Why does advice on when to Epi differ between Aus and US?
June 8, 2021 4:36 PM   Subscribe

Why do the recommendations on when to give an EpiPen seem to differ so much between Australia and the US?

My son has multiple food allergies despite us introducing the foods as early as possible (see a previous question from me).

He's had a few allergic reactions which as far as I know would not be considered anaphylaxis, even when they appeared serious to me and I called an ambulance. He was checked by the ambulance, monitored in hospital, and I described his symptoms to his allergist and no one considers the reaction he had to have been severe.

The recommendation in Australia is to give an EpiPen if the person is experiencing symptoms which are impacting their blood pressure and/or breathing or show that their blood pressure/breathing is impacted.

The recommendations in the US seem to be to give an EpiPen even if the symptoms do not necessarily indicate that blood pressure or breathing is impacted.

For example, full body hives in Australia? No worries, this is a mild-moderate reaction.

Full body hives in the US? Give an EpiPen.

*Please focus on the actual question that I asked and do not turn this into a forum to give me advice on how to treat my son's allergic reactions if he has another one. We have EpiPens as a precaution, if I'm ever in doubt I'll use one and call an ambulance. I'm just asking why the advice differs so much.

I don't feel like I can ask anywhere else without getting answers which are either "Omg, you read too much. Stop worrying" or "Omg, how dare you question whether or not to give an EpiPen? Just give the damn Epi!"*
posted by kinddieserzeit to Health & Fitness (5 answers total) 2 users marked this as a favorite
I am not a medical professional. However, we have had to jab my son with an Epi Pen on more than one occasion. Also, coincidentally, he was born in Australia and we live in the US now, so I feel like I have some sense of both medical systems.

With that background, I would guess - and again, it is only a guess - that the recommendations differ because the medical systems are geared differently. On an imaginary spectrum that goes from "efficiency and greatest good of greatest number" on one side, to "most comprehensive possible intervention, damn the cost" on the other, the Australian and US systems are on different spots.

If you use an EpiPen, it comes with its own risks and the recommendation is to be transported to a hospital ER for observation, because some tiny fraction do have very bad reactions. The risk of dying from an anaphylactic reaction from say a food allergy is small, but higher than the risk of a bad reaction to the EpiPen itself, I think. Of course, a trip to the ER is wildly expensive.

So that's why the recommendations differ. Talk to your pediatrician about what's right for your kid.
posted by RedOrGreen at 4:56 PM on June 8 [1 favorite]

Response by poster: Hmm that's another thing I'll have to look into, I guess. My understanding was that the need for the ambulance and monitoring in hospital was because of the chance of a biphasic reaction, not because the EpiPen itself could potentially cause its own reaction.

Thanks for sharing your experience of the different medical systems.
posted by kinddieserzeit at 5:25 PM on June 8

You're right, and also the Australian Resuscitation Council's recommendations (9.2.7), which guide general community first aid, are similarly broader ('Reaction? Use the injector and call an ambulance') than those of ASCIA's Action Plan for Epipens, and your allergist's. I'd suggest it's either that;

1. Guidelines in the US are closer to the 'community first aid' than 'anaphylaxis plan' point, where people needn't distinguish between mild and severe reactions, or
2. That EpiPens, which are manufactured in the US and imported, are much more obtainable in that country?
posted by Fiasco da Gama at 5:26 PM on June 8

Here is an article that discusses guidance as of 2008. Note that this is from the World Allergy Organization, so not US-specific. In the conclusion, they say:
Experts may differ on how they define the clinical threshold by which they define and treat anaphylaxis. However, they have no disagreement whatsoever that appropriate doses of intramuscular epinephrine should be administered rapidly once that threshold is reached.
And here is another WAO article about the clinical thresholds for anaphylaxis. Notably, the Australian definition of anaphylaxis requires breathing difficulties and hypotension, as you say, while the American definition only requires multiple organ systems (so skin and gastrointestinal alone would count).

Digging in further, here is the most recent American allergists' update to their anaphylaxis treatment guidance. Page 346 is the part of the executive summary that answers the relevant question for you, "Should a patient presenting with mild systemic symptoms involving at least 1 system (eg, urticaria with mild gastrointestinal cramping) be treated with antihistamines and/or corticosteroids and observed rather than given epinephrine?"

Overall, it looks like the Australians and the WAO say "it is very rare for just hives + GI symptoms to be anaphylaxis" but the Americans say "yeah but if it IS anaphylaxis, by the time there is breathing involvement it might be too late".

So I think RedOrGreen is right -- American physicians will err on the side of overtreating to prevent remote risks. This is probably because of a combination of malpractice lawsuit risk and general American insensitivity to cost. Frankly I don't know which is the right answer because there is no quantitative discussion in ANY of the guidelines -- is the risk of death from waiting for respiratory symptoms 1 in 100? 1 in 1000? 1 in 10,000? Who knows?

As for me, I have an EpiPen but have only used it once, at age 7, and specifically don't use it when I my only allergy symptoms are hives and GI cramping. But YMMV!
posted by goingonit at 5:29 PM on June 8 [5 favorites]

Canada is culturally similar to the US but has universal healthcare similar to Australia (and fewer malpractice lawsuits than the US). The official recommendation here is to administer an epi-pen at “severe” symptoms of anaphylaxis - including just hives. When I received my training it was in a school setting where we definitely erred on the side of caution and administered before there was airway restriction or visible bp drop. Working now with adults in the workplace I defer to the adult to make a choice if they feel they need an epi pen or just want medical aid. If an epi pen IS used, the direction was to immediately seek emergency medical help. Epi pens are also relatively cheap in Canada (I believe the comparison is $100 without workplace/govt insurance vs several hundred dollars in the US).
posted by saucysault at 1:04 AM on June 9 [1 favorite]

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