CEimpact Podcast

Epinephrine Injection vs. Inhaler Use in Allergic Reactions

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Allergic reactions can range from a bothersome nuisance to a life-threatening emergency, making it crucial for pharmacists to stay informed about current treatment options and best practices. This episode discusses common triggers, effective therapies—from antihistamines and injections to the newly approved epinephrine nasal spray—and key counseling strategies to ensure patients receive safe, prompt relief. Tune in to improve your preparedness and support confident, patient-centered care.

HOST
Joshua Davis Kinsey, PharmD
VP, Education
CEimpact

Rachel Maynard, PharmD
Lead Editor
Pyrls

Joshua Davis Kinsey and Rachel Maynard have no relevant financial relationships to disclose. 

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CPE INFORMATION
Learning Objectives
Upon successful completion of this knowledge-based activity, participants should be able to:
1. Identify common triggers and clinical features associated with allergic reactions.
2. Describe available treatment options for allergic reactions, including newly approved therapies and their appropriate use.

0.05 CEU/0.5 Hr
UAN: 0107-0000-25-300-H01-P
Initial release date: 10/6/2025
Expiration date: 10/6/2026
Additional CPE details can be found here.

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Speaker 1:

Hey, ce Impact subscribers, welcome to the Game Changers Clinical Conversations podcast. I'm your host, josh Kinsey, and as always, I'm excited about our conversation today. As a reminder, we've launched a special podcast series in collaboration with our friends at PEARLS, a modern drug information resource and app. These crossover episodes, called Game Changing PEARLS, combine PEARLS' trusted evidence-based clinical tools with CE Impact's expertise in pharmacy education and accreditation. Also, for episodes called Game Changing Pearls, combine Pearl's trusted evidence-based clinical tools with CE Impact's expertise in pharmacy education and accreditation, bringing you timely, actionable content that supports both your practice and your professional development. It's a privilege to work alongside the Pearls team and we're excited to continue this series with today's episode focused on allergic reactions. Allergic reactions are unpredictable and potentially serious, which means pharmacists must be equipped to recognize symptoms, recommend appropriate treatments and support safe follow-up care. And this episode will cover common triggers, key therapies, including the newly approved epinephrine nasal spray, and practical strategies for patient counseling. And it is so great to have Rachel Maynard back as our guest for today from Pearls, rachel, welcome.

Speaker 2:

Thanks so much, Josh. Happy to be here again.

Speaker 1:

Yeah. So for those of you that are avid listeners of the podcast, you have probably enjoyed Rachel joining us for a couple of episodes already. But for those of you that may be new listeners or you haven't had a chance to listen to those other Crossover Pearls episodes yet, Rachel, go ahead and take a couple minutes to tell us a little bit about yourself and your role at Pearls and your introduction to pharmacy, or anything else you want to share.

Speaker 2:

Sure, absolutely so. I am the clinical lead at Pearls, so helping to manage the content development process and, as you mentioned, we are a drug information resource and mobile app and some of our most popular features are our drug pages with key counseling points and clinical pearls, and also pharmacotherapy resources like charts and algorithms. Prior to Pearls, I was in a similar sort of role in a drug information space education and I'm very passionate about empowering health care providers and patients with information and resources to optimize care. But originally my heart was in pharmacy because of community pharmacy. I worked as a technician before going to pharmacy school and did a community pharmacy residency and worked as a staff pharmacist after that and managing clinical services for a region of stores, so very passionate about community pharmacy practice in particular. But I'm excited to talk about this topic because I know there's a lot of impact pharmacists can make here.

Speaker 1:

Yeah, absolutely yeah. It's always a pleasure having you on and I always love that. We both have that extreme passion for community practice. It's kind of our humble beginnings and we really just kind of still thoroughly enjoy promoting community pharmacy and making sure that they have the information and tools that they need to succeed. So thanks again, rachel. I know this is time out of your busy schedule, so we really appreciate it. So, yes, let's jump into today's topic on allergic reactions. So let's just. I always like to set the stage and set the foundation for what we're talking about today. So just remind us a little bit about allergic reaction. What do we mean when we say allergic reaction, and how is that really relevant to pharmacy practice?

