Talk:Epinephrine autoinjector

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The generic term "epipen"[edit]

The article currently begins "An epinephrine autoinjector or epipen is a...." I've never seen the word "epipen" used in a generic context. No citation is given, and I couldn't find it in a rudimentary search of online English dictionaries. EpiPen is listed as a trademark (e.g., ). I'm removing the term, and hopefully if it was correct, someone will restore it with a citation. - (talk) 18:28, 10 July 2016 (UTC)

In the U.S., the Mylan EpiPen dominates the market, and many doctors, nurses and patients use it as a generic term. I try to avoid brand names, but I don't want to be pedantic. It can be confusing, misleading or wrong to simply replace "EpiPen" with "epinephrine autoinjector". For example, the section on "Design" indiscriminately refers to EpiPen and Anapen.
Americans are interested to know about the situation in other countries, where it is much cheaper. Rather than deleting U.S.-specific content, it would be better follow Wikipedia policy to add international information. Some of the information here about international products is outdated and some of them are no longer available.--Nbauman (talk) 13:15, 18 August 2016 (UTC)

NYT Aaron Carroll on EpiPen costs[edit]

This article by Aaron Carroll, an MD and contributor to several peer-reviewed journals, has a better account than most and adds a few critical details on costs and competition of the EpiPen.
The EpiPen, a Case Study in Health Care System Dysfunction
Aaron E. Carroll
New York Times
AUG. 23, 2016
--Nbauman (talk) 18:46, 23 August 2016 (UTC)

Good hint, but NYT is not accessible for everyone. In light of the substantial price increase by Mylan yesterday, it would be useful to know when their patents, or any related patents, expire. We can only say today 'just make sure you don't need it until it comes off patent' - which is not a solution. Maybe the patents expire reasonably soon and the size of the price increase is due to making hay while the sun still shines? (talk) 04:31, 26 August 2016 (UTC)
Oy there are patents on Epipen. Adding content about this. Jytdog (talk) 05:09, 26 August 2016 (UTC)

Medical uses[edit]

How come there is nothing about the medical uses of this device in the Medical uses section? Kendall-K1 (talk) 13:52, 25 August 2016 (UTC)

you added it. Thanks. Jytdog (talk) 18:37, 25 August 2016 (UTC)

Auto-injector or autoinjector?[edit]

We should probably pick one and stick to it. Kendall-K1 (talk) 14:15, 25 August 2016 (UTC)

yes, consolidated to autoinjector per our Autoinjector article in this dif. Jytdog (talk)

What happened to reference to Emerade?[edit] In classic Wikipedia, sloppy editing style, someone just deleted the reference? Is there a reason? I understand Emerade is available in Europe and this isn't — Preceding unsigned comment added by Mgunn (talkcontribs) 18:34, 25 August 2016 (UTC)

In this dif I replaced unsourced content with sourced content. That is what we do here. We follow sources. I'll see what I can find on Emerade. The source you provide is not what we prefer Jytdog (talk) 18:48, 25 August 2016 (UTC)

The European Medicines Agency is in some sense the European Union analogue to the U.S. federal government's F.D.A.. Here's a document from the EMA website listing various auto injectors in the EU. Mgunn (talk) 21:52, 25 August 2016 (UTC)

Thanks I was able to work with that. Very useful table! Jytdog (talk) 05:07, 26 August 2016 (UTC)

In France, two EpiPens cost $85.[edit]

The above needs a reliable source. Moved it here to Talk per WP:PRESERVE. Jytdog (talk) 18:49, 25 August 2016 (UTC)


The below...

Consumer reports said that another, cheaper option was using standard syringes and filling them manually from vials of epinephrine. This requires training by a doctor, and the shelf-life of an epinephrine vial is only three months compared to 12 to 18 months for the EpiPen and Adrenaclick. (sourced to here)

This provides medical advice to readers. In my view this violates WP:NOTHOWTO. We don't do this here. Perhaps others differ but lets talk about that. Jytdog (talk) 18:52, 25 August 2016 (UTC)

