Epinephrine autoinjector prescription in food-allergic adults: symptom-based only or allergen-based also? An italian multi-centre study

R. Asero, L. Antonicelli, A. Arena, L. Bommarito, B. Caruso, G. Colombo, M. Crivellaro, M. De Carli, E. Della Torre, F. Della Torre, E. Heffler, F. Lodi Rizzini, R. Longo, G. Manzotti, M. Marcotulli, A. Melchiorre, P. Minale, P. Morandi, B. Moreni, A. Moschella, F. Murzilli, F. Nebiolo, M. Poppa, S.

Background: Epinephrine is the treatment of choice for acute food-allergic reactions but existing guidelines state that it should be prescribed uniquely to patients who already experienced at least one food-induced anaphylactic episode. Objective: We investigated whether in Italy epinephrine auto-injector is prescribed uniquely following the existing guidelines only, or is allergen-informed as well (i.e., based on the potential risk associated with sensitization to certain food allergens), and hence preventive. Methods: 1110 adult patients(mean age 31 years; M/F 391/719) with food allergy seen at 19 allergy outpatient clinics were studied. Patients with a history of probable anaphylaxis were identified. Subjects were classified as having primary (type 1) and/or secondary (type 2) food allergy and were divided into several subgroups based on the offending allergen/food. Epinephrine prescriptions were recorded and analyzed both as a whole and by sensitizing allergen. Results: Epinephrine was prescribed to 138/1100 (13%) patients with a significant difference between subjects with type-1 and type-2 food allergy (132/522 [25%] vs 6/629 [1%]; p< 0.001). The epinephrine group included most patients with a history of anaphylaxis (55/62 [89%]) or emergency department visits 106/138 (77%). In some specific subsets, namely fish-, tree nuts-, and lipid trasfer protein(LTP)-allergic patients, epinephrine was prescribed to patients without a history of systemic allergic reactions. Conclusions: Italian allergy specialists prescribe epinephrine auto-injectors both on the basis of clinical history of severe reactions and on a critical analysis of the hazard associated with the relevant protein allergens, which suggests a good knowledge of allergens as well as acquaintance with the guidelines for prescription of emergency medication.
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