If you've taken a dtWFA course or our Allergies, Anaphylaxis, Epinephrine Mini-Course, you've learned how Epi works, when and with what it needs to be given, and how long it lasts. This forum string contains some fascinating additional information.

PART 1) WHAT IF THE EPI-PEN IS EXPIRED or DISCOLORED? WILL IT STILL WORK???

[For a quick answer, skip to "Conclusion" below]

As always, we focus on evidence-based medicine. Here's the evidence.

• A medical study was conducted to determine the effectiveness of EpiPens after their expiration date.
• Tested: EpiPens from in-date, through out of date as long as 90 months (7.5 years).
• The quotations below are excerpts from the article cited near the bottom of this post.

"Although there is evidence from this study and from a previous study that patients at risk for anaphylaxis have a high awareness of the expiration date on the EpiPen autoinjector, there is also evidence that many such patients may be carrying out-of-date autoinjectors."

"We found that epinephrine bioavailability from the outdated EpiPen and EpiPen Jr autoinjectors varied with the number of months past the expiration date but was significantly reduced compared with epinephrine bioavailability from the in-date autoinjectors."

HOWEVER … take a look at this graph:

• KEY to graph: the epinephrine content, expressed as percent of labeled dose of epinephrine, of 6 in-date EpiPen autoinjectors (CLOSED TRIANGLES) and 6 in-date EpiPen Jr autoinjectors (OPEN TRIANGLES) is shown. The percent of labeled dose of epinephrine in 28 outdated EpiPen autoinjectors (CLOSED CIRCLES) and 6 EpiPen Jr autoinjectors (OPEN CIRCLES) studied 1 to 90 months after the stated expiration date correlated inversely with the number of months past the expiration date (0.63). The EpiPen autoinjectors with discolored contents are indicated with an ASTERISK. The EpiPen stored in the car glove compartment is indicated with TWO ASTERISKS.

"Most of the EpiPen and EpiPen Jr autoinjectors that had a reduced epinephrine content could not have been identified by inspection of the color window on the autoinjectors for discoloration or precipitates."

COMMENTS ON GRAPH: Notice the vertical axis starts at about 50%, not 0%:

• ALL EpiPens tested regardless of their date or condition had at least 50% of the labeled epinephrine content still in it.
• The EpiPens that were ~7 and 7.5 years past expiration date had over 70% of the labeled epinephrine content still in it.

CONCLUSION: "For prehospital self-management of anaphylaxis, we recommend the use of EpiPen and EpiPen Jr autoinjectors that have not expired. If, however, the only autoinjector available is an outdated one, it could be used so long as no discoloration or precipitates are apparent because the potential benefit of using it is greater than the potential risk of a suboptimal epinephrine dose or of no epinephrine treatment at all."

Full Journal Article / Source (same article linked online in two places: place one ~ place two)

PART 2) HOW TO GET UP TO 5 DOSES FROM A SINGLE EPI-PEN!!!

• Step 0) Watch all three videos at this website:
• Step 0.5) Practice on an old unit or two, make sure you wear gloves and safety glasses and make sure you discharge the first dose (into an orange not to be eaten, or box, or whatever) before breaking the pen open.
In a real-life emergency, particularly in a remote setting…
• 1) Use the autoinjector only when, and the way it's supposed to be used. That's dose #1.
• 2) If there is only one autoinjector and it was just used, consider starting to break it apart (to access the additional doses) right away, as it takes a significant amount of time to do so safely. When to administer a subsequent dose? That's one of the dtWFA course topics :)

The videos linked above are a part of the following medical journal article, which offers additional reading material and textual description: link location one ~ link location two

Clever! And life-saving :)

PART 3) EFFECT OF COLD AND HEAT ON EPI

FREEZING & THAWING EPI: A controlled medical study entitled "The Impact of Freeze-Thaw Cycles on Epinephrine" concluded that after repetitive freeze-thaw cycles, the epinephrine concentration was still the appropriate amount. If you don't have a subscription to the "Wilderness & Environmental Medicine" journal, you can't read the full medical study, but you can read an article about the study here.

HEATING EPI: See (Part 1) above. The one Epi-Pen that was left in the glove box of a car for days at a time was done so in a climate that has summertime high temps of 95 degrees (and wintertime well below zero), however the study did not state if that Epi-Pen was in the glove box during summertime or not. Other studies have shown that excessive exposure to high heat can degrade the effectiveness of the drug.

PART 4) FREE Generic EPI-PENs! With the Epi $0 Copay Coupon.

Many thanks to hiking pal Chad F. for the following golden tip.

• Get your doctor to prescribe "epinephrine auto-injector **generic**" and when you go to the store to pick it up, bring the "$0 copay" coupon you can print from www.epinephrineautoinject.com . My physician ordered 2 for me, CVS said they had to special-order it (why don't they carry the generic?!!), they said $178 please, I handed over the coupon, and voila, FREE! The units I received had a 1-year expiration. The coupon doesn't seem to have an expiration date, and works for up to 3 units (per year, I'm told?).
• While you're at it, consider getting a prescription for Erythromycin Ophthalmic Ointment. As noted in the "WILDCARE" textbook and "MEDIC in your Wallet," this little tube is super-handy to have in your first aid kit, and can help with a few different eye conditions one might suffer out in the wilderness. I picked up two tubes (one for each of my first aid kits), which with my not-so-great health insurance cost me a total of $25.

PART 5) LEGALITY OF AN ORGANIZATION GETTING AND USING EPI

Is it legal for an organization (such as a camp) to get a prescription for, stock, and have its employees or volunteers use epinephrine on its clients or grounds? As of the writing of this note, the answer is "yes" in 23 states (though read the state law for specifics), and I'm guessing unclear in the rest.

See this article, and if your state is in the "yes" category, click on its law to ensure your organization qualifies.