SCOTTISH MEDICAL JOURNAL Volume 55 Issue 3 August 2010
ORIGINAL ARTICLE
Survey of Anaphylaxis Management by General Practitioners in Scotland
G Lowe1, E Kirkwood2, S Harkness3
1
Department of Dermatology, Ninewells Hospital, Dundee, DD1 9SY, UK
2
The West of Scotland Anaphylaxis Service, Western Infirmary, Glasgow, G11 6NT, UK
3
Inverurie Health Centre, Inverurie, Aberdeenshire, AB51 4SU, UK
Correspondence to
Dr Graham Lowe, Consultant Dermatologist, Ninewells Hospital and Medical School, Dundee DD1 9SY, UK
Email [email protected]
Financial/commercial interests: None.
Abstract ongoing support for Primary healthcare staff in the
management of allergic disease, and also for necessary
Aim accompanying specialist support.
To obtain a snapshot of how patients with potentially life- Key words
threatening allergies are managed within a Primary Care
setting. General Practitioner, anaphylaxis, adrenaline
Methodology
A questionnaire-based survey sent to all General Introduction
Practitioners in Scotland.
Anaphylaxis, a life-threatening allergic reaction, has an annual
Results incidence in the UK of 8.4/100,000.1 Admission rates to
hospitals in England for anaphylaxis rose seven-fold from
Six hundred and thirteen replies were suitable for analysis. 1990/1 – 2003/4.2 In recent years self-administered adrenaline
Ninety percent of respondents had prescribed adrenaline auto-injector pens have become commonly prescribed for
auto-injector pens, almost exclusively the EpiPen device. patients thought to be at risk of severe allergic reactions (41,519
Less than half were personally confident in their use and dispensed in Scotland 2006/073 – Epipen 27,811, Epipen Junior
only 17% had access to a dummy trainer pen for 12,656, Anapen 633, Anapen Junior 419).
demonstration purposes. Twenty seven percent would At present, there is no consensus on criteria for prescribing
prescribe one auto-injector only. Six percent reported rescue medication4 and some think adrenaline pens are over-
accidental mis-firing of adrenaline pens, although with no prescribed.5 Deficiencies in patients’ and carers’ knowledge
serious sequelae. Refusal of pens by patients was noted about adrenaline pens and in their ability to use them properly
by 1%. are well-documented.6,7
In the event of an anaphylactic emergency, 90% of A survey in 2004 of 240 UK General Practitioners (GPs)8 showed
respondents would use adrenaline as first-line treatment, that most rated their confidence in managing anaphylaxis highly.
although only half would use the UK Resuscitation Council However, in an earlier 2003 survey of 50 GPs in the South of
recommended adult dose of 0.5mg by the intramuscular England7 who had all prescribed auto-injecting devices, only
route (or 0.3mg by auto-injector). Eleven percent would one GP knew how to use an unloaded training pen, 80% relied
give adrenaline by the slower subcutaneous route and 3% on the practice nurse to provide advice on auto-injector use,
by the intravenous route. Thirty six percent had 20% made no provision for training, and 52% did not think that
themselves treated such a case outside of hospital. immediate attendance at hospital was necessary following
adrenaline use for anaphylaxis. Furthermore, a postal
Sixty two percent of respondents would seek specialist questionnaire in 2002 to 107 parents of children prescribed
investigation of anaphylaxis, although only 31% felt that auto-injector pens in the North East of England showed wide
ready access was available. Frequent concerns were variation in prescribing practices for auto-injectors and referral
raised about current provision of care for patients with to specialists.9
allergic disease and their own ability to deal with this.
Education of GPs in allergy and anaphylaxis was one of a
number of key recommendations in a Scottish Medical and
Conclusion
Scientific Advisory Committee report published in 2000 on
‘Immunology and Allergy Services in Scotland’. An information
Investment is required, both to provide basic training and
leaflet drawn up by The Anaphylaxis Campaign on key
messages for GPs about anaphylaxis was distributed in 2003
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via Primary Care Medical Directors in Scotland. We set out the Table I shows GP knowledge and use of adrenaline auto-injector
following year to survey the practice of Scottish GPs in the pens. Ninety percent of respondents had prescribed these,
management and referral of patients with potentially life- almost all the EpiPen device exclusively. Ten had prescribed
threatening allergies. both EpiPen and AnaPen, one AnaPen, three generic and five
were not specified. Sixty three (10%) knew that EpiPen and
Methods AnaPen have different firing mechanisms, including four of the
11 Anapen prescribers. A similar small minority of GPs
A questionnaire was devised in order to ascertain knowledge commented on potential drug interactions. Twenty seven
and prescribing practice of adrenaline auto-injector pens, percent would prescribe only one adrenaline pen. Less than half
emergency treatment of anaphylaxis and ease of access to of GPs were personally confident in their use.
