Anaphylaxis treatment in general practice: devices, PBS, and neffy technique

Dr Elizabeth da Silva

Allergist and clinical immunologist, Gold Coast (adult practice; session chair). Otter labelled her “Liz / Elizabeth”.

Dr Birgit Marchand

Paediatric allergist and clinical immunologist, Southport / Gold Coast. Otter garbled “Bigot / Megan”; the recording is Birgit.

Lena James NP

Allergy and eczema nurse practitioner, Compass Immunology, Brisbane. She led the neffy education and trainer-device segment.

Adrenaline is still the only first-line treatment

Dr da Silva opened this half where part 1 left off. Adrenaline is the only first-line treatment for anaphylaxis. The slide she showed was a reminder of why: vascular effects, bronchial effects, stronger cardiac contraction, and an effect on mast-cell activation. Everything else in the kit is extra.

The practical question for GPs is no longer “do they need adrenaline?” — they do — but which device will this person actually carry, and actually use?

Which device, which weight — and the rule that actually matters

The panel compared intramuscular 1:1000 adrenaline (ampoule) with the equivalent community devices, including neffy. Otter garbled the slide numbers (“one in 1000 acres”), so this article does not reconstruct a dosing table that was not spoken clearly. What was spoken clearly:

PBS: continuing, initiating, one type at a time

This was the GP-heavy stretch of the night, and it is worth getting the verbs right.

Continuing scripts — GPs already do this

If the patient has already had an initial PBS authority for any adrenaline device, a GP can write the continuing prescription. It does not matter whether the first device was an EpiPen, an Anapen, or neffy. You continue it when the current device is used or expired.

Audience question: can you prescribe two types at once? No. Just one subsidised presentation at a time. Audience follow-up: can they interchange? Yes — when the current authority is used or expired, you can switch (injector to nasal, or the other way).

New patients — specialist, ED, or GP initiation

For someone who does not yet have an authority, Dr da Silva’s framing:

• consultation with an allergist / immunology service (herself, Dr Marchand, or Lena’s service), or
• she believed GPs can also prescribe initiation in the right circumstances — a colleague on the floor agreed they “support and prescribe it”, or
• discharge from an emergency department after anaphylaxis.

On ED, she was specific. Over the years she has seen discharge summaries that describe anaphylaxis — and for whatever reason the patient was not given adrenaline in ED. That practice is less common now; emergency departments are more proactive than they were 15 years ago. Her interpretation of the guidelines: if the history and signs are consistent with anaphylaxis, an initial adrenaline-device prescription can be written by the specialists or by GPs — and the patient should still be referred on.

What she actually types

The PBS authority screen she showed looked like Best Practice to people in the room (she does not use BP herself). Like other adrenaline listings: quantity two, no repeats.

Directions: she generally writes something like “neffy nasal spray, 1, p.r.n. for anaphylaxis” rather than “daily”. “Daily” sounds as if you may only use one a day. In anaphylaxis you may need several. Most GP scripts on the night’s accounting will be continuing rather than new initiations.

Why two devices — and why not six

Why does the PBS give two? The folklore on the Gold Coast — one at school, one with the parent — is not why the quantity was designed. Historically both devices were meant to stay with the patient at all times. Dr da Silva still tells adult patients (and “listener” / allergy-clinic patients) to carry both. Australia has drifted into a school-plus-parent split. That is a logistics habit, not the original clinical reason.

The clinical reason: a minority need a second dose. She first said about one in 15, then corrected with the room to about one in 10. Two devices exist so a second dose is in the bag, not in another suburb.

Dr Marchand’s paediatric reality: schools often want two pens, after-school care wants another, and families are pressured into more than two. That is always a bit of a problem. Dr da Silva’s workaround is additional private prescriptions so nobody is left without a device. Lena’s line: nothing worse than not having one.

The other failure mode is the opposite: four or even six devices accrued around the house. Some expire before others. One is in-date in a drawer; the expired one is the one they grab. Trainer devices get left in the same jumble. Adult-practice advice: two that they know are in date, that they know they can use, and that they know where they are — not scattered, and not mixed up with a trainer.

Expiry: injectors versus neffy

Longer dating is not a reason to stop checking the pack. It is a reason families may prefer the nasal option at renewal time — which is already happening.

