Ep. 303: Allergic Reactions - Why Epinephrine Comes First

When an allergic reaction strikes, timing matters—and epinephrine is the first-line treatment for anaphylaxis. Today, there are more ways to deliver epinephrine than ever, from auto-injectors to nasal spray, with additional options being studied. But no matter the delivery method, the message is critical: epinephrine first—and fast.

Joining us is allergist and FAACT Medical Advisory Board member and allergist, Dr. Manisha Relan, who breaks down why using epinephrine promptly matters, what happens when treatment is delayed, and how taking action quickly can impact the course of an allergic reaction.

Resources to keep you in the know:

• Dr. Manisha Relan
• FAACT's What is Anaphylaxis
• FAACT's Signs and Symptoms of Anaphylaxis
• FAACT's Anaphylaxis Treatment and Management

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Sponsored by: ARS Pharma

Thanks for listening! FAACT invites you to discover more exciting food allergy resources at FoodAllergyAwareness.org!

Transcript

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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,

each episode will explore a specific topic, leaving you with the facts to know or use.

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

Please consult with your personal board certified allergist or healthcare providers for advice specific to your situation.

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 GratefulFoodie Blog. And I am FAACT's Vice President of Community Relations.

Before we start today's podcast, I just want to pause for just a moment to say thank you to ARS Pharma for being a kind sponsor of FAACT's roundtable podcast.

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

When an allergic reaction strikes, timing matters. And epinephrine is the first line treatment for anaphylaxis.

Today there are more ways to deliver epinephrine than ever, from auto injectors to nasal spray, with additional options being studied.

But no matter the delivery method, the message is critical. Epinephrine first and fast.

Joining us is allergist and FAACT Medical Advisory Board member Dr. Manisha Relan, who breaks down why using epinephrine promptly matters, what happens when treatment is delayed, and how taking action can quickly impact the course of an allergic reaction.

Welcome back, Dr. Relan, to FAACT's Roundtable podcast. I have been looking forward to this podcast because this is such a critical topic that there's just so much misinformation out there.

And I just want to have this conversation so we can just help our listeners and help the community.

Dr. Relan: Thank you. I'm so excited to be back and I agree with you. This conversation is very important.

Caroline: That it is.

Before we jump into our topic, we'd love for our listeners who may not know you yet to get to know you.

So can you share your journey into the food allergy community and how your passion for patient education has grown from your work as an allergist to social media and even becoming an author.

And you're going to be a speaker soon at our Allergy Summit.

Dr. Relan: Yes.

Thank you so much. I think you pretty much covered it.

I am a pediatric allergist. I would say I've always been interested in food,

mostly because we all eat food right? But also growing up as a vegetarian in a predominantly meat eating society just kind of being aware of how I was a little different compared to my peers.

And then I think it translated into like understanding the food allergy community and just having empathy in a way that, that just made sense. And then I entered into undergraduate studies.

I majored in nutrition and food sciences because I knew I wanted to be a doctor and I wanted to understand how food really worked and the science behind the food.

Not realizing at that point that I was going to end up being an allergist, that was never on my radar, really. It was my love of immunology that drew me to allergy,

and that happened during residency.

So here we are. Long story short,

I am a practicing clinician, clinical private practice setting,

and I see patients. I've dropped to part time so I can tend to my motherly duties and taking care of myself. As many of us in the sandwich generation knows, there's a lot of give and take.

And that also freed up my time a little bit to focus on my passion, which is education.

I missed education and being an academic so much when I went into private practice. And then I thought, wait,

why am I limited? Like, I'm in private practice, but I can be just as academic here if I want to be. It's all in my mindset.

And so I'm like, I have access to these journals. I may not be the one doing the research yet,

but I can read research and I can interpret and I can take with it, you know,

build a community. And now I have many friends online who are equally passionate. And our topic at the, at the upcoming Allergy Summit is going to be focusing on education and raising awareness and advocacy.

Right.

Myself in particular, I will be talking about sharing evidence based content online.

