Epinephrine Injections for Anaphylaxis

In July of 2016, a 15-year-old girl travelling by plane from London to Nice died from an allergic reaction to sesame. She had eaten an artichoke, olive, and tapenade baguette that she had bought from a Pret A Manger store in the airport. The girl was aware of her allergy, but the sesame seeds that killed her were not visible on the surface of the bread (they had been baked into its crust), and there was no label warning about the presence of sesame in the sandwich. During the flight she developed throat itching, then hives, and then difficulty breathing. Her father had 2 epinephrine auto-injectors; he injected her with one, and when her symptoms persisted, with the second, but she lost consciousness and then suffered a cardiac arrest.

Sesame allergy, according to a recent Canadian review1, now affects 0.1% of the North American population. Currently there is no requirement for US food producers to include sesame in their lists of possible allergens, but the FDA is considering its addition. Skin testing can establish the diagnosis in infants, but oral challenges are commonly used in older children and adults. There is no established program for desensitization.

We are preparing an article on a new epinephrine injector with a syringe and a plunger that must be pushed down manually. All the other products on the US market for this purpose are auto-injectors. Which would be more effective in real-world use is unclear; there is no way to conduct randomized clinical trials of these life-saving devices in patients with anaphylaxis. There are so many variables: the training of the person who administers the injection, the dose, the length of the needle, the patient’s weight, the integrity of the epinephrine solution, the time elapsed since ingestion of the allergen and, of course, the severity of the patient’s allergy. Nevertheless, clinicians must advise patients on which device to buy. For the best information available on this subject, see the next issue of The Medical Letter.

  1. A Adacia et al. Sesame allergy: current perspectives. J Asthma Allergy 2017; 10:141.

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  1. Sydne Newberry says:

    The story of the girl is quite sad, and as a co-author of a systematic review on diagnosis and treatment of food allergy (and the wife and cousin of people with egg and sesame allergy, respectively), I’ve corresponded with the FDA about adding sesame as the 9th food allergen requiring posting on food labels. But I’m a little confused. If the US FDA does in fact add sesame to the list, it’s not clear that non-US food manufacturers of foods sold overseas would be required to adhere to this reporting requirement (or would they? You don’t address that question, and frankly, I don’t know). My other source of confusion is whether or how an epi pen that requires manual injection might have affected the outcome for the little girl, as she was treated with two auto inject pens, yet failed to recover.

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