AIEs such as EpiPens are sold in pairs because those who are experiencing anaphylaxis often require another dose.

© Hambardzum Vardanyan | Dreamstime.com

The mother of a friend named Summer taught me how to give an EpiPen injection when I was 9. She had me poke a needle into an orange so I’d understand what it would feel like to jab an EpiPen into my friend’s thigh if needed. Luckily, I never had to practice that skill, but Summer has, multiple times. And each time, the EpiPen saved her life.

The most successful anaphylaxis treatment is an auto-injectable epinephrine (AIE) like EpiPen. Problem is, the company that owns EpiPen has increased its cost by 400 percent, making it more difficult for the average person (and school) to remain well-stocked. More on that later. First, let’s talk about how an AIE saves lives.

What is An AIE and How Does it Work?

AIEs are filled with the drug epinephrine (a.k.a. adrenaline), a natural hormone secreted when your body is under stress. Once injected, the epinephrine “increases your heart rate and blood pressure, but it also relaxes your breathing muscles and reverses the swelling and your immune system’s response to the allergic reaction,” says Don Bukstein, MD, an allergist and pulmonologist in Milwaukee, Wisc.

Epinephrine acts on multiple systems in the body at one time, making it the only medication to reverse a severe allergic reaction. AIEs such as EpiPens are sold in pairs because those who are experiencing anaphylaxis often require another dose. They expire yearly, so the highly allergic will require another pair annually.

While epinephrine can reverse an anaphylactic reaction, it’s not a cure for anaphylaxis. As stated by the Asthma and Allergy Foundation of America, “there is no cure or preventative treatment for most causes of anaphylaxis, so immediate use of a prescription epinephrine auto-injector at the first sign of a severe allergic reaction is the standard-of-care for adults and children.”

Do You Have to Go to a Hospital After Using an AIE?

Once injected, it’s important to seek emergency medical help at a hospital or urgent care facility immediately, says Dr. Bukstein.

Do You Need a Prescription to Get Auto-Injectable Epinephrine?

Although AEIs are available without a prescription in Canada, all US states require a doctor’s prescription to dispense this medication in America.

EpiPen: The Cost Debate

In 2007, drug company Mylan purchased EpiPen. Since that time, Mylan has increased the cost of EpiPens sixfold, claims an article in The New York Times. In 2009, a two-pack of EpiPens cost about $100. Jump forward a few years and the price has risen to anywhere between $340 and $600. If you have good insurance coverage, you may not notice the increase. For those who don’t, however, the price of this medication can prevent them from having access to a life-saving drug.

As Andrew Murphy, MD, Chief Medical Offer of the Asthma Allergy and Sinus Center in West Chester, PA says, “Coverage decisions are made by the insurance company, and I cannot tell you why one brand is covered and another is not. In general, I would say it is probably related to cost-generic epinephrine can be as little as $100 and one branded AEI is [more than] $5,000!”

Amidst great scrutiny, Mylan has been better about offering coupons to help offset the cost. A quick online search at www.goodrx.com, for instance, showed you could purchase EpiPens for just under $147 at Costco, or for just over that amount at CVS and Walgreen’s with the help of coupons. That said, Dr. Bukstein says, “where I practice in the inner city, it’s a huge problem because nobody can afford epinephrine, so we have to try to figure out ways of getting them the epinephrine.”

Does EpiPen Have Competition?

Price isn’t the only setback in the battle to put AIEs into the hands of those who need them. Recently, Mylan’s EpiPen and its main competitor, Adrenaclick, made by Impax Laboratories, suffered from severe shortages. Auvi-Q, another brand of auto-injector didn’t face the shortage but wasn’t covered by many insurance companies.

In August, 2018, the FDA approved the first generic version of EpiPen and EpiPen Jr—a big step in the war on cost and accessibility. This direct competitor, made by Teva Pharmaceuticals USA, has been approved for use in anyone who weighs over 33 pounds. Note: It’s difficult to treat those who weigh less than this as current needle lengths can result in the needle poking a bone upon injection in very small children.

According to the FDA Commissioner Scott Gottlieb, M.D., “approval of the first generic version of the most-widely prescribed epinephrine auto-injector in the U.S. is part of our longstanding commitment to advance access to lower cost, safe and effective generic alternatives once patents and other exclusivities no longer prevent approval.

EpiPen Side Effects

Like all medications, EpiPens come with side effects. The following are the most common of these ill effects, according to the U.S. Food & Drug Administration (FDA):

• Anxiety
• Apprehensiveness
• Dizziness
• Headache
• Nausea
• Pallor
• Palpitation
• Respiratory difficulties
• Restlessness
• Skin or soft tissue infection
• Sweating
• Tremor
• Weakness
• Vomiting

 Those with underlying heart issues (e.g., cardiovascular disease) also may experience chest pain or an abnormal heart rate.

How to Use an EpiPen

At the first signs of anaphylaxis, you must immediately do the following:

1. Remove the auto-injector from the carrier tube. (Flip open the cap and slide it out of the tube).
2. Hold the injector in a tight fist, with the tip pointing down towards your thigh.
3. With your other hand, remove the safety release.
4. Place the tip at a right angle against the middle of the outer thigh.
5. Push the autoinjector firmly until you hear a “click.” This lets you know the injection has begun.
6. Hold firmly for three seconds.
7. Remove the injector from the thigh.
8. Call 911 or get to an emergency room or urgent care center immediately.

Note: Keep your AIE in a dark, cool place. Avoid long exposure to sunlight or extreme temperatures such as above 100 degrees and below 10 degrees.

Warning: Never inject an EpiPen into a vein, buttock, fingers, hands, or feet, advises the FDA.