Speaker 2:

You know, that's actually a great question because, if you say allergic reaction, that means a lot of things to a lot of people, I think right, and there's sort of this spectrum of reactions. So you know there's anything from seasonal allergies and you know allergic rhinitis and hay fever and you know itching, sneezing, runny nose, that sort of thing, all the way up to anaphylaxis, which is where my mind sort of goes, is like a classic allergic reaction where it's a systemic, life-threatening sort of reaction. And then you know there's things like hives, which are sort of, you know, maybe in the middle, where you know have these skin reactions. So that's a very broad question and I think it sort of depends on what kind of.

Speaker 2:

But yeah, I mean, I think it depends, that's where sort of that triage and assessing what's going on with the patient is going to be really important in a community setting or AmCare setting, just to figure out what exactly the patient's talking about. If they say allergic reaction, what does that mean to them? Or even if you're thinking about somebody who's reporting an allergic reaction, if you ask them if you had any allergies to medications in the past, they might interpret that question differently, the way I just did with you. So it's good to narrow it.

Speaker 1:

You answered it exactly how I was hoping, which is that it is dependent upon so many factors, and so it's important, as a pharmacist, to ask questions, to triage, to make sure that we're on the same page with the patient.

Speaker 1:

Because, you're exactly right, allergic reaction to me, I immediately think of, you know, systemic anaphylaxis, but allergic reaction to a lay person could just mean that, you know, ragweed is out and I'm sneezing, you know. So, yeah, so I think that's exactly what I wanted you to kind of say was it's very dependent upon a lot of factors, and so it's important that we're asking the right questions. And that's one of the key things that we want to get across today is that it's really important for pharmacists to triage, to ask questions, to make sure that we're on the same page when we're talking about it. So, with that relevance to pharmacy practice, obviously we all know it's not a hidden fact we're very accessible professionals and we're often the first point of contact for patients, especially if they're quickly coming in to purchase something over the counter or something like that. So what are some of the things that we can do to be prepared for those interactions with patients and understanding, as we mentioned. How do we triage? What kind of questions do we ask? You know that kind of thing.

Speaker 2:

Yeah. So I think, like you mentioned, if you're seeing somebody in the aisle or asking about antihistamines, for example, like or like what is the best allergy treatment, again that's really going to depend on what kind of allergy they're looking to treat. So if it is something like allergic rhinitis or hay fever, ragweed, you know that's going to be a very different management than if somebody has an allergic, a severe allergic reaction to like a food allergen or an insect sting or you know something like that, where it's more of a severe systemic reaction. So and just to sort of differentiate those two off the bat, like if a patient is having seasonal allergies or even hives, you know if they're having minor hives, localized hives, or if they have a localized reaction to an insect sting, for example, with just you know, small swelling, redness right at that area but not getting worse, not progressing. That's the sort of situation where antihistamines are an appropriate option. So that could be something you know we could help them have that on hand in case they do have sort of that localized reaction or they're having more persistent seasonal or chronic allergies.

Speaker 2:

Nasal steroids are certainly another option for more allergic rhinitis sort of symptoms, but they help with those more mild localized symptoms, whereas if you have a patient who has a history of an allergy to a food or sting or to a drug where they're having anaphylaxis, that's where epinephrine is going to be the foundational treatment that they need to have on hand to manage that if they are at risk in the future. So, yeah, I think it depends on you know what kinds of again, what kinds of symptoms the patient's asking about or looking to manage, or what they want to have on hand to help prevent. But narrowing in on some of those questions is going to be key.

Speaker 1:

Yep very key and, as always, making sure that we're using open-ended questions so that we're getting good feedback from the patient as opposed to just the simple yes and no, because we know that if, given the option, patients are going to give the simple yes and no and not expand upon.

Speaker 1:

So, yes, open-ended questions is key when triaging for this. One other thing to point out too, I think just in general, you touched on it, but you know, I think there is potentially misinformation, miscommunication, not fully understanding. You know products that are out there and so it's it's key to to make sure that if we do find out that they're treating something systemic, or you know a food allergen or something like that, to understand that you need more than just the OTC option, like you need to be seeing a doctor to get a prescription for an epinephrine product. So I think that's key too, to make sure that we're asking those right questions that lead to are you getting the right product? You know we can point them in the direction of a good antihistamine and whether they want drowsy, non-drowsy, whatever, but making sure to understand that you know if it is a severe allergic reaction that we're discussing, that you know, pointing them into the right direction to get an epinephrine product.

