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Why the official advice on how to use EpiPens may not be the whole picture


They’re the life-saving devices that people with severe allergies reach for in an emergency — but doctors are now warning that people may not be using EpiPens properly.

About 358,000 Britons regularly carry adrenaline auto-injectors, or AAIs, as they are called, relying on them to deliver a vital dose of adrenaline to counter the potentially fatal effects of a severe allergic reaction to food, drugs or insect stings.

Under official guidelines, these drugs should be prescribed to people who have experienced an allergic reaction or who are allergic to ‘high-risk allergens’ such as nuts, although AAIs (also known by the brand names EpiPen, Jext, and Emerade) may be prescribed. In other cases.

But doctors and activists have raised concerns that thousands of people may not use AAI optimally, making them less effective.

Anaphylaxis occurs when the body overreacts to a substance it is allergic to, such as common foods such as milk and peanuts, and medications (such as antibiotics and chemotherapy drugs).

About 358,000 Britons regularly carry adrenaline auto-injectors, or AAIs, as they are called, and rely on them to deliver a vital dose of adrenaline to counter the potentially fatal effects of a severe allergic reaction to food, drugs or insect stings.

The allergen sends the body’s immune system into overdrive, releasing chemicals like histamine to attack it, and causing symptoms including swelling of the lips, tongue, and throat, difficulty breathing, wheezing and low blood pressure.

Hospital admissions for food-induced anaphylaxis – the most common cause – tripled between 1998 and 2018 according to Imperial College London figures, published earlier this year in the BMJ.

AAI is the only treatment for anaphylaxis — prescriptions for these devices have risen fourfold over the past two decades as more people with allergies have, according to the study.

In some cases, a single injection of adrenaline is required, but if the allergic reaction is severe, two doses may be necessary.

This is why the UK’s medicines watchdog, the Medicines and Healthcare products Regulatory Agency, recommends that people with severe allergies carry two AAIs at all times, with parents and caregivers also trained to help in emergencies.

However, about 10 percent of people may still carry one AAI, according to the charity The Campaign for Anaphylaxis.

Now concerns are also being raised about where it will be run.

AAI is the only treatment for anaphylaxis, and prescriptions for these devices have quadrupled over the past two decades as more people suffer from allergies, according to the study.

AAI is the only treatment for anaphylaxis — prescriptions for these devices have risen fourfold over the past two decades as more people suffer from allergies, according to the study.

New advice issued last month from the Commission on Human Medicines, which advises the government on drug safety, quality and efficacy, states that an AAI should be given at the first sign of anaphylaxis — but it does not recommend where to give the injection.

Previous guidelines advised that the injection be made into the muscles on the outside of the thigh.

The question is whether the second dose–administered five minutes after the first if needed–should be in the same leg or in a different leg.

Adrenaline works by narrowing the blood vessels. In the case of anaphylaxis, this helps restore heart function and blood pressure, which can drop dangerously.

The concern is that if the adrenaline is injected into the same leg twice, the second dose will have little effect as the blood vessels there actually narrow.

The issue was raised in the investigation of Natasha Ednan-Laberous, a teen from London, who died aged 15 of anaphylaxis in 2016, after eating a Pret A Manger baguette that didn’t list the ingredient sesame, to which she was severely allergic.

The issue was raised in the investigation of Natasha Ednan-Laperaus, a teenager from London, who died at the age of 15 of anaphylaxis in 2016, after eating a Pret A Manger baguette that did not list the ingredient sesame, to which she was severely allergic.

The issue was raised in the investigation of London teen Natasha Ednan-Laberous, who died at age 15 of anaphylaxis in 2016, after eating a Pret A Manger baguette that didn’t list the ingredient sesame, to which she was severely allergic.

When Natasha had an allergic reaction while traveling on a plane to Nice, her father gave Nadim two doses of adrenaline via AAI, both in her outer right thigh, but the medication didn’t work.

When asked in her 2018 interrogation why the AAIs didn’t work, Allergy Consultant Dr. Alex Crum said it might have been because both injections were given in the same leg.

`We are very concerned that there is no official advice on where to perform a second AAI in the event of a severe allergic reaction,’ says Natasha’s mother Tanya, who together with Nadim founded the Natasha Allergy Research Foundation to raise awareness of food allergies. These are life-threatening situations where every minute counts and optimal use of AAIs is vital.

