Professor Adam Fox on Allergy, Anaphylaxis & Adrenaline
Ahead of #AllergyAwarenessWeek (April 24th 2023) Zak sits down with Professor Adam Fox to quiz him on all things allergy, anaphylaxis, and adrenaline - busting a few widely believed myths in the process.
We discuss hot topics such as whether or not you should use adrenaline if in doubt, where Adam says “if you're not sure if it's a really severe reaction or not, you're better off treating it as though it is rather than sort of asking questions later.”
We also delve deep into the recent guidance clarification given by the MHRA that you can use spare adrenaline auto-injector pens in schools on those without a prescription, in an emergency (for the purpose of saving a life).
Have a watch ↓ and let us know your thoughts!
(FYI the full interview is also transcribed in the blog below)
Topics we discuss:
0:00 Intro
0:58 What is allergy?
1:46 What is an allergic reaction?
2:34 What are the symptoms of anaphylaxis?
3:16 How do you treat anaphylaxis?
4:18 Different brands & doses of adrenaline pens
7:25 Do's & don'ts of using an adrenaline pen
10:21 Legalities of treatment in UK schools
14:37 Anaphylaxis / allergy anxiety
15:41 Antihistamine isn't enough
16:40 Conclusion
Interview Transcript:
Zak:
Hi Adam! I just wanted to get you on here today to chat a little bit about adrenaline auto-injectors, the recent MHRA guidance, specifically around adrenaline auto-injectors in schools and best practices around allergies in general.
So I thought I would kick it off just by getting you to introduce yourself.
Adam:
Sure. So I'm Adam Fox.
I'm a professor of paediatric allergy at Guy’s and St Thomas's Hospital and a past president of the British Society of Allergy and Clinical Immunology (BSACI).”
And I'm currently chair of the National Allergy Strategy Group (NASG), which is a collaboration between the BSACI and two national allergy charities: Anaphylaxis UK and Allergy UK, working together to try and lobby government for better allergy services for all patients.
Zak:
Awesome! So it’s fair to say you've been around allergy for a while.
Adam:
Yeah, a little while!
Zak:
Okay, so then in your own words, how would you define allergy?
Adam:
“So allergy really is when our immune system gets it wrong.”
I think often people talk about allergy as being when our immune systems mistake something harmless for being something dangerous. But it's not quite the same as that because the immune response that we get when our immune systems come across a virus or a bacteria is different to the immune response that you get when you have allergy. It is another type of response, but it's an inappropriate and potentially harmful one.
So it is when our body wrongly recognizes something that should just be ignored, like a dust mite allergen or grass pollen or milk or peanuts or something like that, and instead reacts to it in a way that can potentially cause ourselves harm.
Zak:
And when it does cause harm, when you have a severe allergic reaction - known as anaphylaxis, would you mind explaining a little bit about that?
Adam:
Yeah, there's a spectrum of allergic reactions that go from the very mild that can still be bothersome but aren’t in any way life threatening or really troubling - all the way to the other extreme, when we start talking about anaphylaxis. That's a severe allergic reaction that potentially could be life threatening.
What we mean by that is it starts to involve your breathing - So it causes difficulty in breathing, tightness of your airway, swelling in your throat, things like that… or if it involves your circulatory system, so if your blood pressure drops, that's a very serious sign. It will cause dizziness, confusion and potentially collapse. But all of those features,
“if it's anaphylaxis, it needs an emergency intervention, which is the use of adrenaline.”
Zak:
And am I right in saying if someone is worried about whether it's anaphylaxis or not, one of the easiest ways to sort of get to the bottom of that is about the breathing and the circulation.
Adam:
Well, there's interestingly, lots of different learned societies around the world would define anaphylaxis slightly differently. They all talk about it being potentially life threatening reaction, but some of them will say you have to have a certain number of symptoms in different systems and others will be more focused on just breathing or circulation.
“But I think the key thing is, is if you're not sure as a patient, if it's a really severe reaction or not, you're better off treating it as though it is rather than sort of asking questions later.”
Zak:
And how would you treat an anaphylactic reaction then?
Adam:
“So the key intervention in the management of anaphylaxis is the use of adrenaline.”
