A as in Anaphylaxis

Auto Injectors – Current Issues


Before I am talking about the two main issues in the UK with the AAI, I am listing the key facts about the 3 different AAI (Adrenaline Auto Injectors) available in the UK, EpiPen (R), JEXT and the Emerade. The latter is the latest addition to the market and comes in 3 doses and 2 needle sizes, which is unique.

Here is the summary of the key features:

Adrenaline Auto Injectors – UK Market 05/2014

EpiPen ®

Shelf life: 18 months (day of production to expiry date)

Dosage: Junior 0.15mg (>15kg-30kg body weight) and adult 0.3mg (>/= 30kg body weight)

Technique: Make fist and hold pen with firm grip in dominant hand, place away from upper outer thigh approx. 10cm, push in firmly, hold for 10 sec (count: 1 elephant, 2 elephants,…), rub in for 10 sec.

Storage: Room temperature. Not in fridge, not in car, not in hot places.

Excerpt from: http://www.epipen.co.uk/patient/



Shelf life: 18 months (day of production to expiry date)

Dosage: Junior 0.15mg (>15kg-30kg body weight) and adult 0.3mg (>/= 30kg body weight)

Technique: Push firmly against the outer portion of the thigh. When you push Jext firmly against your thigh, a spring activated plunger will be released, which pushes the hidden needle through the seal at the end of the black needle shield, into the thigh muscle and injects a dose of adrenaline. Leave in for 10sec, rub in for 10sec.

Storage: Although Jext does not need any special storage instructions, it should be handled with care ensuring that it does not freeze.

Excerpt from: http://www.jext.co.uk/what-is/jext.aspx


Emerade ®

Shelf life: 30 months (day of production to expiry date)

Dosage: 0.15mg, 0.3mg (long needle), 0.5mg (long needle)

Technique: Press against the thigh. Hold for 5 sec. Then, massage the injection site lightly.

Storage: There is no upper temperature restriction. It may be kept cold but no not freeze.

Excerpt from: http://ww.emerade.com


Please keep in mind when receiving a prescription of any of the AAI, ensure you and everyone else taking care of the patient (including nursery staff, school staff, friends, family members) is properly trained on the device. Especially, when the prescription was changed to a different brand.

Also, regularly check expiration dates and repeatedly practice on the training device.

 Current issues with the AAI:

A shortage has been reported in regards to the EpiPen and the Jext. Read the Anaphylaxis Campaign’s statement here:


Unfortunately, there is no mention of the Emerade, which is the latest addition to the UK market. Their manufacturer is currently trying to satisfy rising demand by increasing their capacities as soon as possible.

The reason for the shortage of the AAI in the UK may be due to the fact that EpiPen has been increasingly demanded since Jext had issues with their AAI end of last year/beginning of this year.

Moreover, the AAI are currently under investigation by the European Medicines Agency. Read the Anaphylaxis Campaign’s Statement here: http://www.anaphylaxis.org.uk/living-with-anaphylaxis/news/adrenaline-auto-injectors-to-be-reviewed-by-the-european-medicines-agency

From the Notice of Action, it seems the Regulators will be taking investigation into the needle sizes. In other words: Do AAI on the UK market fulfill the requirement of safe and efficient administration (true i.m. injection of the right amount) of adrenaline into the patient’s muscle? I am sure we will be hearing much more about the needle size issue.

What are your thoughts? Do these issues bother you? Would like to hear about your concerns.


The information provided is given in good faith. Every effort has been taken to ensure accuracy. All patients are different, and specific cases need specific advise. There is no substitute for good medical advice provided by an allergy specialist.














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A as in Anaphylaxis

Introducing: THE Hepi DAY…

courtesy of evolve-trainingsolutions.co.uk

Every 10th of the month, we will take out our trainer pen and practice, practice, practice! Plus, take the opportunity to look through your emergency kit for out of date products.
Let’s get this Epipen Training going! Studies show you have to constantly practice to be prepared and able to use your adrenaline pen correctly! Why the tenth? To remind us to leave the needle in for 10 seconds…
Stay hepi
A as in Anaphylaxis, All About Allergies

Sooner rather than later…


Maybe the most raised question in the allergy community: when is the right time to apply the epipen? No doubt it is the only drug able to break the vicious cycle, and its benefits outweight the risks. But actually when is the right time for it?

