FAACT's Roundtable

Ep. 259: Epinephrine 101

• Season 5 • Episode 259

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Even the most experienced patients and caregivers can sometimes become a little too comfortable when it comes to managing epinephrine. Over time, it’s easy to overlook key details or forget important steps. To help everyone stay sharp and fully prepared, renowned allergist, Dr. Michael Pistiner, joins us to talk all things epinephrine. Think of this conversation as both a refresher and a quick self-check to be sure you’re up-to-date and ready when it matters most. 

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Caroline: Welcome to FAACT's Roundtable, a podcast dedicated to navigating life with food allergies across the lifespan. Presented in a welcoming format with interviews and open discussions,

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Information presented via this podcast is educational and not intended to provide individual medical advice.

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Hi everyone, I'm Caroline Moassessi and I am your host for the FAACT Roundtable Podcast.

I am a food allergy parent and advocate and the founder of the Grateful Foodie Blog. And I am FAACT's Vice President of Community Relations.

Before we start today's podcast, we just want to pause for just a moment to say thank you to Aquestive Therapeutics for their kind sponsorship of FAACT's Roundtable Podcast. And please note that today's guest was not sponsored by or paid by Aquestive Therapeutics to participate in this specific podcast.

Even the most experienced patients and caregivers can sometimes become a little too comfortable when it comes to managing epinephrine. Over time, it's easy to overlook key details or forget important steps to help everyone stay sharp and fully prepared.

Renowned allergist Dr. Michael Pistiner joins FAACT's Roundtable podcast to talk all things epinephrine. Think of this conversation as both a refresher and a quick self checked to be sure that you're up to date and ready when it matters most.

Dr. Pistiner, welcome back to FAACT's Roundtable podcast. We're absolutely thrilled and delighted to continue this conversation about epinephrine and emergency response today. So thank you so much for your time.

Dr. Pistiner: Thanks for having me.

Caroline: You are very welcome. For listeners who may be new to your work or missed last week's podcast,

can you share a bit about your background and what led you to the food allergy community?

Dr. Pistiner: Yeah, so I am a pediatric allergist and I happen to be the father of now a 22 year old with food allergy and wearing the hat of dad of a kid with food allergy while being an allergy fellow drove me into advocacy and community education.

Now with time I've gotten very engaged in management of food allergy and anaphylaxis in infants and toddlers and I've been doing this work for a while and really enjoying it.

Caroline: Let's start at the very beginning. So when and why is epinephrine prescribed?

Dr. Pistiner: All right, so epinephrine is the medicine version of adrenaline.

Epinephrine is the treatment of choice for anaphylaxis and part of the reason why is because it works on all of the end organs. It works at all of the places where an allergic reaction is going to be occurring.

And it also works on the allergy cells. Now,

mast cells and basophils are typically the allergy cells involved in anaphylaxis, a severe, potentially life threatening allergic reaction. Now, at the risk of being impossibly repetitive, I'm going to keep repeating these things because this is the language that you guys, the viewers,

can use to teach other people.

And so epinephrine, again, it works where we want to and it works quickly and it works directly on these allergy cells, the mast cells and the basophils, and it stabilizes their membranes, making it less likely that they're going to continue to release what's inside them that are causing the signs and symptoms that we're seeing.

And so when the mediators of inflammation, the things that are inside these allergy cells are released, that's what causes some of the signs and the symptoms that we see. What's inside these things are going to be things like platelet activating factor,

leukotrienes, and then also histamine. Now, antihistamines are a medication that can be used for comfort and can be used to improve itchiness and other mild symptoms.

Just using antihistamines isn't going to take care of the other things that are happening in these potentially life threatening allergic reactions.

Caroline: I just have to stop you here for a second because this explanation is so clear of what is happening during a reaction, but how Benadryl,

and to me, this is the most profound statement I think I've heard all month is when you just said antihistamine is for comfort.

And so that really explained right now why epinephrine is critical because it does the big job. It does all the jobs to try to stop that reaction. But anahanahistamine sounds like, like you said, it's just for comfort.

It's just to ease it up and make us feel a little better, but it's not going to address all the problems.

Dr. Pistiner: Right. So I like to use, as we're talking about now, I like to say that an antihistamine is comfort medicine.

And it's, we have a lot of histamine receptors on our skin and mucosal surfaces.

And so having an antihistamine which could take 30 to 60 minutes to kick in,

can make itching and skin findings improve.

Now,

as I was mentioning earlier, epinephrine works practically everywhere. We want it to. But most importantly, epinephrine is working directly on the cell membranes of the allergy cells to make it less likely that they're releasing all the stuff that's inside them,

beyond just histamine, but including the other things, the other mediators of inflammation.

