Simplifying Epinephrine with Dr. Farah Khan

Transcript Disclaimer:
This transcript was generated using AI software from the original podcast audio and may contain errors, omissions, or minor inaccuracies. It has been lightly edited for readability. Please refer to the full podcast episode for the most accurate representation of the conversation.

Farah Khan, MD: 0:00

Don't leave it at home. The epinephrine is not useful to you if you are not carrying it. So carry it. Figure out a device that works for you. So if you remember the AuviQ or the Neffy or the Anaphylm that comes out, like whatever you're gonna carry, figure it out.

Amanda Whitehouse, PhD: 0:14

Welcome to the Don't Feed the Fear podcast, where we dive into the complex world of food allergy anxiety. I'm your host, Dr. Amanda Whitehouse, food allergy anxiety psychologist and food allergy mom. Whether you're dealing with allergies yourself or supporting someone who is, join us for an empathetic and informative journey toward food allergy calm and confidence.

Amanda Whitehouse, PhD: 0:35

I cannot wait to share with you my first guest in a new season of episodes that I've been working so hard on to address something that many of us are feeling deeply right now in the food allergy community. We are in the thick of both the excitement and the overwhelm that comes with how quickly the food allergy landscape is changing. Suddenly there are more options, more devices, more information, more treatments, more opinions. And while all of that progress is absolutely exciting and hopeful, it can also leave us feeling unsure of what to trust, what to decide, what actually matters, and how to make our decisions in a way that feels grounded and not reactive. So my guest today is Dr. Farah Khan, a board certified allergist at Nationwide Children's Hospital. But most of you know her because she has become a trusted voice online for so many in our community. Dr. Khan told me that she's not quite sure why her audience grew so quickly and why people are resonating with her voice, but I think I know why. In a time when everything feels uncertain and over complicated, she offers something that many of us are craving, which is clear, direct, evidence-based answers. I asked her to join me today to talk about epinephrine options, the different devices that are available, how they differ, the common myths and misinformation, and why hesitation and second guessing can be dangerous. Dr. Khan helps us to simplify something that has started to feel so complicated and help you feel confident and less overwhelmed as you navigate your epinephrine options. Dr. Khan, thank you so much for being here on the Don't Feed The Fear Podcast. I'm excited to have you.

Farah Khan, MD: 2:10

I'm so excited to be here.

Amanda Whitehouse, PhD: 2:11

Well, I would love it if you would start just by giving us the story of how you ended up in medicine and then in allergy, and then now on social media chatting with all of us.

Farah Khan, MD: 2:20

Yeah, I think most of it was accidental. So I always knew I wanted to be a doctor because of a simple thing that has sort of carried with me even after all these years of training and working, which is, I just wanna help people. I wanna be able to give back to my local community. I just wanna be able to help people. And then in medical school, when you're doing all these rotations and stuff, I really loved general surgery and then I really loved pediatrics. I mean, they are on total ends of the spectrum with very different trainings and very different lifestyles after you're done with training. So I actually applied to both and interviewed for general surgery, residency, and pediatrics. Because of lots of life things going on and sort of big picture goals that I wanted to be able to accomplish, I ended up ranking pediatrics as my top specialty. And I matched up my top program and went on to do pediatrics, which I really, really loved. But it wasn't the cute babies that like brought me into the specialty. Like I didn't know that I was, I wanted to work with the cute babies. It was teenagers that I just really, really loved working with. And then. You know, in residency when you're doing just general pediatrics training and you're getting a flavor of like whether or not you're gonna subspecialize, I really loved everything. I loved the nicu. I didn't love the PICU 'cause I didn't love the call and it was also very, very sad and depressing to work there. But I loved everything else, GI and cardiology. And then one of my senior residents, who's still a very dear friend of mine said, "Why don't you do a rotation with our allergist? She's fabulous." And so I just happened to do the rotation and she was so happy. All the time. She's still so happy all the time. I just saw her at our annual meeting. And I had a little chat with her and I was like, goodness gracious. Like, how do I be more like you? You're the one who inspired me to go into this specialty. And I think it was because she, she just really loves working with this patient population. We're dealing with a lot of chronic medical conditions. We're dealing with a lot of figuring out how to access care and medications and, and getting people to speed and stuff. I just loved it and I don't regret for even a second, going into allergy and immunology and now I've been leveraging what I do in clinic and kind of trying to have a bigger, a bigger impact. The, some of the, some of my friends, who are also physicians who are on social media, we always say like, in clinic or in the ER room or in the hospital room, we make a difference one patient at a time, one family at a time. So even if I can reach like 12 people or 200 people, like that's kind of crazy. So trying to trying to channel the, the, so the power of social media, into some good. So that was a very long-winded answer, but I just wanted to help people and that's, that's basically why I'm on social media

Amanda Whitehouse, PhD: 5:06

And from a couple to a hundred to now many, many thousands of people. I mean, your account just grew so quickly from when I found you to where it is now.

Farah Khan, MD: 5:15

Yeah, I, you know, I didn't even realize I was like making these, like reaching these benchmarks and these milestones. It was other friends that were like, oh my gosh, you know, like cheerleaders, like, you just reached 5,000, you just reached 10,000. Um, which has been really exciting. Um, so it, it's, it's been kind of crazy and I've been able to meet people that I would've never, ever met like you. Right? Like, when would our paths have ever collided? Even though we do work that like really kind of goes hand in hand.