I'm not sure it's quite medical advice but it is howto and I say leave it out. Plus CR doesn't exactly say this is another option, they say "some have turned to using manual syringes". There is a difference between "some people do this" and "you can do this". Kendall-K1 (talk) 19:11, 25 August 2016 (UTC)
This is not medical advice and it's not "how to". Nobody could inject with a syringe by following the advice here or in the CR article. As CR says, they would have to go to a doctor for training. This is explaining another treatment option, much as we list and explain the different treatments for high blood pressure or arthritis. It's important because the article discusses the high price of the EpiPen, what the alternatives are, and why it's so difficult to substitute for the EpiPen.
Jytdog also removed the paragraph that said
Consumer Reports said that another option was the generic autoinjector Adrenaclick by Impax Laboratories, which they found selling for $142 at retail stores. A pharmacist told Consumer Reports that Adrenaclick and EpiPen have the same drug in the same doses, but there are differences in how they are used, so Adrenaclick users must be trained in its use.
The reason we should attribute it to CR is that CR is a well-known peer-reviewed source with a reputation for reliability, unlike some of the "media releases" and news stories where the reporters aren't doctors and don't have time to do major research. If you just say that the Adrenaclick is "another option," who knows how realistic an option that is. If Consumer Reports says it, you know that their medical experts reviewed it.
One of the big questions of this article is why, if there are so many other brands, is EpiPen a near-monopoly that was able to raise its price without competition. This CR article explains why it is so difficult for patients and responders to use another brand of auto-injectors, or manual epinephrine syringes.
This was all well-sourced material relevant to the subject of the article and the issues brought up here. I'd like to see a good reason to delete this. --Nbauman (talk) 23:13, 25 August 2016 (UTC)
WP articles don't tell people how to deliver drugs. They talk to their doctors about that. Also this is an article about autoinjectors. Duh people don't have to use this device and can just use a syringe. Same thing with diabetics. Jytdog (talk) 04:43, 26 August 2016 (UTC)
If you actually read this article you will see that it explains how Mylan ended up with the exclusivity they have. Competing products have had problems (Sanofi's recall), or regulatory failures (Teva's copy) and otherwise, Mylan has just kicked their asses with marketing. There are other options. The thing consumer reports said about "Adrenaclick users must be trained in its use" is off-base and assumes that EpiPen is the magical default (swallowing Mylan's koolaid). People had to be trained to use EpiPen. If they change to a new device - whatever that is - they have to learn how to use that. Which is one of the reasons why I didn't include that - if anything it scares people away from the alternatives they have. Jytdog (talk) 04:46, 26 August 2016 (UTC)
adding content about patents and challenges now... Jytdog (talk) 05:30, 26 August 2016 (UTC)
Nbauman asked why sourced content was removed. There was no good reason given. The following is an admission that WP:OR is either not understood or is being ignored The thing consumer reports said about "Adrenaclick users must be trained in its use" is off-base and assumes that EpiPen is the magical default (swallowing Mylan's koolaid). It appears Jytdog is creating his own argument and now padding the article to support his take. If there is no policy-based argument for the removal, the CR bit should be replaced. petrarchan47คุ 09:06, 26 August 2016 (UTC)
People have to be trained to use any auto-injector, including EpiPen. PMID 25368525; PMID 24384138, PMID 25841557 etc etc. It is not just an issue for Adrenaclick. Jytdog (talk) 19:34, 26 August 2016 (UTC)
This is WP:OR:
"Adrenaclick users must be trained in its use" is off-base and assumes that EpiPen is the magical default (swallowing Mylan's koolaid).
As I said above, this is the opinion of Consumer Reports, which is goes through medical reviewers. "Mylan's koolaid" is Jytdog's personal opinion. You're deleting well-sourced material reviewed by medical experts because you disagree with it. I think this was improperly deleted.
Furthermore, Jytdog hasn't explained why this is "medical advice" or violating WP:MEDICAL. It's not. --Nbauman (talk) 22:38, 26 August 2016 (UTC)

PMID 27555092[edit]

very recent review PMID 27555092, arguing that autoinjectors should be covered under obamacare's prevantative care provisions. authors disclose that they were paid by Mylan. I won't be citing this. Jytdog (talk) 19:03, 25 August 2016 (UTC)

The authors have disclosed their conflicts and was published after undergoing peer review. By not including it you are in fact introducing your own bias here. EditorDownUnder (talk) 20:09, 25 August 2016 (UTC)
Discuss content, not contributors. Jytdog (talk) 20:55, 25 August 2016 (UTC)


I changed "Their advantage over use of a syringe is safety" to "One advantage over use of a syringe is safety". Surely safety is not the only advantage? Speed comes to mind, and I've also heard that it's easier for users to overcome squeamishness because there is no visible needle. I would add these other advantages but I'm not familiar enough with MEDRS and med articles in general to do this. Kendall-K1 (talk) 22:31, 25 August 2016 (UTC)

