Recently, friends of ours had a frightening experience: They were on vacation, and ordered takeout from an unfamiliar restaurant. They specifically asked about peanuts: “Are the egg rolls fried in peanut oil? Our daughter has an allergy.”
The server replied: “No, no peanut oil.”
And so they ordered the egg rolls.
Awhile after eating an egg roll, their school-aged child Anna (not her real name) complained of a tummy ache. Then, nausea. They thought maybe she’d eaten too quickly, or too much.
Suddenly, she started sneezing, sneezing repeatedly and uncontrollably, and wheezing. “Pollen,” they thought. “She’s been running around outside with the other kids.” They gave her a Benadryl.
But within a minute or two, she broke out into hives, and her face started to swell.
“Oh my God,” realized her mom. “This is anaphylactic shock.”
Anaphylactic shock is a severe allergic reaction that can result in such massive swelling that a person’s airway is choked off, and their blood pressure can drop to shock levels. Horrified, she yelled to her partner: “We need to go to the emergency room, Now!”
She fetched the EpiPen, but was too upset to administer it, so she threw it to her partner, who ripped off the top and injected the medication into Anna’s thigh. Then, they ran to the car.
They were barely out of the driveway when Anna observed, “I’m breathing a little better, now.”
The EpiPen effects wear off quickly, and it’s common for patients to require a second injection (that’s why there are two to a pack). But the ER nurses were able to get an IV and give steroids and antihistamines, and after six hours, Anna was able to go home.
Later on, they learned that no, the egg rolls were not fried in peanut oil. But, they actually have peanut butter in them. It was almost a deadly miscommunication.
The whole episode was awful, but it could have been so much worse: The two other children on the trip are also seriously allergic to peanuts. They just hadn’t eaten any egg rolls, for some reason. If they had, the two EpiPens they had with them would not have been enough. There may have been a very different ending to the story.
Our friends need to have multiple EpiPens for each child: A set of two for every place the children are cared for, including school, their after-school program, and home. They have excellent insurance, but regardless, the co-pays for all the very medically necessary EpiPens now end up totaling several hundred dollars.
EpiPens didn’t always cost this much.
Business and investment website The Motley Fool has published a very nice concise history of the EpiPen price inflation. Basically, epinephrine as a medication was developed in Germany in 1904, and has been available via vial and syringe for as long. However, in an emergency like Anna’s, a vial-and-syringe delivery system can be problematic, resulting in delays and dosing errors. It’s hard to think straight when your kid is blowing up in front of you.
The EpiPen is an automatic delivery system of the correct dose via a spring-loaded needle, and has been available since the 1980’s. The convenient drug-and-delivery system originally cost less than $100, but then Mylan Pharmaceuticals acquired the company. The only reasonable competitor device, Sanofi pharmaceutical’s Auvi-Q, was pulled amidst concerns for malfunction. Since then, Mylan’s EpiPen has owned the market, and they know it. A series of relentless price hikes has ensued, and now a pair of pens costs over $600.
Sales of EpiPen nets Mylan approximately a billion dollars annually, and Mylan’s shameless CEO Heather Bresch has hiked her salary accordingly, to a ridiculous twenty million dollars.
Bresch and Mylan have been appropriately pounded with criticism, and have reacted by tossing out a few band-aid public-relations driven provisions: A coupon is available for the uninsured, but they have to jump through a whole bunch of hoops to get it.
Meantime, even families with good insurance are burdened by heavy, heavy co-pays, but they have no choice, unless they feel they can accurately draw up the correct dose via needle and syringe while under duress, and trust all of their child’s teachers and caretakers to do so as well. Epinephrine, which is a synthetic form of the hormone adrenaline, causes the heart rate and blood pressure to increase. Either an under- or over-dosing can have serious clinical consequences.
This is obviously corporate greed at its worst. But what can we do?
A pediatric neurologist friend of mine has made a clever suggestion: Hit them where it hurts the most, meaning, their wallet.
Mylan is a massive company that makes a large number of generic drugs, from antibiotics like doxycycline, to antipsychotics like risperidone, to cancer treatments like Tamoxifen. Her idea specifically: “What if all the prescribing docs agreed to write prescriptions with the annotation, ‘Please dispense any alternative to Mylan products if possible,’ so that the pharmacist could then dispense another company’s generic?”
This may be feasible. For me, that would mean a cut-and-paste text sentence at the bottom of the electronic prescription, an addendum that only the pharmacist sees. It’s simple. If enough physicians get in on the game, we could make a sizable dent in Mylan’s profits.
I’m wondering what my physician colleagues think about this.
Meantime, Mylan’s official website boasts their company motto: “Why Mylan? Because our passion, innovation, and commitment drive us to set new standards in health care. Seeing is believing.”
They’ve set a new standard, all right: A disappointing, frustrating, abysmally low industry standard.
Update: Mylan announced it will sell a generic version of its own product for $300. As many have pointed out, it’s still expensive, but, it’s better than $600. I still cringe at the thought of supporting this company.
Monique Tello is an internal medicine physician who blogs at generallymedicine.