Amanda Whitehouse, PhD: 5:43

For that purpose, it's just so amazing how far you can reach and who you can connect with and get conversations going.

Farah Khan, MD: 5:49

Yeah, absolutely. Absolutely. So I have, I have like a love hate relationship with social media in general. I think most of us probably do. But on the good days where parents will message me and say like, oh my gosh, we got a second opinion, or we did a food challenge, or, oh, we passed. Or, oh, we outgrew this allergy. Like that is, that's so wonderful. Like, it just like amplifies what I'm doing in clinic as well. So, good days and bad days, but more good than bad.

Amanda Whitehouse, PhD: 6:15

And it's funny that you mentioned that I didn't know this about you before, but that you say you're interested in, um, surgery because from the little that I know about the different aspects of medicine you seem like you kind of have that. Approach. Like you could be a surgeon, like you're really not, you can be really grilled. Matter of fact, you know, I know you've gotten some jokes online about sometimes how spicy you can be about it, but that I can see you in that role.

Farah Khan, MD: 6:38

Yes. I mean, that's why I loved it. Right. It's like it's, and it's also like in the OR for the most part, like. Yes, the anatomy can vary, but it's like black and white. Like you know what you're doing and you have expectations and there's just like a, a sequence of events that need to happen. Allergy is really interesting 'cause it's not that at all. Like everybody's story's a little bit different. Everybody's symptoms are a little bit different. Everybody's like, treatment option is a little bit different. Um, but yes. So, and, and in real life, I, I joke about this, but I, it's like not really a joke. Like I, I'm pretty like, matter of fact and like. I'm spicy and sassy in real life too, so what people get online is how I am in real life too.

Amanda Whitehouse, PhD: 7:20

Well, and obviously a lot of people are drawn to that. There's something about that approach that's different from other people like Dr. Reland has such a soft approach and people love her account and then you have a totally different vibe that people are drawn to. What do you think it is that people are resonating with so much that you're sharing?

Farah Khan, MD: 7:35

I, I'm gonna be completely honest. I'm not sure. I dunno, I don't, I don't know like what chord I'm striking. Um, other than being able to just talk about like some of the drawbacks and some of the nuance and some of the, "I don't know, and I'm not sure." And being able to admit that openly, I don't know. Um, I will say that I love me some Manisha love Dr. Reland. Um, and when we co-presented at another conference where I got to meet you in real life, um, it it's, it's so interesting because I think we need people like her that are like soft and caring and just so wonderful on so many levels. And then you gotta have some jerks like me that are gonna be like, but wait a second. You know? Um, and, and to call it out a little bit. Um, so, so it's, it's, I I don't know what chord I'm striking. If people wanna send me a message, like, if you wanna tell me like, what it is that's, that's striking a chord, I'm just gonna, I should like turn that up a little bit.

Amanda Whitehouse, PhD: 8:34

The time that I found you was the picture of you in the t-shirt that says, use the dang epi. And so that's why I was like, we should do an epinephrine episode together. But what do you think, um, what was it about that, like tell me what your mindset was in posting that.

Farah Khan, MD: 8:48

Yeah, so it's interesting when I started on social media, it was literally because I wanted people to just stop telling moms to cut out a bunch of foods from their diet if they were breastfeeding, to try to control like eczema or manage a food allergy in their young baby. Um, and like to stop ordering, like broad food allergy panel testing and young kids and stuff. So I just wanted to be able to like. Shout that from the rooftops. Um, so when I started I was probably a little bit more conservative, like I was just nicer in my delivery and maybe people miss that. Um, and then over time I realized like the stuff that I say in clinic is the stuff that I wanna say online. So I think my patients and family still probably get. A more, an even more direct answer in clinic because I can do that, right? Like, if they tell me about a program or a supplement or like, oh, I heard this, I can just tell them like, no, that's crazy, or that's no, don't do that. Right? But I can't necessarily bring that same vibe online. Um, so that's, that's sort of the little bit of distinction.

Amanda Whitehouse, PhD: 9:49

And in clinic you're their doctor. Literally, it's your job to give them medical advice.

Farah Khan, MD: 10:00

Yes. Yes. Um, and you know, and then what I realized is that like a lot of the recurring themes in clinic, like people are like, oh my God, you only use the epinephrine if you are having trouble breathing. And I'm like, if y'all are waiting until you're having trouble breathing, we have made some left turns, we are not going in the direction we need to. Um, and so it was just really funny, like the, the one post that has. Continued to just go viral. Like I, the last I checked it had like a few hundred thousand views, which is a lot for me 'cause I'm in a small corner of the internet. It was, it was that, which is like, don't, don't wait to stop breathing. Like that's not it.

Amanda Whitehouse, PhD: 10:34

And it takes so much repeated messaging and as we said, I think from different angles, different voices to override some of those things that just linger. Did that actually used to be the medical advice or is that kind of a that all along that you don't epi until it's a breathing issue or it's not anaphylaxis if it's breath?

