|Original Article, Biomed Biopharm Res., 2022; 19(1):72-81
doi: 10.19277/bbr.19.1.287; PDF version here [+] ; Portuguese html version [PT]
Do community pharmacy workers know how to use adrenaline autoinjectors?
Ana Margarida Mesquita*, Ricardo Moço Coutinho, José Luís Plácido, Alice Coimbra
Serviço de Imunoalergologia, Centro Hospitalar e Universitário de São João, EPE, Porto, Portugal
* corresponding author:
Adrenaline is the first line and most effective treatment of anaphylaxis and should be administered as soon as possible. Professionals in community pharmacies (pharmacists and pharmacy technicians) dispense adrenaline autoinjectors to allergic patients and could have a crucial role in reinforcing training regarding the use of theses devices.
A survey to pharmacy workers was conducted in pharmacies located in the north of Portugal. The same professionals were invited to simulate adrenaline administration with training devices of the two autoinjectors available in Portugal.
The majority of the pharmacy workers reported not having training regarding adrenaline autoinjectors and more than a third were unable to correctly demonstrate adrenaline administration with the trainer devices.
Pharmacy workers in community pharmacies could have an essential role in reinforcing patient education. Consequently, it is important to encourage and ensure their training in order for them to provide clearer and more detailed instructions to patients.
Keywords: adrenaline autoinjector; anaphylaxis; community pharmacies; allergy; knowledge
Received: 06/05/2022; Accepted: 12/07/2022
Anaphylaxis is a severe and potentially fatal hypersensitivity reaction. Regardless of the cause, the diagnosis is clinical (1) and should be considered highly probable in the presence of at least one of the following three clinical criteria: sudden onset with skin and/or mucosal involvement and at least one of the following: respiratory involvement or hypotension or associated symptoms; rapid occurrence of two or more of the following after exposure to a probable allergen: skin and/or mucosal involvement, respiratory involvement, hypotension or associated symptoms, or sudden and persistent gastrointestinal symptoms; hypotension after exposure to an allergen known to the patient (2).
Adrenaline is the first line and the most effective treatment and it should be administered as early as possible. It is available as an ampoule or as an adrenaline autoinjector (AAI), the goal of the latter being to facilitate self-administration (3). Patients with a history of anaphylaxis should be referred to an Allergy and Clinical Immunology consultation and may prescribed an AAI (1).
According to the national anaphylaxis registry of the Sociedade Portuguesa de Alergologia e Imunologia Clínica (SPAIC), between 2007 and 2017, 1049 patients were prescribed AAI out of the 1783 reported (1). These data show that AAI are underrepresented in clinical practice (3,4).
Two AAI are available in Portugal, Epipen® (ViatrisTM) and Anapen® (Lincoln Medical Ltd), in two dosages 0.15 and 0.3 mg.
The correct technique for the use of an AAI should always be demonstrated at the time of its prescription. The patient should be provided with a written emergency plan indicating the warning symptoms, the medication that should be used, and how the AAI should be used. SPAIC created an illustrative document for an anaphylaxis emergency plan that includes all the above items (5). The patient’s proficiency (in its use) should always be confirmed following training. All these procedures are in accordance with the international standards of the National Institute for Health and Care Excellence (6).
Pharmacists and pharmacy technicians that dispense these devices could also play a major role in patient education (7). Therefore, they should be aware of the available AAI and know how to use them correctly. A German study concluded that only 1 in 5 pharmacies provided patients with detailed information about AAI and 70% of the pharmacists stated that they were not interested in receiving training (4). An Australian study reported that pharmacists have acceptable rates of Epipen® and Anapen® demonstration accuracy, but there was room for improvement (7).
The aim of this study was to determine the knowledge and the ability to demonstrate the correct use of AAI by pharmacists and pharmacy technicians.
Material and Methods
Between May 2018 and July 2019, a questionnaire was administered in community pharmacies in the north of Portugal. The selection was made according to the geographical proximity to Centro Hospitalar Universitário de São João, and a total of 17 pharmacies were willing to participate. The professionals present at the time of the visit (pharmacists and pharmacy technicians), who gave their consent to be part of the study, completed an anonymous questionnaire (Figure 1), on paper, which included questions about their general knowledge of AAI, their experience in providing them, training on how to use them and their own opinion about their level of self-confidence for instructing patients.
The questionnaire was developed by the authors exclusively for this study and was not submitted to a validation process. All pharmacists and pharmacy technicians who answered the questionnaire were then invited to simulate the administration of adrenaline with both training devices of the two AAI available in Portugal. The simulation was evaluated by the authors according to the indications for use provided by the manufacturers (8,9) and classified into one of three categories: unable to demonstrate adrenaline injection with the AAI, able to demonstrate adrenaline injection with the AAI but with small mistakes in the demonstration or full demonstration without mistakes. Subsequently, the correct technique of administration of these devices was shown to the participants.
IBM SPSS Statistics for Windows, Version 27.0, was used to perform statistical analysis, mostly descriptive, and the chi-square test was used for comparisons. Results were considered statistically significant for p-values less than 0.05.
A total of 53 questionnaires were included. Forty (75%) participants were female, the median age was 36 years (interquartile range 21) and 34 (64%) were pharmacists. Of the total, 47 (89%) knew the name of at least one AAI and 31 (65%) were able to name both. Forty-seven (89%) stated having no previous training or information on how to use an AAI. Thirty-seven (70%) reported they had dispensed at least one AAI and only 3 (6%) confirmed having previously instructed a patient on their use. (Table 1) Thirty-eight (72%) stated they had no idea which AAI would be easier to use or to teach.