So now when those things are released, what they do is they also make blood vessels like leakier.

So capillaries can leak. And that's part of what is happening is fluid and other things are leaving the intravascular space.

So inside the blood vessels, the fluid leaves, and then it could come out and it can cause hives and it could cause swelling.

And if the fluid leaves the vessels,

then that's less intravascular volume. And that's part of why then somebody might have a much faster heartbeat. That's why somebody might have low blood pressure. And that's why somebody might need IV fluid through an IV because they're losing their intravascular volume pretty quickly during an allergic reaction.

And you can shut that down by treating with epinephrine.

Another thing that can happen is that the muscles in your veins can get loose and floppy. So if somebody stands up in the middle of an allergic reaction, gravity can kind of pull their intravascular volume down.

And again, less is coming back to the heart and the brain, and that can then cause extra signs and symptoms. Other things that are happening in the middle of an allergic reaction are the smooth muscle of our lungs are getting twitchy, and so that can cause coughing,

that can cause wheezing.

Mucus is also increased in production in our lungs as well. And so all of that can be causing some of the signs and symptoms. Now, if we're losing some of the fluid, like I mentioned before, in the upper airway, then that can cause swelling of the throat, making it harder to breathe.

It also can increase peristalsis of our gut, making us vomit, puke,

also giving diarrhea, and then also furthering fluid losses. Again back to the intra vascular loss of volume, which then makes somebody need an IV for IV fluid. But if you could stop all that stuff before it goes there,

then you don't need all the extra stuff because epinephrine shuts all that down.

Caroline: I feel like you just gave us a sneak peek inside the body and explained exactly what's happening and what's.

And then why that epinephrine is just key and crucial. It's the number one.

Dr. Pistiner: And you know, with that,

those are the things that can happen.

But each person may have a different allergic reaction than another person.

And Each person's severe allergic reaction can actually be different from another person's severe allergic reaction. And my own severe allergic reaction can be different than the one that I had the last time.

And so that's where understanding these patterns is helpful. To be able to get a sense of when you want to think about treating with epinephrine, but then ultimately knowing epinephrine is the answer to all of it.

Caroline: I love that. I wish the whole world was like that. Right. I just need one thing and this is going to be the big dog that's going to help me.

Dr. Pistiner: That's right. And so then that's kind of where, when in doubt, go ahead,

shut things down with epinephrine. Epinephrine gets control.

And then that over simplification that I was mentioning before, the epinephrine kind of stabilizing those allergy cells and making them less likely to release inside. That's also where I'm not really interested in seeing what's going to happen.

That's why it's kind of cool to just shut it down early. Because if you wait, then you could watch and see how somebody's like sneezing five times might turn into coughing and wheezing and then a really hard time breathing and using muscles to breathe.

You could see how a couple of local hives could then turn into full out swelling and fluid losses. You could see how some early vomiting could turn into full out vomiting with diarrhea.

And so shutting it down early is helpful. So, so this is where when I'm talking to families about when to think about using epi,

so what I say is that if you have even mild symptoms but in more than one system,

then that's a good time to think about shutting it down with epinephrine. So let's say a young child has hives around their face in the area where the food touched.

They now sneezed 10 times and they have hiccups.

Now we're talking about mild kind of nothing burger symptoms. If you just look at them by themselves, but you stick them together after an exposure to allergen. Now we have more than one system.

I'm not interested in seeing what's going to happen.

Shutting it down at this phase makes sense.

So now I think it's an oxymoron to say mild anaphylaxis. But I would call that early anaphylaxis with a set of mild symptoms that is in more than one system.

I think it's a great time to treat.

Caroline: Absolutely profound advice. This is so good and so solid. And so now, just turning to the epinephrine itself,

how many doses should a patient or parent and caregiver be carrying, you know, for their child? Should they have it on them at all time and at home?

Should they keep it in one place, the bathroom, front door? If you can just talk a little bit about just the care and feeding of the epinephrine. Basically, yeah.

Dr. Pistiner: So having epinephrine available is important,

and it's good to have two doses, because if for some reason the first dose,

like, went off in the parent's hand,

or if for some reason it didn't function, having the second dose to treat is really helpful.

Also, not all severe allergic reactions get shut down immediately entirely by the first dose. But then some people having a second dose available to treat is going to be important.

Now,

relatively recently,

recommendations have come out that allergists are now having conversations with the families that we take care of that maybe not everybody has to call 911 when they use epinephrine. So one of the things to just clarify is that back in the day when we were saying that for everybody,

it wasn't because epinephrine was given and then you need to call an ambulance.

It was that we were saying that epinephrine may not always work entirely. So you want to call an ambulance for backup.

But what people are realizing is that a lot of people were withholding epinephrine and not treating with epinephrine because they didn't want to call an ambulance.

