CPDIN OBJECTIVES


After completing this module you should: • Have a good understanding of anaphylaxis and its management • Understand the gaps in current practice surrounding the provision of AAIs following an anaphylactic episode and their subsequent use


• Feel confident in addressing management gaps with ongoing advice and training for patients and parents/carers


• Be aware of the different AAIs, their similarities and differences, and the support available


AUTHOR This article was written and supported by ALK


FOCUS ADRENALINE AUTOINJECTORS


IN ANAPHYLAXIS This module is about the use of adrenaline autoinjectors (AAIs) in anaphylaxis


age, in any setting.1,2 First-line A


management – intramuscular adrenaline – is universally agreed to be life-saving,1


and provision of AAIs


to patients following an initial reaction should ensure prompt treatment in the event of recurrence. Despite the clear consensus on treatment for this life-threatening condition, substantial gaps exist in practice.


Evidence reveals areas for improvement in the management of anaphylaxis and AAI use in all settings,1,3


across healthcare


professionals, patients and caregivers alike.3


too often placed on the initial episode, with long-term management of at-risk patients potentially being overlooked.3


A retrospective survey of first aid anaphylaxis management in children prescribed an AAI reported that it was used in less than a third of anaphylactic reactions – just 29%.4 Potential barriers to administration include reluctance to carry the device, fear of needles and uncertainty about when and/or how to administer the AAI.3,5,6


Why do these gaps in practice persist today in the UK, and how can the pharmacist address them?


18 - PHARMACY IN FOCUS The focus of management is all


naphylaxis is a life-threatening allergic reaction of rapid onset that can affect people of any


Anaphylaxis and the role of AAIs While the Resuscitation Council acknowledges that there is no universally agreed definition of anaphylaxis, they characterise it as a ‘severe, life-threatening, generalised or systemic hypersensitivity reaction’.


A broad range of anaphylactic triggers (allergens) exist, with food, drugs and venom being the most commonly identified.7


Anaphylaxis is


the likely diagnosis if exposure to a trigger is associated with rapid onset of skin changes (within minutes of exposure) and life-threatening compromise of the airway, breathing or circulation.7


Approximately 20 deaths from anaphylaxis are reported annually in the UK, although this may well be an underestimate.7


The incidence of


anaphylaxis has increased over the past decade or two in many parts of the world, including the UK.8


of recurrent anaphylactic reaction following an initial reaction is high, estimated at approximately 1 in 12 per year.7


As described above, immediate intramuscular injection of adrenaline constitutes first-line treatment.1 Adrenaline is the only medication that reduces hospitalisation and death in anaphylaxis. Alpha-1 agonism prevents and relieves airway oedema, hypotension and shock, while beta-1


The risk


agonism strengthens cardiac contraction and brings about bronchodilation.2,9


episode will occur.11 Delayed injection


of adrenaline is associated with increased risk of fatality.1


Resolution of the acute episode, of course, does not signal the end of treatment of anaphylaxis.9


And yet an


alarming number of patients fail to do so; the proportion who do not keep their autoinjectors with them ranges, in different studies, from as low as 15% to 75%.1,2,5,11


Given the


unpredictable nature and rapid onset of anaphylaxis, guidelines recommend the provision of AAIs for patients with a view to rapid treatment of future anaphylactic episodes.1,2


Prescription of an AAI


must be combined with specialist advice on allergen avoidance, a written treatment plan and clear training in AAI use.10


Potential pitfalls in AAI provision and use


• AAI availability Patients prescribed AAI devices should make sure that they are accessible at all times, since they can’t predict when an anaphylactic


Young people may feel uncomfortable carrying the device due to social implications, or may simply forget to do so. Pharmacists are well placed in the community to emphasise the importance of keeping AAIs to hand at all times. Fear of using the device, a considerable obstacle for many patients, must also be addressed during consultation.5


• Administration technique As well as carrying the AAI device, it is imperative that patients or their parents/carers know how to use it properly; the technique varies depending on the device.10,12 Surprisingly frequently, patients, carers and healthcare professionals alike are uncertain about the correct method for AAI use.2,3,11


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