Concerning the demonstration on how to use an AAI with the trainers, 26 (49%) professionals were not able to demonstrate adrenaline administration with the Anapen® trainer and 20 (38%) with the Epipen® trainer. Sixteen (30%) with Anapen® and 24 (45%) with Epipen® correctly demonstrated how to inject adrenaline with the trainers but did not massage the injection site (as indicated in the manufacturer's instructions (8,9)). Eleven (21%) managed to accurately simulate the complete and correct procedure with the Anapen® and 9 (17%) with the Epipen® trainer (Figure 2).
In the group of the participants that mentioned knowing Anapen®, 20 (45%) were unable to administer adrenaline, as were 10 (29%) in the group of those who were familiar with Epipen®.
Of the three professionals who claimed to have already taught at least one patient, one reported having taught both devices and demonstrated the correct technique of use with both. The remaining two reported having taught only Anapen® but were unable to simulate adrenaline injection with the respective trainer.
No statistically significant differences were found between pharmacists and pharmacy technicians in relation to the administration technique and no differences were found when comparing the injection simulation with both AAI. Forty-four (83%) participants considered the Epipen® easier to use and to teach after the demonstration of the correct procedure.
To the best of our knowledge, this is the only study conducted in Portugal that assesses the level of knowledge of community pharmacy professionals, including pharmacists and pharmacy technicians, about the (patient’s) proper use of AAI. Despite the differences in training, function, and responsibilities between the two classes, the authors considered it important to include all professionals who dispense these devices.
According to a study performed in 2016, whose objective was to assess the ability of patients to use the AAI prescribed to them, more than one third were unable to do so correctly (10). This demonstrates that there still is much work to be done in patient education.
Previous study also indicate that teaching by repetition increases the capacity for learning and contributes to retention of the acquired knowledge for longer periods of time (11). These studies concerning memory formation lead us to believe that more instruction moments of the AAI administration technique can improve patient learning. With this in mind, community pharmacy professionals can become an additional opportunity to reinforce the education of these patients.
Although approximately 90% reported knowing at least one AAI, the same percentage of participants said they had no previous training on its use.
When the technique of usage of the AAI was evaluated, almost half were not able to simulate the injection with Anapen® and more than a third with Epipen®. It was also found that two participants who reported having taught Anapen® failed to demonstrate the administration. This exposes the gap that exists in the training of pharmacy professionals on AAI independent of their professional class, as no statistically significant differences were found between the two classes regarding the administration technique.
It would be important that the acquisition of knowledge about these devices and the technique for their correct use were included in the academic training plan of these professionals, or that educational programs were created with this purpose. This would create the possibility of teaching moments for patients, specifically at the time of the device dispension, to avoid errors in the transmission of information.
The authors acknowledge that the limitations of this study include its sample size and its convenience nature due to geographic proximity. The years of professional experience were also not taken into account. Since pharmacies were aware of the visit by the investigators, it should also be considered that some professionals might have tried to acquire knowledge that they otherwise would not have. As future perspectives, it would be interesting to reassess the technique of AAI use among the professionals participating in this study, and to expand the study to different regions of the country to allow for a more representative national sample.
In this group, most pharmacy professionals reported having no training on AAI and the techniques of its use, and more than a third were unable to simulate adrenaline administration with a training device.
It is essential that patients with severe allergic reactions know how to correctly use their AAI. Therefore, it is important that both those who prescribe and those who dispense these devices are completely familiar with them and their proper use in order to give clear and thorough instructions to the patients.
With these results, we conclude that there is still room for improvement in the training of pharmacists and pharmacy technicians on this topic. With such, they could play an essential role in reinforcing patient education whenever dispensing these devices.
Consequently, it is necessary to encourage and ensure the training of these professionals, creating more educational opportunities and raising their awareness of the importance of the correct use of adrenaline autoinjectors to treat anaphylaxis.
Author Contributions Statement
AMM, conceptualization, study design, data analysis, drafting and final writing; RMC, data analysis, drafting and final writing; JLP, revision and supervision; AC, revision and supervision
Conflict of Interests
The authors have no conflict of interests related to this manuscript.
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Appendix - Questionnaire Translation
- Age: years
- Sex: Female / Male
- Profession: Pharmacist / Pharmacy Technician
- Do you know any adrenaline autoinjector / pen (AAI)?
4.1. If YES, which one? Anapen® / Epipen®
- Are there adrenaline autoinjectors / pens in your pharmacy?
5.1. If YES, which one(s)? Anapen® / Epipen® / Both
5.1.1. Which is the most sold in your pharmacy? Anapen® / Epipen®
5.1.2. When was the last time you sold an AAI?
188.8.131.52. Which one? Anapen® / Epipen®
5.2. If NO, please indicate the reason:
- Have you ever had training on how to use an AAI? Yes / No
6.1. If YES, please indicate how / where?
During the (academic) course / (Professional) training / Information leaflet / Internet /
- Have you ever taught a patient how to use an AAI? Yes / No
7.1. If you indicated YES, when was the last time?
7.2. Which one? Anapen® / Epipen®
7.3. How many times have you taught the use of an AAI?
- Which do you think is easier to use / explain? Anapen®/ Epipen®