This form is to be completed by Prescribing Doctor. Please print off this form, complete details and fax to Dr Mullins at 02-6282 2526. Dr Mullins will attempt to contact prescribing doctor as soon as possible regarding authorisation.
ASCIA guidelines for EpiPen prescription (see end of this form)
Anaphylaxis Action Plans at http://www.allergy.org.au/aer/infobulletins/posters/Anaphylaxis_plan_(child)_Au.pdf
Doctor's Name Provider no:
Address
Phone Fax
Email
Signed: Date
Name D.O.B.
Contact Details (if indicated)
Date of reaction: Location:
Suspected allergen:
Confirmation by:
Skin testing? Yes 0 No 0 RAST testing? Yes 0 No 0 Neither
Did the patient have:
Anaphylaxis? Yes 0 No 0
Generalised allergic reaction? Yes 0 No 0
Is the patient:
Asthmatic (concurrent or past)? Yes 0 No 0
Adolescent/ young adult? Yes 0 No 0
Nut allergic (peanut or other nut)? Yes 0 No 0
Stinging insect allergic (bee, wasp, jumper ant)? Yes 0 No 0
Suffering from ischaemic heart disease? Yes 0 No 0
Unable to readily access emergency medical care? Yes 0 No 0
Has the patient been given:
An Anaphylaxis Action Plan?* Yes 0 No 0
Allergen avoidance advice? Yes 0 No 0
Would you like this patient assessed by immunologist / allergist?
Yes 0 No 0
If 'yes', please provide a referral letter to Dr Mullins
with patient contact details
DISCLAIMER: Decisions about
advising EpiPen and instructions for use remain the responsibility
of the prescribing doctor. Dr Mullins's role is ONLY that of determining
whether the patient's details fulfil the current criteria for
PBS Authority subsidy. Patients falling outside these criteria
are still able to purchase EpiPen privately.
PBS Authority EpiPen® prescription authorised:
Yes 0 No 0
Assessment by immunologist/allergist recommended: Yes 0 No 0
Signed: Date:
Guidelines for EpiPen® Prescription
© ASCIA 2003
These guidelines were developed by the ASCIA Anaphylaxis Working
Party.
Membership of the working party and references for these guidelines
are available on the
ASCIA website www.allergy.org.au
1. RECOMMENDED
History of anaphylaxis* (unless patient is no longer considered
to be at risk)
2. MAY BE RECOMMENDED
History of a generalised* allergic reaction with one or
more of the following modifying factors These modifying factors
should be considered when deciding whether an EpiPen is prescribed,
as they are known risk factors for more severe or fatal reactions.
ß Asthma - concurrent or
past history
ß Age - adolescents and young adults have a greater
risk of fatal anaphylaxis.
- the majority of recorded fatal reactions to foods (~90%)
occur in children over the age of 5 years.
ß Specific allergic triggers
Nut allergy (to peanuts or other nuts) - most deaths from
anaphylaxis occur from allergies to nuts. Generalised allergic
reactions can be triggered by exposure to trace or small amounts
of nuts, which can be difficult to avoid. Subsequent allergic
reactions to nuts may be unpredictable.
Stinging insect allergy (Bees, wasps, Jumper ants) in adults.
ß Co-morbid conditions - Ischaemic heart disease.
ß Limited access to emergency medical care - in remote
locations early administration of adrenaline may not be possible
unless an EpiPen is available.
3. NOT NORMALLY RECOMMENDED
ß Asthma - in patients
with asthma without anaphylaxis or generalised allergic reactions.
ß Elevated specific IgE only (positive RAST and/or skin
test) without a history of clinical reactions.
Positive test results alone do not necessarily mean there
is allergic disease. These patients may be referred to an allergy
specialist for assessment of their risk of allergy and anaphylaxis.
This may include further investigations such as challenge testing.
ß Family (rather than personal) history of anaphylaxis
or allergy.
Whilst the risk for allergic disease is inherited, anaphylaxis
is not inherited.
ß Local reactions to insect stings in adults and children.
ß Generalised skin rash (only) to bee or wasp stings
in children.
Prospective follow-up studies of subsequent bee stings in
children presenting with local reactions or generalised skin rash
(only) show that these children are at a very low risk of experiencing
anaphylaxis with subsequent stings.
ß Resolved food allergy.
EPIPEN JR vs EPIPEN PRESCRIPTION**
ß EpiPen JR and EpiPen
are not usually recommended for children less than 10kg
ß EpiPen JR recommended for children between 10 and 20kg
ß EpiPen recommended for adults and children over 20kg
* Refer to definitions on page 2.
** These are based on expert opinion which is at variance with
the approved product information.
IMPORTANT: An EpiPen must be prescribed within the context of a comprehensive ANAPHYLAXIS MANAGEMENT PLAN (see page 2).
ANAPHYLAXIS MANAGEMENT PLAN
An EpiPen should only be prescribed within the context of a comprehensive anaphylaxis management plan that includes the following;
ß REFERRAL TO AN ALLERGY SPECIALIST
ß IDENTIFICATION OF THE ANAPHYLACTIC
TRIGGER(S)
This should include a comprehensive history, clinical examination,
appropriate use and interpretation of allergy testing.
ß EDUCATION ON THE AVOIDANCE
OF TRIGGER (S)
This is particularly important with food anaphylaxis.
ß PROVISION OF AN ANAPHYLAXIS
ACTION PLAN
This should document the following;
o Name of child/adult
o Allergic triggers
o Carer contact details
o Symptoms and signs indicating when to use the EpiPen
o Instructions on how to use the EpiPen.
Anaphylaxis action plans for EpiPen use can also be located at www.allergy.org.au
ß APPROPRIATE FOLLOW-UP
Review by an allergy specialist should occur to;
o Ascertain if the correct trigger(s) have been identified
o Determine whether the allergy persists
o Provide re-education on EpiPen use
o Renew action plan
o Ensure the EpiPen has not expired.
DEFINITIONS
# 1 ANAPHYLAXIS
Anaphylaxis is a rapidly evolving
generalised multi-system allergic reaction characterized by one
or more symptoms or signs of respiratory and/or cardiovascular
involvement and involvement of other systems such as the skin
and/or the gastrointestinal tract. Symptoms/signs of respiratory/cardiovascular
involvement are:
Respiratory:
ß Difficulty/noisy breathing
ß Swelling of tongue
ß Swelling/tightness in throat
ß Difficulty talking and/or hoarse voice
ß Wheeze or persistent cough
Cardiovascular:
ß Loss of consciousness
ß Collapse
ß Pale and floppy (in young children)
ß Hypotension
# 2 GENERALISED ALLERGIC REACTION
A generalised allergic reaction is a characterized by one
or more symptoms or signs of skin and/or gastrointestinal tract
involvement without respiratory and/or cardiovascular involvement.
Skin:
ß Generalised pruritis
ß Urticaria / Angioedema
ß Erythema
Gastrointestinal:
ß Abdominal pain
ß Vomiting
ß Loose stools