Even experts discuss the issue widely and have not come up with a formal consent. Based on experience, literature and recent incidents, this is one of the most sufficient answers I have encountered yet. So please take five minutes of your precious time and read this excellent advice by M.D. Phil Lieberman.

A as in Anaphylaxis, Travel

Come fly with me…updated

Air Canada: I just learned about an official decision (and final decision) by the Canadian Transportation Agency (CTA) from June 16th, 2011.  Here are the essentials:

– Air Canada is to create a buffer zone for seriously peanut allergic passengers. You can request your seat here.

– only peanut free and nut free foods are to be served within the buffer zone.

– a briefing will be given by Air Canada personnel to passengers within the buffer zone that they can only eat foods that are peanut-free and nut-free and that they will only be offered peanut-free and nut-free foods as part of Air Canada’s onboard snack or meal service. In addition, Air Canada personnel is to address situations where a passenger refuses to comply with this requirement by moving the non-obliging passenger or, if necessary due to that passenger’s refusal to move, moving the person with the disability due to their allergy to peanuts or nuts to a seat where the buffer zone can be established.

Delta Airlines: let them know about your peanut allergy and they will create a buffer zone three rows in front and behind. No peanut snacks in buffer zone. Additional non peanut snacks for buffer zone. Pre-boarding to wipe down seats possible.

Lufthansa: Cannot guarantee peanut free flights, but do not serve peanuts. Passengers suffering from severe cases of peanut allergy should get in touch with Lufthansa Medical Operation Center (+49-69-696-550 77 (06:00 – 22:30 hours).

British Airways: “crew are unable to make on board announcements or alert other customers to individual medical conditions. ” Crew are Epipen trained, but expect travel companions to administer epipen. “In-flight meals do not contain peanuts or peanut products. However, we cannot guarantee meals and snacks are completely peanut free as they may be produced at a facility that handles peanuts”, and “are therefore unable to offer a peanut-free special meal.”

American Airlines: do not serve peanuts, but cannot guarantee peanut free meals. In First, they rost nuts during the flight!

Virgin Atlantic: Peanuts are never knowingly included in any Virgin Atlantic aircraft meals or snacks. However, our meals are not produced in a nut-free environment so may contain traces of nuts. And we can’t stop other passengers from bringing (or eating) their own food onboard, which may include peanuts. Nuts other than peanuts may be served on all Virgin Atlantic flights as part of the menu ingredients and/or the snack service, in all cabins. Any specific and essential dietary requirements need to be ordered through VAA’s Special Assistance department (T: 0844 412 4455)

Japan Airlines: Advance notice (14d minimum)and the airline crew will take measures, such as removal of peanut products from snack and in-flight meals. JAL do not use peanut products inside aircraft snacks for international flights, but other types of nuts may be included and served. JAL cannot guarantee that the flight is completely peanut-free.

Singapore Airlines: Do serve nuts and peanuts during flight, but cater for allergy sufferers with a nut and peanut free meal (and mention the possibility of cross contamination!). Orders take 48 hours notice via local airline office. Rated Best Airline in the World 2013


International Study of Risk-Mitigating Factors and In-Flight Allergic Reactions to Peanut and Tree Nut

A as in Anaphylaxis, All About Allergies

How to find the right nursery for your allergic child

Even the thought of having someone else taking responsibility for allergybabe gave me goosebumps.

After all we went through together, 24/7, day and night, I was very uncomfortable to leave our well established safety zone, our castle of protection, into a new and dangerous outside world.

On the other hand, allergybabe is our first and so far, only child. He needed to be around other children, other people with different stimuli and a different language (not just english, but british english…).

So I gave it a try. Equipped with a heavy suit of armour, we were ready to conquer the non allergy friendly world and so far, succeeded.

For over a year now, allergybabe (who is 2,5 years now) is at a very caring nursery, playing happily along his peers and learning something new every day. What makes it such a good and healthy experience is, that we constantly talk about anything that occurs. From management to the practicioners and the catering staff, I could not be more pleased.

