ARS Pharmaceuticals, Inc.  has developed an intranasal (IN) epinephrine, “neffy”, designed for use in severe allergic reactions.  neffy is an aqueous epinephrine preparation with the addition of the functional excipient Intravail® A3 (dodecylmaltoside) to improve the bioavailability of the drug to increase absorption through nasal mucosa to injection-like levels without known injection-related adverse effects such as pain or irritation, and is already used in two other FDA-approved products.  

While still under review by the FDA, the data surrounding neffy’s safety and efficacy is pretty convincing.  Although there is no talk yet about what the cost will be, this could be a game changer for dentists.  Instead of buying expensive epinephrine autoinjectors or drawing up and injecting an intramuscular dose of 1:1000 epinephrine, a single dose sprayer can be applied into a patient’s nostril.  The sprayer device is identical in design to that which is already used to administer six other medications, including Narcan (naloxone).

In anticipation of neffy receiving FDA approval, Have Dummy Will Travel is working with our suppliers to provide this product to our clients.  In addition, we will be creating a brief training video to help relieve any anxiety over delivering medication through the intranasal route.     

Intramuscular administration of epinephrine is considered to be the  treatment of choice in patients experiencing anaphylaxis in community settings.  Considering the skills that are needed to provide IM injections are often unfamiliar to dentists, many keep very expensive epinephrine auto injector devices in their emergency drug kits.  Since aqueous epinephrine degrades quickly in normal storage conditions, including exposure to light, heat, oxygen and neutral or alkaline pH values¹, they have a relatively short shelf-life (12-14 months).  Wouldn’t it be great if there was a cheaper, easier to administer, and longer lasting alternative?

Sublingual epinephrine has been under development for at least 20 years, and a recently published study touts a new sublingual matrix, AQST-109, as a promising vehicle by which epinephrine may be administered².  Results showed nearly equivalent, if not better, loading and peak concentrations, when compared to traditional intramuscular absorption.  

Don’t get too excited yet, as that study was only the first human study, as was performed on only 24 healthy adult volunteers.  While low molecular weight, lipophilic drugs such as epinephrine are likely absorbed across sublingual mucosa into venous circulation by transcellular diffusion³, there still is no evidence that absorption will be effective in the presence of edema in the lingus and other proximal mucosa, when the osmotic gradient favors mass movement to the interstitial space– a common occurrence during anaphylaxis.  In addition, a previous study⁴ found varied absorption rates of epinephrine delivered through the sublingual route.  To be fair, the epinephrine was in a powered formulation, different than the AQST-109 sublingual matrix, and included only 10 adult men in its dataset.  Another rabbit study⁵ hypothesized that sublingual absorption occurs in a series of peaks, as alpha effects of epinephrine causes vasoconstriction, limiting the amount of absorption possible after initial exposure.  

So for right now, we are in a holding pattern. 

This might also be a good time to think about the incidence of anaphylaxis in dentistry.  In my hundreds of conversations with dentists, it seems to me that anaphylactic shock is one of the most feared emergencies, yet very few have actually encountered a true anaphylactoid-like reaction in practice or elsewhere.  This inexperience is consistent with estimates that anaphylaxis occurs in 0.004 – 0.015 cases per dentist per year. ^6-8  Morbidity occurs only in 0.5% to 1.5% of all anaphylaxis cases.^9-11

Please do not get the impression that I am advocating for a dentist to abdicate responsibility to be prepared to manage an anaphylactoid-like scenario.  However, given the above, it seems difficult to justify spending upwards of $1000 every year or so on something you should not use during the off-chance of encountering a case of anaphylaxis.  Instead, you should know how to recognize anaphylactoid-like reactions, administer epinephrine, diphenhydramine and oxygen immediately, position the patient in the trendelenburg position (or as close as possible), and be ready to administer albuterol.  Most importantly, call 9-1-1 as soon as possible, keeping in mind that your emergency medical kit should be designed to keep your patient alive for 15 – 30 minutes.

Erik Zalewski is a Nationally Registered Paramedic and New York State EMS Certified Instructor Coordinator with almost 30 years experience responding to 9-1-1 calls for medical emergencies.  Erik has taught EMTs and paramedics at Stony Brook University and the Suffolk County, NY EMS academy.  He and his team at Have Dummy Will Travel, Inc. are dedicated to helping medical professionals respond to emergencies safely, efficiently and in the most cost-effective manner possible.  Call or text 631-849-4978 for additional information.  

