1. Access to Epinephrine for Self-Administration (EPI Rph)
Talking points:
During the call:
Patient reported allergy history, nature of reaction, and access to EAI were discussed. Patients with a history of anaphylaxis or systemic reaction were encouraged to follow up with their primary care provider to discuss obtaining a prescription for EAI if clinically appropriate.
Effectiveness of Pharmacist Use of the Electronic Medical Record to Identify Adults at Risk for Anaphylaxis Without
Access to Epinephrine for Self-Administration (EPI Rph)
Katherine Sulkowski, PharmD Candidate 2015 and Autumn Stewart, PharmD, BCACP
Duquesne University Mylan School of Pharmacy, Pittsburgh, PA
Background
Methods
Discussion
At least 1 in 50 Americans are affected by anaphylaxis; failure to use epinephrine for auto-injection (EAI) during anaphylaxis can result in death.1
Guidelines recommend EAIs be prescribed to any patient with:1
a history of anaphylaxis with potential exposure to the allergen.
a history of a systemic allergic reaction (any trigger).
IgE-mediated food allergy and a history of asthma, or to specific food triggers associated with severe reactions.
Despite guidelines, gaps in long-term, preventative management of patients at risk of anaphylaxis exist at an alarming rate.2
52% of adults with anaphylaxis are not prescribed EAI. 3
Less than 50% of patients with a history of anaphylaxis have EAI readily available. 2,3
Patient data related to allergies, readily available in the EMR, may be an effective, widespread strategy for identifying patients in need of EAI.
Prospective, observational study conducted among patients recruited from an urban, free care center for the uninsured. 
Using a report generated by the EMR vendor, patients with “anaphylaxis”, “bee”, or “nut” in allergy history fields were identified and contacted via telephone by a clinical pharmacist.
Allergy history and use of EAI were discussed and assessed by the pharmacist. Patients were invited to participate in the research study. Enrollment procedures are summarized in Figure 1.
Availability of viable EAI, clinical history related to anaphylaxis, and demographic data were collected and entered into Microsoft Excel for descriptive analysis.
This pilot project demonstrates the utility of EMR data in the identification of patients for whom a gap in care related to anaphylaxis management with EAI exists.
This study further validates the need to identify patients as potential candidates for EAI as a strategy for improving the long-term management of anaphylaxis.
National estimates of EAI access may be overestimated in some patient groups such as those who are uninsured or low-income.
Pharmacist use of EMR data coupled with patient-interview may improve management of anaphylaxis and allergies and has the potential to improve access to medications among high risk groups.
Limitations
Results
The findings of this study may not be generalizable to all settings or patient populations as the subjects were limited to an urban, ambulatory care center comprised of uninsured, low-income adults with a working telephone.
Selection bias could have occurred as only patients with anaphylaxis, or a nut or bee allergy listed in the EMR were identified as potential subjects. Patients with other food allergies or a systemic reaction to any trigger were not included.
Assessment of EAI need was based on patient report.
Of the 12 participants in the study, 6 (50%) were female and the mean age was 49 years old (range 33-63).
Additional demographic data and clinical findings are summarized in Table 1.
Seven subjects were candidates for EAI per self-reported history of anaphylaxis.
Of the 5 subjects without a history of anaphylaxis:
3 are likely candidates for EAI due to systemic reaction
1 is a likely candidate due to specific food triggers
None of the subjects identified as candidates or potential candidates for EAI had a viable EAI product in their possession.
Objective
This project focuses on improving the long-term management of patients at risk for anaphylaxis.
The objective of this pilot project is to determine the feasibility of using data from the EMR to address a gap in care through the identification of patients at risk for anaphylaxis in need of EAI.
Further Research
Figure 1. Study Enrollment
67 potential subjects identified (inclusion criteria “anaphylaxis”, “bee”, or “nut” in EMR allergy history fields)
15 patients were contacted via telephone
3 patients did not provide informed consent
12 patients provided informed consent
32 potential subjects excluded due to medication allergy (allergen avoidance recommended over EAI)
20 patients excluded for not being able to be reached
(Did not answer=15, Phone disconnected=5)
A 3-month follow-up assessment will evaluate the impact of the pharmacist intervention on patient access to EAI.
Future studies among a generalizable population are needed.
References
Rudders SA, Banergi A. An update on self-injectable epinephrine. Current Opinion in Allergy and Clinical Immunology. 13 (4):
Kastner M, Harada L, Waserman S. Gaps in anaphylaxis management at the level of physicians, patients, and the community: a systematic review of the literature. Allergy 2010; 65: 435–444.
Wood RA, Camargo CA, Lieberman P, et al. Anaphylaxis in America: The prevalence and characteristics of anaphylaxis in the United States. The Journal of Allergy and Clinical Immunology. 2014; 133 (2):