Farah Khan, MD: 10:52

I think allergists have probably had a better understanding of anaphylaxis. 'cause this is just what we do for a living. This is what we read about, this is what we're researching. This is like what the risk is of a lot of the conditions that we manage. Um, but I think unfortunately, I don't know when it happened, but it just start like that was the thing that sort of came about, which is you don't use the epinephrine unless you're having trouble breathing. Um, and I still have patients and families that come to me and they were like, we were shamed by the EMS guys, or we were shamed by the ER providers or the staff or whatever, because we used epinephrine. And then by the time we got into the ER and the doc got by the bedside, all of our symptoms had resolved and they were like, well. That was an overreaction. And um, it's sad that that still exists. Right. But they, they got better because they did the right thing. They used the emergency epinephrine.

Amanda Whitehouse, PhD: 11:42

So they were great by the time they got there or were seen. My sister had a friend just the other day who's an adult with food allergies and she ordered a cranberry muffin. It accidentally had blueberries in it. She's allergic, you know, and she did the thing we hear all the time that makes us cringe. You know, she took a bunch of Benadryl and she went and slept it off. And she said, “You mean I should epi even if I am not having trouble breathing? And I was like, yes, yes.” I’m not a doctor, but I'm trying to share all of you who are saying this over and over so we can get through this hesitation that people have, what else are you hearing as far as people being so afraid to use it?

Farah Khan, MD: 12:16

There's a couple things. So I think for me, what I keep in mind is the unpredictability of allergic reactions and anaphylaxis, right? So some people will just have hives and it won't progress to anything else. But there isn't a skin test or a lab test or a magic eight ball that I can use that can help me predict like, that's it. That's all you're gonna have. It's some hives. It's gonna get better with some oral antihistamines like. Zyrtec or Claritin or something like that. Um, and we'd al we always want people to err on the side of caution, so if you start to like, have a tickle in your throat and maybe you have like a cough and now you're breaking out in a rash, that's two systems. Just use your epinephrine. You're never gonna be wrong to use it. So I think people underestimate allergic reactions or they're really nervous and they're, and, and they're just like, well, if I have to use the epinephrine, then I'm gonna have to call 9 1 1, or I'm gonna have to go to the emergency room. And I think. Most of us, unless we need it, like we kind of hesitate to seek emergency care services. Um, or some of us, right? Like, we're not you, we, like, we don't wanna end up in the er, we don't wanna go to that urgent care. Um, and I, what I tell patients is, if you use it and your symptoms get better, call us. Right? Let us know so we can like do an assessment and keep you out of the er. Like I don't wanna send you to the ER either. But if you don't use it, that's where you might end up.

Amanda Whitehouse, PhD: 13:32

Have you seen that help people be less hesitant now that that recommendation has officially changed? That you don't necessarily have to call 9 1 1 and go if your symptoms resolved.

Farah Khan, MD: 13:41

Yeah, so there's been, so we saw this big shift with the pandemic, right? Where we were trying to keep people, um, out of the ER and urgent cares and stuff. And, um, this, this guideline of like, use the epinephrine and go to the ER or call 9 1 1, is almost exclusively an American guideline. So our, our counterparts in Canada and other countries internationally don't, haven't necessarily always had that. So again, it takes time to like get people on board with this. So I will tell you, I have even met other allergists and healthcare professionals that don't feel comfortable saying, don't go to the er. You're not like having even a risk benefit discussion with the family, which I think. Is a disservice right. To that family because I don't want them to be in a position where they're scared to use it.'cause they're gonna have to go to the er. And then the big classic one that you, that everybody hears is like, oh, I don't wanna have to poke my kid because they think it's like a giant six inch needle that you're gonna have to jab into your thigh. And it's not, it's not. Um, but that's, I still hear that too. Like, oh, I don't, I don't wanna have to like stick my kid or stick myself.

Amanda Whitehouse, PhD: 14:46

Tell me if you think this is true in your experience, but I wonder if those are the people who haven't seen the anaphylaxis in action yet. Once I saw how bad it was in my kid, there was never any hesitation again. Like, I'm sorry if this hurts, but I will not hesitate to prevent that from happening. And then the kids' experience how, or adults, how much better they feel so quickly. I feel like that melts away, that hesitation. Do you think so too?

Farah Khan, MD: 15:11

Yes, yes. That's definitely what we hear from parents and older kids and teenagers in clinic, if we're doing a food challenge and we're trying to either like start them on oral immunotherapy or we're trying to figure out like, have you outgrown this? If they develop any symptoms and we need to use the epinephrine, I don't think I've ever, heard from a parent that they feel bad about having had to use it in a monitored setting. Um, almost always what I hear, um, after some tears. And scared and nervous feelings that bubble up during the acute reaction is, oh my gosh, that worked so quickly. Especially in young toddlers when they're fussy and inconsolable and crying and they're breaking out in hives and they look miserable, and then you give them the epinephrine and within a couple of minutes symptoms start to reverse. Like the, I think that also has empowered other teenagers patients, and. Parents and caregivers to just use the dang epi if they find themselves in that position again, and just hearing that from them makes the entire experience worth it for me as an allergist. Like I gave you the information. We walked through this and you guys were able to do the right thing

Amanda Whitehouse, PhD: 16:19

For the millionth time on my show and everywhere else in every corner of the internet, it doesn't hurt you if you epi and it turns out you didn't need it, correct?