References

1. Rawas-Qalaji, M.M. et al (2013). Long term stability of epinehrine sublingual tablets for the potential first-aid treatment of anaphylaxis.  Annals of Allergy and Asthma Immunology. 111:567-579.
2. Golden, D. et al. (2023). Pharmacokinetics and pharmacodynamics of epinephrine sublingual film versus intramuscular epinephrine.  Journal of Allergy and Clinical Immunology.  AB4.
3. Birudaraj, R., Berner, Shen, S. & Li, X. (2005).  Buccal permeation of buspirone: mechanistic studies on transport pathways.  Journal of Pharmacological Science.  94:70-78.
4. Simons, K.J., Gu, X., & Simons, F.E.R. (2004). Sublingual epinephrine administration in humans: A preliminary study. Journal of Allergy and Clinical Immunology.  113(2):S260.
5. Rawas-Qalaji, M, Simons, F.E.R. & Simons, K.J. (2006). Sublingual epinephrine tablets versus intramuscular injection of epinephrine: Dose equivalence for potential treatment of anaphylaxis.  Journal of Allergy and Clinical Immunology. 117(2): 398-403.
6. Girdler,  N.M. & Smith, D.G. (1999). Prevalence of emergency events in British dental practice and emergency management skills of British dentists. Resuscitation. 41:159–167. 
7. Muller, M.P., Cansel, M., Stehr, S.N., Weber, S. & Koch T. (2008).  A statewide survey of medical emergency management in dental practices: incidence of emergencies and training experience. Emergency Medical Journal. 25:296–300. 
8. Arasti, F., Montalli, V.A., Florio, F.M., et. al. (2010). Brazilian dentists’ attitudes about medical emergencies during dental treatment. Journal of Dental Education. 74:661–666.  
9. Moneret-Vautrin, D., Morisset, M., Flabbee, J., Beaudouin E., & Kanny, G. (2005). Epidemiology of life-threatening and lethal anaphylaxis: a review. Allergy 60:443–451. 
10. Helbling, A., Hurni, T., Mueller, U. & Pichler, W. (2004).  Incidence of anaphylaxis with circulatory symptoms: a study over a 3-year period comprising 940,000 inhabitants of the Swiss Canton Bern. Clinical and Experimental Allergy.  34:285–290. 
11. Sheikh, A. &  Alves, B. (2001).  Age, sex, geographical and socio-economic variations in admissions for anaphylaxis: analysis of four years of English hospital data. Clinical and Experimental Allergy. 31:1571–1576.

Good Samaritan CPR saves another life:

Check it out!

Are you registered to certify yet? Why wait, join a CPR class now!

The following link is another horrible reminder that we must always remind ourselves to practice safety in and around the water:

Three-Year-Old Drowns In New Jersey

As we enter into the middle of the summer, the temperature is certainly going up.  How wonderful it is to spend some time in the pool or at a nearby lake or beach.

But how horrible it is to hear about so many recent drownings, especially because they involve children.

Keep yourself and your family safe this summer.  Here are a few tips to help:

In general:

• Teach children how to swim and tread water at a young age.
• When in public places, note the locations of AEDs and First Aid Stations
• Learn / refresh your skills in CPR and AED use.

In the pool:

• Always close and lock gates to the pool to keep children out when no one is available to directly supervise them.
• Enforce “No-Diving” rules as indicated by your pool’s manufacturer.
• Younger children should wear personal flotation devices until they can swim and tread water.
• Never leave children unsupervised in the pool area – Not even for a minute!
• Keep your cell phone close, but only use it in an emergency if there are no other adults to concentrate on watching children. Texts can wait.

At the lake or beach:

• Do not allow children to go swimming alone in areas without lifeguards and always swim in designated areas only.
• Always follow posted rules and the directions of the lifeguards.
• Never let children swim without an adult watching and never drift more than an arms-length away from younger children, especially in the surf.
• Younger children should wear personal flotation devices until they can swim and tread water.
• Teach children to swim parallel to the shore if the current pulls them away from the beach.
• Notify lifeguards and police immediately if a person from your party is missing.

Wishing you a safe and enjoyable rest of the summer.

Greetings,

Here’s to wishing you a Happy July 4^th weekend!  While celebrations are often marked with cook outs, fireworks or even a day at the beach, those of us who work Emergency Medical Services are preparing to see an increase in call volume. 

To help everyone stay safe, I am writing to address common illness and injuries seen around this time.   Continue reading First Aid For Common July 4th Emergencies →

Our owner, Erik, appeared in a NY1 report about one of our clients:  Kings Combat Fitness.

See if you can spot ’em . . .

Every five years, the International Liaison Committee on Resuscitation update their recommendations for CPR and First Aid.  The most recent changes are relatively minor, but important.   Continue reading The Top Three Changes To Look For In Your Next CPR Class →

Have Dummy Will Travel, Inc. is now using QR codes to help you connect more easily.  Look for these codes on all of our printed literature as well as on our emails and web site. 

To access QR codes, you will need to download a free app for your mobile device.  Simply go to your devices “App Store” and download a free mobile scanner device that supports QR codes.  The app will use the camera on your device to “scan” the QR code and will follow the instructions embedded in the code.