Guidelines for prescribing Epipen for severe allergies in Children in the Community.

Transcription

1 Guidelines for prescribing Epipen for severe allergies in Children in the Community. Several studies have recognised that allergy is on the increase worldwide, it is estimated that around 5-15 incidence per 100,000 people which has almost doubled in the last few years and food induced anaphylaxis is the quickest growing aetiology especially in school aged children. (Jarvinen et al, 2008, Muraro et al, 2007) Epinephrine (Adrenaline) is considered to be the mainstay of treatment worldwide and it is universally recommended that an auto-injector device is recommended for first-aid treatment of anaphylaxis in the community. There are several devices on the Market currently. These are considered to be a more effective option for treatment outside of a hospital setting that ampoules and syringes. Other therapies and medications should be considered adjuvant to Epinephrine in the treatment of anaphylaxis. As Epinephrine has a relatively narrow therapeutic window, reports have emphasised that treatment with Epinephrine is needed early in the reaction to optimise recovery and has been associated with a better outcome for patients (Pumphrey 2008, Muraro et al, 2007) In Walsall the auto-injector of choice for children currently is Epipen. This is because all of the auto-injector devices are administered slightly differently and there is current a comprehensive school and community teaching package in place which teaches carers using an Epipen training device to minimise the risk of errors with multiple device techniques. Other devices are available including Anapen and Jext Auto-injector but it is recommended that only Epipen devices be prescribed at present as this is the training package in place locally. Definitions. Anaphlaxis. Severe life threatening generalised or systemic hypersensitivity allergic reaction (Johansson 2004)

2 Referral Pathway and indications for referral to secondary care. It is important that children with allergies are referred to secondary care if appropriate. There is a referral pathway for children with suspected food allergy and anaphylaxis to be referred for allergy testing, based on the NICE guidelines on food allergy in children (2011) (appendix 1) It is important that any child who is prescribed an Epipen has a comprehensive allergy focussed clinic history taken and any indicated diagnostic testing before the Epipen is prescribed, if the prescribing clinician does not feel competent to carry out the allergy focussed clinical history and allergy testing, it is important the patient be referred onto a dedicated allergy clinic or the CCN with specialist allergy training for review and/or signposting to the appropriate services. Prescribing and management of children with Epipen in the Community. There is currently no national agreement about how many auto-injectors an allergic child should carry. Allergy specialists recommend every child with indications for an auto-injector should be furnished with 2 devices for use at home and 2 devices for use in school. Often one device is sufficient to treat an anaphylactic reaction but if the symptoms get worse whilst waiting for help to arrive a second dose may be administered 5-15 minutes after the first dose until an ambulance arrives. There would also be a need to use a second injector if the first dose was wrongly administered and therefore wasted. If a child has been diagnosed as needing an Epipen the diagnosing clinician should give the family a prescription for 4 Epipen of the appropriate strength based on the British National Formulary guidelines below. This is rationalised by the fact although data is limited there have been several studies have been carried out in the use of repeated Epinephrine treatments and have found around 21% - 36% of food and venom induced reactions needed treating with a second dose of Epinephrine (Ellis 2003, Kelso 2006, Oren 2007) Around 20% of reactions will be biphasic in nature occurring after an asymptomatic period of 1-8 hours (Ellis et al 2003), this is clearly not enough time to request and collect a new prescription for a new device therefore it is imperative families have the use of a second device at all times and it is not practical for families to hand in their home devices into school each morning and collect back each night as this leaves the child vulnerable if Devices are forgotten and left at home or at school. It is also important to remember at the time of diagnosis that adjuvant therapies should be prescribed as necessary for mild symptoms for example antihistamines to treat mild allergic reactions ideally a fast acting liquid form such as Chlorpheniramine syrup and any inhalers thought to be necessary

