Intranasal Epinephrine ("neffy") Is Now Available . . . At A "Hefty" Cost

ARS Pharmaceuticals, Inc.  has received FDA approval to sell “neffy” an intranasal (IN) epinephrine that is designed for use in severe allergic reactions.  “neffy” is an aqueous epinephrine preparation with the addition of the functional excipient Intravail® A3 (dodecylmaltoside) to improve the bioavailability of the drug, increasing absorption through nasal mucosa to injection-like levels without known injection-related adverse effects such as pain or irritation.  The sprayer device is identical in design to that which is already used to administer six other medications, including Narcan (naloxone).

As you can imagine, this device has the potential to be a game changer for dentists, as it is much more convenient and comfortable for providers who do not perform regular intramuscular injections. I have worked tirelessly with ARS Pharmaceuticals, Inc. and other wholesalers to bring this to you.  However, the bad news is that “neffy” is being priced exorbitantly: $766.80 for just two doses.  In addition, the manufacturer has no interest in working with smaller distributors.

This might also be a good time to think about the incidence of anaphylaxis in dentistry.  In my hundreds of conversations with dentists, it seems to me that anaphylactic shock is one of the most feared emergencies, yet very few have actually encountered a true anaphylactoid-like reaction in practice or elsewhere.  This inexperience is consistent with estimates that anaphylaxis occurs in 0.004 – 0.015 cases per dentist per year. 1-3  Morbidity occurs only in 0.5% to 1.5% of all anaphylaxis cases.4-6

Please do not get the impression that I am advocating for a dentist to abdicate responsibility to be prepared to manage an anaphylactoid-like scenario.  However, given the above, it seems difficult to justify spending upwards of $800 every year or so on something you will, in all likelihood, not use.  

Remember that drawing fluid from a vial and injecting it intramuscularly is a skill that every dentist MUST have.  This is non-negotiable.  The ADA ⁷, AGD⁸ and British Dental Journal⁹ all recommend your emergency drug kit contain an injectable antihistamine.  In the US, Benadryl (diphenhydramine) is the choice.  This cannot be in pill form, as PO meds must pass through the liver first (ASA is an exception because it is absorbed in the stomach) before entering general circulation.  This can take upwards of 20 minutes.  Diphenhydramine is not available in an autoinjector “pen” style device. 

The same EXACT skill needed for diphenhydramine injection is used for epinephrine 1:1000 injection from vials.  I can show you how in under 5 minutes.  The cost for me to teach you through a virtual experience or in-person, plus the medication itself, is less than the cost of a single Epipen autoinjector.  Click here to schedule a private training session, and start saving hundreds of dollars every year for the rest of your career!

Erik Zalewski is a Nationally Registered Paramedic and former New York State EMS Certified Instructor Coordinator with over 30 years experience responding to 9-1-1 calls for medical emergencies.  Erik has taught EMTs and paramedics at Stony Brook University, Borough of Manhattan Community College, and the Suffolk County, NY EMS academy.  Erik is also a certified flight paramedic.  He and his team at Have Dummy Will Travel, Inc. are dedicated to helping medical professionals respond to emergencies safely, efficiently and in the most cost-effective manner possible.  Call or text 631-849-4978 or email erik@havedummy.com for additional information.

1. Girdler,  N.M. & Smith, D.G. (1999). Prevalence of emergency events in British dental practice and emergency management skills of British dentists. Resuscitation. 41:159–167. 

2. Muller, M.P., Cansel, M., Stehr, S.N., Weber, S. & Koch T. (2008).  A statewide survey of medical emergency management in dental practices: incidence of emergencies and training experience. Emergency Medical Journal. 25:296–300. 

3. Arasti, F., Montalli, V.A., Florio, F.M., et. al. (2010). Brazilian dentists’ attitudes about medical emergencies during dental treatment. Journal of Dental Education. 74:661–666.  

4. Moneret-Vautrin, D., Morisset, M., Flabbee, J., Beaudouin E., & Kanny, G. (2005). Epidemiology of life-threatening and lethal anaphylaxis: a review. Allergy 60:443–451. 

5. Helbling, A., Hurni, T., Mueller, U. & Pichler, W. (2004).  Incidence of anaphylaxis with circulatory symptoms: a study over a 3-year period comprising 940,000 inhabitants of the Swiss Canton Bern. Clinical and Experimental Allergy.  34:285–290. 

6. Sheikh, A. &  Alves, B. (2001).  Age, sex, geographical and socio-economic variations in admissions for anaphylaxis: analysis of four years of English hospital data. Clinical and Experimental Allergy. 31:1571–1576.

7.  ADA Council on Scientific Affairs. Office emergencies and emergency kits. J Am Dent Assoc. 2002;133:364-365.

8. Roberson, J. & Rothman, C. Supplying Safety: The Importance of Drug Kits. AGD Impact. 2008;36(7).

9. Jevon, P. Medical emergencies in the dental practice poster: revised and updated. British Dental Journal. 2020;229(2):97-104