So being online has afforded me a lot of opportunity to connect with many different types of people, including building a team and falling into a space of the infant world where early introduction is helpful, but not 100% protective, and jumping kind of into just how do you feed infants and what can I do,

what kind of education can I promote that I want the public to know before they meet me,

like where I wish they had received that information beforehand to be more proactive. And so that kind of led me into falling into the 101 before one community,

which then led me falling into the AAP and writing a book with the AAP publishing it. And it's just kind of gone on from there, I suppose.

Caroline: You have quite the path and it's really fun watching you unfold because you are constantly changing. And I love this and Growing.

So we're just very appreciative of you serving on FACTS Medical Advisory board, speaking at our summit, and participating in these podcasts, and just appreciative of everything you do in the community for education.

So thank you for all of that.

Dr. Relan: Absolutely. It is my absolute honor. Thank you for having me back.

And I love anything about allergies. So I can talk to anyone for any length of time.

Just tell me when and where.

Caroline: And that's why we love you. We love that.

So now let's dive in. Before we talk about why epinephrine is so critical. Help us understand what's actually happening inside the body during an allergic reaction and, and then why things can escalate so quickly.

Dr. Relan: Yes, Actually, I want to address a really common misunderstanding about anaphylaxis. People think that taking an antihistamine is a treatment option for anaphylaxis. And the reason it is not is because of the very pathogenesis of anaphylaxis.

Anaphylaxis is an immune mediated reaction that occurs by activating two allergy cells in our body.

Mast cells and basophil,

which by the way, the basophils don't get enough love. I feel like a lot of people talk about mast cells, but people forget about basophils. And what's unique about these cells is that they have these IgE molecules and they get cross linked.

And this is the most common type of anaphylaxis. We can talk about zebras in another talk.

This is this cross linking. So this like eating something that you're allergic to, for example, getting a bee sting is also an example of anaphylaxis. Latex can be certain medications can it, even allergy shots can induce anaphylaxis.

So whatever your thing that you're allergic to, we call that an antigen. So whatever your thing that you're allergic to or your allergen,

you are exposed to it, your immune system is exposed to it and it causes this cross linking of the IGE that's already on the mast cells and basophils. And it kind of sets off this chain reaction.

The activation of the mast cells or, and, or the basophils causes a release of ton of mediators and histamine is one.

But there are way,

way more mediators like tryptase and proteoglycans. And I can send you a list if you want to read about all of them. But they all kind of activate this storm cascade and get other cells involved because it's all a signaling mechanism.

So kind of like sending off the smoke, that's sending off the fire, and it's kind of like all encompass.

So taking an antihistamine only interferes with one of those many cascade of reactions.

And that is why antihistamines are not the first line treatment for anaphylaxis.

So very multifactorial. So many different triggers, and then lots of different types of mediators that get released that send signals to different parts of our body. So this is what we see, right?

Why do we see hives?

Why do we have trouble breathing in anaphylaxis? It's all because of these mediators that go and act on the blood vessels,

they go and act on the skin cells,

and they cause that histamine release which causes that bump to appear that looks like a mosquito bite. That itchiness that follows,

it's all from that cascade.

Caroline: I think that is the best explanation I have ever heard in my life.

I understood things that I didn't understand before that I just was like, well, I just take that for granted. I'm not very medical and there's magic that happens in there in a way.

This was amazing. What a great explanation. I am going to make sure that my kids listen to this podcast. This is amazing. Thank you so much for that.

So now that we understand what's happening inside the body, let's talk about epinephrine and what exactly is it? How does it work? And then why is it so critical for stopping a serious allergic reaction?

Dr. Relan: Yeah, I think that there's a lot of questions in one, so let's break it down one at a time.

Epinephrine is almost like a naturally occurring thing, you know, it's our adrenaline, it's. We make it inside the body, too. This reaction, severity of anaphylaxis,

it can range. It's a syndrome of type because it can have mild symptoms,

which is why sometimes people will say, oh, but I gave my kid an antihistamine and they were fine.