Offering both, and the 150 microgram versus 1 mg question

Dr da Silva said she openly offers either an intramuscular device or nasal neffy. In the first month on the PBS, an overwhelming number of patients preferred neffy — mostly new / initial prescriptions, but also a high percentage of continuing switches.

Dr Marchand feels obligated to show the new device. She keeps one next to the desk. Patients volunteer for it; they are intrigued. She also talks through side effects (see below).

A question her patients actually ask, looking at the dosing slide: is 150 micrograms (junior injector) the same as 1 milligram (neffy)? No. As the surface area of administration goes up, the labelled dose goes up. It is not milligram-for-milligram the same thing — hence a different colour on the pack. Do not tell a parent “it’s the same 150.”

Lena’s counselling frame: people cope best when they are given the options and can make an informed decision. neffy may suit patient A and not patient B. For most, she can offer it, explain how it works and what to expect, and leave room for the family who still want an injector. She expects a large community uptake as it filters through schools and pharmacies.

How Lena teaches the device

This was a Wednesday-night education session, late, and she kept it simple. Every encounter is different: a mother and child, two partners, a first reaction versus a decade of allergy. That changes the tone. The method does not.

• Pictures work at every age. She has guides and diagrams out. A video or an administration diagram on the desk is useful to point at.
• Start with their knowledge. “How much do you know about neffy? Any concerns? Any questions? Any experience with it?”
• Then a short, specific explanation of how it works — not a lecture — so the rest of the demo has a frame.
• Trainer on the table. There were trainers at each table on the night. Show every component. Get them to hold it. Simulate — do not fire it up your own nose in the consulting room.

Dexterity is not usually the limiter. Most people are strong with their thumb. The hold she teaches: thumb on the plunger, first and third fingers around the base of the nozzle. Left- or right-handed — whichever is easiest.

It comes ready to go. One dose per device. Do not prime it. It is actually hard to fire by accident: you need a lot of force. The click is firm — described as a snap or a crack — similar to an autoinjector, and that click is how you know the dose has gone.

Keep the printed instructions in the little blue pack (about $17–18 from pharmacies, as discussed). The two sprays can sit in that plastic holder, instruction pad inside. Grab it, take it out, it is ready.

Dr da Silva’s add-ons, which she also uses with patients:

• The trainer springs back. The real device does not. Say that out loud during the demo so nobody waits for a rebound that never comes.
• Two steps, said simply: “You stick it in your nose and you click it.” A lot of people respond to that.
• Give the patient booklet (paper if you have it; she now emails an electronic copy).
• Give an ASCIA action plan even to adults — even if it only goes on the fridge. Somebody at home was not in the room. The plan is how the patient trains the rest of the household.

Allergy & Anaphylaxis Australia (Otter: “Anaxius” / “Amphilia Access”) has a large public section on the device. ASCIA resources, and the school / childcare guidelines, have been updated to reflect any adrenaline device, not injectors only.

Technique, as spoken — no extra steps

Positioning is the same counselling you already give for adrenaline. The patient should be lying down or sitting up comfortably. Lena’s line for school children in Queensland heat: if you are having anaphylaxis, sit down under a tree, in the shade, and get someone else to run for the device. Do not send the unwell child across the oval.

Then, as demonstrated (she did not spray herself):

1. Get it out of the blister. It is ready. Do not prime.
2. Hold it: thumb on the plunger, first and third fingers around the base of the nozzle.
3. Choose one nostril — it does not matter which one first.
4. Insert straight up toward the forehead, not aimed at the septum and not aimed outwards, until your fingers hit the end of the nose.
5. As soon as it is in, push the plunger very firmly until you hear the click / snap / crack.
6. Take it down. Call an ambulance. Follow the usual anaphylaxis action plan.

You do not blow the nose afterwards. Intravail (Otter: “vision land”) is the absorption enhancer already in the spray; you are not trying to clear a path. Try not to sniff during or after. People sometimes inhale a little into the throat; she was not aware of harmful study repercussions from that, and Dr da Silva noted throat irritation and odd sensations if some adrenaline sits at the back of the throat.

After firing, the plunger stays up. Single-use. Do not expect it to reset.

