Injectable epinephrine often isn’t used quickly enough

Mark Twain once said, “The difference between the right word and the wrong word is the difference between lightning and lightning bug.” He was referring to the power of language. With an allergist, the consequences of the right and wrong words have measurable consequences, ranging from comfort to chronic misery, to medical payments spent wisely or wasted, and sometimes life or death.

For example, people with lactose intolerance will mistakenly believe they are allergic to milk. They are not. Lactose intolerance means they are missing an enzyme they need to digest milk sugar, whereas a milk allergy is caused by an immune response to proteins in the milk. People who react in certain blood tests to foods will mistakenly avoid those foods when they are not really allergic at all; they are confusing sensitivity with allergy.

I started thinking about this recently when I read about a study published in one of our specialty’s journals that people with tree-nut and peanut allergies couldn’t even identify the ones they were allergic to, and, moreover, they didn’t know the difference between tree nuts and peanuts, which aren’t nuts at all, they are legumes. Thus it is very possible to be allergic to one and not the other. Interestingly, my very Orthodox Jewish patients get the distinction right away because not only do the names for nuts and peanuts in Yiddish or Hebrew not have the word “nut” in common, but the prayers for nuts and legumes are different, so there is no confusion.

However, if “amateurs” — patients and patients’ parents — are confused, they are in good company because the pros — doctors — also have our share of misunderstanding, and this is where it can be a matter of life and death. The word “anaphylaxis” describes the worst kind of allergic reaction. It can be deadly in the case of a food allergy or an insect sting, especially when the patient also has asthma. The word means one thing in textbooks, something different to an allergist in practice, and something different to emergency room doctors who frequently have to treat it.

Dr. Carlos Camargo recently wrote an editorial for the Journal of Allergy and Clinical Immunology (JAC) entitled “Potter Stewart and the Definition of Anaphylaxis.” The title refers to Supreme Court Justice Potter Stewart’s criterion for hard-core porn: “I know it when I see it.”

He says:

I heard that quote many times when I began clinical research on food allergy and asked my allergist/immunologist colleagues about their definitions of anaphylaxis. I complained that allergy textbooks offered definitions based on IgE levels, mast cells, and other mechanistic details that I had never seen at the bedside. Unfortunately, the experts provided very different clinical definitions, ranging from ”mild anaphylaxis” (simple urticaria) to a requirement for hypotensive shock. On that broad severity spectrum, most emergency physicians were in the latter camp, with a reluctance to consider the diagnosis until there was shock.

His research shows that allergists are able to diagnose anaphylaxis pretty accurately based on multiple symptoms, not all of which present themselves in every patient every time, and unsurprisingly resort to the use of injectable epinephrine more readily than emergency department docs.

I hope that Dr. Camargo’s article sparks some reexamination of the way ER doctors assess their patients’ condition. A shot of injectable epinephrine is unpleasant, but it’s not a treatment that’s worse than the disease itself.

Hundreds of thousands of parents and food-allergy patients have mastered these criteria:

• LUNG: Short of breath, wheeze, repetitive cough
• HEART: Pale, blue, faint, weak pulse, dizzy, confused
• THROAT: Tight, hoarse, trouble breathing/swallowing
• MOUTH: Obstructive swelling (tongue and/or lips)
• SKIN: Many hives over body or combination of symptoms from different body areas
• GUT: Vomiting, diarrhea, crampy pain

Why should anyone who is hiving and throwing up have to wait until they go into shock before they get this proven treatment?

Paul Ehrlich is an allergist and is co-author of Asthma Allergies Children: a parent’s guide.  He blogs at Asthma Allergies Children.

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  • Payne Hertz

    “Why should anyone who is hiving and throwing up have to wait until they go into shock before they get this proven treatment?”

    They shouldn’t. Epi-pens should be available over the counter, and should be a standard item in every first aid kit. Asthma inhalers should also be available over the counter. I’m reasonably certain most people having a severe asthma attack coupled with other anaphylactic symptoms aren’t going to have any problems recognizing the need for this med.

  • DrGetWell

    The present comment,raise an old issue:The undiscovered Innate Immunity,H.D.L. and Niacin.
    It is known that Innate Immunity is the”First Responder”in the living organism’s self defence.It acts within
    seconds,especially when Niacin Immediate Release is taken as an I.V. push, or just sublingual,like
    Nitroglycerin.
    Niacin is widly available as prescription and O’T’C.
    With Niacin the time delay in administration of this medication,is very short. Niacin tablets are very affordable.

  • buzzkillersmith

    Dr. Ehrlich has it right.  Anaphylaxis is under-diagnosed. I can’t tell you how many times I used to fool around with Bendryl and Zantac and steroids and suchlike instead of just using the epi.
    Finally I’d give the epi and watch patient immediately improve.  Now I give epi early. My pts are better off for it. Don’t be afraid of epi–it is your friend in times of anaphylaxis.