Ariana Hawkins, PharmD candidate

As everyone prepares to head back to school, it is important for all to be prepared for crises that can arise.

Anaphylaxis is a life-threatening health condition that can be induced by several triggers (see table 1).

Prompt epinephrine administration can reduce morbidity and mortality.

 Children with severe allergic conditions must have immediate access to epinephrine for life-saving emergencies.

Epinephrine is a nonselective alpha- and betaadrenergic agonist that can reverse anaphylaxis and serious allergic reactions (see table 2).

 It is available in various formulations such as auto-injectors, injectable solutions, and prefilled syringes, with more formulations on the horizon. An auto-injector and a prefilled syringe both contain a single ready-to-use dose of epinephrine.

Epinephrine auto-injectors have been in short supply since May 2018. This shortage has led to a surge in the use of epinephrine prefilled syringes.

Epinephrine increases vascular permeability and lessens the vasodilation experienced during anaphylaxis.

 The medication also alleviates bronchospasms and dilates bronchial smooth muscle.

 It comes in 2 formulations: 0.15 mg, for patients who weigh 33 to 66 lb (15 to 30 kg); and 0.3 mg, for patients who weigh 66 lb (30 kg) or more.

 Although epinephrine has no known contraindications, several drug classes can interact with it (see table 3).

 Caregivers and physicians should carefully observe patients receiving epinephrine who are taking medications within these drug classes concomitantly for the potential development of severe adverse effects and reactions.

Prominent warnings indicate that epinephrine use does not replace immediate medical care. Pharmacists need to advise patients to check the syringe solution’s turbidity and discard and replace the syringe if the solution is cloudy with or without particulates.

 The prefilled syringe comes in a convenient 2-pack carrying case with a safety guard to encapsulate the needle after use.

An important distinction between epinephrine auto-injectors and prefilled syringes is that patients must manually insert the prefilled syringe needle and push down the plunger to administer the medication.

 Auto-injectors, on the other hand, inject the substance automatically.

Pharmacists should note warnings about several patient populations. For pediatric patients, the Centers for Disease Control and Prevention recommends injecting epinephrine into the outer thigh until 2 years of age.

 After that age, when the deltoid muscle is more developed, parents or patients can inject it into the deltoid muscle or outer thigh.

Few studies have examined the use of epinephrine in patients who are pregnant.

Older patients should use epinephrine cautiously, because of their greater risk for adverse effects.

Larger amounts of subcutaneous fat tissue associated with obesity create difficulty in establishing an effective dose of epinephrine for emergencies. Epinephrine auto-injector needles are often too short for patients with obesity

 and, in emergency situations, intravenous administration of epinephrine in hospital settings is deemed safer.

 Investigators have considered formulating higher doses of epinephrine and longer needles for patients with obesity, but clinical studies are needed.

Patients with diabetes, heart disease, hyperthyroidism, and Parkinson disease should use epinephrine cautiously, as they can experience worsening symptoms.

Lack of correct use and response are the 2 most common obstacles caregivers and patients face, which can lead to fatal anaphylactic reactions.

 Health care professionals must explain directions to caregivers and patients regarding the proper use of epinephrine devices.

Epinephrine prefilled syringes cost less than epinephrine auto-injectors, making the product more accessible to patients. 

Auto-injectors and prefilled syringes should not be stored in the refrigerator or in a vehicle’s glove compartment.

 They should not be exposed to extreme temperatures or light, as these conditions can affect the drug’s potency.

Although epinephrine has a short duration of action, it is stable and sterile in syringes for up to 3 months.

 Patients should replace the syringe before it expires to ensure that an active drug is administered.

Health care professionals play an important part in emergency preparedness related to anaphylaxis. Pharmacists can educate caregivers and patients about anaphylaxis prevention and reinforce proper epinephrine delivery techniques. Providing patients with pertinent knowledge can help reduce morbidity- and mortality-related events.

 is a PharmD candidate at the University of Connecticut School of Pharmacy in Storrs.