As a physician I think anyone other than a young child can be taught to use a simple glass vial and a disposable 1cc syringe, which together provide enough for up to three doses at a total cost of about $15. The autoinjector is a little easier to explain but is not significantly faster or safer simply because the optimal dose does vary. It was developed for soldiers to use while wearing chemical warfare suits. Danwoodard (talk) 22:49, 26 August 2016 (UTC)

I would suggest reverting it back until a source is found that speaks to multiple advantages, otherwise it's OR territory. petrarchan47คุ 09:11, 26 August 2016 (UTC)
I doubt that the cited source says this is the only advantage. Can you confirm? Kendall-K1 (talk) 12:22, 26 August 2016 (UTC)
I may have misunderstood your objection, and if so I apologize. To me, the old wording says "There is only one advantage to using an autoinjector, and that one advantage is safety." The new wording says "We are not going to tell you how many advantages the autoinjector has, but there is at least one, and that's safety." I don't like the old wording because I don't think it's true and doubt that's what the cited source says. Are you objecting to the new wording because you don't think that's what the source says, or because you think it says something other than what I think it says? I will try to get a look at the source, which should help clear this up. Kendall-K1 (talk) 13:56, 26 August 2016 (UTC)

I'm looking at the source now [1], and I don't think it supports the statement at all. We've said "the dose is fixed, the user does not have to handle an exposed needle, and intramuscular injection avoids the risk of injection into a vein." But the source says the fixed needle length is a disadvantage because it may not be long enough for obese kids; it says exposed needle is a risk not of syringes but of double-dose injectors; it says injectors are prone to accidental needle sticks; and it says the fixed dose is a problem because it "may be too strong for infants and toddlers weighing <15 kg, and the 0.3-mg dose may be subtherapeutic for children weighing >30 kg." Kendall-K1 (talk) 14:09, 26 August 2016 (UTC)

I agree and removed it. Jytdog (talk) 18:45, 26 August 2016 (UTC)

History section[edit]

Fleshed this out tonight. For a long time there have just been two autoinject devices in the US and only recently 3.

  • EpiPen - made by Survival Technology in the 1970s which became part of Meridian Medical Technologies which was acquired by King which was acquired by Pfizer. This device has dominated the market going back to 2001 at least, well before Mylan had it. Has at least one patent that is apparently still standing that lasts til 2025, per the content I added tonight. (See also the Orange Book listing for EpiPen here)
  • Twinject/AdrenaClick - invented by Hollister-Stier over ten years, finally was done and received approval from the FDA in 2003, sold to Verus in 2005 and sold to Sciele Pharma in 2008, acquired by Shionogi in 2008, sold to Amedra in 2012, acquired by Impax in 2015. (fwiw this product seems to have been kind of a hot potato; am guessing that people thought they could make traction against EpiPen and couldn't). According to the Orange Book here there are no unexpired patents.
  • Auvi-Q invented by Intelliject, acquired by Sanofi in 2009 and approved in 2012. According to the Orange Book here their last patent expires in 2029. Sanofi recalled the devices in Oct 2015 and terminated the deal in Feb 2016. This device is not available since Oct 2015.

For generics...

  • EpiPen: Teva had a shot to bring a generic EpiPen and was rejected by the FDA this year; Novartis/Sandoz tried to bring a generic EpiPen but was sued by Pfizer/Mylan in 2011 ... as of this year the litigation is ongoing/unsettled, according to Pfizers annual report. Of course Mylan has announced it intends to bring a generic of its own product.
  • Adrenaclick: in 2010 Shionogi gave a Pfizer subsidiary, Greenstone, the right to market an authorized generic of Adrenaclick. That right was acquired at some point by Lineage, a wholly owned subsidiary of Amedra, and the generic was relaunched at the same time that Amedra launched Adrenaclick - in June 2013. This was also acquired by Impax in 2015. Anybody could bring a generic whenever they want.
  • Auvi-Q will not be off patent until ~ 2030.