But how to find the right nursery? Here is some advise that helped me with my decision:

  • Ask if the staff has had any previous experiences with food allergic children. It is always easier to go somewhere someone else has implemented the rules and procedures then to do it all from scratch.
  • Ask as many questions and meet as much staff as possible. A truly caring nursery will always be happy to answer as many questions as possible.
  • Find out if staff get regular emergency training including Epipen (or other adrenalin devices) training?
  • Drop the word ‘cross contamination’. How familiar are they with it? Can they explain their measures to avoid accidental exposure?
  • Ask about an established plan to proceed in case of emergency. If they not have a plan, are they willed to set one up with professional support?
  • Are they comfortable to give emergency medication?
  • Can the catering provide allergy friendly meals?
  • ask yourself if you feel comfortable with the nursery and the responsible people (management, practicioners, etc.). If you do not feel comfortable, do not  proceed.

Once you have found an appropriate place, do not forget you are a team and that you have to continously work together to avoid an allergic reaction:

  • It is very helpful to have one person as the main responsible carer and one person of the management staff you can turn to all the time. In building a trustful relationship, it is much easier to pass on new information or to raise concerns. They will also get used to your child’s individual case, which is important when allergy symptoms occur, when food has to be ordered, medicine has to be applied or other decisions have to be made.
  • Point out, on a regular basis, how important it is to avoid cross contamination and oral allergen contact. The longer the child has not had a reaction, the easier it is to forget to be vigilant at all times.
  • Ask them to show you how an Epipen works by using the trainer pen. Routine is the best friend in emergency situations.

Have you had any experience about finding a nursery, babysitter, nanny or school for your little one? Are you more comfortable with a nanny who is solely responsible or with a nursery, were contamination may be more likely, but a team of people are there to take care? Is it important to have peers to learn and play with? Would love to read some comments.

A as in Anaphylaxis

Yes, my dear, this needle goes into the thigh, now!

Epinephrine, or adrenaline, is a vital hormone produced in the adrenal glands located on top of both kidneys. In the human body, it serves to prepare for an acute stress response (also known as the fight or flight reaction), e.g. in a life threatening event like a bear attack or, as it is more likely nowadays, an encounter with a fox… .To enable an individual to react to a threatening situation appropriately, epinephrine rapidly

1. relaxes muscle to open airways

2. tightens blood vessels

3. releases energy (glucose, sugar)

by linking to compatible receptors, like a key (epinephrine) solely fitting into its proper lock (epinephrine receptor).

In anaphylaxis

1. Smooth muscle tightens (leads to tightening of airways)

2. Blood vessels relax (leads to heart rate and blood pressure decrease and skin swelling)

3. High quantities of allergic chemicals occur (leads to further and even more severe allergic reaction)

So we learned that epinephrine tackles severe allergic reactions on different levels (muscle, blood vessels, chemicals) and in different organ systems (airways, cardiovascular, skin, bowels) and is capable of interrupting the vicious circle which makes it a unique substance in anaphylaxis.


One of the Epinephrine Auto Injectors is the Epipen and Epipen jr.

Since it does not treat the actual allergy but the life threatening symptoms that occur during an anaphylactic reaction, it is vital to

administer the epinephrine within a short time frame

monitor its effect (always call an ambulance and get further treatment at hospital) and

keep a second Auto injector at hand.

If possible and reasonable, remove the underlying allergen (this is an advise I consider doubtful, since in most cases, tiny amounts of food trigger the reaction, and we certainly do not want anyone presenting with an allergic shock to vomit forcefully, most certainly not). The literature for advise on discontinuation of the causative agent is inconclusive (1,2,3). Some guidelines promote a mouth rinse, others do not. Depending on the patient’s alert level, severity of reaction and amount of suspected residual food in the oral cavity, the judgement is left to the individual case. In latex allergy or bee venom it makes sense to remove the allergen.


1. Resuscitation Council (UK) The emergency medical treatment of anaphylactic reactions for first medical responders and community nurses. Revised Jan 2002, May 2005 (originally published July 1999). http://www.resus.org.uk/pages/reaction.htm.

2. Gavalas M, Sadana A, Metcalf S. Guidelines for the management of anaphylaxis in the emergency department. J Accid Emerg Med 1998. 1596–98.98. [PMC free article] [PubMed]
3. Jackson M, Shaikh T. Emerg Med J. 2007 Dec;24(12):865.Mouthwash for anaphylaxis