We know that if it's used earlier that you're more likely to have a good outcome. So that means it's worth giving people adrenaline to carry around with them in the community so that were they to have an anaphylaxis in a completely unexpected way, they've got the adrenaline with them rather than having to call for help.
So for me, the important things are using the adrenaline early, calling for help, but also also important - and often this is sort of left out of conversation - is position, because what we know is that if people try to stand themselves up, we try and stand somebody up who's having a severe allergic reaction, walk them somewhere or walk around, that's a bad idea and that can affect their circulation in a really unhelpful way.
So the right thing to do, as well as getting somebody to call for help and using the adrenaline early, is lying that patient down and ideally elevating their legs or if they're more comfortable, they can sit up but don't try to stand them up or walk them around anywhere.
Zak:
Yeah, we hear too many horror stories about people running around trying to find their medication. And you also get a lot of people confused about the brands and the dosages. And can you provide a little bit of clarity on that?
Adam:
Yeah, I guess in the olden days when I started, it was a little easier because there was only one type of adrenaline auto injector. There was the ‘EpiPen’, and that was it.
“But there are now three types that are available in the UK. That's ‘EpiPen’, which comes in two doses, 150 micrograms and 300 micrograms, then the ‘Jext’ which in the same way has a 300 and then 150 for younger patients.”
And we normally suggest that anything from about six or seven kilos so from infancy,up until 25 to 30 kilos, you should have the junior one, which is 150 microgram. And then once you're in that range of 25 to 30 kilos, you go up to the bigger one. Now what that means in practice is you can still have the smaller one if you weigh between 25 and 30 kilos, but when you renew it, if you're between those weights, it's a good idea to get the higher one. Once you're 30 kilos, you should have the 300 of either the ‘EpiPen’ on the ‘Jext‘.
Now there's also ‘Emerade’ - That's a newer brand. It's a slightly different design and it's really important that you know how to use the one that you've got.
This has actually come up at inquests - People might have their devices switched and then they're not familiar with the new one. And of course when it comes to need it, they need to know how to use it, and that's not the time to start looking up the instructions or going on the website. You need to be able to use it instantaneously.
So really important that you know which pen you've got and that it's the right dose, but also that it's in date and you know how to use it. And of course that you’re carrying it around with you.
So the ‘Emerade’ comes in three doses: a 150, a 300 and a 500. And the idea there is that for teenagers and adults, there's a 500 which is a slightly higher dose - but it’s not as straightforward as you think as to say well clearly that every adult should have the 500, because
“interestingly, it looks as though because of a difference in the way that the that the pens are designed, a 300 ‘EpiPen’ or ‘Jext’ seems to deliver at least as much adrenaline into your system as a 500 ‘Emerade’ would.”
So I think in reality, what happens is that people are generally prescribed the one that their GP surgery or the clinic that they go into has an agreement with or a deal with. And then it's been discussed with your doctor as to which the right doses for you.
Zak:
I mean, I know I have lived with severe allergies to nuts for most of my life and I've been given ‘EpiPens’ all the way up to a point and then ‘Jext‘ at a certain time and you're pretty much prescribed whatever you're prescribed and having a knowledge of knowing how to use whichever pen is only going to be beneficial to you.
Adam:
Yeah, that's the important thing.
“And of course, what's inside those pens is the same! A 300mcg ‘EpiPen’ or 300mcg ‘Jext’ is absolutely fine - even for most adults. It tends to be sort by exception that there's a need to go for the 500mcg.”
Zak:
And, you know, personal preference and sort of personal knowledge levels is one thing. But then legal guidance is a complete other thing. And I speak to a lot of people and I have a lot of people that talk about their worries when it comes to, “oh, what if I don't have my prescribed pen” or “can I use someone else's pen in an emergency”… ‘are the brands different”, you know, “is there some sort of hold up” “should I be 100% sure anaphylaxis” - all these sorts of things that people hesitate for any sort of reason around anaphylaxis. What are your thoughts on that?
Adam:
Yeah, hesitancy is a really big issue because what it means in practice is that when patients should be just getting on and giving themselves their adrenaline for whatever reason, they don't. And that's a potential problem because we know that you get the best outcomes the earlier it's given.
Sadly, when you hear about somebody - in incredibly rare cases - of fatal anaphylaxis, it's not uncommon that there's been some sort of story of a delay in the use of adrenaline, which may have contributed.