Speaker 2:

So I will just to add to that thought. You know, I think it could be one of those things where cost is a consideration or getting prescription is a consideration and maybe trying to find alternative OTC options is something that is trying to solve for the problem of not being able to get epinephrine. And that's again where clarification is really really important, because we're talking about a life-threatening systemic reaction. If we're talking about anaphylaxis and that is not something that can be managed with antihistamines that's something that needs epinephrine really to help with the swelling, bring down the swelling, raise the blood pressure, the trouble breathing that's not going to be managed with antihistamines alone. So it's really important. If a patient's trying to solve for not being able to get epinephrine for one reason or another or maybe they have a product at home but they don't feel like they need to refill it just yet, or they just want something else to have on hand reinforcing the role of epinephrine, I think, is really critical there.

Speaker 1:

Yeah, great point, Great. I love the point out of making sure that it's not an access issue you know that it's not. I can't afford it.

Speaker 1:

The copay is too high, or, you know, there was a time I'm not exactly sure, but there was a time when there was a shortage on the product, and so I think we're out of that moment now, but you know, that was an obvious point of concern for some people as well a few years ago. So, yeah, great point, and again something that either we as pharmacists or members of our team can help. Also, you know, are there copay cards? Are? There you know, are there other resources in the community that can help if it is an access issue that a patient is having.

Speaker 1:

So, yeah, great points On that. We've brought up epinephrine, the importance of epinephrine, and so I'd like to take a few minutes to talk about the elephant in the room, which is the new epinephrine product. You know, it's the intranasal spray and I think, gaining some traction over, it's been out maybe a year now, I think.

Speaker 2:

Yeah, it was approved around this time last year.

Speaker 1:

Yeah, so maybe a year now, potentially, you know, with school starting back this fall and it being an option, maybe it was something that you know. Typically you're getting your injectors refilled and getting ready for school and that's kind of a step to take. So potentially, perhaps it was mentioned or an option for patients. So I do want to spend some time to talk about that product. So I'll kind of give you the floor to lead us on all the good ins and outs of intranasal epinephrine, and I know you have some counseling points to share, which is going to be super helpful.

Speaker 2:

Yeah, lots of considerations there and so I think like just to step back. It still does go back to access and affordability and so this is a very it's great to have another option because there's many patients who don't like the thought of needles at all, even if you're not seeing the needle with an auto injector, you know there's people who for size considerations with some of the other products. You know they want something more portable or you know they just have less anxiety around using it because it's a nasal spray. So having another option is always a good thing. But again, cost access you know we want to work with the patient and what's going to make the most sense for them, what they're going to be able to get. You know if that's and there are, as you say, like manufacturer programs and insurance does cover some many of these options but it's going to be working with the patient to find out what works for them. So, just as you know, more options is always good, but always working with the patient to find out what they prefer.

Speaker 1:

Absolutely, absolutely, and it's important to note too. Like you said, it could be that they've heard about it and they're asking questions, so that's another reason why it's important for us to be in the know, because they may come to us and say I've always done injectors, but what's this new product? Tell me what the pros and cons are. You know that kind of thing, so yeah.

Speaker 2:

So yeah, so I think it is nice to have another option for people who might be a little bit more wary of injections. It is a nasal spray and it's actually almost identical, I think, if not identical in the device, to the naloxone nasal spray that you might be, familiar with.

Speaker 2:

So it's basically used the exact same way as that naloxone nasal spray and even patients may be familiar with that too. So that's a nice you know relationship to kind of share that it's just one, one spray, one nostril and that's your dose. I think I would say a key is that it's not like some other nasal sprays that patients may be used to. Where it doesn't should not be primed because it's just one dose, and so we don't want people accidentally trying to test it or prime it and see if it's working. They'll lose their dose. So we want to make sure they know to just do the one dose in one nostril. With any epinephrine device they may need a repeat dose.

Speaker 2:

So the standard practice is usually for people to try to have two devices on hand, whether that's two autoinjectors or two nasal sprays on hand, so that if their symptoms are not getting better after five minutes or are getting worse, they have that extra spray or injector to be able to give another dose.

