Emma Westermann-Clark

The High Cost of Epinephrine Autoinjectors and Possible Alternatives

Epinephrine autoinjectors provide potentially life-saving therapy for pediatric and adult subjects with systemic allergic reactions, including anaphylaxis. However, the cost of these devices, specifically the EpiPen (Mylan, Canonsburg, Pa), is increasing exponentially. Epinephrine autoinjectors are commonly prescribed in the United States but are not readily available worldwide. Alternatives for the self-administration of epinephrine exist and should be considered for patients who cannot afford or do not have access to these devices. The epinephrine prefilled syringe, stored in an eyeglass or pencil case, is a safe and viable option for the self-administration of epinephrine. Epinephrine prefilled syringes may not be as ideal as using autoinjectors but are superior to patients living without access to this medication.

Cardiovascular and Diabetic Medications That Cause Bradykinin-Mediated Angioedema

Medication-induced angioedema is a bradykinin-mediated process that results from increased production or decreased degradation of bradykinin. These reactions are documented for several cardiac medications including blockers of the renin-angiotensin-aldosterone system (RAAS). Other cardiovascular and diabetes medications further increase the risk of medication-induced angioedema, particularly with concomitant use of RAAS inhibitors. Dipeptidyl peptidase IV inhibitors are a class of oral diabetic agents that affect bradykinin and substance P degradation and therefore can lead to angioedema. Neprilysin inhibitors are a separate class of cardiac medications, which includes sacubitril, and can lead to drug-induced angioedema especially when used in combination with RAAS inhibitors. This article discusses the proposed mechanisms by which these medications cause angioedema and how medication-induced angioedema differs from mast cell-mediated angioedema. It also details how to recognize medication-induced angioedema and the treatment options available.

Specific Immunoglobulin E and Immunoglobulin G4 toward Major Allergens of House-Dust Mite during Allergen-Specific Immunotherapy

Background Specific immunoglobulin E (sIgE) and sIgG4 to house-dust mite (HDM) major allergens during allergen immunotherapy (AIT) and their clinical relevance remain unclear. Objective To investigate the variation of sIgE and sIgG4 to HDM major allergens and the correlation with clinical responses during AIT in patients with allergic rhinitis. Methods Thirty-nine patients with HDM allergy were divided into the AIT group (taking immunotherapy) and the control group (medication only use). The AIT group was subdivided into negative clinical responses to AIT (nAIT) group and positive clinical responses to AIT (pAIT) group according to symptom relief and subjective evaluation. sIgE and sIgG4 to Dermatophagoides pteronyssinus (Dp) and Dermatophagoides farinae (Df), and their group 1 and group 2 major allergens (Dp1, Df1, Dp2, and Df2) were measured before AIT, at 6 months, and at 1 year after starting AIT. Results Dp2, Df, and Df2 sIgE values decreased significantly in the pAIT group versus the nAIT group after 1 year of AIT (median values of delta change were Dp2, -10.09 versus 5.89 kU/L, p = 0.001; median values of Df were —9.69 versus 17.54 kU/L, p = 0.004; median values of Df2 were -11.06 versus 20.08 kU/L, p = 0.013). There was a robust increase in the sIgG4 values to Dp, Df, and their major allergens in both the pAIT and the nAIT groups overall after 1 year of treatment. Conclusion Patients with a positive response to AIT showed a significant reduction of HDM group 2 sIgEs compared with those with a negative response to AIT, which indicated that a decrease in group 2 sIgEs could be a marker that reflected AIT clinical efficacy.

Debunking myths about “allergy” to radiocontrast media in an academic institution

Abstract Purpose: Patients with “allergy” to iodine and shellfish often do not obtain necessary radiologic procedures due to anxiety about potential radiocontrast media reactions. This study assesses the impact of an educational intervention to dispel these myths. Methods: The authors surveyed 252 internal medicine, emergency medicine, pediatrics, radiology, obstetrics/gynecology, and surgery health professionals before and after an educational intervention. Pre- and posttest responses were analyzed to assess the impact of the intervention on beliefs about radiocontrast media reactions and their perceived relationship to shellfish allergy and iodine “allergy.” Results: The mean pre- and posttest correct response scores were 41% and 91%, respectively. The intervention had a greater impact on respondents’ knowledge about iodine allergy than shellfish allergy, most likely due to the difference in baseline knowledge (P < 0.005). Emergency medicine garnered the highest pretest correct response score (54%). Internal medicine earned the lowest pretest score (30%). There was a significant difference between the highest and lowest scoring specialties on the pretest (P = 0.037). There was no statistically significant correlation with training levels. There was a considerable decrease in the percentage of respondents who would withhold radiologic studies from patients suspected of shellfish or iodine allergy. The percentage of respondents who would premedicate patients with antihistamines or steroids also decreased significantly. Conclusion: An educational intervention helps rectify misconceptions among health care professionals about radiocontrast media reactions and their perceived relationship to shellfish or iodine allergy.

Global gene profiling of aging lungs in Atp8b1 mutant mice.

Objective Recent studies implicate cardiolipin oxidation in several age-related diseases. Atp8b1 encoding Type 4 P-type ATPases is a cardiolipin transporter. Mutation in Atp8b1 gene or inflammation of the lungs impairs the capacity of Atp8b1 to clear cardiolipin from lung fluid. However, the link between Atp8b1 mutation and age-related gene alteration is unknown. Therefore, we investigated how Atp8b1 mutation alters age-related genes. Methods We performed Affymetrix gene profiling of lungs isolated from young (7-9 wks, n=6) and aged (14 months, 14 M, n=6) C57BL/6 and Atp8b1 mutant mice. In addition, Ingenuity Pathway Analysis (IPA) was performed. Differentially expressed genes were validated by quantitative real-time PCR (qRT-PCR). Results Global transcriptome analysis revealed 532 differentially expressed genes in Atp8b1 lungs, 157 differentially expressed genes in C57BL/6 lungs, and 37 overlapping genes. IPA of age-related genes in Atp8b1 lungs showed enrichment of Xenobiotic metabolism and Nrf2-mediated signaling pathways. The increase in Adamts2 and Mmp13 transcripts in aged Atp8b1 lungs was validated by qRT-PCR. Similarly, the decrease in Col1a1 and increase in Cxcr6 transcripts was confirmed in both Atp8b1 mutant and C57BL/6 lungs. Conclusion Based on transcriptome profiling, our study indicates that Atp8b1 mutant mice may be susceptible to age-related lung diseases.

Economic considerations in the treatment of systemic allergic reactions

Epinephrine is a life-saving medication used to treat systemic allergic reactions including anaphylaxis. Epinephrine autoinjectors (EAIs) are expensive and worldwide availability is limited. Epinephrine prefilled syringes and epinephrine kits are potentially lower-cost alternatives to EAIs. Advantages, disadvantages, and costs of available products are discussed. The socioeconomic factors impacting access to EAIs are described.