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Epinephrine Choices in 2017; So Many, And What To Do?

posted in Medication News

It is not uncommon for us to say every so often that “Life used to be much simpler.”  This year, medical professionals find that to be the case when discussing prescriptions for epinephrine devices.  There are, at present, five different ways in which we can prescribe what is commonly referred to as “the EpiPen.”

  1. EpiPen brand (sold by Mylan)
  2. Epinephrine Injection, USP Auto-Injector (authorized generic sold by Mylan)
  3. Auvi-Q (sold by Kaleo, which bought the rights from Sanofi-Aventis)
  4. Adrenaclick brand (sold by Lineage Therapeutics)
  5. Adrenaclick generic (sold by Impax Laboratories)

Which one to choose?   The only wrong answer is not filling the prescription and not having it immediately available when one has a condition that warrants it.  As with all decisions that we make, various factors are considered and some factors mean more than others at a given time.

What do I do?  I show the trainer devices of each and review with patients the following factors:

  • Product Longevity: EpiPen was approved by the FDA 30 years ago; the generic form has been marketed for the past 6 months. Auvi-Q was launched in 2013. The Adrenaclick device has been on the market since 2005 under a different name when it stored two doses of epinephrine in the same device.
  • Product Recall History:  The Auvi-Q was withdrawn between late October 2015 and February this year because of some devices having inadequate dosage delivery. This year, thirteen lots of the EpiPen/EpiPen Jr. brand product, with expiration dates in April, May, September and October 2017 were recalled because of the potential that they may contain a defective part.
  • Size of the Device: For those who haven’t seen them, (a) the Auvi-Q is about 3 ½ inches long and 2 inches wide; (b) the EpiPen brand and generic devices are obviously longer (about 5 ½ inches) and about one inch wide; and (c) the Adrenaclick brand and generic devices are about 5 ¾ inches long, less than ¾ inch wide and can be stored in a protective pen-shaped case.
  • Audio/Visual Features: The Auvi-Q “speaks for itself” over approximately 15 seconds on how to use it when the device is removed from the same-sized case. All the devices, though, have visual instructions on their devices.
  • Number of Steps: The EpiPen products require one step of removing the cap at the other end of the device before injecting into the outer thigh. For the Adrenaclick products, two caps need to be removed before injecting into the outer thigh. Before the Auvi-Q is injected, the device must be removed from the case and a cap must be removed. For all of these devices, the time it takes to do the respective steps can be accomplished in less than 3 seconds.
  • Needle Visibility: The Auvi-Q needle retracts back into the device after the injection. The EpiPen brand and generic needles are covered as the device is withdrawn from the skin. The Adrenaclick brand and generic needles are still visible after their use.
  • Cost: I saved this for last—not because of importance, but because it is the least certain information that we can provide. We are asked all the time how much each device costs. There are just too many variables for medical professionals to know, and that periodically change:

–the negotiated price between the manufacturer and the wholesalers;
–the negotiated price between the wholesaler and the pharmacy;
–whether the insurance is commercial or government;
–whether the patient’s deductible for medications has been met;
–whether the product is on or is not on formulary;
–whether a discount card is offered by the manufacturer or wholesaler;
–whether the patient’s health insurance plan has a co-payment.

What I can tell you—as of today—when I went to two different pharmacy chains in the local area is that these are the retail prices—before any of the above variables are considered :

EpiPen brand              Pharmacy 1–$730.33          Pharmacy 2—$549.99
EpiPen generic           Pharmacy 1–$494.01           Pharmacy 2—$109.99
Auvi-Q                          Pharmacy 1–$5,400            Pharmacy 2—$5,295.99
Adrenaclick brand     Pharmacy 1–$553.12           Pharmacy 2—$545.99
Adrenaclick generic   Pharmacy 1–$72.00            Pharmacy 2—$339.99

The shocking price of Auvi-Q at retail pharmacies is because Auvi-Q’s manufacturer has an arrangement with a specialty pharmacy called ASPN that offers zero patient cost—if the patient arranges purchase through this specialty pharmacy and agrees for delivery to either the patient’s home or to the physician’s office.  How long this will last, and whether the other manufacturers will also start offering this option, is uncertain.

We find the link below to be helpful information in trying to reduce the cost of these devices.

http://blog.foodallergy.org/2017/02/01/2017-patient-assistance-resources-for-epinephrine-auto-injectors/#_ga=2.147936119.1199183186.1498686119-1615791167.1498686119

Whatever choice of device that is made is the correct choice. When we take a step such as having a needed epinephrine device available within one minute of reach, we are doing the right thing.

More to follow later this year, when the sixth option for an epinephrine auto-injectable device called Symjepi becomes commercially available!

Dr. Klein