Speaker 2:

And with the case of the nasal spray they actually would give their second dose if they need it into the same nostril. So again, that's a little different than I think we often think of with nasal sprays where it's like maybe you switch or yeah, but this is just one dose in the same nostril if you need a second dose, and then just again with any of the epinephrine products. Like ensuring they know to call 911 and get emergency care as follow-up, especially if their symptoms were severe and or not resolved like immediately getting that emergency care is helpful. One thing I didn't know about in pharmacy school and I just learned within the last few years is that people can have what's called a biphasic reaction, where they have the initial reaction and then even up to 48 hours later they can have this sort of recurrence of symptoms.

Speaker 2:

And so getting that emergency care so that they are being monitored and evaluated for that biphasic reaction is important. That's more likely if they have an initial severe reaction, but again something they might not be familiar with and again another reason to have additional devices available in case that does recur. The other thing that I think is, you know, something to be aware of with the nasal spray is if a patient's had so, they did do testing in people with allergic rhinitis, which is good because a lot of these patients have, you know, concomitant asthma, allergies, eczema, but so that that's one population that was studied in. But we don't know if it's going to be effective in people who have nasal polyps or who've had a fractured nose in the past or have had nasal surgery. So that might be reasons where it wouldn't be an appropriate option for those patients. If they have nasal congestion, like from a cold or allergies, it does work. They can still use it.

Speaker 1:

I was just about to ask that because you know, like, if you think about not the entire population that's using this, but a large population that's using this, are children, and you know, and, and let's face it, kids always have snotty noses you know like, especially in different seasonal times and it just it feels like that they're always congested and whatnot. So that was going to be one of my main questions was does it, does it get in there, does it bypass that? Does it, you know, still work. So okay, yep.

Speaker 2:

The labeling says it can. It will, you know, work with, with the congestion. The key is that it's getting to that. That nasomycosis, you know the, and usually that sinus congestion is. You know, deeper, further back, so like the nasal, and usually that sinus congestion is, you know, deeper, further back, so like the nasal, the blood vessels in the nasal cavity are going to be exposed.

Speaker 2:

Yeah, yeah, but I will say once if a dose is given, it can actually, for two weeks after that dose, affect the systemic absorption of other nasal sprays. So if a patient is using a chronic nasal steroid, for example, and they've used the intranasal epinephrine, it might increase their absorption of any other nasal spray. So that is something to be aware of for two weeks after their dose. Again, just to be aware of it so that if they're having any other side effects from medications that they can be alert to that. But yeah, there are just some interesting nuances.

Speaker 2:

One of the consideration that I think often comes up is around storage of these products. So it's really important to reinforce keeping it at room temperature, All of these products. Keeping them at room temperature. Don't put them in the dashboard of your car for long periods of time, anything like that. There is a little bit different storage description for the intranasal product. Where it can be stored for a few days is what it specifies, but up to 122 degrees Fahrenheit. But it's still most important that they try to keep it at room temperature as much as possible. But there is a little bit more flexibility, it seems like, in terms of excursions. But for any of these products, do not freeze them. For the liquid products, just be checking that the liquid is not crystallized. There's substances that it's clear before they use it, and with any of these products too, keeping an eye on expiration dates and making sure that they are getting refills before the expiration date hits Exactly.

Speaker 1:

So, rachel, I know that it's been a while since I've been in practice, but I know in previous experience it seemed like the injectors always had like just a one year shelf life. Basically, is that still the case with the injectors, and or is it different with the nasal spray? Like, what kind of shelf life are we looking at?

Speaker 2:

Yeah, you know, I think that's one of the things that the manufacturer is touting about the nasal spray is that it might have a little bit longer shelf life than the auto injectors. And you know, typically I do think it's still like in the year range, but potentially up to two years for the nasal spray. So still not long, not great. Yeah, yeah, yeah.

Speaker 1:

But better than I mean. I remember there were some times when I'd have to make sure that it at least had six months left, you know. And so, yeah, just really that was always, I think, a big issue or problem or concern. So hopefully they're working to remedy that, so that's good. Well, this is great. I love the point of making sure you know, when counseling patients, to tell them not to prime it. I mean, I think that's it's critical because, like you said, if they prime it they lose the only dose that's there. So I think that's really really key and and I love the clarification that it does still work with nasal congestion, because I feel like that is an obvious first question for anyone and I think it's important to remember and to note, like you said, if they do have a history of polyps or a fractured nose or I don't know if even like a deviated septum would come into play and all of that like potentially so understanding.