Of course, it's impossible to be sure whether it does or not, but it's always good idea to try and get on and give it as early as possible.
“Now, in my mind, for a lot of people, there is that uncertainty about “is it a bad enough reaction” and what they're really saying is “is this going to be harmful if it turns out that it wasn't that bad a reaction” and I therefore didn't need to give it.
And the answer is almost always with incredibly rare exception, no, it's not harmful at all. There's no downside - other than the fact that you're going to have to go and replace it! It's it's a very, very safe drug.”
So we always say to patients, if you're not sure if your reaction is bad enough - it's really important when you get training on how to use your device that it's not just about how to use it, it's also when to use it. But we really, really push this message that if you're not sure if the reactions are bad enough, that's probably the right time to be giving it. But certainly don't hesitate.
And really important to not think of it as some sort of nuclear option that you only press that button and give the adrenaline if something absolutely catastrophic is happening - that's too late at that point.
“It really is a first sign of anything severe or suspect that anything severe is happening - that's the time to get on and give it.
And the great thing is, is that as well as being really safe, it's extremely effective. So even if it wasn't that bad a reaction, then you're still going to feel a lot better a lot quicker as a consequence of using it.”
But interestingly, if you go to the US, for example, they have a much lower threshold to advise of use of of adrenaline, and they show very clearly that adrenaline works really well in relatively mild reactions.
Zak:
Wow. I mean, all of that is very, very calming to hear as someone with an allergy, because you do sort of worry about whether you need to use it or not in certain times and just knowing that if you use it there’s really little-to-no downside, and you're better off using it in emergency. It just can help you feel a little bit - I mean, allergy anxiety is such a big thing nowadays. If it can quell that, then it's great to know.
Adam:
Yeah, and I think one of the other concerns about hesitancy and this is really relevant now because there's been a bit of an update to the guidance that we're getting from the MHRA was sort of around the legality of this as well, because going back to 2017, that was a really helpful change in the Human Medicines Regulations, which meant that schools could actually stock their own ‘Epipens’ / ‘Jext’ / ‘Emerade’ adrenaline pens.
So rather than where we were previously - any patient that was considered at risk of anaphylaxis would have been prescribed by their doctor, their own adrenaline pens, and two of those would have been kept for that individual at the school. Now, there was always the worry about how instantly could they access those pens, and what if there was a problem? What if it turned out one of them was out of date or that they couldn't be found or, you know, any number of things that might go wrong?
“Didn't it make more sense if the school could also additionally keep their own supply of adrenaline injectors much in the same way as they were able to for ventolin inhalers - say salbutamol for asthma - and the law changed in 2017 to allow that.”
Now it's not mandatory for schools, it's entirely voluntary. So I always encourage my patients to speak to the authorities at school and say, Look, it would be really great if we could get these generic auto-injectors. And just to be really clear, they are not to replace the individual's pens, those should still be there. But it's an extra layer of protection.
“If the school have these, they can sensibly place them in appropriate places around the buildings to make sure that they're always easily accessible. So, for example, near the canteen, which is always going to be the place where you're more likely to get nasty reactions to food, for example.”
But then on top of that, there was an additional anxiety because the the change that happened was pretty clear that what it was suggesting was that if there was somebody who had already been prescribed adrenaline injectors, they couldn't quickly access them or it was fault by exception… If there was a reason they could use their own auto-injectors, then this was there was a sort of back up to that.
But then that raises the obvious question, which is, well, what if it's somebody who didn't know that they have allergies, but is having anaphylaxis in the canteen, or a member of staff or somebody visiting the school, if they don't have this emergency plan with the signed consent of the patients already saying “I'm okay for you to use these spare pens if you need to”… What about that, too?
Surely you don't want to have to watch as they're having their severe reactions deteriorating and you're waiting for the ambulance and you've got an ‘EpiPen’ or ‘Jext‘ there and you're not using it, that just doesn't make any sense.
“So there's now been a clarification from the MHRA that says that under something called Regulation 238, it's okay to use one of these unprescribed pens on somebody who wasn't already prescribed their own pens.”
You can still use it on them, which is great because that just gives everybody the confidence for knowing that if they recognize that somebody is having a bad allergic reaction and they have adrenaline to hand, they can get on and use it and not worry about the legalities of it. You know, that’s really helpful.
