Home Forums Discussions General Discussion Epinephrine for anaphylactic reactions in the office

Things like this just pop up. I was signing a check for supplies when I noticed a check over $840 from a local pharmacy. It was for a 2-pack of 0.15 mg epipens and a 2-pack of 0.3 mg epipens. You can't get them any other way. I looked at other pharmacies, and the $400 ones I had were $150 cheaper than the other companies. Henryschein, who we have an account with, charges $730 per package.

So, I have a couple of questions about this. First, I should say we obviously keep them on hand for emergencies mainly given the fact we give tons of immunizations and have in the past given allergy shots (which I do not plan on doing anymore). One person with asthma nearly went into anaphylaxis, but at this point, only one person in over nine years came close and, it was that person. Another way of putting it is we have not used an Epipen before. This even though we are paying $800 or more each year.

Now, of course, it's like fire extinguishers and oxygen tanks, etc. You need them when you don't have them. I keep hearing things about the need for Epipens, but is there a law in each state? I don't know. I have also spoken to a pharmacist who states they are required to keep at least two of each strength since they give shots at the pharmacy.

Now, I do know you can buy ampules or vials of epinephrine and use them during an emergency. But, you do draw up the exact dosing or do you just have 0.3 mg and 0.15 mg on hand. The dosing for Epipens are strange because of the 33 to 66 pounds and 66 pounds and over, yet there seems to be no dosing for the 0 to 33 pounds, although allergists have told me to use the 0.15 mg on anyone under 66 pounds.

Certainly, there is a huge advantage price-wise to use ampules and just make sure everyone is trained or even draw them up ahead of time. The FP doctor I lease from has them in each room. I find that would be dangerous in a pediatric office.

Part of the issue is that no matter how much one trains, the chance of a mistake is much greater during a panicky situation if you must either draw then or even find and use the predrawn syringes. There is an actual case of a local hospital where an overdose was given from a crash cart with a very bad outcome.

Given that one can give one dose while waiting for paramedics and repeat it five minutes later, it is good to have the two packs.

Granted Epipens were invented so those with peanut allergies or bee sting allergies could always have Epinephrine available. But, in some places, they have replaced the ampules. Also, given that Epinephrine comes in two strengths and the dosing is different dependent on IV or SQ (I realize it wouldn't be IV, but it is locked in my brain), it can even be more risky.

I guess part of it is how liable are you and how careful do you want to be with having extra doses. And, how much are you willing to pay each year for medication you have less than 0.01% chance of needing. Maybe some pharmacies will replace the meds when they expire which is a bit over a year. So, here are the options I have come up with and wonder what others think or do.

1. Pay the $800 and keep two of the different strengths available.
2. Buy just a two pack of the 0.15 mg. You now have Two doses you can give of the 0.15 and one dose of the 0.3 mg.
3. Go strictly with the ampules or vials.
4. Buy just a 0.15 mg two-pack and then have extra ampules which can be drawn up if more is needed. If you have someone trained they would have plenty of time to think clearly to draw them up. Or the doctor could draw it up, but he or she is usually needed for ALS, etc.

I am bringing this up now, since I need to make a decision on what is the right thing to do. It also depends on what the rules and regulations are, because if it is only having enough for one dose, then only having the 0.15 mgs makes sense.

Also, any experiences people have had with using epinephrine in the office and was it with Epipens or synringes.

Never used Epipens in the office, maybe because I spent enough time in ER and use to drawing up Epi from 1/1000 vials.
I think in 29 years have only had to give Epi twice. The Epi is always in the front of my supply cabinet with an allergy syringe taped to the inside of that cabinet door

Suppose a little dosing chart could be taped on the door also but since I don't do little patients I rely on memory.

Dear Bert,
as I am an allergist I have some experience with using epi in the office. I do not have epipens as there is no flexibility in dosing. I buy the 30 ml bottle of epi 1: 1000.
It is no longer recommended to use Epi via allergy syringes as these are for SQ use only. The absorption of epi is much quicker and more reliable using the IM route and the preferred area of injection is the thigh - studies confirm that this is the best way to administer Epi. So I keep 1 ml syringes with 1" IM needles for use with epi .
this is much cheaper than buying epipens and doses can be adjusted depending on the weight and age ( 0.01 mls/kg) .
When the 30 ml bottle multi dose vial is not available, I order the single ampules . Of course since I use epi more often this is a more cost effective approach for me .
In an emergent situation I have found that it is easier for most of my MAs to draw from a multi dose vial than to break open a ampule and draw from it
hope this helps
Bala

These are great answers. So to either. Given Epipens are generally given right through the patient's clothing or at least that is the instructions we give them, do you give the 1 inch needle directly through, say, blue jeans, in the thigh or do you pull the pants down or up?

Dear Bert,
so far in the office , I have not had to give epi thru clothing but you could do that in a very emergent situation where the benefit outweighs the risk of any infection being introduced via clothing. The key of course is early recognition of anaphylaxis and the severity of anaphylaxis. If it is recognized early enough, there is usually enough time to pull the pants down. It is also increasingly recognized that the patient must be recumbent as soon as possible to prevent 'empty heart syndrome' and this is an important factor in reducing mortality . I usually have the patient in a recumbent position first then give the epi.
hope this helps
bala

It does help. Thanks. Another great benefit of the ACUB.

I just want to keep this going a bit. First, I think the idea of a chart is a good idea. If you use it a lot, you can probably calculate the 0.01 mLs/kg rather easily. But, maybe a chart would be helpful. And, possibly in pounds. Even my staff will give me the weight in pounds, especially given that the weight defaults to pounds in the MRE. Even when I ask for the weight to calculate a script, my staff (all MAs) will give the weight in pounds. Plus, if you need to rely on the parent, they will usually give pounds. Actually, they will ALWAYS give pounds. I can convert lbs to kgs in about two seconds, but not necessarily the staff.

If you did use a table or chart, would you recommend using a five pound grouping rather than a dose for each lb? And, if you do use epi or any medication in a ALS type situation, do you have someone write down the med, dose and time sort of how it would be done in the hospital?

Finally, how often do you think it can be given? Every five minutes? As often as necessary? Generally, paramedics arrive within ten minutes and more likely five after we call. I know I can look some of this stuff up, but I trust your judgment more.

Dear Bert,
having a chart or table is a good idea for the reasons you have specified. The margin of safety is high so you could use a 5 lb grouping for ease of use .
I usually have a MA write down the time of administration then enter into AC as we give the epi or shortly thereafter .
the usually recommended time interval for repeating epi is 15 mins .
Bala