Adrenaline injector Q&A

Further questions from Anaphylaxis Update: Schools and CEC Webinar that could not be answered during webcast.

• What is the difference between EpiPen® and Anapen® adrenaline injectors? Is one more effective?

  Both EpiPen® and Anapen® contain adrenaline and both devices are autoinjectors, which provide effective emergency treatment of anaphylaxis. They have different mechanisms for activation and a summary of their features is outlined below.

  Feature	EpiPen®	Anapen®
  Adrenaline dose	Single pre-measured	Single pre-measured
  150 microgram device 7.5-20kg (aged around 1-5 years) Green label
  300 microgram device Children 20kg and over (aged around 5 years and over) and adults Yellow label
  500 microgram device Children 50kg and over (aged around 12 years and over) and adults Magenta (purple) label	Not available
  Viewing window to check adrenaline for discolouration or precipitate	Yes	Yes
  Availability	Available over-the-counter at full price 2 devices on Pharmaceutical Benefits Scheme (PBS) authority prescription	Available over-the-counter at full price 2 devices on Pharmaceutical Benefits Scheme (PBS) authority prescription
  Activation of device	Press firmly against outer mid-thigh	Press red button when device on outer mid-thigh
  Safety	Blue safety release Orange needle end automatically extends over needle after use	Grey safety cap Black needle shield can be replaced over needle after use
  Trainer devices	Available from Allergy & Anaphylaxis Australia - here	Available from Allergy & Anaphylaxis Australia - here
  Expiry reminder service	MyEpiPen	Optional patient sms/email Anapen® expiry reminder available at participating pharmacies

  Source: Adapted from Vale S, Smith J, Loh R. Safe use of adrenaline autoinjectors. Aust Prescr 2012;35:56-8.https://doi.org/10.18773/austprescr.2012.025

• Why do we now have two different brands of adrenaline injectors?

  Both EpiPen® and Anapen® devices are widely used in other countries. Most countries have multiple brands of adrenaline injector devices available, and this is important for the following reasons:

  • To ensure continued supply of life saving adrenaline, particularly if one brand has stock shortages.
  • To provide choice of dose, including people over 50kg who may prefer a higher dose (500 microgram).
  • A 500 microgram device can potentially prevent the need for further doses of adrenaline.
  • To encourage suppliers to provide devices with longer shelf life.
  • To provide choice for consumers to access different devices.
• Is EpiPen® being phased out?

  No, we now have two adrenaline injector devices in Australia. This is beneficial to people at risk of anaphylaxis as it means that if there is a supply shortage of either of the adrenaline injectors, there is another brand device available.

• Anapen® seems more complex. Why would someone bother getting one?

  Both brands have been designed for use by anyone. Whether a person has an Anapen® or EpiPen® is a decision that should be made by the person with their doctor. The devices have different features (refer to the table in the first question shown) and doses (Anapen® has a 500 microgram dose) and these need to be considered when choosing the adrenaline injector device.

• Is there a cost difference between the adrenaline injectors?

  In Australia, both Anapen® and EpiPen® cost the same through PBS subsidised prescription (known as an ‘authority script’). When purchased over the counter (not on prescription), the devices will have a similar cost also. Please note that the cost of the devices may depend on location (for example, metropolitan versus rural and remote). Pharmacies vary in price for adrenaline injectors bought over the counter just like any other over the counter medicine.

• Can parents buy either EpiPen® or Anapen® over the counter without a script?

  Yes, both adrenaline injector devices can be purchased at full price (not PBS subsidised) without a prescription from pharmacies.

  If they are purchased directly from pharmacies without a prescription, you should request training from the pharmacist on how to use the adrenaline injector purchased.®

• Will schools be required to carry both brands adrenaline injectors in first aid kits?

  No. Schools and children’s education and care services will be able to choose which brand of device they have as general use devices. As they differ in how they are administered, any school/CEC service should have the one brand device in their first aid kit. Individuals coming into those schools or CEC services can have either brand device as prescribed by their doctor.

• Is it up to the parents to decide which adrenaline injector device they want? Will doctors now be giving parents both ASCIA Action Plans at their appointment?

  Parents and people with severe allergy should discuss which adrenaline injector is most suitable for them with their doctor. Their doctor will provide them with education about how to use the device and provide an ASCIA Action Plan for the device prescribed. Substitution of a prescribed adrenaline injector at the pharmacy when the device is dispensed is not recommended.

• Can an Anapen® be used as a substitution for an EpiPen® and vice versa in case of an emergency?

  Yes, as long as the dose is appropriate.

  In children 7.5-20kg (around 1-5 years of age) a device containing 150 micrograms of adrenaline should be used.

  However, if only a higher dose device is available (containing 300 micrograms of adrenaline) this should be used in preference to not using one at all. Under-treatment of anaphylaxis is more harmful (and potentially life threatening) than over-treatment of a mild or moderate allergic reaction.

  An injector containing 500 micrograms is not recommended in children under 50kg however, if an adrenaline injector containing 300 micrograms of adrenaline is not available then an injector containing 500 micrograms can be given to a child over 20kg if there is no other device available.

• Do Anapen®s have longer expiry dates?

  Depending on the batch and sometimes supply issues, there will be times when one brand will have a longer expiry than the other device. Generally however, they have similar expiry dates when they arrive in Australia.