Zak:
And I think, you know, it goes full circle because we speak to so many people, whether it's first aiders or anyone that's had some sort of medical training practice, maybe it's someone with an allergy themselves. And they have been told at some point that they can't use these other pens if someone else doesn't have a prescription but has an allergic reaction.
And, you know, it goes all the way back to that hesitancy point. If at the end of the day, you know that adrenaline isn't going to cause harm and you shouldn't be waiting around, then why would that be this block on not using it or using it. And so the MHRA triple clarifying that as as recently as three weeks ago is incredibly helpful.
Adam:
Yeah, I think it just sort of square the circle for those of us involved in managing anaphylaxis in school so that that you can give the reassurance that I think teachers and staff ones rather just being told, yeah, it would probably be fine if you did that. And I think we all know we've got a moral obligation to use adrenaline on somebody who clearly needs it and would clearly benefit from it as it would be potentially life saving. But I think it's always nice to know that you've also got the law on your side as well.
Zak:
Okay. I'm going to finish off by asking you one thing that you may have already answered - is there any other particular allergy myth that you wish people understood better, that you could sort of disprove?
Adam:
That's a really good question. I think that's there's two or three things. I think the first thing is just in terms of the anxiety it provokes.
Yes, anaphylaxis happens, but I think there's this misperception that the outcome of anaphylaxis is sort of more likely to be bad than good, when actually that's not the case at all. Thankfully, even without treatment, most anaphylaxis just recovers on its own. With treatment, of course, the outcomes are even better still, but I think a lot of people imagined that and certainly my patients when I speak to them, they have this sense that if their child is unlucky enough to have that more severe reaction, that somehow it's sort of 50/50 whether they survive and it just couldn't be further from the truth.
The overwhelming majority of people are absolutely fine even after severe reactions. But of course, that's not in any way to detract from the definite value of having adrenaline there!
I think the other misconception which I think causes a lot of concern as well, is this idea that if you're having a what's becoming a severe reaction that you should try antihistamine is a way of stopping it from developing into a more severe reaction.
And of course, in reality, antihistamines just provide symptomatic relief from mild reactions. That's all they do. They're just for hives. If you've got some itchiness, it make you feel less itchy. They don't stop the progression of a reaction.
“So if a reaction is clearly becoming more severe, don't say, “okay, let's try some antihistamines and see what's going to happen”. You're better off at that point saying, “okay, this is the time to start reaching for the adrenaline.””
And I think that feeds into that sort of further myth that there's a risk of using adrenaline - if the reaction isn't that bad. If you're not sure if the reactions bad enough, if you suspect it's in any way anaphylaxis, just use your adrenaline pen and call for help.
Zak:
Lovely. Well, thank you for doing this, Adam! It’s very timely given it’s Allergy Awareness Week, and hopefully we can help spread the message that allergies are something to be fearful of, adrenaline isn't something to be hesitant about, and we can all do our part to be more prepared and aware about anaphylaxis.
Founded by Zak Marks (who lives with a severe nut allergy), Kitt Medical’s award winning Anaphylaxis Kitt service provides schools with a wall mountable emergency anaphylaxis kit, a dependable supply of adrenaline pens, unlimited access to online CPD accredited anaphylaxis training, and more – all in one convenient yearly subscription.
For more information on Kitt Medical and anaphylaxis guidance, click here
Adam (MA Hons Cantab., MSc, BS, DCH, FRCPCH, FHEAm Dip. Allergy.) is a Professor of Paediatric Allergy at St Thomas' Hospital & King’s College London, the ex-president of the British Society for Allergy and Clinical Immunology (BSACI), and the current chair of the National Allergy Strategy Group (NASG). He is also a clinical advisor for Kitt Medical.
For more information on Professor Adam Fox, click here
The Medicines and Healthcare products Regulatory Agency is an executive agency of the Department of Health and Social Care in the United Kingdom which is responsible for ensuring that medicines and medical devices work and are acceptably safe.
All information and publication which are available to you on the website is general information only and correct at the time of writing. They are not intended to constitute medical advice - If you require such advice, please speak to your GP or other qualified healthcare professional.
For the MHRA adrenaline pen guidance clarification document, click here.
