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Colonoscopy revealed diverticulosis in a 47-year-old man who had presented with rectal bleeding. A polypoid lesion was noted in the sigmoid colon.

Inverted Diverticulum

The mother of a 10-year-old boy brings him in for evaluation of his moles (which are all benign). During the visit, the mother asks about the lesions on the first 2 knuckles of his right hand; she initially noticed them several months earlier. The boy is otherwise healthy.

Clinical Topics

White Knuckles

A 42-year-old man presents with a pruritic rash characterized by pink, scaly plaques with a few crusted erosions on the elbows

knees, lower back, and buttocks. Review of systems was negative, although there was a strong positive family history of celiac disease. He took no medications and was otherwise healthy.

A pruritic, scaly rash appeared on this 42-year-old man's elbows, knees, lower back, and buttocks. Can you ID? 

Elbow Erosions 

A panelist discusses how the current anaphylaxis grading system classifies reactions from zero (no reaction) to four (death), with grade two representing moderate but significantly uncomfortable symptoms affecting multiple body systems.

Oral Food Challenge (OFC) Study with Epinephrine Nasal Spray 

Video content above is prompted by the following: 

The availability of specific data on oral food challenges using epinephrine products has historically been limited, with most published research consisting of case series and retrospective studies. However, a significant advancement came with the launch of Nephi (epinephrine nasal spray), which included a dedicated study conducted in Japan examining its effectiveness during oral food challenge procedures. This Japanese study provided valuable clinical evidence by observing 15 pediatric patients who underwent oral food challenges and experienced grade two allergic reactions or worse, though the majority of participants specifically presented with grade two symptoms.

The study's significance becomes clearer when viewed through the updated allergic reaction grading system introduced by professional allergy, asthma, and immunology societies two years prior. This revised classification system ranges from grade zero (no reaction) to grade four (death), with grade three representing severe reactions. Grade two reactions, which comprised the majority of cases in the Nephi study, represent moderate but clinically significant allergic responses that cause considerable patient distress and require immediate medical intervention.

Patients experiencing grade two allergic reactions during oral food challenges face substantial symptoms including abdominal pain, recurrent vomiting and diarrhea, persistent coughing, chest tightness, and audible wheezing detectable through auscultation. Additional manifestations may include mild hypotension and tachycardia, creating a genuinely distressing and potentially dangerous clinical scenario. The Japanese study's focus on these grade two reactions demonstrates the real-world effectiveness of epinephrine nasal spray in managing moderate allergic reactions during controlled oral food challenge procedures, providing crucial evidence for clinical practice and patient safety protocols.

A panelist discusses how a study of Neffy (epinephrine nasal spray) in Japan demonstrated effectiveness in treating 15 pediatric patients who experienced grade 2 allergic reactions during oral food challenges, with these moderate reactions including symptoms like abdominal pain, vomiting, wheezing, and mild cardiovascular effects according to the updated grading system from professional allergy societies.

Video Series

Oral Food Challenge (OFC) Study with Epinephrine Nasal Spray

A panelist discusses how education about anaphylaxis recognition, early epinephrine administration, and addressing barriers like device portability remains crucial, with intranasal epinephrine potentially solving many existing challenges in anaphylaxis management.

Closing Thoughts on Treating Anaphylaxis with Epinephrine Nasal Spray  

In the final segment, Dixit synthesizes key takeaways from the presentation and audience interaction. He reiterates the fundamental importance of ongoing patient education regarding anaphylaxis recognition and the necessity of early, correct epinephrine administration. These foundational elements remain central regardless of delivery method or device innovations.

Dixit acknowledges the persistent barriers revealed through polling questions and research data: device portability challenges, cost concerns for some patients, and difficulties with correct administration technique. He notes how Neffy addresses these challenges by offering an effective delivery method that’s easier to carry, less intimidating to use, and more tolerant of environmental variations than traditional autoinjectors.

