Bendaryl vs. Epi ... help!

[2boyz4me]

I'm glad I read this. Holden is at 55lbs at nearly 10 - I'm guessing I should ask the allergist for a change in our script from Epi Jr to Epi??

[ctmartin]

Hi, Everyone!

Thanks for such great, thought-provoking responses.  In revisiting this thread, I see that I spelled benadryl wrong in the title ... oops

ANYWAY, we did go ahead and purchase the adult epi pen for our daughter,  and based on what has been said here and on conversations with others I feel comfortable in that decision.

I still am a bit confused about the role of benadryl in a reaction, but this confusion has led me to revisit her action plan (yes, macabre, we have the one from burks) which has made things *slightly* clearer.

Basically, it calls for treatment with benadryl for EACH of the following (alone):  skin symptoms (localized hives), GI symptoms, or swelling (even lips and tongue!!).  The only symptoms treated with epi (and benadryl) are a combo of two or more of the above, respiratory distress (coughing, wheezing, etc), and persistent vomiting.

I guess it makes sense:  hives alone could be a contact reaction that might not progress to anaphylaxis.  GI symptoms could be something totally unrelated, but with swelling it seems a bit risky to only give benadryl (?)

What I didn't really understand and was wondering if someone could clarify ... for the symptoms that require an epi pen, benadryl is also checked.  Are we supposed to follow administration of the epi with benadryl as a routine protocol? (we did not do this with her last reaction).  If so, what is the purpose of this??

Thanks! 

[CMdeux]

Diphenhydramine can really help with nausea.  That would be one reason.

It's also a helpful add-on in terms of blockade at H1 and H2 receptors in cardiac tissues and the GI tract, though it can't effect adequate blood pressure on it's own during anaphylaxis due to loss of peripheral vascular tone.  That's what Epi is for.   

[Susan]

The issue of antihistamines (Benedryl) vs Epinephrine (epipen) has gone on for quite some time.  I have mentioned this to the AAAAI and they will be issueing and article on this,  I don't know if it will trickle down to us but there you go!

For anaphylaxis reactions the standard advice according to both AAAAI and CSACI is to use an auto injector and call 911.  For localized hives or for contact reactions I can see why one would want to use anti-histamines.

My daughter has enviromental allergies and these we treat with an anti-histamine,  For any reactions due to ingestion or if we aren't sure, we will use an auto-injector.

[cmf]

antihistamine's WONT stop anaphylaxis as anaphylaxis involves cells other than histamine (mast cells and basophils etc that can cause massive swelling and leakage from tissues that aren't stopped by an antihistamine).
We use Zyrtec because its non sedating and drowsiness can be a sign of anaphylaxis (with low blood pressure you can get 'drowsiness' ie beginning to loose consciousness/finding it hard to keep awake)...so it can sometimes be tricky to see what is antihistamine or allergic reaction progressing to anaphylaxis if you have a sedating one.
Product info for epipen here (aust) is 25kg for junior but all allergist prescribe adult one at 20kg based on current research in management of anaphylaxis.

So....an antihistamine will help the itching and some of the swelling due to histamine release...but if the reaction is going to progress to anaphylaxis then it will happen with or without antihistamine (remember the body produces its OWN adrenaline as a response to allergic reaction...sometimes this is enough to stop anaphylaxis and other times its not...hence our need to always use an autoinjector at the first sign of anaphylaxis as you can never tell what point it will progress to)

edited...tongue swelling should ALWAYS be treated with epipen as it can occlude the airway if it gets big enough (it goes down the back of the throat so will occlude nasal airflow as well). Lips can always be 'opened' to maintain an airway but the tongue is a very different matter-I would get this clarified for your own peace of mind with your allergist.

[Carefulmom]

Product info for epipen here (aust) is 25kg for junior but all allergist prescribe adult one at 20kg based on current research in management of anaphylaxis.

Is the above a typo?  All allergists don`t prescribe adult epi at 20 kg. In fact, most allergists and pediatricians don`t.  An adult epi is .30 mg which at 20 kg would be .015 per kg.  I just don`t want someone seeing this and getting wrong information about something so important.