Yeah, because the anaphylaxis was mild and your own body's physiological response took care of the rest,

that the antihistamine could not treat.

Whereas when you have moderate or severe symptoms, you're going to need that epinephrine from another source from the outside the body, basically,

which is when we give the epinephrine auto injectors or we use a nasal epinephrine device, it's giving our body something that our body knows and recognizes in a larger quantity to combat the cascade that was Started by that allergen.

So epinephrine acts on multiple receptors,

and that is why it is first line treatment. It's not histamine specific.

It's not histamine specific.

So it acts on the whole cascade.

And what it does is that it acts on the adrenergic receptors of the body,

of which we have quite a few.

We have alpha and beta receptors, and you guessed it, we have Alpha 1, Alpha 2, Beta 1, Beta 2. Like, it just doesn't end. We can keep going more and more and more microscopic as we desire, keep magnifying the lens, if you will.

And so the three main receptors that are really important is alpha 1, beta 1, and beta 2.

And these receptors on the body are found in things like our lungs,

in our skin,

in the smooth muscles, I should say specifically, and then in the heart. And so basically, we're changing the blood pressure because we are constricting the blood vessels.

We're going to decrease the fluid shifts from our blood vessels back into our blood vessels, so it goes away from the tissue and it increases the heart rate. It gets the heart pumping again,

relaxes the muscles in our lungs so we can breathe again.

And there's no other medication that can do this at this moment in time that can compete with how fast and how effectively and how many multiple receptors that epinephrine can hit.

Caroline: I can't stop saying this,

but how you're explaining things makes such big sense, because, you know, you hear so many people talking about using an antihistamine and even saying that in casual conversation. Oh, I always carry my antihistamine and I always take that first.

But now you're explaining that basically, if we were to do that,

we're not going to hit everything that needs to be hit to stop that reaction. I mean, it might hit one thing, right? Not going to hit this whole array.

This is incredible.

Dr. Relan: Well, and sometimes I tell people, and this is not me giving medical advice to anybody over the podcast, but just I tell people you can take a step by step if you know the definition of anaphylaxis is two body systems getting involved.

And so you. If your only manifestation is itching or your only manifestation is skin, it is written in the guidelines. So you can use an antihistamine. But the minute the second symptom starts, we need to be thinking about epinephrine, because now we're crossing borders and we're trying to stop a cascade.

I mean, think about.

It's almost like a waterfall, like the dam being open, you know, Like a small leak, we can temper it. But, like,

when it's big and it's just crushing, like, we gotta. We gotta stop.

We gotta use the right medication.

The timely delivery of epinephrine makes a difference, because the bigger and broader that cascade and the wilder it gets, you know, the harder it is to stop. And that's why in 10% or so of reactions, you might need a second dose.

Caroline: Can you talk about that? Needing a second dose?

Dr. Relan: Yeah.

So there are many reasons why a person may need a second dose of epinephrine, or one may be the amount of allergen ingested.

One may be the delay in using epinephrine. So the cascade has kind of gotten wild and out of control. This doesn't happen, thankfully, very often,

but it does happen.

And we practicing allergists have seen it.

Sometimes it's unpredictable, which is why we have to carry epinephrine. I wish we could predict all the reactions. I wish we didn't have food allergies. You know, I wish we didn't have to have this podcast episode today.

But we do, and we're stuck with what we got. So we just have to remember that occasionally in about 10%. Some studies vary with the number,

but the ones that most practicing allergists keep in mind is about 10% of people will have a reaction that might need a second dose of epinephrine.

And of that 10%, an even smaller amount will need a third or more. They will need more care, who will need an escalation in their therapy.

Caroline: Thank you so much for explaining that, because definitely I've seen that in my son, where he's administered his epinephrine, and then you can see,

you know, certain symptoms elevating after a little bit. And I'm just glad you explained that, because I think it's really important for people to realize that.