He concludes by addressing audience concerns about Neffy’s effectiveness with mucocutaneous involvement, citing reassuring evidence from food allergy challenges and direct allergen nasal challenges where the medication worked effectively despite inflamed nasal mucosa. This real-world evidence, combined with the physiological and pharmacokinetic data presented earlier, provides clinicians with confidence in offering this alternative to appropriate patients. Dixit thanks the audience for their engagement and questions, which revealed shared clinical concerns about anaphylaxis management across different practice settings.

Closing Thoughts on Treating Anaphylaxis with Epinephrine Nasal Spray

A panelist discusses how real-world cases demonstrate both the effectiveness of epinephrine when properly administered and the importance of ensuring patients actually carry their medication, through the stories of a college student with cashew allergy and a child undergoing a peanut challenge.

Real-World Case Examples: The Impact of Epinephrine Nasal Spray

Dixit presents 2 case studies illustrating real-world anaphylaxis management challenges. The first involves John, a 19-year-old college freshman with cashew allergy who experienced anaphylaxis after accidentally consuming cashew-contaminated Chinese food. Despite owning an EpiPen and understanding anaphylaxis, John couldn’t locate his device during the emergency. With help from his resident adviser, who had a personal autoinjector, John eventually received epinephrine and improved within 5 to 10 minutes, though his reaction had progressed to full-body hives and worsening swelling due to treatment delay.

The case highlights several critical issues: John brought his EpiPen to college but stored it inconveniently under his bed rather than carrying it due to the device’s bulkiness and his concerns about temperature exposure. His reaction progressed from localized symptoms to systemic involvement during the 5 to 8 minutes spent searching for epinephrine. Dixit emphasizes that while epinephrine worked effectively, the case demonstrates how carrying challenges can prevent timely access during emergencies.

The second case involves Nick, a 12-year-old with peanut allergy undergoing an oral food challenge to assess possible outgrowth. After 2.5 hours and approximately 5 g of peanut protein, Nick developed anaphylaxis with multiple systems involved (respiratory, cutaneous, gastrointestinal). He received Neffy in the clinic and experienced rapid improvement with minimal adverse effects (mild localized nasal vasoconstriction). Dixit notes this real case reinforces Neffy’s effectiveness, even in clinic settings where inflamed nasal mucosa might theoretically interfere with absorption.

A panelist discusses how Neffy offers significant advantages over traditional autoinjectors including longer shelf life (24-30 months), better temperature tolerance, and needle-free administration that addresses several unmet needs in anaphylaxis management.

Clinical Perspectives on Real-World Utility and Impact of Epinephrine Nasal Spray

This segment highlights Neffy’s practical advantages over traditional autoinjectors, particularly regarding storage and shelf life. Dixit notes Neffy’s significantly longer shelf life: 30 months for the 2-mg dose and 24 months for the 1-mg dose, compared with autoinjectors’ shorter expiration periods. He also emphasizes Neffy’s superior temperature tolerance, which enables more flexibility in storage conditions, though he still advises against extreme temperature exposure like leaving it in hot cars.

Dixit summarizes Neffy’s key benefits in addressing unmet needs: needle-free delivery, improved portability, and ease of use. When asked about appropriate patient candidates for Neffy, Dixit challenges the notion that it’s only for specific populations, suggesting it’s suitable for all patients within approved parameters (ages 4-plus years with appropriate weight-based dosing). He cites its carrying convenience, storage advantages, and effectiveness as making it appropriate for general use.

Responding to audience questions about postmarketing experience, Dixit shares that while he lacks official data, his colleagues report positive clinical outcomes with Neffy, noting patients recover similarly or sometimes faster than with IM epinephrine administration. He also addresses questions about the pediatric 1-mg dose, confirming it became available approximately 2 weeks prior and was developed based on pharmacokinetic studies showing blood concentration levels similar to those achieved with the 2-mg adult dose.

A panelist discusses how Neffy offers significant advantages over traditional autoinjectors, including longer shelf life (24-30 months), better temperature tolerance, and needle-free administration that addresses several unmet needs in anaphylaxis management.

Gregory Cetton, MD

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