And that's what we all want to do away with.

It's not the fact that you gave epinephrine to your child that makes you want to think about calling that ambulance. It's that if that epinephrine doesn't entirely take care of that allergic reaction, you want the backup.

You want the ambulance to be there. You want the potential for more epinephrine, more people,

IV fluid, oxygen, and then again the backup of being in the emergency care setting where there's more things and friends.

But what we're all realizing is that the earlier you treat,

the more effective the epinephrine is,

and the less likely you actually need what the ambulance brings.

So now with these new guidelines,

allergists are starting to have conversations with our families saying that if you have two doses of epinephrine available,

and they were only mild symptoms in the first place, but again, as I was talking about mild symptoms in more than one system,

and we are fulfilling the allergy action plan, Criteria for treating with epinephrine or whatever your primary care or allergy clinicians have told you and you do treat with epinephrine and that clinician gave you permission not to call 911,

then the only time that you wouldn't call 911 is if you have two doses available,

is if there were no severe,

scary symptoms in the first place.

You did fulfill criteria for treating with fe,

but it worked and almost entirely took care of all of the symptoms and they go away and they stay away.

Then that would be why somebody might give someone permission not to call 91 1.

Now, if there were severe symptoms in the first place, place,

let's say there was somebody who was coughing and wheezing and having a hard time breathing, then I would say, please give that epinephrine as fast as you can and call 91 1.

But in the example I used before,

and this I would say to my families, which is if the kid had exposure to the food that they're allergic to, they now sneeze five times. They have hives around their mouth,

they look good, but now they have some hiccups. Then I would have the family treat and then they would then look at the action plan that I gave them. They would call after the epinephrine was given, they would call our office and they would watch the kid.

And if they felt uncomfortable in the slightest, then they would call 911 and consider treating with a second dose.

But if the signs and symptoms all go away,

then they may not need to necessarily have that ambulance come.

Caroline: Well, and I think one of the key words you just said too was permission, that it's important to work with your physician and discuss.

And like you said, get the permission, have the action plan, get the guidance to learn when to administer epinephrine.

Dr. Pistiner: By the way, with that permission,

I'm talking about at the healthy check in,

not during the allergic reaction. Right.

So this is where I encourage these conversations at the well, child visits with primary care. I encourage these conversations at the check in with the allergy team at the beginning of the year or whenever, but during an allergic reaction.

Please follow the plan that your allergist team already set up with you.

Do not deviate. I am not your allergist. Don't listen to me, listen to them.

But this is a conversation you want to have when your kid is well.

Caroline: That is a great, great point. And can you just quickly review the actual administration of the epinephrine? We had a really great discussion in the last podcast about infants and Toddlers, but with an older child or just an adult.

What tips do you have? I mean, I know we get trainers in their videos, but if you don't mind touching on that.

Dr. Pistiner: Yeah, I mean, I think getting the trainers and getting really comfortable with the trainers and understanding the nuances of each of the epinephrine,

the self administered epinephrine, community administered epinephrine. So now what's fun is, is that now we're needing to change the way we talk about the epinephrine that's available in the community setting.

Because now in addition to the intramuscular,

now we have intranasal and we also have,

FDA is likely going to approve for 2026 a sublingual version. So we're going to have different modalities of epinephrine, which is neat.

The thing is that I like to get across is that the FDA approved ones,

they all work and, but they only work if you use them and they only work if you know how to use them. So ultimately, in whatever modality of the self or community administered epinephrine you have or your child has, you're going to want to use the trainers, you're going to want to learn about how to administer the epinephrine and have it available and have it available in two doses.

Caroline: Dr. Pistiner, can we just circle back around and talk a little more about caring epinephrine? And with Halloween coming up and all the different holidays, holidays and all this travel,

I know that carrying epinephrine is more important than ever. So can we talk a little more about that?

Dr. Pistiner: Yeah, you always hear me talking about the pillars of food allergy management,

of prevention and emergency preparedness, and that we need those pillars no matter where we are and no matter who we're with. And if it's Halloween,

if it's traveling to your family on Thanksgiving,

you need to maintain those pillars of prevention and emergency preparedness.

And the pillar of emergency preparedness only exists with epinephrine.

Now, in some cases, somebody might not administer epinephrine the right way the first time. And having a second dose available is nice for backup.

Another practical thing to think about is that I mentioned earlier that the practice parameter update on the management of anaphylaxis allows allergists and other healthcare clinicians to talk about the option of not necessarily calling 911 when somebody treats anaphylaxis with epinephrine.

Now, one of the stipulations is that you need two doses available.

If you are going to not call 911 when treating anaphylaxis with epinephrine. And so that's the first practical thing is, is that when I talk to my families and I am talking about that option, I don't give a family that option if they only have one dose of epinephrine available.