specialist care for investigation or advice about anaphylaxis
care. Thirty nine (6%) reported inadvertent firing of adrenaline pens,
usually into members of healthcare staff. Several attended
The questionnaire was sent electronically in 2004 to each Health Accident and Emergency departments and one lost a nail, but
Board area (n=15) in Scotland for onward transmission to all there were no reports of serious sequelae. Nine (1%) reported
Practice Managers; one of these areas required postal delivery. patients who had refused adrenaline pens – three of these had
Each questionnaire was accompanied by a covering letter needle phobia/dislike, two did not feel they were necessary, two
explaining the nature and purpose of the survey, and these were did not want to use them, one felt too much responsibility, and
distributed to an estimated 3,845 GPs. one decided against after discussion with a specialist.
Table II shows the normal practice of the 549 GPs who had
Results
prescribed adrenaline auto-injector pens. Ninety six percent
would remind the patient to carry adrenaline at all times and
Six hundred and thirty seven (est 16.6%) replies were received.
90% would ensure optimal preventative treatment of asthma,
Twenty four were discounted as they were incomplete or
but only 17% would arrange demonstration of when and how to
undecipherable. Of the 613 questionnaires suitable for
use adrenaline with a trainer pen, and repeat demonstration on
evaluation, 159 came from GPs in Lothian, 94 Greater Glasgow,
pen renewal was offered by just 6%. Eighteen percent would
45 Ayrshire and Arran, 44 Grampian, 41 Argyll, 40 Lanarkshire,
not routinely inform patients of the need to seek immediate
37 Tayside, 30 Forth Valley, 25 Dumfries and Galloway, 25
medical attention in the event of having to use a pen, and a
Borders, 25 Fife, 24 Highland, 11 Western Isles, three Shetland,
similar number would not remind the patient of the need for pen
two Orkney and eight uncertain location.
Table I: GP knowledge and use of adrenaline auto-injector pens. n=613 Table II: Routine practice for GPs who have prescribed adrenaline auto-
injector pens. n=549
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SCOTTISH MEDICAL JOURNAL Volume 55 Issue 3 August 2010
Table III: ‘If you had to treat an renewal on reaching expiry cocaine (adrenaline contraindicated).10 It is concerning that 18%
anaphylactic emergency in your
date. Sixty two percent would not normally advise patients to seek immediate hospital
surgery, which would you use first?’
n=613 would seek specialist or medical care if the auto-injector is used, suggesting lack of
investigation, if available, but awareness of biphasic reactions. A similar number would not
only 15% would offer written remind the patient of the injector expiry date.
information about
anaphylaxis or advise joining Instruction by a physician who is familiar with adrenaline auto-
a support group. injectors along with regular review of technique and
reinforcement of the issues surrounding their use is vital for
GPs were asked what patients who have been prescribed these devices.11 However, in
medication they would use this survey, less than half of the GPs felt confident in their use
first if they had to treat an and only 359 (65%) of those who have prescribed adrenaline
anaphylactic emergency in pens would arrange demonstration of when and how to use
their surgery and responses them. Furthermore, only 93 (17%) had access to a trainer pen,
are shown in table III. Five and a meagre 6% would repeat demonstration on auto-injector
hundred and fifty two (90%) renewal. As Davies has commented, doctors have a
would use adrenaline, 49 of responsibility to ensure that patients know how and when to
these in conjunction with take any prescribed medication, and it is plainly inadequate to
parenteral chlorpheniramine prescribe a dangerous drug with no demonstration on how to
and /or hydrocortisone. use it.12
Three hundred and nine
(50%) would use the UK Most respondents in this survey would prescribe two auto-
Resuscitation Council injectors for an adult, but 27% of respondents would only supply
recommended adult dose of one. A survey of Anaphylaxis Campaign members has shown
adrenaline 0.5mg that 4/22 who received one dose of adrenaline for food-induced
intramuscularly (or 0.3mg by allergic reactions also received a second dose,13 and a five year
auto-injector.)10 Sixty five review of an immunotherapy clinic in California showed that
(11%) would use adrenaline 64/9,592 patients required adrenaline for systemic reactions, 10
subcutaneously and 20 (3%) of these requiring more than one dose.14 National guidance is
intravenously. Fifty three awaited on this issue, but these reports together with occasional
(9%) would not use adrenaline as initial treatment. Two hundred inadvertent firing (one GP in this survey commented that ‘in the
and eighteen (36%) had treated at least one such case outside heat of the moment it is very easy to discharge the EpiPen too
of hospital. early’) would seem to make a strong case for prescribing a
minimum of two devices for each patient.