Dr. Relan: Yeah, I mean, there's many other factors, and

many co factors that we consider anaphylaxis that can change your threshold for accepting an allergen,

and quantity and timing of epinephrine are just 2. But I don't want to leave people stranded and think like, oh, but in my case, that wasn't true.

Having asthma, having uncontrolled allergic rhinitis, having stressors, psychological exercising, menstruation, other medications, alcohol. Like, there's a long, long list. So I don't want anyone to walk away with a negative feeling.

This is not your fault. It just happens.

If we were perfect human beings, and we could be perfect and not Having this diagnosis, that would be amazing.

And we have to let that, like, give ourselves grace. So we don't know everything at all times, and we're just gonna walk away with what we can take away from today, which is to be prepared.

Honestly, like, that's what I wanna leave this podcast episode today with. Why are we being prepared?

Caroline: That's perfect. And, you know, and thank you for mentioning giving ourselves grace. I think sometimes we expect ourselves to be perfect since it's related to a health care concept. But, you know, we're all human, and so I really appreciate you saying that.

Dr. Relan: Yeah. I've met many, many families who didn't realize when they came to see me for the first time that the reaction they described to me was anaphylaxis. Like, they didn't realize.

And it's like having that conversation is so hard because I don't pass judgment. You didn't know.

And even if you knew,

sometimes the healthcare facility that you go to to receive emergency care downplays the reaction or won't take you in or doesn't believe you or just any kind of X, Y and Z gets inserted.

And so shaming doesn't help us get anywhere.

It just doesn't. And so why even bother? It's like, let's use this as a moment to learn and let's get better.

Caroline: Well put. Absolutely. Perfectly put.

Now let's bring it all together with the message that you want every listener to remember. Epinephrine first and fast.

Can you talk to that now?

Dr. Relan: Yes.

EPI first and EPI fast. For all the reasons that we just discussed in terms of how it works, what's happening with anaphylaxis, and why there's all these other co factors that we can't always account for.

So the faster we deliver this medication, the faster the symptoms can resolve and hopefully everyone can breathe easily.

My other one big takeaway is to carry the device that you will not hesitate to use.

And there are so many devices out there on the market with more to come.

So if you haven't been aware, I'm still meeting people that don't realize that epinephrine is available in a nasal spray form.

Soon,

I think maybe we'll see how it all goes this fall. We might even have an under the tongue option.

And so having different types of auto injectors on the market, having this nasal, potentially new option with the sublingual just. There's multiple devices. Yes, I know. Insurance limits some of our ability to make those choices in terms of what we can carry and what we can afford to carry rather.

But just having a form of epinephrine that you will not hesitate to use is my biggest plea.

Carry what you will use.

Caroline: That is such a strong message. I again appreciate it so much. But that is such a strong and important message for everybody to hear.

So before we say goodbye today, is there anything else you want listeners to hear? You've covered a lot, but I just want to see there might be something else you want to share with people.

Dr. Relan: I think that one last thing is sometimes people hesitate to use expired devices and that is true. We don't want you to use an expired device. But in Anaphyaxis,

if that is the only thing available to you,

my plea is to make sure that the window, if it's an auto injector, is clear and see through.

So as long as it's not a contaminated device,

you know, just anything is better than nothing.

Antihistamines are not. First sign EPI first and fast. Carry what you will use and give ourselves grace.

Caroline: Perfect. Absolutely perfection.

Thank you so much, Dr. Rayland for your time. You are very busy, but your passion is so strong and that's coming through today.

And you just have a brilliant way of communicating. So thank you so much for being with us today.

Dr. Relan: Thank you for having me. It's been a pleasure.

Caroline: You're welcome.

Before we say goodbye today, I just want to pause for one more moment to say thank you to ARS Pharma for being a kind sponsor of FAACT's roundtable podcast. And please note, today's guest was not sponsored by or paid by ARS Pharma to participate in this specific podcast.

Thank you for listening to FAACT's Round Table Podcast.

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