Farah Khan, MD: 16:26

Right. Right, right. Um, because it's, it's, you make epinephrine, right? So you can't be allergic to it. Um, if you're on certain medications or have like cardiac conditions and stuff, sometimes we wanna caution a little bit. But again, that needs to be a very specific conversation for the meds that you're on your past, um, previous medical history and things like that with your allergist to get a risk assessment for you, you can't take like a risk assessment that I've done on a 16-year-old, totally healthy teenager. Then apply it to a 52-year-old man with hypertension, diabetes, and heart disease. Right? Like that's, that's not it.

Amanda Whitehouse, PhD: 17:03

I mean, if someone's giving you a prescription for it, that's the conversation to be having for them. Right. And they wouldn't have prescribed it if they didn't feel that the risk was appropriate if there's a chance that a anaphylaxis.

Farah Khan, MD: 17:19

Correct. Correct. So we still use epinephrine even if you are on certain medications like beta, beta blockers, which are often used in hypertension management. But sometimes we may need to reach for a different medication called glucagon. Um, if, if you end up in the ER and you're just not as responsive as we would've thought or hoped with the initial epinephrine

Amanda Whitehouse, PhD: 17:38

Where I spend a lot of time obviously is working with families and this balance that you touched on, like we get shamed if we react and we treat and we go to the er, but we feel like we're shamed if and guilted if we don't use it. And I feel like there's always this really precious balance that families are stuck trying to strike. So what's your perspective on how they find that?

Farah Khan, MD: 17:59

Exactly what you said. Like it feels like you're, you're oscillating between shame and a little bit of embarrassment, like, oh my gosh, my kid had an accidental exposure on my watch at the birthday party. Right? Um, and just being really scared and then having a lot of noise, right? They're getting maybe like some information from their allergist in their allergy office, but then maybe they found like a friend or a neighbor or support group and they're hearing something a little bit different. And then they're looking for their own information online. And there's lots of noise online around epinephrine, right? Um, and depending on who your source is, like some, sometimes. The way that I talk about allergic reactions and epinephrine and using it, um, is very different from an ER provider, right? And then, and then parents and caregivers and patients have to be the ones that like reconcile the differences. And because you're usually not seeing your allergist every two weeks just to check in to be like, Hey, how's it going? Right? Um, the, it, the, all of those questions is in like, the small things don't always get addressed. And then when you have your you know, every six month or every year evaluation, not everything gets, um, touched on that you have consumed. And so then you're just, you're stuck navigating all this information.

Amanda Whitehouse, PhD: 19:11

Yeah. And there's a lot of that swirling around in our heads. Everyone says don't play Dr. Google, but at the same time, we we're looking for information, you know? We are just desperate to find answers, so it is tricky.

Farah Khan, MD: 19:22

It is very, very tricky. What I try to do in clinic when I hear this from families and parents is like, oh my gosh, the EMS guys said we should not have given epi. Or the ER provider said we should not. I'm just like, they were wrong, right? Like, period. End of sentence. It's black and white for me because your kid got better. It doesn't matter if the hives were faint or it was just one episode of vomiting. Right. And I think sometimes hearing that in black and white at least helps them to be able to navigate and go forth to do the rest of the hard work. But it's, it's really hard and it always makes me, it really kind of pisses me off when parents come in and tell me that they got shamed for, for using freaking epinephrine. Like that's, that's not okay. We need to do better. That's also why I'm online, right, to help raise awareness because there shouldn't be this big discrepancy between what the allergist is saying and what the ER doc is saying. There just shouldn't be.

Amanda Whitehouse, PhD: 20:12

Thank you for saying that. I mean, I, I can't complain. We've had amazing emergency workers every time, you know, good job, mom patting me on the

Farah Khan, MD: 20:18

That's great.

Amanda Whitehouse, PhD: 20:19

For people who don't hear that from their own providers, I think it'll be helpful for them to hear it for you because we're just doing the best we can. We need to hear that. You know, I became an allergy mom. There's one, no, there's two types of injectors. There's an EpiPen and a generic and you avoid, and that's it. And now, you know. I'm thrust into this world along with all the other parents of an abundance of options, which is amazing and so overwhelming and so stressful. So much guilt about do I choose it, do I not? You know, we're looking at all these options, but I think the biggest and the most important one is the epinephrine options. So tell me about what the patients you're working with are saying now that they have to choose and what they're carrying and what, how you're guiding them through that.

Farah Khan, MD: 21:04

Yeah. Um, I, I think it's so exciting that we even have options, right? The, the fact that we only had a generic epi and an EpiPen for a really long time. And then, do you remember, was that like five to 10 years ago when the kits were costing like 600 bucks or something? Insane.

Amanda Whitehouse, PhD: 21:24

$700 it was for us, with insurance to get a pair

Farah Khan, MD: 21:29

No! See? Holy moly.

Amanda Whitehouse, PhD: 21:35

It's ridiculous. Mm-hmm.

