With Halloween safely behind them, parents of the millions of children with severe food allergies are now preparing for an onslaught of pecan pies and gourmet side dishes. It’s not just the holidays that scare us, however; every school day brings new and well-founded fears about accidental exposures to tiny, but potentially lethal, amounts of foods commonly packed in other kids’ lunches, concealed in birthday cupcakes, or cross-contaminating meals purchased on field trips. We fear whether school personnel will fail to recognize the variable signs of anaphylaxis, or know when and how to administer life-saving medication to our children.
Approximately six to eight percent of children have food allergies, and one percent of the population—including my nine-year-old son—is allergic to nuts or peanuts, which cause 94 percent of deaths from food-related anaphylaxis. Most allergic reactions in children occur at school or daycare, and the majority of schools do not have full-time nurses (if they have them at all). Put simply: Most allergic reactions occur when children are away from home, without their parents, in places without trained medical personnel on site. In fatal cases of food-related anaphylaxis, the average time from exposure to death is less than 30 minutes.
When given promptly, epinephrine is tremendously effective in treating anaphylaxis. Despite this, rates of epinephrine administration by pre-hospital medical personnel in documented cases of anaphylaxis are alarmingly low. Non-medical caregivers are even less likely to feel comfortable “giving a needle,” though delays or failure to do so endanger children’s lives.
Given the rapid progression and life-threatening nature of anaphylactic reactions, all children should have access to epinephrine auto-injectors that are virtually foolproof.
As a pediatric emergency medicine physician, I have seen plenty of examples of this. As a parent of a young child with severe food allergies, this terrifies me.
Given the rapid progression and life-threatening nature of anaphylactic reactions, all children with severe allergies should have access to epinephrine auto-injectors that are virtually foolproof, and can be easily administered by parents, babysitters, teenage camp counselors, daycare staff and classroom teachers, grandparents who can't find their reading glasses, and even children themselves.
Last year, the Auvi-Q epinephrine auto-injector finally became available. Unlike the bulky six-inch-long Epipen, Auvi-Q provides simple audio instructions for administration and is small enough to fit comfortably in a pocket. Families prefer the Auvi-Q because it is easier to use and easier to carry. As a prescribing physician, I believe the Auvi-Q is more likely to be administered correctly by a wide range of caregivers, preventing severe and fatal anaphylactic reactions.
But as I recently learned while trying to replace my son’s expired Auvi-Q epinephrine auto-injectors, ensuring that your child has access to a potentially life-saving medication is anything but easy. Though my prescription plan covered the Auvi-Q in 2013, the pharmacist told me the Auvi-Q is now classified as “non-preferred,” and my claim had been rejected.
I tried to calculate the added cost to my insurer of filling a prescription for Auvi-Q rather than Epipen. The retail cost of the Auvi-Q twin pack is now about $30 higher than for the Epipen. My plan’s co-pay, however, is $50 higher. On the face of it, my insurer should be making a $20 profit each time a patient fills a script for Auvi-Q.
I have no first-hand knowledge of the financial basis of decisions made by my insurer, but a pharmaceutical sales representative told me that the key to successfully negotiating “preferred” status for a medication was not to provide a lower price than competitors, but to offer insurance companies a higher percentage reduction on the retail price.
“They increase their retail price, then we have to increase ours,” the sales representative explained, “so we can offer a better discount without decreasing our profits.”
It is a matter of public record that the retail price of the Epipen jumped to $240 per twin pack in 2013 from $86 per single unit in 2011. This increase preceded the release of the Auvi-Q, at a time when Epipen enjoyed a 97 percent market share and no real competition. In a free market, competition is generally expected to bring prices down, yet the opposite has been true for epinephrine auto-injectors since Auvi-Q became available in 2013.
Last year, the retail price of both Epipen and Auvi-Q was $240. An Epipen twin pack now costs, on average, $365; an Auvi-Q twin pack $400—increases of more than 150 percent in a single year.
Skyrocketing prices and preemptive formulary changes are both keeping life-saving medication out of people's hands. Epinephrine auto-injectors need to be replaced every year. Co-pays for multiple devices add up quickly, but are nothing compared to the $800 retail cost now faced by families without prescription coverage when re-stocking a child's home and school medications. Increasingly, some have no choice but to go without, forced to gamble on their children's safety.
I don't know whether the egregious price inflation of both products is the result of high-stakes negotiations between rival pharmaceutical firms and prescription management companies. What I do know is that this is not a game in which children with life-threatening allergies should be the pawns.