[CMdeux]

I'm not sure, Carefulmom, but I know that DD was just over 20 kg when she was switched over.
(That's about 45 lbs, yes? 1 kg = 2.2 lbs, or 1 lb = 453 g = .453 kg)

I think that most US allergists are following professional advice to prescribe the higher dose at about 50lbs, or around 23 kg.  It used to be that they didn't switch until much closer to the nominally 'correct' dosage at 66lb, but the risks of underdosing are so much higher than overdosing in someone over 50 lbs, YK?  I think that is why thinking there has changed in recent years.  There has been some rumbling about producing a larger dose for larger adults, as well, because let's face it, a 200 lb guy is going to be massively UNDER-dosed with an autoinjector appropriate for someone my DD's size.

Also want to reiterate why hospitals frequently give diphenhydramine--
remember that the second generation antihistamines are NON-SEDATING precisely because they only hit ONE histamine receptor subtype-- the one that isn't present in CNS and cardiac tissue. 

Unfortunately, that means that during anaphylaxis, diphenhydramine and other drugs in its class have the edge as antihistamine add-ons.  Yes, there is a possibility for laypersons to be confused about the meaning of drowsiness, but in a setting where BP and O2-sats are being monitored, this is a smaller concern than leaving those receptors vulnerable to circulating histamine in a severe reaction.

Therefore, while diphenhydramine cannot elevate blood pressure or open airways (as epinephrine does-- and this is why there is NO substitute for epinephrine for a person experiencing anaphylaxis)... it can serve as an excellent secondary support in management.  Proton-pump inhibitors act at some of the same receptors, and that is why they are sometimes used as supportive medications, too.

Just thought I'd explain the seemingly contradictory advice on this one. 

[stpauligirl]

My son was switched to adult epi last year, age 7 and barely 50 lbs.

As for Bendryl vs. Epi, the ped allergist said that we could keep benedryl on hand for skin reactions, but it wouldn't stop anaphylaxis. She said she did not include benedryl in my son's school action plan at all, as school nurses (along with everyone else!) sometimes tend to avoid using an epipen, especially if there's another option in someone's school action plan. She said the risks of giving epi to an otherwise healthy kid are minimal; no sense risking it. We haven't even had benedryl in the house. Just my experience, based on my kid's doc's advice for my particular kid.

[Carefulmom]

My son was switched to adult epi last year, age 7 and barely 50 lbs.

Exactly.  20 kg would be 44 pounds (also replying to CM Deux).  50 pounds is the more common weight to switch (about 23 kg), or even 55 pounds (25 kg).  Some allergists do it at the lower end (20 kg) due to reaction history, but to say that " all allergist prescribe adult one at 20kg based on current research in management of anaphylaxis" is not true.

[cmf]

oooppps....Im talking about what we do in australia (and yes all allergists here do prescribe it over 20 kg) ....Not a typo..just what is standard here (australia) (under 20kg is .15mg over is .3mg)..but obviously you use what your allergist prescribes you. (the comment was to do with product info which for our epipens states  adult is for over 25kg when in fact we actually have it prescribed by our allergists at 20kg..a standard variation here based on what they believe to be best practice....here).   My point was really to say that product info doesnt always reflect what is considered best practice at the time and sometimes dosages will be adjusted to suit that. ....

"Who should be prescribed the "Junior" version of adrenaline autoinjector?

The Australasian Society of Clinical Immunology and Allergy (ASCIA) Prescribing Guidelines recommends EpiPen®Jr and Anapen®Jr for children weighing 10-20kg and EpiPen®  or Anapen®  for adults and children weighing more than 20kg.

This recommendation is based on consensus and standard practice by ASCIA members and is published in the Australian Medicines Handbook and the National Prescribing Service information on adrenaline autoinjectors.  It is also consistent with recommendations from the American Academy of Allergy, Asthma and Immunology (AAAAI) position statement   www.aaaai.org/media/resources/academy_statements/position_statements/ps34.asp  (this quote comes from here)   http://www.allergy.org.au/health-professionals/anaphylaxis-resources/adrenaline-autoinjectors-faqs....sorry to get off the topic and not wanting to confuse anyone-just sometimes product info is different from what is prescribed (I guess that was the point I was trying to make and obviously things can be very different from one country to another...and nothing beats the advice of your own allergist if at all in doubt.

[cmf]

Also, she told me that it is time to get Epi, rather than Epi Jr., but the packaging says 65 pounds for Epi, and my daughter is only 44 !

This was what my comments related to.