It is so crazy - of these 3 products, 2 are going to have the branded product and the generic in the same company's hands - Mylan/Pfizer and Impax. Kooky. There is no independent generic anywhere right now. -- Jytdog (talk) 09:11, 26 August 2016 (UTC)(revised Jytdog (talk) 05:31, 31 August 2016 (UTC))

Question - this is now in chronological order pretty much, with content about the three devices interspersed. Would it be better to organize in three parts, one for the story of each device? I can see it either way but am not sure which is most useful for readers. Jytdog (talk) 02:26, 28 August 2016 (UTC)

Should we change the numbers used to show the cost change?[edit]

The article says "Mylan raised the price from $57 each in 2007 to $600 for a package of two in 2016". Thats an odd way to write it. Would it be better to say "$300 each"? Or if the epipens were originally sold just in a package of one instead of two, and not sold in packages of one now, should the article explicitly state that? (talk) 23:03, 28 August 2016 (UTC)

Yes, done. Jytdog (talk) 23:10, 28 August 2016 (UTC)

Mylan's claim it will offer an authorized generic[edit]

Just saying, yes

But right now that is WP:CRYSTALBALL so I am not adding it to the article; this is unlike the discount cards, which they actually did. We can add this stuff if they actually launch the generic. Jytdog (talk) 05:42, 31 August 2016 (UTC)


How long do they last? The article doesn't say and this is an important fact considering this whole price issue. Anna Frodesiak (talk) 21:05, 31 August 2016 (UTC)

a year. I will add it. Jytdog (talk) 21:45, 31 August 2016 (UTC)
Thank you kindly, Jytdog. :) Anna Frodesiak (talk) 23:45, 1 September 2016 (UTC)


I suggest removing the "Society and culture" section heading and making main sections "US price controversy" (or something like that) and "Brands". Thoughts? Anna Frodesiak (talk) 23:49, 1 September 2016 (UTC)

Actually, I just boldly did it, putting the price controversy last as is conventional. Please revert or improve as you see fit. Anna Frodesiak (talk) 23:52, 1 September 2016 (UTC)
Thanks that is much better Jytdog (talk) 00:00, 2 September 2016 (UTC)

Hi everyone and Doc James. Jytdog and I think the sections are better like this. You changed it back to this in this edit.

Opinions on how the sections should look are needed and welcome. Thanks. Anna Frodesiak (talk) 22:59, 3 September 2016 (UTC)

We have WP:MEDMOS which recommends brands and price occur under society and culture. Doc James (talk · contribs · email) 15:40, 4 September 2016 (UTC)
Hi Doc James. Fair enough. So, how about "US price" --> "US price controversy" or scandal or something like that? Anna Frodesiak (talk) 22:34, 4 September 2016 (UTC)
I am OK either way; both are better than what we had Jytdog (talk) 20:39, 5 September 2016 (UTC)
Hi Jytdog. "Had"? It is exactly how it was in the beginning. SFriendly.svg Anna Frodesiak (talk) 21:09, 5 September 2016 (UTC)
Anna did this. You 1) flipped the order of brands and pricing 2) removed the "Society and culture" heading and elevated the subheadings Brands and "~pricing~" to main sections, and 3) changed "US prices" to "US price controversy. I very much appreciated 1) and didn't notice or care about 2) and 3).
Doc James 1) kept the order 2) restored the main Society and culture section and demoted the 2 to subsections; 3) changed the now-subsection name back to "US prices".
The thing I cared about - 1) - remains unchanged, so I am happy. As for 2, WP:MEDMOS does put brands/pricing under the "Society and culture" heading so it is valid; I don't care either way. As for 3, I don't care. Doc James it would be good if you justified removing "controversy" (that said I don't see much controversy; nobody has really defended Mylan's pricing so "US price criticism" would be a more accurate section header than "US price controversy". But I don't care. Jytdog (talk) 21:39, 5 September 2016 (UTC)
Yes, "criticism". That's the word I was hunting for. And I don't care either. This is small potatoes and we have other fish to fry. (I'm not sure why, but I am suddenly hungry for some fried fish and potatoes.) Anna Frodesiak (talk) 22:08, 5 September 2016 (UTC)
That section is for the wider discussion of the price. It is not just for criticism about the price but can include criticism. Prices in other countries should also be added which I will do latter. Doc James (talk · contribs · email) 08:27, 6 September 2016 (UTC)

more references[edit]

  • [2]NIH (Epi-pen)
  • [3] UK
  • [4]price info CNN

came across these references--Ozzie10aaaa (talk) 01:33, 4 September 2016 (UTC)