3 depending on symptoms. If antihistamines are to be taken regularly then a second generation, non sedating antihistamines such as Cetirizine would be the gold standard especially for school age children who may be affected by the sedating properties of a first generation antihistamine, unless used for Pruritis at night whereby a first generation antihistamine with its sedating properties would be beneficial. BNF dosage guidelines. Epipen Auto-Injector 0.3mg, for children over 30kg (delivering a single dose of adrenaline 300micrograms) adrenaline 1mg/ml (1 in 1000) Dose by intramuscular injection preferably into anteriolateral thigh, for adult or child over 30kg, repeat after 5-15 minutes as necessary. Epipen Jr Auto-injector 0.15mg, for children 15kg-30kg, (delivering a single dose of adrenaline 150micrograms) adrenaline 500mcg/ml (1 in 2000) Dose by intramuscular injection preferably into anteriolateral thigh, for children 15-30kg, repeat dose 5-15 minutes as necessary. Chlorphenamine oral solution, for treatment of mild/moderate allergic reactions. Children 1-2 years. 1mg by mouth twice daily as required. Children 2-6 years. 1mg by mouth 4-6 hourly as required. Max 6mg Daily. Children 6-12 years 2mg by mouth 4-6 hourly as required. Max 12mg Daily. Cetirizine Hydrochloride. Oral solution or tablets Children over 6 years. 10mg once daily or in two doses of 5mg twice daily. Children 2-6 years, 5mg once daily or 2.5mg twice a day. Children under 2 years refer to BNF for children. The information contained in the Formulary is based on evidence available at the time of writing; it is issued for guidance and advice only. For information on the cautions, contra-indications, side effects and doses of individual drugs, please check the current SPC or BNF section for that drug. Prescribers remain responsible for their patients care and prescriptions signed. Training The child and family must receive adequate age appropriate training about using the device at the point of prescription and the importance of carrying the device with them at all times. Training in how to administer Epipen devices is an important factor in ensuring parents are comfortable in treating their child s condition. This is to ensure the child and family have the device available and can administer the device in a timely fashion and correctly via intramuscular injection. It has been shown that for the device to offer optimal treatment it must be intramuscular. Accidental subcutaneous injection causes intense vasospasm at the injection

4 site which would then lock the epinephrine into the surrounding tissues which renders it sub-optimal for treatment of anaphylaxis and as devices are single dose this would mean the device was wasted. Several studies have identified that patients who do not have a comprehensive understanding of when and how to use their auto-injector devices wait longer to use them in an anaphylaxis situation therefore risk poorer outcomes for that acute episode (Bakirtas et all 2011) This is especially important when there is a coexisting asthma as fatal anaphylaxis in the children has been linked to existing asthma and failure to administer Epinephrine promptly or correctly. (Sicherer et al 2007) Training devices should be used to show patients how to use their device and these are freely available from for both carers and health professionals. Written information should also accompany the prescription and diagnosis of the need for an Epipen with contact numbers for professionals (appendix 3) this has been proven to be an important strategy in improving the confidence and concordance of patients. (Johnson et al 2004) Further Support/Community follow up There is a dedicated allergy clinic held weekly at the Manor Hospital and any clinician can refer into this service for more advice. If the child is under 16 (or under 19 with special needs) and has been diagnosed with an allergy and prescribed an Epipen by Primary care, they need a referral (appendix 2) to the Children s Community Nurses (CCN) at the point of diagnosis. The referral can be made via telephone to the Community Children s Nurses on If the child fits the CCN criteria they will be taken onto the caseload and the CCN with specialist allergy training, will endeavour to support the family with home visits, follow-on training and support in administration of Epipen and signs and symptoms of anaphylaxis and adjuvant treatments with antihistamines and inhalers as prescribed. Including completing a comprehensive annual schools training programme (allergywise training package) and annual Epipen protocols and care plans as necessary. Contacts for advice. Doctor Drusilla Ferdinand, Paediatric Consultant, Walsall Manor Hospital. Sister Jayne Breakwell. Paediatric Assessment Unit, Walsall Manor Hospital. Emma Hughes and Teresa Stokes, Children s Community Nurses for allergy, Sai Medical Centre, Forrester Street, Walsall. WS2 9PL

5 References. Bakirtas A et al Make up of the epinephrine auto injector: the effect on its use by untrained users. Paediatric allergy and immunology. Ellis A, Day J Diagnosis and management of anaphlaxis. Canadian Medical Association Journal volume 169. number 4.. Jarvinen et al, 2008, Use of multiple doses of epinephrine in food-induced anaphlaxis in children. 1-6 Johansson et al Revised nomenclature for allergy for global use. Journal of allergy and clinical immunology. Volume 113. issue 5, pages Johnson A. et al Written and verbal information versus verbal information only for patients being discharged from hospital settings to home: systematic review. Oxford Journals. Kelso J A second dose of epinephrine for anaphylaxis: how often needed and how to carry. Journal of Allergy and Clinical Immunology. Volume 117, issue 2, pgs Muraro et al The management of anaphylaxis in childhood: position paper of the European academy of allergology and clinical immunology. Oren E, Banerji A, Clark S, Camargi CA Food-induced anaphylaxis and repeat Epinephrine treatments. Journal of Allergy and Clinical Immunology. Volume 119, Issue 1, Supplement Pages S114 Pumphrey R. 2008, when should self-injectable epinephrine be prescribed for food allergy and when should it be used. Current opinion in Allergy and Clinical Immunology. 8: Sicherer S, Estelle R, 2007.Self-injectable epinephrine for first aid management of anaphylaxis. American Academy of Paediatrics. 119;