Farah Khan, MD: 21:37

It is so ridiculous. Especially because the medicine itself is like a dollar. It is a dollar. Okay. Um, um, so it like we've come a way. I am not even gonna say a long way. Um, but the fact that we have like something like AuviQ, which, um, the device shape is a little bit different. Sometimes teenagers feel a little bit more comfortable and more inclined to carry it. Right. Your epi is useless if it's not actually with you. And then now the intranasal epinephrine, which is also super exciting. And then the sublingual, um, uh, epinephrine from Aquestive. I'm super excited about that too. I think change is hard. For everybody, especially in medicine, like we tend to be a very conservative bunch of people. Like we are not cowboys. We want to know, like study after study after study after study and decade after decade of experience that is traditionally what we have responded to. And it's very hard to like take something new and be like, oh, okay. Yeah, like the, okay, you want me to. Uh, I, there are still allergists even that are hesitant about prescribing the intranasal epinephrine. Some of them just straight up won't, and some of them have sort of come up with a plan, like still carry your traditional auto-injector and have the, as a backup and then have the intranasal, right? So people are like finagling some, some treatment plans and, it's not just providers that are hesitant, it's also families that are hesitant, right? They're like, what? You just put it up your nose. Like some of it is, oh my gosh, you don't have to stick my kid with a needle. And then some of it is like, wait, what now? Are you sure it works? How do you know it's not gonna dribble out? What if he's sick? What if he's congested? Right? Even though we have data on all those things.

 And, and it's not that, and I'm not like shaming asking questions 'cause I, I mean I had all those questions too. Right? Um, and I think what's important is that our ability to pivot and start to incorporate that stuff and then to follow it after it hits. The market, right? Like what are we gonna learn over the next few years from, from Neffy, the intranasal epinephrine. We're gonna learn a lot. And just having that option. And I will say that the biggest driver right now for me in clinic, on how I prescribe unfortunately, is cost. So what's insurance gonna cover? And for some people, even with the patient assistance program for the intranasal, like it's still a couple hundred bucks. And I do tell them like there's a little bit of a trade off rate. It has a longer shelf life. The intranasal, it doesn't just expire automatically after a year. Um, it's two and a half years, I think it's. 24 plus six, 30 months to do some math. Um, um, so there's a little bit of a trade off. And then depending on sort of what they feel comfortable with, um, and if my teenagers are more inclined to just carry the intranasal epinephrine device because it's not bulky, it's super, super light, um, a teenage girl can throw it in her purse or, uh, the kid, like any of them can just throw it in their backpack. Um, and if they're more likely to carry it, I think that's a big win, guys.

Amanda Whitehouse, PhD: 24:39

I agree. said it already. The epi that works the best is the one that you're going to carry and use, right? Yeah.

Farah Khan, MD: 24:45

Yes, exactly.

Amanda Whitehouse, PhD: 24:46

One of the hesitations that I hear the most that I don't feel qualified to explain, even though I read all the studies, but I think people need to hear this over and over. Parents are saying, but I read this is mostly for the Neffy, but it's coming up with with Anaphylm two, read that they didn't actually test it on people who are having anaphylaxis. So could you please explain why that is the case?

Farah Khan, MD: 25:05

Yeah, so we don't have any studies even with the traditional injectors because it is not ethical to induce anaphylaxis. So this is why it becomes really important to monitor these devices after they hit the market once we start prescribing them and seeing how this plays out in real life scenarios. The studies that we have stimulate what epinephrine is supposed to do. And what we have seen, even with the intranasal stuff, is that your blood pressure rises, your heart rate rises, um, your blood pressure even rises a little bit better than like the traditional, um, subcutaneous autoinjectors. So it, it's reassuring. Um, but there's never gonna be a study where you're like, Hey. You're allergic to peanut come in and eat this peanut on purpose so I can see what anaphylaxis looks like and whether or not you're gonna respond to the intranasal Neffy. Like that's just, that's just not how we do clinical studies anymore in clinical trials,

Amanda Whitehouse, PhD: 25:54

But it's well established epinephrine works and it's well established that the, the amount of epinephrine in the system is occurring regardless of these modes of delivery. Right? That's the bottom

Farah Khan, MD: 26:04

Yes. Yes. Yes. Um, and I just think it's so interesting, right? The way that it gets delivered, whether it's, it's a shot or it's like dissolving under your tongue potentially, or like a spray in your nose. Like, how cool is that, right? Like, how far have we come? Um, so yes, people are nervous, but also like, wow, how cool is this?

Amanda Whitehouse, PhD: 26:23

Well, and correct me if I'm wrong, but isn't the next level now where in clinic, if at a food challenge someone goes into anaphylaxis, you are recording the data?

Farah Khan, MD: 26:32

Yes. So, so now that Neffy's on the market and it's available and we can prescribe it, now there are some centers that are using it in their food challenges that we are challenging anyway, right? We have, we think you've outgrown it, you're coming in anyway, and then if you have, um, anaphylaxis and you need epinephrine, then we can figure out the Neffy or the traditional, and then compare those. So I think we're gonna learn a ton, right? How incredibly informative, right?

Amanda Whitehouse, PhD: 26:58

More information is always better.