Speaker 1:

if patients have issues already in the nasal area, then maybe this isn't the best product for them. So yeah, that's great. Anything else on the intranasal spray that you want to share?

Speaker 2:

I think I will just say, like with the other injectables, there is a trainer device that's available, so both to have in the pharmacy and for patients to have to order directly from the manufacturer. I think having those trainer devices is really helpful for us as we're counseling, but also for them as they're reinforcing, because, again, this is hopefully not something you're going to need to use often, and so to refresh your memory on proper uses is important, and also because, especially for younger patients who might need epinephrine, making sure that anyone who might be around them in the event of an emergency is able to use the product properly. And that's where those trainer devices at home are also so helpful, because it might be a caregiver, it might be a friend, it might be a neighbor. You know, you never know who might need to know how to use these products.

Speaker 2:

So having that trainer device to show other people how to use it when the child may not know how to self-administer is again just a good reminder to let people know about. With any of these devices. There are trainer devices available for home use.

Speaker 1:

Yeah, absolutely, and I think that's just a great counseling point in general. You know, just from personal story, a friend of ours one of their children has a nut allergy and was at a birthday party and it was clearly told and everybody was aware. But there was a chocolate chip cookie and apparently that recipe included nuts in the chocolate chip cookie, which is not super common but sometimes happens. But yeah, it's super important to note that. You know you sent them to someone's house for a birthday party and you know it's important that whoever is there and in charge and the adult in that moment is aware of what could happen and how to treat it. So yeah, I love the idea of utilizing those trainer things even at home. You know, like you said, getting them for the patient, not just using it in the pharmacy. Right, right, right very helpful.

Speaker 2:

And to your point also. Having it on hand is important because you think okay, I have it. It's at home, but you have to bring it with you to wherever you might be exposed to that potential allergen.

Speaker 2:

So having it on you wherever you are and, again, having two devices ideally, is key. Yeah, that you know you were. Just that just reminded me like thinking about time of year right now and coming up to Halloween and you know Halloween being a big potential trigger for many children with food allergies. And, interestingly, there's this you know sort of teal pumpkin project where, like, if you have a teal pumpkin on your deck, it's it's showing that you are offering non food related treats, so toys or you know, crayons or bouncy balls, these kinds of things that are not food related, to sort of avoid that potential risk of allergies.

Speaker 2:

Again just as more awareness around food allergies, I think, is becoming more common and the importance of avoidance. It's just a good reminder that that time of year might be problematic for some people.

Speaker 1:

Absolutely, because you know some people it's coming into contact with not just necessarily ingesting.

Speaker 1:

So, yeah, great points. Okay, so some other opportunities for pharmacists. I think those understanding the intranasal spray and being able to fully counsel on that and giving all the key information is very important. What are some of the other things that pharmacists can do? So we've talked about making sure that we're improving access to these products and making sure that we are providing support and resources to ensure that they are A getting a prescription for it and, b filling it and receiving it and, if there's any kind of barriers there that we're helping to overcome, those being in the know about any existing and new formulations of epinephrine so that we can answer questions, counseling, triage and OTC. And I think one of the other things that I want to touch on for a few minutes is what are all the different common triggers? So we've obviously mentioned a few of them, but let's just kind of reiterate what those triggers are. What are the things that we should be in the know about and should be counseling our patients on?

Speaker 2:

a large number of types of foods. So, as you said, nuts, eggs, milk, shellfish, soy, wheat and food labels are often calling out these things and that's another tip for avoidance is making sure that patients are reading those food labels, that they have certain food allergies, but when you're at a restaurant that may not be called out. So highlighting those discussions with staff, if needed, to try to identify potential allergens there. Also, as I said, stings, so hornets, wasps, bees there might be an insect sting reaction, medications too. So that's something that we think about with allergic reactions. But to your point earlier, what that reaction actually was is so important to dig down into.

Speaker 2:

So, asking about medication allergies, if a person says they have an allergy, what does that mean to them? Was it actually a side effect? Was it nausea, constipation, something like that to a medication? Was it something that they had years ago and they may not know what the actual reaction was? There's a big push to try to de-label penicillin allergies in particular, so that patients aren't having this allergy, live on with them forever and never can get a penicillin. So yeah, those are, I think, some of the big ones for pharmacists in general to be aware of. But yeah, any medication-related allergy is always something that's top of mind, I think, for us.

