Epinephrine Auto-Injector Trends & Oral Immunotherapy Treatment

Transcription

1 Epinephrine Auto-Injector Trends & Oral Immunotherapy Treatment Travis A. Miller, M.D. Medical Director, The Allergy SACENT 1528 Eureka Road, Suite 102 Roseville, CA (916)

2 Disclosures! Board of Directors of: BloodSource California Society of Allergy, Asthma & Immunology Western Society of Allergy, Asthma & Immunology Allergy Care 4 You Foundation! Speaker/Honorarium/Research: Alcon Mylan AstraZeneca Novartis Genentech-Roche Sunovion MEDA TEVA

3 Today s Outline! Definition & History! Symptoms and Epidemiology! Trends and Risk Factors! Recent Articles on Anaphylaxis*! Dosing and Available EAI forms! Concerns and Conclusions for Treating Anaphylaxis! Immunotherapy for Food Allergy + Early Introduction! Questions +/- Answers

4 Definition Anaphylaxis Acute systemic allergic reaction Can vary in severity from mild to lifethreatening reaction Can progress rapidly Previous reactions do not predict severity of future reactions Prince Albert I of Monaco Guest include Drs. Richet and Portier Portugese Man of War anti-toxin for dogs Phylaxia -> Anaphylaxia

5 Symptoms of Anaphylaxis Airway a 70% of episodes 1 Larynx: pruritus and 1ghtness in throat, dysphonia, and hoarseness 1 Lung: dyspnea, chest 1ghtness, wheezing/bronchospasm 1 Skin 80% 90% of episodes 1 Ur1caria, pruritus, flushing 1 Mucosal 1ssue: pruritus and swelling of lips, tongue, uvula/ palate 1 Central nervous system Up to 15% of episodes 1 Uneasiness, throbbing headache, dizziness, confusion, tunnel vision 1 Cardiovascular system a Up to 45% of episodes 1 Chest pain, hypotension, tachycardia, weak pulse, faintness 1 Gastrointes:nal tract Up to 45% of episodes 1 Nausea, cramping, abdominal pain, vomi1ng, diarrhea 1 a Poten1ally life-threatening symptoms. 1. Simons FE. J Allergy Clin Immunol. 2010;125(2 suppl 2):S161-S Simons FE et al; World Allergy Organiza1on. World Allergy Organ J. 2011;4(2):

6 Anaphylaxis Location Location of Reaction Proportion Home 51% Hospital/clinic 14% Family/friend s home 7.3% Work 6.1% Restaurant 6.1% Traveling 4.6% School 3.4% Outdoors 3.1% Wood R et al. J Allergy Clin Immunol. 2014; 133(2):

7 Anaphylaxis in the Community Survey (N=1385) 1 Reasons Epinephrine Auto-Injectors Were Not Used to Treat Anaphylaxis Antihistamine was used 38% Did not receive a prescription for epinephrine auto-injector 28% Allergic reaction was mild 13% Asthma puffer used 8% Did not have an epinephrine auto-injector available 8% Unsure when to give injection 8% In previous reaction no treatment was needed 8% Afraid to inject epinephrine 6% In a separate survey Anaphylaxis in America 28% of responders with confirmed anaphylaxis only self-administered an anehistamine to treat their signs and symptoms Simons FE et al. J Allergy Clin Immunol. 2009;124(2): Wood RA et al. J Allergy Clin Immunol. 2014;133(2):

8 Risk Factors for Fatal Anaphylaxis 1! Underused- failure to treat with epinephrine! Delayed treatment with epinephrine! Improper administration Inappropriate route of administration! Rapid progression of symptoms 1. Simons FE et al. J Allergy Clin Immunol. 2004;113(5):

9 Hot off the Press!!!

10 Children presenting to the ED with Anaphylaxis W. Alqurashi et al. Annals of Allergy Asthma Immunology 115 (2015)

11 Adapted from Table 1- W. Alqurashi et al. Annals of Allergy (2015) Age range : 2-17 Gender: ~72% Male EMS: 28% Biphasic 74% before ER 25% after d/c from ER hrs range from onset 1 st to 2 nd phase Cutaneous = 85.5% Respiratory = 40% Cardiovascular = 29.9% Gastrointestinal = 11.3% Epinephrine => 49.3% H1 Antihist => 66.2% Systemic Steroids => 38% B2 Agonists, H2 Antihist, IVF, Oxygen MgSO4 also used Abbreviations: ED, emergency department; IQR, interquartile range; SaO 2, oxygen saturation. ain relation to ED presentation for the initial anaphylactic reaction.