First aid—anaphylaxis. Mayo Clinic. February 6, 2018. Accessed July 28, 2020. https://www.mayoclinic.org/first-aid/first-aid-anaphylaxis/basics/art-20056608

Ratanaprug C, Srisuwatchari W, Jirapongsananuruk O, Visitsunthorn N, Pacharn P. Carrying rates of epinephrine devices in children with food-induced anaphylaxis. 

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An epinephrine prefilled syringe (Symjepi) for anaphylaxis. 

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Symjepi—epinephrine injection. Prescribing information. Sandoz, Inc; 2019. Accessed July 28, 2020. https://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=b1c6a201-4f23-489f-9fcaf8c82bb9fa58

Current and resolved drug shortages and discontinuations reported to FDA. FDA. May 9, 2018. Accessed July 28, 2020. https://www.accessdata.fda.gov/scripts/drugshortages/dsp_ActiveIngredientDetails.cfm?AI=Epinephrine%20Injection,%20Auto-Injector&st=c&tab=tabs-1

Epinephrine auto-injectors. American Society of Health-System Pharmacists. July 23, 2020. Accessed July 28, 2020. https://www.ashp.org/Drug-Shortages/Current-Shortages/Drug-Shortage-Detail.aspx?id=420

Brown JC. Epinephrine, auto‐injectors, and anaphylaxis: challenges of dose, depth, and device. 

 2018;121(1):53‐60. doi:10.1016/j.anai.2018.05.001

Moss J, Jani Y, Edwards B, Tomlin S, Rashed AN. Pharmacokinetic and pharmacodynamic evidence of adrenaline administered via auto-injector for anaphylactic reactions: a review of literature. 

. Published online June 19, 2020. doi:10.1111/bcp.14438

Prince BT, Mikhail I, Stukus DR. Underuse of epinephrine for the treatment of anaphylaxis: missed opportunities. 

. 2018;11:143-151. doi:10.2147/JAA.S159400

Moss RB. Anaphylaxis: getting to the point (and price) of diagnosis and treatment. 

. 2018;11:109-110. doi:10.2147/JAA.S170650

Articles

Pharmacists can educate caregivers and patients about proper epinephrine delivery technique.

Prepare for Anaphylaxis in School-Aged Children

Patients with cancer use cannabis to manage their symptoms related to their diagnosis and clinical treatments. With medicinal cannabis research in its infancy, many health care providers are unsure how to provide accurate counseling and appropriate treatment to their patients.

 published a study in its May 2020 issue indicating the lack of knowledge about cannabis recommendations along with notable barriers among health care professionals regarding direct patient care. These investigators identified monitoring patients’ cannabis use, prescribing an accurate dose or strain, and insufficient research as significant barriers.

In this study, an anonymous 45-question survey measured health care professionals’ opinions regarding cannabis use in oncology. Oncology nurses, radiation therapists, and pharmacists were among the participants.

The survey results indicated that a collective lack of knowledge in cannabis drug therapy made them unable to recommend this substance. More than half of respondents said they would need more information or training to feel confident about cannabis.

Despite the collective lack of knowledge, researchers reported that many participants counseled patients about cannabis use in the month preceding this study. To eliminate knowledge gaps, teaching future health care professionals about cannabis education early in their curricula can improve clinical preparedness. 

The lack of clinically-based research regarding cannabis use increases concern about potential drug interactions with patients’ other cancer medications and adverse drug reactions (ADRs) to cannabis. This is especially a concern within older patients and those with cognitive impairment or mental illness, as they are more likely to experience cannabis-associated ADRs.

Given these study findings, health care providers need more clinical cannabis research, education, and training to correct knowledge gaps and barriers to effective treatment for cancer patients.

 is a 2021 PharmD candidate at the University of Connecticut in Storrs.

McLennan A, Kerba M, Subnis U, Campbell T, Carlson LE. Health care provider preferences for, and barriers to, cannabis use in cancer care. 

