Adrenaline auto-injector prescription for patients at risk of anaphylaxis: BSACI guidance for primary care.

Anaphylaxis is ‘a severe, life-threatening, generalised or systemic hypersensitivity reaction’.1 It is characterised by rapidly developing features involving one or more of the airways (laryngeal oedema and/or bronchospasm) and circulation (hypotension) often with associated skin and mucosal changes (urticaria, angioedema). Hospital admissions for anaphylaxis are increasing. However, fatalities remain very rare at a stable rate of approximately 20 per year in the UK.2 This primary care guidance builds on the 2016 British Society of Allergy and Clinical Immunology (BSACI) specialist guideline plus other recent statements (World Allergy Organisation, European Academy Allergy and Clinical Immunology and Resuscitation Council UK).3-6 This guidance aims to help risk assess community patients who might be at risk of anaphylaxis. The guidance was created to address key primary care clinical questions which are informed by current practice and known gaps in care from reported fatalities. A literature search (Medline and Ovid) was performed alongside review of key papers and recent guidelines. These were discussed and agreed upon by the lead authors and BSACI Standards of Care Committee and feedback from stakeholders was incorporated. It is intended to act as a resource and signpost to materials for primary care workers. It is intended to assist in decision making during consultations especially around risk assessment, need for referral and prescription of adrenaline auto-injectors. Further details and illustrative case studies can be found on the BSACI website (www.bsaci.org). When considering advice on acute allergic reactions, patients should use their AAI if they develop breathing problems or feel they are about to collapse during an acute allergic reaction (see online cases 2, 4, 5, 9). They should sit up if they are having breathing difficulties and lie down if they are feeling faint with their legs raised and avoid sudden changes in posture.9 Patients should use their AAI and then call 999, ask for ambulance services, state their location, and that they are having an anaphylactic reaction (phonetically ANA-FIL-AX-IS) to ensure the call is prioritised. If there is no improvement in symptoms after 5 minutes, they should administer a second AAI. Children at primary school should have an AAI administered by a trained adult. Children at secondary school should be trained to carry and administer their autoinjector themselves. Some may still need the assistance of a trained adult. There are multiple different types of AAI devices available in the UK with different instructions. Training should be specific to the device and practical training with a trainer device should ideally be repeated annually (e.g., at re-prescription). If a different brand is prescribed, the patient will require retraining in the use of the new devices.1, 9 When seeing patients prescribed AAIs, check if appropriate for weight, ask to see their devices to check that they are carrying them and that they are in date. Patients should be reminded that AAIs expire, to check the date when picking up their prescription and know the process for renewal. Patients can register for a reminder system that companies have in place using text messaging. Patients should be informed about storage of AAIs. Patients should obtain their own trainer pens (they can get these free from the brand company) and practice with them regularly. Signpost to patient organisations for resources and peer support.1, 5, 9 Remind patients to carry a charged mobile phone in case they need to call for help. This can be done by any competent healthcare professional including pharmacists. Certain co-factors may worsen the severity of an allergic reaction. These include exercise, lack of sleep, stress, alcohol and NSAIDs, asthma and acute illness.4, 5 Patients should be made aware of these. It is recommended that patients give a copy of their individualised allergy action plan to school, universities, colleges and employers so that staff are aware of their allergies. The fourth question was how many adrenaline autoinjectors should be prescribed? The longstanding regulatory advice is that patients should be prescribed two AAIs as the norm, and that the patient should always have immediate access to these (online cases 2, 4, 5, 9).1, 9 This is because of the possibility of a severe reaction that needs more than one dose of adrenaline before the arrival of emergency services, or device failure or misplacement of the first injection. Parents may request that a total of four autoinjectors are prescribed, two for school and two for other times. This can be reduced back to two once the child is able to administer and allowed to carry their own AAIs at school. Parents should be reminded that their child should always have access to the AAIs even on the way to school. Requests for more than two (four for a child) AAIs should be discouraged. The overriding principle is that the patient should always be carrying the AAIs rather than having them at multiple locations which might not be accessible at all times. The final question was how can at risk groups and at-risk situations be recognised and how should they be managed? Adolescents and young adults are at highest risk of severe or fatal anaphylactic reactions to food, but the elderly have the highest risk of fatal drug anaphylaxis (see online case 5).2, 5 Adolescents and young adults need to know how to advocate for their allergy within peer groups or other social situations. Caution needs to be exercised during parties, travel in unfamiliar places and different languages, and eating from roadside vendors, festivals, takeaways, restaurants and food stores. Signpost to patient organisations resources to cover advocacy, translation cards, air travel. This guidance highlights how to identify which patients are at risk of anaphylaxis and the need for referral to a specialist allergy clinic. The executive summary acts as a reminder of points to consider (Table 1). The recent Medicine and Healthcare Regulatory Agency report also sets out clear recommendations about training, carrying pens, patient positioning and self-management.9 The evidence base for the prescription of AAIs is limited, it is described in the BSACI guideline.3 It is important that a system wide approach is taken to ensure the right patients are prescribed AAIs, that they are appropriately trained with re-prescription and re-training at appropriate intervals. Further materials, including frequently asked questions and a service delivery pathway, to facilitate the optimal prescription of adrenaline in primary care can be found at www.bsaci.org. Elizabeth Angier and Deepa Choudhury conceptualised the original draft the other authors have provided feedback and content and have approved the final draft. All the co-authors contributed to writing of the article. The document was discussed within the British Society of Allergy and Clinical Immunology SOCC committee. Dr Elizabeth Angier Research PhD study funding from Natasha Allergy Research Foundation. Andy Clarkes Chief Medical Officer and shareholder Camallergy. The data that support the findings of this study are available from the corresponding author upon reasonable request.