12 Commercially available epinephrine! Several epinephrine auto-injectors are currently available! All contain the drug epinephrine! Each device has its own unique set of instructions for administration! Understanding the difference is important in maximizing successful administration

13 Commercially available epinephrine! The FDA has assigned a BX rating to all EAI s! Despite BX rating, EAIs can be substituted in 21 states! HCP and patients should be made aware of the differences among EAIs! Recognize the negative impact substitution and inadequate education may have on adherence and proper usage during an anaphylactic event.

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15 Adrenaclick Available Strengths Manufacturer Generic Available Include Trainer Talking Feature Needle exposed after injection Discount Program Refill Reminder Feature 0.3 mg, 0.15 mg 1:1000 Amedra Pharm Yes No No Yes Copay card provides up to $100 discount per twin pack (can be redeemed up to 3 times) No

16 Auvi-Q Available Strengths Manufacturer Generic Available Include Trainer Talking Feature Needle exposed after injection Discount Program Refill Reminder Feature 0.3 mg, 0.15 mg 1:1000 Sanofi-Aventis U.S. No Yes Yes No Copay card provides up to $100 discount per twin pack (up to 3 per prescription) & App

17 EpiPen, EpiPen Jr Available Strengths Manufacturer Generic Available Include Trainer Talking Feature Needle exposed after injection Discount Program Refill Reminder Feature 0.3 mg, 0.15 mg 1:1000 Mylan, Inc No Yes No No Copay card provides up to $100 discount per twin pack

18 Epinephrine Injection, USP auto-injector, AG Adrenaclick Available Strengths Manufacturer 0.3 mg, 0.15 mg 1:1000 Lineage Therapeutics Generic Available ** Include Trainer Talking Feature Needle exposed after injection Discount Program Refill Reminder Feature No No Yes Copay card provides up to $100 discount per twin pack (can be redeemed up to 3 times)

19 Epinephrine PFS! Adamis Pharmaceuticals! Company filed a New Drug Application with the FDA (May 2014)! If approved the PFS intends to compete as a lost-cost epinephrine therapeutic alternative! Would come in 0.3 mg (1:1000) prefilled syringe

20 Another EIA in the works?! Potential approval of an AB rated generic EpiPen! Estimated to be launched ~ in early 2016! TEVA pharmaceuticals

21 Dosing! Recommendations are based on anecdotal experience! Vary Maximum initial dose Route of injection (SC vs IM) Interval (5-30 mins)! Evidence is derived from clinical pharmacology studies and population based studies! 0.01mg/kg

22 Dosing and Administration Epinephrine Concentration 0.3 mg (0.3 ml, 1:1000) 0.15 mg (0.3 ml, 1:2000) Patient Weight 30 kg ( 66 lb) kg (33-66 lb)

23 Dosing When in doubt! Too little epi is better than NO epi! Too much epi is better than NO epi! Expired epi is better than NO epi! In an emergency situation Give what you have

24 Conclusions! Anaphylaxis Incidence Increasing Causes Increasing Prescriptions for Epinephrine Auto Injectors Increasing Preparedness Increasing Use of Anaphylaxis Action Plans Increasing Awareness - Increasing

25 Changing Directions

26 ORAL (FOOD) IMMUNOTHERAPY TRENDS

27 Desensitization Protective effect depends on daily uninterrupted ingestion of food allergen Protective effect may be lost if dose is interrupted Tolerance Permanent tolerance that allows food to be ingested without allergy symptoms despite periods of abstinence