. 2020;27(2):e199-e205. doi:10.3747/co.27.561

With medicinal cannabis research in its infancy, many health care providers are unsure how to provide accurate counseling and appropriate treatment to their patients.

Study: Health Care Providers Need More Knowledge About Medicinal Cannabis Use in Oncology

Most clinical studies regarding cannabis use have centered on its primary phytocannabinoid constitutes, delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD). THC is classified as mood-altering with its psychoactive components; CBD has no significant mood altering effects. The lack of clinical research surrounding cannabis limits its use as an effective therapeutic option to patients.

 published a study in its May 2020 issue assessing health care providers’ knowledge and beliefs related to medical cannabis use. Researchers distributed an online survey to neurologists, nurses/practitioners, and pharmacists to glean information related to their knowledge, attitudes, and beliefs.

Surveyed participants supported the use and legalization of medicinal cannabis, but half were unacquainted with its clinical use and pharmacology. Study results indicate cannabis has potential in medicine due to growing interest, however, the lack of clinical research and knowledge limits provider recommendations.

The study concluded that pharmacists reportedly scored higher on the knowledge test than neurologists and nurse practitioners. Results also showed that nurse practitioners had more favorable attitudes toward medicinal cannabis use than neurologists and pharmacists.

The study correlated participants’ geographic locations and survey responses. Participants employed in states with legal access to cannabis are more open to medicinal treatments compared to states with restricted policies in place. The results also indicated that younger health care professionals are more open to recommending cannabis as a therapeutic option than older health care professionals.

Providing cannabis-related education early on in future health care professional curricula can lead to better preparation in addressing patient inquiries surrounding cannabinoid therapies.

Szaflarski M, McGoldrick P, Currens L, et al. Attitudes and knowledge about cannabis and cannabis-based therapies among US neurologists, nurses, and pharmacists. 

. 2020;109:107102. doi:10.1016/j.yebeh.2020.107102

The study concluded that pharmacists reportedly scored higher on the knowledge test than neurologists and nurse practitioners.

Study: Health Care Professionals Vary in Their Beliefs About Medicinal Cannabis Use

Most people recognize Vitamin D for its bone health benefits. Many are unaware of its pleiotropic effects including from neuroprotection, brain development, immune protection, and various other benefits.

Vitamin D is a neurosteroid responsible for brain maturation and growth, and stimulation of the most important antioxidant in the brain, the neuroprotectant glutathione (GSH). It also regulates melatonin production and hormone regulation responsible for the development of normal sleep patterns and human circadian rhythm.

Vitamin D deficiency is associated with medical conditions such as Alzheimer disease, Parkinson disease, autism, OCD, sleep impairment, infectious/inflammatory diseases, autoimmune disorders, and mood disorders such as treatment-resistant depression.

 recently published an article related to Vitamin D’s role in treatment-resistant depression.

 The study suggested that Vitamin D supplementation was useful in improving symptoms of Vitamin D deficient patients with mood disorders, especially in patients with reported inflammatory-related conditions.

Recent evidence in clinical literature suggests that the development of autism spectrum disorders may be attributable to maternal Vitamin D deficiency. Vitamin D is a critical contributor to immune function during pregnancy as the placenta contains a considerable amount of Vitamin D necessary for fetal development. Vitamin D deficiency can also increase risks of inflammatory and infectious diseases given its role in innate and autoimmunity in various medical conditions.

Bone health will no longer be recognized as the predominate benefit of Vitamin D. This article highlights its effect in neurological development, autoimmunity, and sleep regulation as just a few of its underlined pivotal roles. Further research create better understanding of more effective therapy regimens to patients eligible for Vitamin D supplementation.

di Michele F. Why Vitamin D Status Might be Important for Brain Health and Mental Well-Being?. 

. 2020;26(21):2439-2441. doi:10.2174/138161282621200520085710

Vitamin D is a neurosteroid responsible for brain maturation and growth, and stimulation of the most important antioxidant in the brain.