain a needle or medication and can be reused. You should store the auto-injector at room temperature, away from extreme temperatures and light. Regularly check the expiration date and replace the device before it expires. 

Ensure family members, friends or caregivers know how to use the auto-injector and can recognise the signs of anaphylaxis. For tips on how to educate friends and family about anaphylaxis, please see our knowledge base.

The Importance of Timely Administration

Timely administration of an epinephrine auto-injector is crucial for several reasons when treating anaphylaxis. Epinephrine works quickly to reverse the symptoms of anaphylaxis by:

• Constricting blood vessels, which increases blood pressure and reduces swelling.
• Relaxing the muscles in the airways, improving breathing.
• Reducing hives and itching.

Anaphylaxis can escalate rapidly, potentially leading to respiratory or cardiac arrest within minutes. Early administration of epinephrine can prevent the reaction from worsening. Studies show that epinephrine is most effective when administered promptly after the onset of symptoms. Delayed administration can lead to more severe reactions and can decrease the effectiveness of the treatment.

Timely administration can reduce the need for further medical interventions such as additional doses of epinephrine, intravenous fluids, and other medications. It can also reduce the likelihood of hospitalisation.

Early intervention with epinephrine can prevent complications such as airway obstruction, severe hypotension (low blood pressure), and cardiac arrhythmias.

Dispelling Myths and Misconceptions

There are several common myths and fears surrounding epinephrine auto-injectors that can deter people from using them or understanding their importance. Some common myths include:

• Epinephrine auto-injectors are only for people with severe allergies – the reality is that while they are crucial for people with severe allergies, they can also be life-saving for anyone who experiences a severe allergic reaction for the first time.
• Once someone uses an auto-injector, they are safe and don’t need further medical attention – the reality is that epinephrine is a temporary measure that can help stabilise someone until they receive professional medical care. It’s essential to seek emergency medical help immediately after using an auto-injector.
• Epinephrine auto-injectors are complicated to use – they are designed to be user-friendly with clear instructions. Many models have audible prompts to guide the user through the injection process.
• Carrying an auto-injector is unnecessary if I avoid allergens – accidental exposure to allergens can happen despite best efforts to avoid them. Having an auto-injector readily available is crucial for immediate response to unexpected allergic reactions.

Some common fears can include:

• A fear of needles and pain – many people are afraid of needles and worry that using an auto-injector will be painful. While there is some discomfort, the needle is typically very small, and the benefits of using the injector far outweigh the momentary pain.
• A fear of side effects – some people are concerned about the potential side effects of epinephrine, such as increased heart rate, anxiety or dizziness. These side effects are generally mild and temporary compared to the life-threatening nature of anaphylaxis.
• Fear of using it incorrectly – there is a common fear of administering the auto-injector incorrectly. This fear can be alleviated with proper training and practice. Many organisations offer training sessions, and some auto-injectors come with trainers for practice.
• Fear of legal repercussions – some people worry about the legal implications of administering epinephrine to someone else.
• Fear of dependency – there is a misconception that frequent use of epinephrine can lead to dependency or reduced effectiveness over time. Epinephrine does not cause dependency, and its effectiveness does not diminish with repeated use in emergency situations.

Access and Availability

Epinephrine auto-injectors are prescription-only medications in the UK. This means that they cannot be purchased over-the-counter and must be prescribed by a healthcare professional, such as a GP, allergist, or other qualified medical personnel. 

Several brands of epinephrine auto-injectors are available in the UK, including:

• EpiPen
• Jext
• Emerade

Pharmacies usually stock these brands, but availability can sometimes be affected by supply issues. In recent years, there have been occasional shortages, prompting regulatory bodies and healthcare providers to offer guidance on managing such shortages.

Regulations allow schools in the UK to keep spare, non-patient-specific epinephrine auto-injectors for emergency use. This policy aims to ensure that epinephrine is readily available in school settings for students who may not have their auto-injector with them during an allergic reaction.

The Medicines and Healthcare products Regulatory Agency (MHRA) and other health authorities provide guidelines for the proper use, storage and expiration management of epinephrine auto-injectors. Training for patients, caregivers, school staff and the public on the recognition of anaphylaxis and the correct use of auto-injectors is strongly encouraged.jhvbjhvjh