Farah Khan, MD: 27:00

Yeah.

Amanda Whitehouse, PhD: 27:00

Can you talk about your experience, because what I'm hearing is a little bit confusing about people who are having those uncomfortable nasal symptoms with the Neffy?

Farah Khan, MD: 27:09

So everything that we do has risks and benefits, right? Even when we get in the car, when we decide to cross the street. And that's the perspective that I try to keep. Um, there. I mean, there are side effects even to something like Tylenol. And Motrin, they're incredibly safe, but they, they have some potential side effects. So it's the same thing with the Neffy, unfortunately, the stinging burning sensation that I've been hearing mostly from online, that from parents who have, um, had to use it and then what their kids are telling them back. Um, they've said it's been pretty intense. And then maybe I would say, maybe a dozen people have reached out to me like, Hey, have you heard anymore about this? And maybe a couple of them were like, I don't think we would use this again, because it was just not worth it. It lasted for several hours. It took until the next day. Um, and then the rest were like, you know, it stung and it burned. But he started to feel better from an allergic reaction standpoint. And then once he calmed down, everything kind of went away pretty quickly. So again, it's gonna be a conversation with that patient. With that family. And then we decide, and I'm not trying to push Neffy, like I'm not sponsored by anybody. I should have said that.

Amanda Whitehouse, PhD: 28:16

Me neither.

Farah Khan, MD: 28:18

I just want people to use the device that they are most comfortable with. And if you're like, intranasal is way too new, or I've heard too many horror stories about it, that's fine. Just make sure you're having that conversation with your allergist as well, so that they can come up with a plan that makes sense for you.

Amanda Whitehouse, PhD: 28:33

It's gonna hurt if you use an injector in your leg. We're just more accustomed to the idea of like, a needle is gonna cause some pain in your leg.

Farah Khan, MD: 28:42

Yeah. That's an excellent point. There is some injection site soreness and sometimes it can last for until the next day or two depending on like who jabs you because people think you really do have to like jab somebody. Um, and the pressure, you, you don't need to, you just need to apply enough pressure for it to click and then hold for three seconds. You don't need to jab people, but they do. And then you can end up with a little bruise at the site. So it is, it is a trade off. That's a great point.

Amanda Whitehouse, PhD: 29:07

We're recording this just before we're expecting it to be approved, but tell us a little bit more about Anaphylm.

Farah Khan, MD: 29:12

I'm not gonna speculate too much. I'm super excited for them to like, hit the market and for us to like, see more data and, and, and, and get it, um, into people's hands. I think what's interesting is, um, somebody had asked me right before Neffy got released, Dr. Khan, don't you think everybody's gonna convert to Neffy and everybody's gonna feel way more comfortable using it? And look at this conversation we just had where we're like, people aren't using Neffy. and I had said even then, I was like, this is so great. Like I am super excited for all the biotech advances within the world of allergy and stuff. So same, same thing with the, with the Anaphylm. Um, but there are still gonna be people that are like. I'm not sick enough, like, oh, I just ate a piece of shrimp accidentally. Or, oh, I had a bite of that toast. Even though I have a wheat allergy, uh, I'm just gonna like, wait and see. Right? And it's that part that I wanna work on, um, online and spread awareness. Like, it's okay if you have an accidental exposure. It is like, I'm an allergist, I have a food allergy. I've had multiple accidental exposures, not because somebody like made me, it's because of my own doing. You know, like we're, we're allowed to have mistakes. Um, and to screw up a little bit, um, as, as long as you know what to do, if that should happen and you should have symptoms

Amanda Whitehouse, PhD: 30:29

Do you experience that moment of hesitation too?

Farah Khan, MD: 30:31

Um, so I have a pine nut allergy. And the first exposure that I had back when I was in grad school, um, I had anaphylaxis and I didn't even know what it was, to be honest. I thought it was like food poisoning. And I was like, why, why did I have all this vomiting and diarrhea and like my, my roommate didn't, and I don't understand. And the next day I went to class and I was still beet red. That's sort of like a delayed skin reaction sometimes that happens when you have anaphylaxis and you just end up looking like a lobster for a while 'cause of all of the delayed chemicals and mediators. And I was beet red. And I am brown. Okay. I am very, very brown. And I was walking around like a lobster and she was like, what happened to you? Um, because I had had the pesto, the pine nut, um, pesto for dinner. Um, and I was like, I think I got food poisoning. Like I was just hugging my toilet all night. And she was like, I think you had an allergic reaction. And that was the first time I had even like, it even was like, oh. Is it a food allergy? And then I still didn't believe it, so I didn't, I didn't avoid pine nuts 'cause I didn't know any better. And then I had like a few other, um, exposures in like a pasta or a pesto or something like that. And I was like, why does my throat always get scratchy when I have pesto? So it took a little while. Okay. It took a little while. This is being in your twenties. Okay. In your twenties you were invincible and you're like, nothing, nothing. And then as I got into like med school, I was like, oh my God, I think I have a pine nut allergy. So, so I avoid, but I, I have still had accidental exposures, um, usually in restaurants when. Um, I, it either like slips my mind because things are busy and chaotic and I forgot if I forget to tell the waiter or waitress, I have a pine nut allergy and then like I get a salad or something that, that has some pesto on it. And the last time it happened was. Three years ago I was having dinner by myself after a long interview day for the current job that I'm in and I went downstairs to the hotel restaurant and I was like, I'm gonna get this salad. It sounds so good. And then I forgot to tell the waitress, and it was an incredibly busy night and she was like stretched and covering like 22,000 tables that I had a pine nut allergy. So she brings out this salad and they have a couple of bites and I'm like, this is really good. Oh, but why is my throat scratchy?