28 Oral Immunotherapy! OIT is still considered experimental! Goal is to alter the allergic response to food allergen so that patient is either (or both) Desensitized Tolerant*! Before these approaches can be applied in clinical practice they must be carefully evaluated for side effects Acute adverse reactions Long term side effects " Toxicity " Overstimulation of the immune system

29 Oral Immunotherapy! Generating increased interest*! Studies have shown a high rate of desensitization! Fewer patients become tolerant! The rate of acquisition of tolerance is higher than that seen in patients who completely avoid the allergen *No less than 30 unique articles in 2015 published in journals with CIF s of 3 or higher

30 Oral Immunotherapy! Protocols have most clearly been reported Milk, egg, peanut, tree nut! Patients are generally started on a very small daily dose! Slowly advance to maintenance dose (4-10gms)! Alternative is to combine OIT with administration of anti-ige antibodies! Introduction of extensively heated milk & egg is an alternative approach

31 Milk OIT! Likelihood of developing full tolerance was 10 fold higher and partial tolerance was 5 fold higher when compared to children on milk elimination diet! Risk of adverse reaction was 34-fold higher Lip/mouth pruritis Approximately ~10% needed epinephrine! Limited long term follow-up! Some data suggest that desensitization may not be maintained in some patients! Additional long term follow-up is needed to determine the ideal patient

32 Egg OIT! Appears to be effective in desensitizing most patients! Permanent tolerance is induced less frequently! Protocols were done using egg-white powder! Mild allergic symptoms were common, particularly in the first 10 months of dosing

33 Peanut OIT! Peanut allergy is rarely outgrown! Uncontrolled studies have shown that OIT can lead to successful desensitization in patients who are able to tolerate therapy! Smaller percentage of patients have sustained unresponsiveness after discontinuing OIT! Higher rates of side effects when compared to milk and egg OIT! More significant improvement in QOL scores

34 Things to consider! Allergic reactions during home dosing is common! Patients required treatment, including, epinephrine during home dosing phase! At least one case of life-threatening anaphylaxis has been reported during the escalation phase of OIT! 10-20% incidence of EGID or eosinophilic esophagitis have been reported in patients undergoing OIT

35 Things to consider! OIT can lead to desensitization but tolerance is more difficult to achieve Would longer OIT therapy help? Would adding adjuvants help?! Oral Immunotherapy to multiple foods! OIT combined with anti-ige

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37 LEAP Study! Learning Early About Peanut Allergy Study! 640 High Risk United Kingdom Infants! Between 4 to 11 months of age! Randomized consume peanut products at least 3 times a week Avoidance diets! Negative skin test to peanut or SPT wheal diameters between 1 & 4 mm

38 LEAP Study! Demonstrated an 80% relative risk reduction in high risk infants if peanut was introduced between 4 & 11 months of age! AAP endorsed the guidance of early peanut introduction (June 2015)! The practice of early introduction is safe and effective in selected high risk infants! No data investigating the benefit or risk or early peanut introduction in the general to low-risk populations! More extensive guidelines are upcoming

39 The Viaskin Peanut Allergy patch! Recently received FDA Fast Track designation following encouraging safety test results! DBV Technologies! If approved by FDA following Phase III Trials, it will be the first skin patch intended to treat peanut allergies.! Designed for Epicutaneous Immunotherapy (EPIT) of patients with peanut allergies.! Administers allergens through the skin in order to improve the patient's tolerance of peanuts,! The next step is a clinical study to demonstrate the safety and effectiveness of the peanut patch.! If the product is able to desensitize peanutallergic patients, it may receive FDA approval, becoming available to U.S. patients with peanut allergies.

40 QUESTIONS?

41 Thank You! Allergy & Asthma Network! Brenda M. Silvia-Torma, M.Ed! Erika Gonzalez-Reyes, MD " Associate Professor of Clinical Pediatrics " Baylor College of Medicine " Children s Hospital of San Antonio! Cynthia Hespe! Kari Nadeau, M.D. PhD.

42 Contact Information Travis A. Miller, M.D. Medical Director The Allergy SacENT 1528 Eureka Road, Suite 102 Roseville, CA (916) [email protected]