Two extra technique points from Dr Marchand, not in the video script:

• The whole device does not have to disappear up the nose. You need enough mucosal contact, not a deep packing.
• Warn children and parents about the jolt of the device — it can be confronting if unexpected. Keep the head stable so they do not jerk, especially if they are sitting rather than lying down. (Otter garbled “kitchen side” / “gentleman”; the clinical point was the kick and a steady head.)

Storage, freeze, travel, schools

neffy is quite temperature-tolerant, in the same family of advice as the injectors: keep it below 25 °C, knowing it can take a bit of heat for shorter periods. Never store it in a car. Keep it out of the sun. Adolescents from around age 10 who are comfortable carrying it (and whose parents are comfortable) can keep the blue container in a pocket or bag — that is part of the carry argument.

If it has been frozen, it can still be used once it has thawed. Freezing was not described as ruining shelf life. The counselling line Lena added, and stressed: do not wait for it to thaw if you have another device — use the other one.

Travel: same as any adrenaline. Carry-on, never checked luggage. Hold-baggage can freeze. You also need it on your person if a reaction happens in the air.

Schools: Queensland Department of Education has been rolling out education; ASCIA communication and protocols sit alongside that. School and childcare guidelines, and best-practice documents, had just been updated in a busy week. Government and Catholic schools are both in the communication. Ideal: children should have access to two adrenaline devices at school. How many neffy packs end up in sick bays and after-school care will emerge in practice. The panel’s position: neffy is accepted as an adrenaline device across schools and other facilities looking after children — there should not be a refusal because it is not a pen. Sometimes a short letter to the school still helps.

Side effects and the unconscious patient

It is liquid adrenaline as a fine mist at the back of the nose — not a powder. Absorption is from mucosal contact, not from sniffing. That is why you can use it in a patient who has lost consciousness. You do not need them awake, and you do not need them to sniff. The blunt floor instruction: put it in the nose and press.

Counselling on how it feels, as taught:

• Local: nasal and throat irritation, odd sensations if some of the mist reaches the throat.
• Headache, more pronounced after a second dose.
• Systemic adrenaline effects you already know: racing heart, feeling stressed, tightness in the chest, sometimes nausea and vomiting — particularly in children who are already agitated from the reaction. Lena has seen a lot of children vomit after adrenaline from the shock response itself.
• With neffy, those effects were described as a little more locally felt than the more systemic hit of an injection — still adrenaline, still the same drug.

Dr da Silva’s close: it is rapid, reliable, pocket-sized, well tolerated. Same adrenaline. Shared decision-making: ask the patient what will actually work for them. GP prescribing is in the same muscle memory as other adrenaline devices. She is happy to take GP calls and correspondence.

Take-home messages for clinic

1. Adrenaline remains the only first-line drug. Device choice is a carry-and-use problem, not a brand beauty contest.
2. neffy from 15 kg and 4 years; next strength at 30 kg (most 10-year-olds). Under that: an injector.
3. PBS: one type at a time, quantity two, no repeats. Continuing scripts can switch between EpiPen, Anapen, and neffy when the current pack is used or expired. Check current initiation rules before a first-ever authority.
4. Write p.r.n. for anaphylaxis, not daily. Several doses in one episode is allowed by physiology, not by a “once a day” direction.
5. Two devices are meant to travel with the patient because about one in ten need a second dose. School-and-parent splitting is a local habit. Extra school devices: private script. Do not leave four expired pens in random drawers plus a trainer.
6. Dating: EpiPen often 6–18 months; neffy about 2 years (1 mg) and 2½ years (2 mg). Below 25 °C, no car, carry-on only. Frozen pack: use the other device rather than waiting to thaw.
7. 150 micrograms is not 1 milligram. Different surface, different labelled dose, different colour. Explain that.
8. Technique, as taught: no prime; thumb on plunger; one nostril, straight up; press hard to a click; no sniff, no nose-blow; trainer springs back, real one does not. Unconscious patients can still receive it. Then call 000.
9. Give an action plan even to adults, and point families to Allergy & Anaphylaxis Australia and current ASCIA device pages. Offer both devices; many will pick the nasal one, not all will.

Recognition, delay, and why a nasal option exists at all are in part 1 of the same night.

Dr Kotha · Gold Coast · anaphylaxis-treatment.drkotha.com · companion to anaphylaxis.drkotha.com