[CMdeux]

Thanks for the clarification!  Yes, there isn't such prescribing recommendation from AAAAI here in the states.  Most physicians who keep up with the field do understand that there is a "hole" in prescribing autoinjectors, where the junior runs the risk of under-dose, and the regular runs presents an over- dose, so an individual physician has to decide which risk if preferable in an individual patient.   

[LinksEtc]

Bumping.

Our allergist thought it was time to switch my dd over to the regular epi and she's about 48 pounds.

[John]

I am an EMT and have a lot of knowlege on food allergies and thought I would clear up some confusion in here.

If you go to the ER for Anaphylaxis, you will get Epinephrine as primary treatment but you will also get IV Benadryl as well, because your body is having a "histamine dump" and the only thing that can stop it is the Benadryl. From the people talking on this board, it seems people think that Benadryl has no place in Anaphylaxis treatment and nothing could be further from the truth. Benadryl is exactly what gets you out of Anaphylaxis. Usual treatment in an emergency room is Epinephrine followed by an IV of Benedryl plus Ranitidine.

My recommendation to those of you with loved ones with allergies, you need to brush up on how histamines work and what works best. If you suspect an Anaphylaxis, then giving them the Epi-Pen is recommended, however, Benadryl cannot HURT your child (unless they are choking and can't swallow). It is specifically what they are going to give to your child after they Epi-Pen them. The Epi-Pen is used to treat the airway constriction and low blood pressure which can lead to death. But the Benadryl is what is used for long term treatment to stop the histamine dump and keep the anaphylaxis from continuing.

If they can swallow, the liquid Benadryl on top of the Epi-Pen give them the best chance at survival (if it's progressing to an Anaphylactic episode). And for what it's worth, the reason Benadryl isn't given as first line is because it takes about 20 to 30 minutes to start working whereas the Epi-Pen is instant.

By giving your child Benadryl, you are not hurting them (just make sure their airway/esophagus isn't constricted). You can only help their situation by counteracting the histamine dump. This doesn't mean you shouldn't also use the Epi-Pen if you need to use it. I know this can be confusing, but it's crazy to hear people talking about Benadryl as if it has no place in Anaphylaxis. It is used in every Anaphylactic episode in the ER - of course it's good for you.

[twinturbo]

John, how were you taught to identify anaphylaxis and treat it? Have you ever worked with a board certified allergist and are you familiar with what they write up for patients in something called an EAP (emergency action plan)?

These aren't nonsense questions. I'm sincerely interested in your experience and training as an EMT--whatever level you are. Are you able to administer to patients adult and/or pediatric in your state? I know laws differ.

My kids have anaphylaxed in the allergist's office and of course ambulance and ER. Quite a breathtaking difference in treatment and identification every time.

But this...

But the Benadryl is what is used for long term treatment to stop the histamine dump and keep the anaphylaxis from continuing.

Where did you get that? Because even the use of prednisone to prevent the further degranulation of mast cells post-incident is at best likely, not guaranteed. You're going to have to support that statement with something SOLID. If you're talking just its symptom controlling anti-histamine effects that's different. But preventing anaphylxis no can do.

Anyhow, I won't have time to say this later so I have to do it now.

As patients we get different marching orders from our allergists for emergency action in the field. You may think you're in the field. You're in a truck prepped with lots of equipment with 2-3 of your best trained friends in that equipped vehicle that also has a radio and the ability to drive like a bat out of hell to a the ER where we meet even more trained people with lots of medication and equipment.

You know what we have as parents/patients? An epinephrine autoinjector, some Benadryl and keeping it together to follow the emergency action plan that our allergists give us based on best known practices. Mortality decreases positively with the prompt administration of epinephrine. Technically, epinephrine isn't going to hurt you, either, which is why as a medical discipline immunology tells us to not be afraid of administration upon recognizing anaphylaxis or even asthma unresponsive to rescue inhalers. Similar to a patient who presents with similar symptoms of asthma, anaphylaxis needs recognition as rescue inhalers are not going to treat it.

So as an EMT of whatever grade you're part of the equation but not the one between the allergist and the patient. That's really what is being discussed here. Not that your input isn't appreciated, any increase in knowledge is a positive gain. But do realize we aren't advised on IgE-mediated allergies by EMTs but board certified immunologists whose treatment plans for patients WITHOUT medical personnel and equipment is different than your vocation, equipment and resources.