• If a student has an Anapen® and they require a second dose of adrenaline, can they have an EpiPen® administered?

  Yes. Both adrenaline injectors contain adrenaline. A person can be administered an Anapen® for a first dose and an EpiPen® as a second dose (or vice versa).

• What is the best method of disposal for an expired device.

  Expired devices can be taken to the local pharmacy for safe disposal.

• Was Anapen® available in Australia over a decade ago?

  Yes. Anapen® was available in Australia from 2011-2014, however Anapen® 500 was not available in Australia at that time. Design changes have since been made to the device.

• Do you need proper training from a health professional to use an Anapen®?

  ASCIA anaphylaxis e-training provides education on how and when to use both brands of adrenaline injectors, with a new refresher course also being available – https://etraining.allergy.org.au/course/index.php?categoryid=3. In an emergency, however, anyone can give an adrenaline injector by following the instructions on an ASIA Action Plan and/or on the adrenaline injector itself.

• Would the EpiPen® with a 3 second hold be preferred for children under 5 years old as opposed to the Anapen® with a 10 second hold?

  With regards to the prescribed adrenaline injector, parents should discuss which device is most appropriate with their child’s doctor. With regards to general use devices, schools and children’s education and care services should discuss which brand device will be stocked as part of their emergency response plan.

• Can you use an expired Anapen® in an emergency?

  If the only adrenaline injector available is an expired device (either Anapen® or EpiPen®), the expired device should be used in preference to no device at all.

• For EpiPen®, sometimes it may be necessary to give a second dose. Is that the same for Anapen®?

  The need for a second dose is dependent on the person’s response to the first dose of adrenaline. If a person experiencing anaphylaxis does not improve after the first dose or improves but then gets worse again, they should be given a second dose of adrenaline.

  If needed, give whatever brand device is available. It is preferable to give the same dose as has been prescribed but if another device of that strength is not available then:

  • a 150 microgram device can be given to anyone;
  • a 300 microgram adrenaline injector can be given to children weighing 10kg or more and adults; and
  • a 500 microgram adrenaline injector can given to a child weighing 20kg or more if a 300mg adrenaline injector is not available, and adults.
• Should schools and CEC services be asking for two devices from each student at risk of anaphylaxis, not one?

  Students at risk of anaphylaxis need to have at least one device that is with them at all times. Schools and CEC services need to work on a system that makes sure that at least one of the prescribed devices is with the child when at school or the CEC service.

• If 500 microgram Anapen® is prescribed but only a 300 microgram EpiPen® or Anapen® is available in the first aid kit, is it OK to use the 300 microgram dose device?

  Yes. A 300 microgram device can be given to anyone weighing more than 20kg if that is what is available. For children over 10kg, if only a 300 microgram adrenaline injector is available, it is better to give the device than not give it. If only a 500 microgram adrenaline injector is available, it can be given to children over 20kg.

• As the expiry date of adrenaline injectors is only about 12 months, is it worthwhile keeping the older out of date injectors on hand, along with a new one?

  No. This increases the risk that an out of date device will be given instead of a current device.

• Do we need to write the time the device was administered on Anapen® like the EpiPen®?

  Where possible, it is good to note the time the adrenaline injector was administered, regardless of what brand of device was given.

• Should you send the adrenaline injector with the person in the ambulance?

  Yes. Providing the adrenaline injector to the paramedics allows them to know what dose/s of adrenaline were given and they can provide this to the emergency department staff. The hospital will then dispose of the device.

• Does the Anapen® have a viewing window like the EpiPen®?

  Yes, Anapen® has a viewing window to check if the adrenaline is discoloured or contains floating particles (sediment).

• Can we give two injections to a child over 20kg when we only have 150 microgram EpiPen®/Anapen®?

  Yes. If you only have 150 microgram devices for an older child, you can give both doses. If there is no improvement after 5 minutes or the child improves but then symptoms of anaphylaxis recur, you can give another dose if a device is available.

• Would you recommend an Anapen® for primary school aged children?

  The decision as to which adrenaline injector device is prescribed for a child, is one that parents should make in consultation with their child’s doctor. With regards to general use devices, either adrenaline injector brand can be used and the individual school or childcare service should make that decision as part of their risk management plan which would include whether staff are trained to use the device.

• Where can we get trainer devices from?

  Both EpiPen® and Anapen® trainer devices can be purchased from Allergy & Anaphylaxis Australia - https://allergyfacts.org.au/shop/adrenaline-injector-trainers-and-resources

• Can you please repeat the rhyme?

  The rhyme for EpiPen® is – Blue to the sky, orange to the thigh.

  The rhyme for Anapen® is – White end on leg, press thumb on red.

• Why would we recap an exposed needle that has been used on the Anapen®? This is a dangerous practice.

  It is recommended that you place the used Anapen® in hard plastic container where possible (such as a lunchbox), rather than replacing the needle shield. The distributor of Anapen® is looking into providing plastic cases so that the needle does not need to be re-capped.

• Is the move away from colours to do with colour blind people so they can know what to do based on shades?

  Colour blind people need to familiarise themselves with the use of the device without using colours, and focus on the information (such as the dose) printed on the device.

Content updated January 2022