However, we know from people with food allergies that many who have been prescribed anaphylaxis receive no information about where they should inject the second dose.

Clarification is urgently needed on how to use it to prevent further avoidable deaths from severe allergic reactions.

Dr. Mark Porter, a GP in the Cotswolds and TV presenter, also raised concerns about the issue on social media.

He says: ‘The second dose should not be given in the same place, because adrenaline causes vasoconstriction (reduced blood flow) which may impair absorption of the second dose.

So always use a different site. Using the opposite thigh is a simple way to ensure this.

However, others say that this view is based solely on an understanding of how adrenaline works, and there is no published research to prove that the opposite leg is better than another site on the same leg.

New advice this year from the UK Resuscitation Council, which publishes guidance on saving lives for healthcare workers, acknowledges that a different leg can be beneficial – but the evidence is ‘unconfirmed’.

Dr Paul Turner, Reader in Pediatric Allergy and Immunology at Imperial College Healthcare NHS Trust, who oversaw these latest guidelines, says he believes this advice is “appropriate” because “there is no clear evidence that administration into the same leg is a problem”.

“Our experience in counseling and training patients is that people tend to use their dominant hand and may abuse the device if they are forced to inject into the opposite thigh,” he adds.

So, the bottom line is that if the opposite thigh is easy to use as you remember, great. But other than that don’t worry about it. The most important thing is to get another dose and be sure to call 999.

There is a real concern that if the focus becomes an injection into another leg, the well-intentioned advice may actually lead to confusion and risk delaying the proper and appropriate administration of a second dose – which would obviously be the most important issue. “

Separately, in an effort to prevent avoidable deaths caused by severe allergies, the government announced last month that EpiPens could soon be available in restaurants, railway stations and other public places.

Under the microscope

Author and broadcaster Hugo Vickers, 70, answers our health test

Can you go up the stairs?

Yes sure. I remember the Duke of Windsor saying about the Duchess: “She does a lot of exercise at home.” I do the same thing – I’m always on the move.

Get five a day?

Maybe not permanently. If I’m traveling I often forget lunch or grab a sandwich, but with closing I saw an opportunity to spoil the day with food. My lunch was three slices of bacon and three free eggs.

ever diet?

I pop on my bathroom scale regularly. I am just under 6 feet tall and weigh about 13 stone.

How has the epidemic affected you?

One of my sons was living with me when the lockdown started. Literally overnight – like the Russians left Moscow before Napoleon’s invasion of 1812 – we left the London flat for my country house and never came back. I’ve never worked harder in my life – finish a book, start another, and give lectures all over the world via Zoom.

Which vices?

I will occasionally drink half a bottle of wine in one meal.

worst disease?

Aside from childhood illness, I was lucky. Eight years ago, part of my thyroid was removed because I had a lump in my neck.

Pop any pills?

I take vitamins C and D3 to help the immune system.

Cope well with pain?

Yes. I rarely take painkillers.

Have you tried alternative treatments?

I wouldn’t turn it down, but I had no need to try it. I cover a lot of royal things and the Queen Mother – who outlived over 100 people – loved complementary medicine.

Ever depressed?

Was there once a few years ago when I was for a short time. You’ve finished a book, and sometimes you get frustrated when a project is over. And my cat died. Then I remember going to Bodmin to give a couple of lectures and driving home and listening to a tape of a great book and then feeling high.

What keeps you awake?

Sometimes the thought of a book I’m writing keeps me awake, but I usually sleep well. Changing the sheets regularly helps. Feel so much better in freshly ironed sheets.

Which phobia?

wasps; If there is a wasp in the room I will keep an eye on it.

Do you like to live forever?

I’d like to live a long time because I’m interested in seeing what happens next.

Malice In Wonderland: My Adventures In The World Of Cecil Beaton (Hodder), directed by Hugo Vickers, has been released.

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Make your own ground beef patties using wholemeal flour instead of white flour to increase the fiber content.

Sweeten your pastries with mixed dates instead of sugar (dates provide added benefits like polyphenols, which are compounds with antioxidant properties). You can even add fresh fruits and vegetables like shredded carrots to the filling for extra vitamins, minerals and fiber, says Evelyn Toner, nutritionist at foodhip.co.uk.



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