Amanda Whitehouse, PhD: 32:52

Oh no.

Farah Khan, MD: 32:54

So I stopped eating and my symptoms didn't progress to anything else. But, um, I like that was, that was just me, right? Like, I can't blame the waitress. I can't blame the restaurant. That was just me. I had an accidental exposure because it was me.

Amanda Whitehouse, PhD: 33:06

And it, and it happens, and I think you made a good point. Like there's no shame mistakes happen. That's why we always carry it. That's why we use it when we're in doubt, it's just always a risk.

Farah Khan, MD: 33:15

Yeah. I didn't even know it was anaphylaxis the first time I had it. Um, but now I do carry, um, EpiPens or the generics or whatever auto-injectors.

Amanda Whitehouse, PhD: 33:24

Hopefully you never have to use it, but if you do, I wanna hear what you, the queen of "use the dang epi," like, I wanna hear how it's for you.

Farah Khan, MD: 33:33

Yes, yes, I will. I will.

Amanda Whitehouse, PhD: 33:36

That touches on something I notice all the time, which is that it seems harder for adults to adjust or to even let it sink in, that it's a reality. Not just that I'm invincible, I'm in my twenties, but you know, older people developing a shellfish allergy into their thirties, forties, fifties, What's your take on that?

Farah Khan, MD: 33:52

I think we're embarrassed. I think we are just really, really embarrassed. That's what it was for me. The first few years after that big anaphylaxis, I was like, no, like I can't, like I don't wanna go out to eat with my friends and like, why, why should I be the one that has to like, make this accommodation for this like, stupid nut that's threatening my, my, my allergy cells? Um, so I was embarrassed for a really long time. Um, and even my close friends didn't know that I had a pin allergy and I don't think. A lot of them found out until I started educating on social media. And I would like drop it in here and there. Like, oh, I have a food allergy, or, oh, I've had anaphylaxis before. They were like, what? We've gone out to eat with you 32 times. Like, are you serious? And I was like, yeah, I just, just wouldn't wanna say anything. Now I don't care. Like we'll travel internationally and I'll like look up the words that I need, um, and have it like on my phone so I can like tell it in the native language to the waiter. And now like, I don't care. But I was really embarrassed for a really long time and I think that's what happens. Like people just don't wanna make adjustments

Amanda Whitehouse, PhD: 34:55

Well, yeah, and I think that's one of many barriers. I hope that hearing that especially from you, I hope that alleviates some of that from people because it is a, I think it's a natural response because we don't like to feel different in any way. But you didn't ask for it, you didn't create it. It's,

Farah Khan, MD: 35:10

No.

Amanda Whitehouse, PhD: 35:10

It’s not anything that anyone should be ashamed of. What do you wanna sum up and leave them with in terms of epi decisions?

Farah Khan, MD: 35:17

Just use the dang epi. Don't leave it at home. Don't leave it at home. Like the epinephrine is not useful to you if you are not carrying it. So carry it. Figure out a device that works for you. So if you remember the AuviQ or the Neffy or the Anaphylm that comes out, like whatever you're gonna carry, figure it out. And if you're really, really nervous because maybe you have asthma or. Um, hypertension or just other things that you're also managing. Please, please, please talk to your allergist about it. We wanna know all of those nitty gritty details, including whether or not you can afford the epinephrine, whether or not you're moving. What are you stressed out with? Like, I need to know that information so that I can best take care of you. And I think even though we are constantly strapped for time, those are things that I absolutely need to know. And I think, um, sometimes people hesitate 'cause they're like, oh, well I'm kind of embarrassed, or, oh, maybe she doesn't have time. But that's the stuff that I just want you to tell, like upfront when my nurse is rooming you. And, and she's like doing vital signs, like, tell her I can't afford the epi and you know, XYZs happened or my insurance denied it, or something like that. Because then that's stuff that I know upfront and I think most allergists would say that we want more information, and more of the nitty gritty details

Amanda Whitehouse, PhD: 36:27

I do think people are afraid. We don't wanna annoy you. We don't wanna go on and on. We don't wanna ramble. That's I think, very helpful to hear, to go into it, lead with that, make it a point so that you can help us.

Farah Khan, MD: 36:38

Yes. Yes. 'cause I, I won't know it's a problem until you tell me, and I never know what insurances are gonna cover or what your plan is or what your deductible is, right? But if you tell me, then I have like parameters to work with it and then we can figure out like a prior authorization or a different device

Amanda Whitehouse, PhD: 36:54

Let's do the pros and cons of all of our different options. And as we said, Anaphylm will be coming soon. Pros and cons.

Farah Khan, MD: 37:01

Yeah, so the, I will say that the pro to all of these devices is that they are epinephrine.

