Access to Epinephrine Autoinjectors, the Patient Perspective
Authors: Nadia Baichoo, Joanna Fishbein, Punita Ponda
Journal: Allergy (2025)

Food allergies present a significant global health concern with profound societal, familial, and personal impacts. The increasing prevalence of food allergies has led to a heightened demand for epinephrine autoinjectors (EAIs), which are critical for managing severe allergic reactions [1]. Despite their importance, many barriers limit access to EAIs [2, 3]. Understanding these barriers through patient experiences is crucial for addressing the challenges. This study aimed to assess the experiences and challenges faced by patients or caregivers of patients with food allergies in obtaining EAIs. We conducted a survey through the FARE (Food Allergy Research & Education) Patient Registry, approved by our Institutional Review Board. The survey, consisting of 41 questions, was distributed via Redcap to 10,599 registered FARE users. Informed consent stated that participation was voluntary and all data was to be collected anonymously. A follow-up reminder was sent to non-responders after 15 days. The survey collected demographic data and detailed patient experience obtaining EAIs. Responders were categorized as "pediatric" (< 18 years old) and "adult" (≥ 18 years old). Statistical analyses, including chi-square tests and Wilcoxon rank sum tests, were performed to identify significant differences between groups, with a significance threshold of p < 0.05 (Table S1). Out of 1984 responses, 1884 were fully completed (94.8%). Among responders, 1908 (98.3%) were prescribed an EAI for food allergies. Difficulties in obtaining EAIs were reported by 720 (37.7%) individuals, with pediatric patients facing more challenges (42.4%) compared to adults (32.5%). The main barriers included drug shortages (67.2%) and high costs (43.6%). Most responders (75.1%) expressed concern or anxiety about obtaining their EAI. Patient self-reported confidence levels varied by brand, with Auvi-Q scoring the highest among users. Approximately 44% of participants had used an EAI for a reaction; 24.3% used it within the last year. Of those who used an EAI, 24.8% required multiple doses (Table 1). This study provides valuable direct patient insights from Patient Reported Outcomes (PROs) into the barriers that patients face in accessing their EAIs (Table S2). Almost 29% of children and 28% of adults had difficulty in obtaining their EAI (Table 2). High costs and insurance-related issues were listed as significant obstacles that contributed to delays and anxiety. Nearly half of the pediatric responders experienced changes in their EAI prescriptions due to insurance coverage, which can lead to unfamiliarity with new devices; thus, increased anxiety. Confidence and satisfaction levels were higher among those who had used their EAI. There was also a significant association between familiarity with a specific EAI brand and higher levels of confidence and satisfaction among users. Patients who had access to their original EAI brand reported fewer issues with usage and felt more prepared. Frequent substitution of EAI devices might undermine patient confidence and pose risks during emergencies if patients are not trained on new devices [4]. Financial barriers were a recurring theme, with 34% of free-text comments highlighting cost concerns (Table S2). These findings align with previous studies indicating that high-cost medications can lead to adverse medical outcomes and decreased satisfaction [5, 6]. Limitations for this study include the self-reported diagnosis of food allergy that were not challenge proven, a response rate of 18.7%, and no objective correlations with prescription rates. However, these limitations are expected in a survey-based study, and prior similar reports in the literature have response rates between 5%–30%. Overall, this study provides insight into responders' personal experiences regarding the barriers that were faced when attempting to obtain EAIs. Insurance-related factors, high costs, and delays in obtaining prescriptions contribute to significant anxiety and dissatisfaction. Efforts to reduce costs, enhance insurance coverage, and ensure consistent training on EAIs are also crucial for improving patient outcomes, quality of life, and reducing healthcare disparities. Ensuring equitable access to EAIs is imperative to address these pressing concerns. P.P. designed the study, supervised the project, and edited the manuscript. N.B. compiled the data and wrote the manuscript; J.F. performed the statistical analysis. All authors provided feedback on the manuscript. This work was supported by Food Allergy Research and Education (FARE). The authors declare no conflicts of interest. The data that support the findings of this study are available from the corresponding author upon reasonable request. Data S1. Supporting Information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.