Anaphylaxis and shock, reversed by epinephrine
By Richard P. Holm, MD
Ms. A. was in the bagel shop line and told the server she was allergic to peanuts. The server reassured her there were no peanuts in the bagel but was unaware some peanut butter was left on the knife from an earlier sandwich. After a few bites of the bagel, Ms. A.’s face and lips started swelling, she itched all over, slipped off her chair, vomited and fell flat losing consciousness. When the ambulance arrived the emergency team kept her flat, gave an intramuscular injection into her thigh muscle of epinephrine (also known as adrenalin), then took her off to the hospital.
Anaphylaxis is a severe allergic reaction that can follow exposure to an allergic trigger and will happen in the lifetime of one or two out of every one hundred people. Symptoms are secondary to the release of histamine and other mediators causing a severe drop in circulating blood pressure. Triggers can be from food such as peanuts, wheat, nuts, shellfish or milk, an insect bite or sting, or a medication like penicillin. The full list is long.
Aside from avoiding the trigger in the first place, the single most important treatment for anaphylaxis is epinephrine which is a hormone released from our adrenal glands. There are few reasons not to give an injection of epinephrine if there is a chance that anaphylaxis is happening. Our bodies make natural epinephrine when we are faced with fight or flight situations. Antihistamines like Benadryl®, Claritin® and others have no role in the prevention or treatment of anaphylaxis as they only help the itch. The single treatment for anaphylaxis is epinephrine, period. Have injectable epinephrine available and near persons at risk and use it if worried.
To obtain a self-injector of epinephrine, you need a prescription. There are now five types available and they all work well. Ask your pharmacist to get you the least expensive one and be sure you know how to use it.
The price for a kit with two autoinjectors runs from $375 to $600. The cost to the pharmaceutical company to purchase one autoinjector from the manufacturer was reported as approximately $30 by NBC News in 2016 after a U.S. House Committee looked at the price of autoinjectors. I believe excessive markup of the prices of medicine by drug manufacturers or pharmaceutical companies is unethical and we need to pressure our national legislators to do something about it.
Patients with anaphylactic allergies must know what to avoid, have epinephrine available, use it when necessary, and after any reaction see their provider.
Ms. A recovered fine and never went without her epinephrine rescue injector again.
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