Caroline: Now let's dive into travel a little bit. What do you recommend? If someone's getting on an airplane or they're taking a road trip,

should they bring prescription with them? How many should they carry? Can you just touch on that?

Dr. Pistiner: Yeah, I mean, some things to think about as far as airplanes are going to be that having epinephrine available on the airplane is going to be really important.

Thinking about also where you hold your epinephrine is going to be key.

Having it on your body and in the cabin with you is going to be important because if you were to put it in your bag, that then gets checked, and then that's in the external parts of the airplane that don't have the same temperature and as inside the cabin,

then you can have extremes of heat, or if the luggage stays on the tarmac and it's very, very hot, then epinephrine can fry. And if it's very, very cold, then you could be concerned with freezing.

And so bringing them on you in the cabin with you is the only way that you actually can use it if you need it on the airplane itself. And the best way to ensure that your epinephrine stays viable.

So you could then use it on vacation if you needed it.

Caroline: I always make sure that I don't even put it in my carry on that it goes above me. As soon as I get onto the plane, we pull out the epinephrine and I have asthma, so I have my asthma inhaler and I put it in my pocket and I make sure everything is in a pocket or within an arm's reach because I'm short too,

so getting up to the overhead bin is a little tough and especially if you're on the window seat. So it's our family policy just to have it within, like, a physical reach so we can actually grab it.

But also, is there a certain number of epinephrine devices you would recommend? Is it okay to have two as you get on an airplane? Should you bring four or how many?

If you have access to multiples,

at least two.

Dr. Pistiner: Two is what I recommend all the time for some of the points that I just talked about before.

But then having additional epinephrine doses available in case you lose A bag in case you leave it somewhere and it fries. It's nice to then have backup so you don't have to worry about checking in at a pharmacy and then getting your doctor to call in the prescription.

And then you lose a couple hours of your day trying to get your medicine where if you just had an extra two pack available, then that would have saved you a lot of time and headache.

So it's nice to have extras for backup.

Also, one thing that I also like to keep in mind is that reminding people again that it's not using epinephrine that makes you call 911 or makes people in the past say that you call 911 or an ambulance.

It's the fact that somebody's having an allergic reaction that requires epinephrine. Because if the epinephrine didn't work fully,

then it's nice to have the folks that bring more epinephrine,

oxygen,

IV fluid on the ambulance. But if you're on an airplane,

nobody's coming for backup. And so dealing with an allergic reaction swiftly and early is the key.

So that's where you don't want to delay.

You want to treat as soon as you're fulfilling the criteria that your doctor talked about or your healthcare team talked about with you and that your action plan suggests. And so being a little bit less choosy for what you treat and a little bit earlier in treatment makes sense when you're 35,000ft up.

Caroline: Thank you so much. Because we need these reminders. You know, you have to remember we first learned about epinephrine at diagnosis. And if you're in 10, 15, 20 years, you start to forget things.

So thank you very much. Is there anything else you would like to add about carrying epinephrine?

Dr. Pistiner: Getting used to making it. Part of what you do is you're not going to leave your house without your keys,

you're not going to leave your house without your pants.

Don't leave your house without your epinephrine.

Caroline: Perfect. Thank you so much.

So our time once again has gone by so fast. I just enjoy speaking to you because again, you explain it in ways that, you know, I don't know, lifts up the veil so we can understand what's behind it.

So then we can understand what and why we're doing and why it's so critical. And I just think, I just love this.

So before we say goodbye today, is there anything else you want our listeners to hear from you?

Dr. Pistiner: Yeah, I think that my closing point the last time is that if you're ever feeling uncertainty and you're feeling like you're losing control when you're thinking about an allergic reaction, then epinephrine is going to get control.

And when your child is well and when you're not in the middle of a circumstance like that, learn as much as you can so you can teach all of the people who are going to be responsible for your kid to get comfortable so they can get control.

And then also kind of the parting comment is that it makes you feel better fast,

especially if you're in the middle of a severe allergic reaction. So that's something to keep in mind.

Caroline: Absolutely brilliant podcast. Brilliant advice. Thank you so much for your time. You are so incredibly busy. We appreciate every minute you spend with us. So thank you so much.

Dr. Pistiner: Thank you for having me.

Caroline: Before we say goodbye today,

we just want to pause for one more moment to say thank you to Aquestive Therapeutics for their kind sponsorship of FAACT's Roundtable Podcast.

And please note that today's guest was not sponsored by or paid by Aquestive Therapeutics to participate in this specific podcast.

Thank you for listening to FAACT's Round Table Podcast. Stay tuned for future episodes coming soon.

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Have a great day day and always be kind to one another.