Amanda Whitehouse, PhD: 37:07

Good point. Same medicine.

Farah Khan, MD: 37:09

It's the same medicine, it is just the, the device that's a little bit different. So EpiPens or even the generic equivalents are the autoinjectors. And what I, what we mean by autoinjectors is once you actually place on your thigh and have enough. Pressure, um, that activates the injection needle part to sort of, um, uh, pierce your skin and, um, deliver the medication. Um, there some, some people would argue that like when you get one kit and it has the two pens, it's kind of bulky. And so the teenager who's leaving the house to go to dinner, is he gonna put that in his back pocket? Like, no, absolutely not. Which is also why I think parents butt heads with their kids if they're just flying out the door without like a jacket or a purse or something like that, because. They're like, take your EpiPen. And they're like, but I don't want to. Where am I gonna put it? Um, so, so it's bulkier, but it's, um, it's epinephrine. So if that works for you and your insurance covers it, great. And then AUVI-Q is the other one. Um, it looks more like a credit card shape. I wish it was as thin as the credit card. Um, it's, it still has maybe like. Half an inch, half, what do you think? Like a centimeter. So three quarter. So it still has a little bulk to it, but the idea with that one is that it actually talks to you. So once you activate it and take the top off and then it tells you like, um, in inject it and how long to hold it, and sometimes people feel more comfortable with it. Um, because of the voice activated, um, instructions that come with it. The Auvi-Q is also interesting because it comes in three different doses. So typically you have the regular generic EPIs are just 0.15 milligrams. If you're less than 25 kilos. Um, and then anybody above that and adults, it's uh, 0.3. And even if you just have the adult dose, but you have like a 2-year-old who's having anaphylaxis and you've recognized the symptoms, there's no harm in just using the higher dose. Um. But Auvi-Q also has, um, a really small dose, a 0.1 milligram dose for babies that are less than 15 kilos. Um, you can use those like do am, am I stressed out if you get the 0.1 milligram versus a 0.15 milligram? Not really. Um, and sometimes because of the cost, sometimes I. I don't even prescribe the 0.1 milligrams 'cause these young babies, like they tend to grow and gain weight and then they sort of like weigh out of the, the, um, Avi Q 0.1 milligrams. So if, if that feels comfortable for you and your insurance plan covers it, great. Get that. Um, and then the intranasal device, which we talked a lot about today, um, also comes in two different doses and then, um, the idea even with that is that in each kit you get two of those intranasal devices and it's basically like a squirt, like a, like a mist up your nose. And if you need the second device, you should use it in the same nostril, um, based off of what they found in the studies.

Amanda Whitehouse, PhD: 40:01

And then Anaphylm, which is coming soon

Farah Khan, MD: 40:03

Hopefully. It's gonna dissolve under your tongue. I'm kind of curious to see how they'll package it and how, like how many strips are gonna come in it? Is it just two

Amanda Whitehouse, PhD: 40:12

I think you'll get it in a pack of two, but they’re like Listerine strip size.

Farah Khan, MD: 40:24

This is so wild. So wild. I love it.

Amanda Whitehouse, PhD: 40:26

It’s gonna be exciting. Well, I appreciate you laying that out because bottom line is they all work.

Farah Khan, MD: 40:30

They all work. They're all epinephrine guys.

Amanda Whitehouse, PhD: 40:33

Well, thank you so much for taking the time to chat. This was amazing.

Farah Khan, MD: 40:36

I was so excited to be here.

Amanda Whitehouse, PhD: 40:39

I love the way that Dr. Khan took something that feels so complicated and boiled it down to such a simple message for us. When emergencies happen, we don't rise to the level of information that we've skimmed. We fall back on what we truly understand and trust. Here are three action steps that you can take after listening to this episode. Number one, just take a moment to get familiar with your specific epinephrine device. Whatever you carry, review how it works at a time when you're calm. Practice with the trainer, review it with everybody who needs to know how to use it. Confidence is built before emergencies happen. Number two, notice where your doubt is coming from. If you find yourself second guessing epinephrine use, or the type of device that you're carrying, ask yourself if this is based on medical guidance or on fear or misinformation. Clarity and awareness about that can reduce your hesitation and save your life in an emergency. Number three, Keep learning, but choose clarity over quantity. This whole season is going to be about navigating options without drowning in them. So follow educators and clinicians who are qualified, who are providing quality information and who help you feel steadier, not more anxious. Dr. Khan is one of those voices, and if you haven't found her on social media yet, her account on Instagram is@farah.khan.md The link will be in the show notes. If this episode helped you to feel more confident or grounded, I'd love for you to share it with someone else who is also feeling overwhelmed or excited about Epinephrine options. As always, a like a review, a subscribe, all help the show to grow and reach more people. And thank you again to Dr. Khan for being such a great guest.

Amanda Whitehouse, PhD: 42:25

The content of this podcast is for informational and educational purposes only, and is not a substitute for professional medical or mental health advice, diagnosis, or treatment. If you have any questions about your own medical experience or mental health needs, please consult a professional. I'm Dr. Amanda Whitehouse. Thanks for joining me. And until we chat again, remember: don't feed the fear.