Epinephrine is cheap. My office purchases a multi-dose vial for less than $10.
That is why it is ironic that there has been so much discussion and debate recently about the increased cost of EpiPens, which are well-known auto-injectors for epinephrine. The reasons for the price uproar can be found in a combination of supply and demand, lack of competition, insurance deductibles and increasing allergies.
First, it is useful to define the risks of allergies and anaphylaxis, a severe, potentially life-threatening allergic reaction.
As many as 15 million people in the United States have food allergies, which occur in 8 percent of children and 4 percent of adults. Food allergies have become more prevalent in recent years and result in 200,000 emergency room visits each year.
Up to 10 percent of people are allergic to penicillin, up to 5 percent are allergic to Latex and up to 5 percent are allergic to insect stings. In total, up to 45 million Americans have allergies and are at risk for anaphylaxis.
About 1,500 people die each year in this country from anaphylaxis. Many of these deaths are due to penicillin allergic reactions. Up to 200 die annually from food allergies, and up to 100 from insect stings.
Anaphylaxis can happen quickly, within 1 to 2 minutes of a mild allergic reaction. Epinephrine administered promptly can prevent anaphylaxis or keep it from becoming fatal. In one study of anaphylaxis patients, none of those who died had received epinephrine before severe respiratory symptoms started, while all the survivors got epinephrine before (or within five minutes of) developing severe symptoms.
Since anaphylactic reactions can occur and progress quickly, individuals with allergies need ready access to epinephrine. Epinephrine auto-injectors were developed to provide doses that are portable, safe and reliably deliver a precise dose of epinephrine.
An EpiPen, the best-known and prescribed brand of epinephrine auto-injector, is about the length of a pen, though thicker around. To treat an allergic reaction, or anaphylaxis, a patient or parent (for younger children) simply uncaps the device and pushes it firmly against the thigh (the injector needle goes easily through clothing).
For a number of years, EpiPen’s main competitor was Auvi-Q, a device that was the size and shape of a thick credit card and had the added features of giving audible instructions on its use — very helpful for frightened patients or caregivers. Auvi-Q was pulled from the market in October 2015 due to concerns about its ability to consistently deliver correct doses of epinephrine.
EpiPens have suddenly become very expensive. The retail price has increased from $100 in 2007 to more than $600 currently.
Many families have switched to health insurance with high deductibles, meaning the cost of the EpiPen is now totally out-of-pocket for them.
In addition, even though EpiPens typically come as a 2-pack, many allergic patients purchase multiple injectors to keep at work, at home, at school, at grandparents’ homes, etc., to ensure that one is available when needed. The cost for EpiPens easily exceeds $1,000 for many families. Since an EpiPen typically has a shelf life of less than 15 months at time of purchase, this cost recurs every year.
In response to public and political pressure due to the cost increases, the manufacturer of Epi-pens, Mylan, recently announced expanded programs to produce a generic version of the device and provide more discounts and coupons to lower the price.
The economics of the issue extend beyond our borders and show the complexities of drug pricing. Heather Bresch, CEO of Mylan, admitted in a recent interview that the high cost of EpiPens in this country subsidizes the much lower cost of the devices in other countries where government-run health care systems limit prices charged by drug and device manufacturers.
One interim step would be for schools to purchase EpiPens and keep them in their clinics. This would be particularly helpful because up to 25 percent of epinephrine administrations in school are for children whose allergy was not known at the time of the reaction.
Longer-term solutions may rely on promotion of generics and competition among drug and device manufacturers. The federal and state governments may have a role to play in stabilizing the cost and improving access to this life-saving medicine.
The overwhelming majority of people with allergies will never need to use an EpiPen. They will continue to avoid their known allergens and treat minor reactions with over-the-counter medicines. They will also continue to purchase EpiPens every year to remain prepared.
Epinephrine may be a unique drug. It’s one that millions of Americans need to purchase every year and keep close at hand, while hoping never to have to use.
Perhaps this particular medicine calls for innovative solutions and can serve as an example of how to merge America’s love of free markets and capitalism with the need to preserve health and protect its citizens.
I hope we can work toward making epinephrine auto-injectors universally affordable and available as we try to eliminate all avoidable deaths due to anaphylaxis.
Dr. Bob Wiskind is a pediatrician at Peachtree Park Pediatrics in Atlanta.