Speaker 1:

Absolutely, absolutely. And to that point too, another key thing that we can do in this space is be sure that after we're asking, getting the answers, that we're documenting it in the patient's chart and that we're making sure that it's there, we're actually paying attention to it, we're not bypassing that screen quickly. We're paying attention to the allergies and you know the reviews and the documentation that we have there. So I think that's another, just a key role that pharmacists can play is making sure that the system that we have is up to date and has the most accurate information for our patients. So let's dig into a few challenges briefly before we wrap up.

Speaker 1:

So we kind of talked a little bit about seeing some of that confusion over the counter, or maybe it's just you know, you're not visually seeing it, but your patients are asking about antihistamines versus epinephrine and making sure that we're clarifying that. Let's just briefly touch on misunderstanding or underuse of epinephrine and making sure that we're clarifying that. Let's just briefly touch on misunderstanding or underuse of epinephrine in an emergency scenario. Is there ever a case where I'm sure there is where patients think like, oh, I'll try an antihistamine first and then I'll use this as a last resort. But we know that that is not how it should be done, so maybe just speaking to that for a minute or so.

Speaker 2:

Yeah, absolutely. And again it's going back to that as soon as those signs and symptoms of anaphylaxis are starting, just treat, always err on the side of treating. And I again, I know there can be barriers to that for lots of reasons. It might be the needle is one reason, might be not being sure it's severe enough that it warrants treatment. But anaphylaxis progresses quickly and it happens quickly and so we don't want people to be holding back and waiting to see if it's going to get worse because you can die from anaphylaxis.

Speaker 2:

So it's really important to emphasize the point of erring on the side of caution and treating as soon as you have those symptoms. And again, I think of it like naloxone, where if someone is having an opioid overdose and if you're in doubt about what's actually happening or why the patient is unconscious, you give it. Same thing with hypoglycemia and giving glucagon If you're not sure, you would give it. It's an emergency situation and we want to make sure patients feel comfortable administering it and not holding back, because I think a majority of people do hesitate and that can lead to significant complications down the road or, like I say, death that's a real outcome that can happen from anaphylaxis.

Speaker 2:

So yes, encouraging treating ASAP at the first symptoms.

Speaker 1:

And I'm sure there is some misinformation out there or misunderstanding on some patients' part where it's like I don't want to harm my child by giving it when it wasn't needed. But we're talking about a, you know, a chemical that's already existent in the body, so it's not like.

Speaker 2:

It's a great way to put it.

Speaker 1:

Yeah, you can't you're not going to harm them. Even if it really wasn't an anaphylactic response, you know like they might just be ramped up for a little bit but it's not going to harm them. So I think just really kind of bringing that to light as well, in a sense of you know, don't delay and wait to see because you fear that giving it would be harmful if it really was an allergic reaction.

Speaker 1:

So, like you said, err on the side of caution and give it when you feel like it's needed. So yeah, and then I think the only other challenge that I really kind of wanted to touch on was and we already have, really which was just differentiating between adverse drug reactions and actual allergic reaction, as opposed to the difference so yeah. So I know that you wanted to spend a couple minutes. As we mentioned, pearls has so many great resources. I know that you wanted to spend a couple minutes.

Speaker 1:

As we mentioned, pearls has so many great resources, and so we really wanted to spend just a couple of minutes on showing you some of the drug charts that are available online and with your Pearls subscription. So, rachel, I'll let you share your screen, and so those of you that are listening, only you're not going to be able to see this, but maybe you can navigate to watch this at a different time, but those of you that are visually able to see this right now, rachel's just going to kind of quickly show us. This is the homepage of Pearls, and she's just going to show us where some of those drug charts are and reiterate where some of the information that she shared is available for you to access.

Speaker 2:

Absolutely, and I'll try to make this applicable to those listening too. But if you're on the Pearls homepage and just go to the search bar, you can just type in the name of a drug and then you get to our Pearls drug page and all of our drug pages are set up with these five key sections. So two of the sections that are sort of most interesting tend to be most interesting for pharmacists are the counseling points, which are really drilling down to some of those patient talking points that we ran through today, as well as the clinical points which clinical pearls talking about you know place in therapy considerations if you're working with a colleague, or considerations for the patient. So with an epinephrine we have both a parenteral page and an intranasal page. So again addressing both of those forms and if we just go on to the intranasal, since we talked about a few of those counseling points today, I just want to click on the counseling section and within the counseling points you can see we have these quick bullets. All of the bullets are expandable if you want to get a little bit more detail about them, but it's really meant to be again reinforcing those points that you're walking through with the patient.