One hundred and ninety two (31%) GPs stated that they had
ready access to Secondary Care for investigation or advice Adrenaline is a useful adjunct to local anaesthetic agents to
about anaphylaxis, and a further 106 (17%) had access but with minimize bleeding during minor surgical procedures, but
long waiting times; for 24 of these respondents access was for because of its potent vasoconstrictor properties, it is
paediatric cases only. Two hundred and forty three (40%) felt contraindicated for injection into end-artery structures such as
they did not have ready access available and 71 (12%) did not digits, and inadvertent firing of an adrenaline auto-injector into
answer this question. Hospital departments referred to were such areas carries a risk of harmful ischaemia.15 Such cases
nitroglycerin paste, topical administration of the short-acting α
Immunology/Allergy (96), Dermatology (83), General Medicine have been treated with warm water immersion, topical
(56), Paediatrics (28), Respiratory (23), ENT (8) and
Haematology (2). blocker phentolamine,16 Iloprost® infusion and stellate ganglion
block.17 Remarkably, in this survey, there were 39 reports of
Open comments were invited on anaphylaxis and provision of accidental firing of auto-injector pens, which suggests that this
allergy care. Nineteen stated that allergy was under-recognised may occur with greater frequency than has thus far been
or resourced, 23 that it is becoming commoner, 61 thought reported. Victims of mis-firing incidents included doctors,
provision of care was poor, 153 emphasised the need for practice nurses, a head teacher, a pharmacist and the mother
specialist advice/clinics, 50 felt ill-prepared and required of a child having an acute reaction (fortunately another EpiPen
training, and 17 found this area scary and stressful. Five was available for the child). Settings included mistaken use of
hundred and twenty five (86%) would welcome guidelines on live rather than trainer pen, stocking up medical bag, working
anaphylaxis management. out how to use the device and panic during a reaction. Some
attended Accident and Emergency departments, but others did
Discussion not seek medical attention. Treatments mentioned by
respondents were watchful waiting, heat, nifedipine and glyceryl
Although the response rate to this survey was less than 20%, it
trinitrate spray. Some noted white fingers and one a loss of nail,
has nevertheless revealed a number of inconsistencies in
but there were no reports of serious sequelae. Again, the need
approach to prescribing of adrenaline auto-injector pens within
for improved training of staff and use of dummy trainers for
NHS Scotland Primary Care. The overwhelming majority of
demonstration seem all too obvious.
responding GPs have prescribed these (one practice reported
that 23 of their patients had been issued with adrenaline pens), In the event of an anaphylactic emergency (and these are not
in almost all cases the EpiPen device. However, few are aware rare as 36% of respondents in this survey had treated at least
that this has a different firing mechanism from the AnaPen one such episode outside of hospital), 90% would correctly use
device, including just 3/10 who had prescribed both devices. adrenaline as first line treatment,10 but only 50% would use the
Similarly, only a small minority noted potential interactions with UK Resuscitation Council recommended adult dose of 0.5mg
beta blockers, tricyclic antidepressants, monoamine oxidase intramuscularly (or 0.3mg by auto-injector).10 Eleven percent
inhibitors (should receive half the dose of adrenaline)10 and would use the subcutaneous route, although intramuscular
13
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injection into children has been shown to achieve much faster
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