6 Appendices. Appendix 1. Referral Pathway for Skin Prick Tests in Children We have recently revised the process for Skin Prick Tests (SPT) for children under the age of 16 years. This is in keeping with the NICE guidelines for food allergy in children and young people. Our aim is to standardise the process and ensure that the SPT are undertaken by a competent health professional to ensure standardisation of care and a safe environment for the child or young person. Due to the potential for systemic or anaphylactic reactions SPT should be undertaken in an area where this can be dealt with. Currently we are performing SPT in the paediatric outpatients department or paediatric assessment unit where there are paediatric nurses and doctors who are trained and competent in paediatric resuscitation. The practitioners performing SPT are fully trained. There are two referral pathways. For children with a suspected food allergy please refer to the paediatric allergy clinic where they will be reviewed by the medical team, the opportunity for SPT and other allergy testing as indicated and review by an allergy nurse and dietician if required. For children with suspected non-food allergy these can be referred to the paediatric nurse led SPT service. This should be done by completing the usual white pathology request form, ensuring that all the patient details, referring clinicians details, clinical details are all clear and legible. It is also important to state which allergens are requested. Requests for allergy testing or other incomplete request will be returned to the referring clinician.

7 There are some group tests available:- - Aeroallergens :- House dust mite, grass, mid-blossom pollen, early blossom pollen, moulds, cat, dog - Nut panel: - peanut, walnut, hazelnut, brazil nut, almond, cashew - Oral allergy:- birch pollen + fruits as indicated Please see the flow chart below for information The paediatric allergy team Dr. Drusilla Ferdinand, Sister Keri Christie, Sister Jayne Breakwell, CCN Teresa Owers, CCN Emma Hughes

8 Appendix 1. Assessment by health care professional Identify requirement for SPT Querying food allergy Querying sensitisation to non-food allergens Refer to paediatric allergy clinic - Detailed allergy history - SPT - Allergy nurse - Dietician Complete SPT request form - patient details - clinical details - specific allergens required Send request form to Sister Jayne Breakwell, c/o Paediatric Assessment unit SPT performed in paediatric nurse led clinic Results will be available on Fusion system Contacts for more information. Dr Drusilla Ferdinand at the Manor Sr Jayne Breakwell on PAU at the Manor Emma Hughes, Teresa stokes. Community Children s Nurse

9 Appendix 2.

10 Appendix 3. SECTION A Baby, Child or Young Person s Details NHS No: Surname: Forename(s): Also known as: DOB: Title: Sex: Address: Correspondence Address (if different): Post Code: Temporary Permanent Parents/Carers wish to receive copies of letters, reports, referrals Yes No Contact Tel No: Ethnicity: GP: GP Address: Interpreter required: Y/N Language: Religion: Registered Disabled Disabled Parking Required Personal Carer Information (NB: Personal Carer is the Main Carer with Parental Responsibility) Next of Kin Name: Relationship: Sex: DOB: Ethnicity: Religion: Address: Post Code: Contact No: Other Carer Name: Relationship: Sex: DOB: Ethnicity: Religion: Address: Post Code: Medical Diagnosis/Difficulties Contact No: Current Medication

11 Referral Details Referral date: Referring Agency: Referred by: Print name: Signature: Contact number: Referral Priority: Routine Urgent School or Nursery attended: Reason for Referral: Referral has been discussed with: Parent Carer Young Person Date: Is Child: Signed: On CP Register Adopted Travelling Family Looked After Children Referred to Service/Speciality*: Any Additional Supporting Information: Continue over Child Concern Referred to Team/Clinician: For Office Use Only: Date Received Referral: Referral Reason: Referred to Team Purpose: Authorisation: Referred to Clinician: Continue over Referral Rejection: Reason for Rejection: Signed by: Date: * If referred to Speciality is Team Around Child, Physiotherapy, Speech & Language Therapy or Occupational Therapy, then please provide any appropriate additional information in Section B Page 2 or for CAMHS please use additional supporting information section and refer to the guidance notes.