Speaker 2:

So we talked about not priming single use only for each spray. You just put it straight into the nostril, you don't need to angle the spray one way or another. The importance of having that second dose available, and then you know the idea that we might see absorption of other nasal products for up to two weeks after use. So all of those points that we chatted about are just reinforced with these counseling points. And then we also have the instructions for use right within those counseling sections. So I know sometimes it's a little tricky.

Speaker 2:

You know, if you have the box you don't always want to open the box with the patient in front of you, you know.

Speaker 2:

So to just have that instructions for use that you can pull up on your phone or the computer and walk through that with the patient with them right there in front of you, and then they have the instructions at home for future reference.

Speaker 2:

So just an example of how our drug pages are set up and how you can get to those points quickly.

Speaker 2:

You know, josh, one thing I didn't mention before, that I was just thinking about as we talked about the dosing considerations, is with the injectors there are, you know, a couple of different dosing options depending on the patient's weight. So typically we think of the 0.15 and the 0.3 milligram dosing, depending on the patient's weight. So for children who are 33 to 66 pounds or so, you know that 0.15 milligram dose is typically recommended. But one thing that's interesting is, you know children grow right and so, like that's another point to keep in mind that as the child's growing, you might need to adjust their dose proactively as well and not forget that they're going to need a higher dose when they get close to that 66 pound mark. And some organizations actually suggest, at the 55 pound mark or 25 kilo, to go to that 0.3 milligram dose so that you're not at risk of underdosing, and so I just wanted to mention that I was looking on the page and seeing dosing information and, yeah, that's just a reminder that we need to be aware of that as the child's growing.

Speaker 1:

That's a great call out because, I mean, children grow so quickly, even within a year. So if you think of, you know like you've got it filled and you think it's going to last for a year and then midway through you know they've already surpassed it. So, yeah, that's a great call out. So, as I always like to do as we're wrapping up, rachel, what is the game changer here? What do you think is the critical take home point for our listeners from today's episode?

Speaker 2:

I think based on what we've talked about, the importance of not holding back on using epinephrine if you are having an anaphylactic reaction, encouraging patients to do the same and feel comfortable using it as soon as they have those symptoms. Being aware of the symptoms of anaphylaxis and you know we often think about, like the hives, the swelling, the maybe dizziness this feeling of doom is sometimes described the maybe dizziness this feeling of doom is sometimes described but also nausea, vomiting, diarrhea is another sort of symptom that I learned about again just in the last couple of years as a potential symptom of the anaphylaxis that can happen, you know, with, without those other symptoms.

Speaker 2:

So just being attuned to, you know, possible exposure and then those symptoms happening. And again treating proactively and then, as you said, just having these options available for treatment. Epinephrine options Epinephrine is the gold standard and we have auto-injectors. We have a couple of different auto-injectors, including a voice-activated one. We have the nasal spray now. So there are lots of options available and it's working with the patient and their insurance or other cost considerations to find out what's going to make the most sense for them.

Speaker 1:

Yeah, that's great. That's great. Well, rachel, thanks again for joining us. This has been great. It's a good refresher on allergic reactions and epinephrine in general, so just really great to have you again, and thanks for giving us your time today.

Speaker 2:

Thanks so much for having me. This is fun, thanks.

Speaker 1:

Absolutely. Before we wrap up, here's a quick tip Sign up for a free Pearls account at pearlscom and get free pharmacotherapy charts and other practical resources. These resources are designed to enhance your workflow and support patient care. If you're a CE plan subscriber, be sure to claim your CE credit for this episode of Game Changers by logging in at ceimpactcom. And, as always, have a great week and keep learning. I can't wait to dig into another game-changing topic with you all next week. As a reminder, we've launched a special podcast series in collaboration with our friends at Pearls, a modern drug information resource app and proud Health Mart Perks member. These crossover episodes called Game Changing Pearls combine Pearl's trusted evidence-based clinical tools with the same high quality education you're accustomed to accessing through Health Mart University, bringing you timely practical content to support your pharmacy. We're thrilled to partner with the Pearls team and continue this series with today's episode focused on allergic reactions.