From Ampoules to Auto‐Injectors: Advancing Anaphylaxis Management in China

The introduction of epinephrine auto-injectors (EAIs) in mainland China marks a significant advancement in the management of anaphylaxis, particularly in the context of food allergies. However, despite the approval of EAIs for clinical use in the Guangdong-Hong Kong-Macao Greater Bay Area in 2023 (Figure 1), their widespread availability and use across mainland China remain limited. Before the approval and introduction of EAIs in the region, epinephrine was predominantly administered via injections drawn from ampoules [1], which required trained healthcare professionals to deliver the drug. Although effective, the use of injections drawn from ampoules introduces critical delays during anaphylactic reactions, particularly in settings where immediate medical assistance is unavailable. In contrast, EAIs allow patients or caregivers to administer epinephrine quickly and independently, potentially reducing the time to treatment and mitigating the progression of life-threatening symptoms during anaphylaxis. However, while EAIs are designed to improve access to life-saving treatment, current data do not conclusively demonstrate a reduction in anaphylaxis-related mortality [2]. Fatal outcomes from anaphylaxis remain rare and difficult to study systematically due to the unpredictable nature of severe allergic reactions and the low incidence of anaphylaxis-related deaths. Pre-filled syringes with epinephrine represent an alternative option for emergency treatment. However, a study conducted by the Asia-Pacific Research Network for Anaphylaxis highlighted significant disparities in the prescription and utilisation of these devices [3]. For example, while prescription rates for EAIs or pre-filled syringes reached 82% in Thailand, no such devices were prescribed upon discharge in Qingdao. This disparity underscores the broader challenges in China, where access to epinephrine—whether via EAIs or pre-filled syringes—remains severely limited. Globally, several countries have successfully implemented EAIs as first-line treatment for anaphylaxis [4]. In Europe, for example, the integration of EAIs into clinical and emergency care protocols has improved response times and patient outcomes. These international efforts provide valuable lessons for China and the broader Asia-Pacific region, suggesting that increased access to EAIs could support improved anaphylaxis management and health outcomes, though further research is needed to assess their long-term impact. The introduction of EAIs in China could help reduce mortality associated with food allergies and anaphylaxis, serving as a model for other regions to follow. However, several barriers continue to hinder the adoption of EAIs across China. One major challenge is the limited availability of these devices, which have been introduced primarily in regions such as Hong Kong and Macao [1]. Outside these regions, access to EAIs remains restricted. Additionally, while EAIs in Hong Kong cost between 1600 and 1900 HKD (approximately 205 to 245 USD), epinephrine ampoules in mainland China cost only 50 to 80 CNY (around 7 to 11 USD), creating a significant cost disparity that may limit nationwide uptake, particularly in lower-income areas. Food allergy is an emerging public health issue in China, with reported prevalence rates ranging from 4.0% to 8.2% [5]. However, most prevalence studies in China rely on self-reported surveys rather than objective diagnostic methods such as oral food challenges, which likely lead to an overestimation of the true prevalence. Despite this growing burden, epidemiological data remain sparse, and significant gaps in awareness and access to care persist. Effective management of food allergies, particularly life-threatening anaphylaxis, depends on the timely administration of epinephrine. EAIs, which have long been considered the standard of care for anaphylaxis management in developed countries, only recently became available in mainland China. Knowledge gaps persist among healthcare professionals in certain regions of China regarding the optimal management of anaphylaxis. While epinephrine is widely recognised as the first-line treatment, some clinicians continue to rely on glucocorticoids, which do not address the acute symptoms of anaphylaxis, such as airway constriction or cardiovascular collapse [6]. This mismanagement can delay the timely administration of appropriate treatment, leading to worsened clinical outcomes. Furthermore, standardised protocols for anaphylaxis management are lacking across China, with healthcare facilities varying in their approaches. Despite the growing incidence of anaphylaxis, fewer than 15% of anaphylaxis survivors were prescribed EAIs before hospital discharge between 2009 and 2019 [7]. To address this issue, the Hong Kong Anaphylaxis Consortium has developed consensus guidelines aimed at improving the prescription of EAIs in acute care settings; however, broader adoption across regions is needed [4]. Improving the accessibility and affordability of EAIs, particularly in rural and low-income regions of China, is critical. Although the burden of food allergy and food-induced anaphylaxis is lower in rural regions [1], ensuring access to EAIs remains essential to prevent disparities in care and address potentially life-threatening emergencies. A tiered pricing system based on income levels or the provision of direct subsidies for low-income populations could help reduce financial barriers to access. Additionally, collaboration between healthcare professionals and pharmaceutical companies could further support the widespread distribution of EAIs in China, especially in underserved regions. Healthcare professionals across China would benefit from incorporating internationally recognised best practices for anaphylaxis management into their ongoing professional development. Ensuring that clinicians are familiar with established global guidelines for anaphylaxis management—such as the timely administration of intramuscular epinephrine and the correct use of EAIs—would significantly enhance their ability to provide effective care. Evidence from a study conducted in a paediatric emergency department in Tel Aviv demonstrated that implementing structured protocols for anaphylaxis management, combined with educational initiatives, improved the recognition and treatment of anaphylaxis, resulting in increased rates of correct diagnosis, timely epinephrine administration, and provision of EAI prescriptions [8]. Furthermore, the potential misclassification of anaphylaxis-related deaths as asthma-related deaths underscores the need for improved recognition and diagnostic accuracy among healthcare providers. Raising awareness of anaphylaxis among individuals at risk, including those with food allergies, would improve public preparedness and patient outcomes. To support this, online platforms, webinars, and local workshops could be utilised to ensure that healthcare providers—particularly those in rural or underserved areas—remain informed of the latest developments in anaphylaxis care and treatment protocols. Public education on food allergies and anaphylaxis remains limited in China, with many individuals unaware of the signs and symptoms of severe allergic reactions, which can delay timely intervention. This lack of awareness is particularly concerning in rural areas, where access to healthcare may be more limited. Promoting awareness of the importance of timely epinephrine administration may help improve patient outcomes [9]. However, the use of EAIs should be accompanied by appropriate education to minimise misuse and improve confidence in their use. Public education campaigns, community outreach, and accessible resources—such as informational materials and local workshops—could help individuals at risk of anaphylaxis recognise symptoms earlier, seek appropriate care promptly, and reduce the likelihood of severe outcomes. The introduction of EAIs represents an important advancement in healthcare access for managing anaphylaxis in China. However, ongoing evaluation and monitoring of their implementation and impact are needed to ensure equitable and safe use. Expanding the availability, affordability, and integration of these devices into clinical practice is critical to ensuring timely access to life-saving treatments. A collaborative approach—combining ongoing education for healthcare professionals, increased public awareness, and equitable access to EAIs—can further strengthen anaphylaxis management and improve health outcomes. By addressing these areas, China can enhance healthcare access for its population and contribute to global efforts to ensure EAIs—a critical advancement in the treatment of food allergies and anaphylaxis—are accessible and available to all individuals in need. A.L.R.B.: Conceptualisation (lead); data curation (lead); supervision (lead); visualisation (lead); writing – original draft preparation (lead); writing – review and editing (lead). A.B. serves on the Manitoba and Saskatchewan Steering Committee for ImmUnity Canada. Data sharing is not applicable to this article as no new data were created or analyzed in this study.

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