A new survey shows that only 39 percent of adults with food allergies or caregivers of food-allergic children know when to use epinephrine as the go-to treatment for anaphylaxis. The other 61 percent would first choose an antihistamine or an albuterol inhaler, before reaching for the lifesaving epinephrine.
The confusion over when to use epinephrine stems from patients and families not recognizing what symptoms qualify as anaphylaxis. Or they think it’s OK to wait and see if an antihistamine works before trying epinephrine. (This isn’t recommended).
Antihistamines, such as Benadryl or cetirizine (the brand Zyrtec), can treat milder skin-related symptoms of an allergic reaction such as hives, itchy eyes or runny nose, says Dr. Sasha Alvarado, the senior study author.
But when it comes to more serious symptoms of anaphylaxis, such as breathing trouble, airway swelling, vomiting, or anaphylactic shock, epinephrine is the only first-line treatment.
“Benadryl isn’t going to be lifesaving. It’s epi first,” Alvarado stresses. While there’s no harm in also giving an antihistamine, “my bigger concern is giving epinephrine early to have good outcomes.”
Alvarado is co-director of quality and safety for the Division of Immunology, Allergy and Retrovirology at Houston’s Baylor College of Medicine.
Confusion About When It’s Anaphylaxis
The survey, led by Dr. Joni Chow, a Baylor pediatric resident, was being presented at the American College of Allergy, Asthma & Immunology’s annual meeting in Boston. Ninety-six food allergy patients and caregivers in an allergy clinic took part. Nearly all had been prescribed epinephrine auto-injectors.
Eighty-five percent correctly recognized that “taking antihistamines prevents the need for epinephrine” is false. Seventy-three percent said they felt comfortable recognizing anaphylaxis symptoms.
While this sounded promising, much of that confidence turned out to be misplaced. The survey revealed gaps when the participants were asked how they’d handle some clear symptoms of anaphylaxis.
About 39 percent correctly said they’d use an epinephrine auto-injector if they or their child developed rash and wheezing after suspected allergen exposure. Those are signs of an anaphylactic reaction involving two body systems.
However, 24 percent said they’d first try an antihistamine for the same symptoms. Five percent said they’d use an albuterol inhaler, and 32 percent said they’d give both antihistamine and albuterol. Albuterol, also called a rescue inhaler, relaxes the bronchial tubes and is used to treat asthma symptoms.
“Any allergist would recognize the scenario as anaphylaxis happening,” Alvarado says. But many patients and caregivers “were not recognizing it as a situation that requires epinephrine.”
When symptoms affected three body systems, like a cough, vomiting and rash after eating a possible allergen, 64 percent said they’d use epinephrine. While a considerable improvement, 24 percent still said they’d first try an antihistamine. Another 2 percent said they’d turn to albuterol, and 10 percent said they’d head for the emergency room.
Why the Epinephrine Hesitation?
The survey revealed some key reasons why people hesitate to use auto-injectors:
• About 41 percent weren’t sure which symptoms required treatment.
• 24 percent didn’t want to go to the ER.
• 18 percent were reluctant to call 911.
A February 2024 update to allergists’ practice parameters may help those hesitating to administer epinephrine over the need to go to the ER or call 911. If symptoms of anaphylaxis quickly resolve after using epinephrine and don’t return, the new guidelines say patients often will not need to seek further care.
If the reaction is severe, doesn’t resolve completely or nearly completely, or if symptoms return, EMS should be called.
Lowering Epi Anxiety
With this updated guidance, “more patients are using epinephrine and using it appropriately,” Alvarado says. “It’s definitely decreasing the overall anxiety.”
The survey also found about 11.5 percent weren’t sure how to use epinephrine auto-injectors, while 5 percent feared needles.
Patients also now have a needle-free option with the Food and Drug Administration’s approval of neffy in August 2024. Neffy, made by ARS Pharmaceuticals, is a nasal epinephrine sprayer for adults and children weighing 66 pounds or more.
About 36.5 percent of food-allergic adults and caregivers surveyed had an anaphylaxis action plan. Respondents with plans were more likely to say they would use epinephrine as a first-line treatment.
The researchers used the survey results to develop an action plan that includes visual depictions of anaphylaxis symptoms. This is meant to assist younger children, non-English speakers or those with communication difficulties to express what they’re feeling.
Knowing when to use epinephrine is crucial, because waiting to see if antihistamines work can delay the treatment that will actually halt the anaphylaxis.
As a new doctor, Alvarado recalled the time an allergy patient said “they didn’t feel right” during an oral food challenge. She administered an antihistamine. Within moments, the patient had progressed to facial flushing, profusely watering eyes and a dry cough.
“It progressed so quickly,” she says. From then on, “I have never given Benadryl [as a first-line treatment for anaphylaxis] again.”
Related Reading:
Advice to Always Go to the ER After an Epi Shot is Set to Change
Inside the Epidemic of Epinephrine Hesitation