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Blog post:
Epinephrine Additional Learning
Date:
this blog came out some time before year 2017. A facebook blog app
ceased to function, and MEDIC's back-up captured the content but not the date of
writing.
If you've taken a
dtWFA course, you've learned how Epi works, when and with what it needs to
be given, and how long it lasts. This forum string contains some
fascinating additional information.
PART 1) WHAT IF THE EPIPEN IS EXPIRED or DISCOLORED? WILL
IT STILL WORK???
PART 2) HOW TO GET UP TO 5 DOSES FROM A SINGLE EPIPEN!!!
PART 3) EFFECT OF COLD AND HEAT ON EPI
PART 4) FREE Generic EPI-PENs! With the Epi $0 Copay
Coupon
PART 5) LEGALITY OF AN ORGANIZATION GETTING AND USING EPI
PART 1) WHAT IF THE EPI-PEN IS EXPIRED or
DISCOLORED? WILL IT STILL WORK???
[For a quick answer, skip to "Conclusion" below]
As always, we focus on evidence-based medicine. Here's the evidence.
>>> A medical study was conducted to determine the effectiveness of EpiPens
after their expiration date.
>>> Tested: EpiPens from in-date, through out of date as long as 90 months (7.5
years).
>>> The quotations below are excerpts from the article cited near the bottom of
this post.
"Although there is evidence from this study and from a previous study that
patients at risk for anaphylaxis have a high awareness of the expiration date on
the EpiPen autoinjector, there is also evidence that many such patients may be
carrying out-of-date autoinjectors."
"We found that epinephrine bioavailability from the outdated EpiPen and EpiPen
Jr autoinjectors varied with the number of months past the expiration date but
was significantly reduced compared with epinephrine bioavailability from the
in-date autoinjectors."
HOWEVER … take a look at
this graph:
>>> KEY to graph: the epinephrine content, expressed as percent of labeled
dose of epinephrine, of 6 in-date EpiPen autoinjectors (CLOSED TRIANGLES) and 6
in-date EpiPen Jr autoinjectors (OPEN TRIANGLES) is shown. The percent of
labeled dose of epinephrine in 28 outdated EpiPen autoinjectors (CLOSED CIRCLES)
and 6 EpiPen Jr autoinjectors (OPEN CIRCLES) studied 1 to 90 months after the
stated expiration date correlated inversely with the number of months past the
expiration date (0.63). The EpiPen autoinjectors with discolored contents
are indicated with an ASTERISK. The EpiPen stored in the car glove
compartment is indicated with TWO ASTERISKS.
"Most of the EpiPen and EpiPen Jr autoinjectors that had a reduced epinephrine
content could not have been identified by inspection of the color window on the
autoinjectors for discoloration or precipitates."
COMMENTS ON GRAPH: Notice the vertical axis starts at about 50%, not 0%.
>>> ALL EpiPens tested regardless of their date or condition had at least 50% of
the labeled epinephrine content still in it.
>>> The EpiPens that were ~7 and 7.5 years past expiration date had over 70% of
the labeled epinephrine content still in it.
CONCLUSION: "For prehospital self-management of anaphylaxis, we recommend
the use of EpiPen and EpiPen Jr autoinjectors that have not expired. If,
however, the only autoinjector available is an outdated one, it could be used so
long as no discoloration or precipitates are apparent because the potential
benefit of using it is greater than the potential risk of a suboptimal
epinephrine dose or of no epinephrine treatment at all."
Full Journal Article / Source (same article linked online in two places:
place one ~
place two)
~ ~ ~ ~ ~
PART 2) HOW TO GET UP TO 5 DOSES FROM A SINGLE
EPI-PEN!!!
Step 0) Watch all three videos at
this website:
Step 0.5) Practice on an old unit or two, make sure you wear gloves and
safety glasses and make sure you discharge the first dose (into an orange not to
be eaten, or box, or whatever) before breaking the pen open.
In a real-life emergency, particularly in a remote setting…
1) Use the autoinjector only when, and the way it's supposed to be used.
That's dose #1.
2) If there is only one autoinjector and it was just used, consider
starting to break it apart (to access the additional doses) right away, as it
takes a significant amount of time to do so safely. When to administer a
subsequent dose? That's one of the
dtWFA course topics :)
The videos linked above are a part of the following medical journal article,
which offers additional reading material and textual description:
link location one ~
link location two
Clever! And life-saving :)
~ ~ ~ ~ ~
PART 3) EFFECT OF COLD AND HEAT ON EPI
FREEZING & THAWING EPI: A controlled medical study entitled "The Impact of
Freeze-Thaw Cycles on Epinephrine" concluded that after repetitive freeze-thaw
cycles, the epinephrine concentration was still the appropriate amount.
If you don't have a subscription to the "Wilderness & Environmental Medicine"
journal, you can't read the full medical study, but you can read an article
about the study
here.
HEATING EPI: See (Part 1) above. The one Epi-Pen that was left in the
glove box of a car for days at a time was done so in a climate that has
summertime high temps of 95 degrees (and wintertime well below zero), however
the study did not state if that Epi-Pen was in the glove box during summertime
or not. Other studies have shown that excessive exposure to high heat can
degrade the effectiveness of the drug.
~ ~ ~ ~ ~
PART 4) FREE Generic EPI-PENs! With the Epi
$0 Copay Coupon.
Many thanks to hiking pal Chad F. for the following golden tip.
1) Get your doctor to prescribe "epinephrine auto-injector **generic**" and when
you go to the store to pick it up, bring the "$0 copay" coupon you can print
from
www.epinephrineautoinject.com . My physician ordered 2 for me, CVS
said they had to special-order it (why don't they carry the generic?!!), they
said $178 please, I handed over the coupon, and voila, FREE! The units I
received had a 1-year expiration. The coupon doesn't seem to have an
expiration date, and works for up to 3 units (per year, I'm told?).
2) While you're at it, consider getting a prescription for Erythromycin
Ophthalmic Ointment. As noted in the
WILDCARE textbook and "MEDIC in your Wallet," this little tube is
super-handy to have in your first aid kit, and can help with a few different eye
conditions one might suffer out in the wilderness. I picked up two tubes
(one for each of my first aid kits), which with my not-so-great health insurance
cost me a total of $25.
~ ~ ~ ~ ~
PART 5) LEGALITY OF AN ORGANIZATION GETTING AND
USING EPI
Is it legal for an organization (such as a camp) to get a prescription for,
stock, and have its employees or volunteers use epinephrine on its clients or
grounds? As of the writing of this note, the answer is "yes" in 23 states
(though read the state law for specifics), and I'm guessing unclear in the rest.
See
this article, and if your state is in the "yes" category, click on its law
to ensure your organization qualifies.
.
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