That last one is interesting! Imprimis Pharmaceuticals has plans to introduce an epinephrine autoinjector through compounding pharmacies for less than $100.. Will have to keep an eye out and see if they actually launch that. Jytdog (talk) 21:11, 7 September 2016 (UTC)
another competitor ref due to launch in 2018 is Windgap Medical; their device is Abiliject. Jytdog (talk) 21:27, 7 September 2016 (UTC)
the price controversy (in this case Epi-pen) but in other cases[5] shows difficulty in controlling/regulating US companies(not to mention healthcare overall cost...IMO)--Ozzie10aaaa (talk) 23:14, 7 September 2016 (UTC)

Epinephrine autoinjector vs. EpiPen[edit]

According to this USA Today story, Mylan deliberately created marketing materials and draft policy recommendations that did not mention "EpiPen". They used phrases like "epinephrine autoinjector" instead, in order to conceal Mylan's role and make them look less like marketing materials.

This name change for the article from "EpiPen" to "Epinephrine autoinjector" was in 2009, which was before the EpiPen was owned by Mylan and before Mylan made that marketing effort, so it seemed like a good idea at the time. But as it turns out, Mylan and EpiPen dominate the market in the U.S., and other epinephrine autoinjectors are essentially unavailable. And Mylan is promoting the generic terms for purposes of concealment. Is Wikipedia improperly reinforcing that marketing effort?

I think the story of the EpiPen has gotten enough coverage in WP:RSs, including WP:MEDMOS, to justify a separate story on the EpiPen (including competition), which is a US story, along with a story on Epinephrine autoinjector, which would be a world view.
Family matters: EpiPens had high-level help getting into schools Jayne O'Donnell
September 21, 2016

"Then, as now, EpiPen was about the only auto-injector for the drug epinephrine, which has been around since about 1900. The Mylan-sponsored materials rarely mentioned EpiPens. Instead, references to treatment for anaphylaxis mentioned only epinephrine and auto-injectors."
--Nbauman (talk) 13:48, 25 September 2016 (UTC)

Almost everything you wrote above is incorrect. Per the sourced content in this article, Mylan got the exclusive right to market the EpiPen in 2007, two years before the name of this article was changed. EpiPen already had ~ 90% of the market when Mylan acquired it, as again is sourced and stated in this article. The source says nothing like "Mylan deliberately created marketing materials and draft policy recommendations that did not mention "EpiPen". They used phrases like "epinephrine autoinjector" instead, in order to conceal Mylan's role and make them look less like marketing materials." What is says is: "Part of the "boilerplate" language in the association’s Mylan agreement says the group "will not directly or indirectly promote Mylan Specialty’s products," Amundson said. It didn't have to. Then, as now, EpiPen was about the only auto-injector for the drug epinephrine, which has been around since about 1900. The Mylan-sponsored materials rarely mentioned EpiPens. Instead, references to treatment for anaphylaxis mentioned only epinephrine and auto-injectors." It says nothing about "concealment"
I find the argument that keeping EpiPen subject matter here somehow "promotes" EpiPen to be bizarre; generally companies seek to have their own article on X in order to promote it.
We generally have articles entitled and focused on the generic version of drug or device X; specific brands get split out when the brand becomes notable as a brand per se. (for example, our article on the headache drug is Paracetamol; we have a separate article on Tylenol, which became notable due to the cyanide poisoning incident and the way J&J acted to preserve that brand)
Under that practice I could see splitting out a separate article for EpiPen; I struggle with that in this case for two reasons. First, this general article provides the context that shows how EpiPen's market dominance started because it was the only product on the market and was maintained by other products failing due in part to their own mistakes and due in part to Mylan's use of IP, marketing, and lobbying. To tell the story of EpiPen we would have to duplicate all that in the split article... which wouldn't really be a split then. On a much more minor note, the pricing controversy stuff is pretty much duplicated here and in the Mylan article and somewhat in the Heather Bresch article; this would create a fourth place where we would need to duplicate this. So at the moment I would oppose a split. Jytdog (talk) 19:28, 25 September 2016 (UTC)

Gayle and Joe Manchin[edit]

Is there any reason why this entry doesn't include any reference to Heather Bresch's father, Joe Manchin, governor of WV and now senator from WV, who according to many WP:RSs helped her promote the Epi-Pen?

Again from that USA Today story (summarizing): Gayle Manchin, husband of Joe Manchin and mother of Heather Bresch, became president of the National Association of State Boards of Education in 2012. Her husband, as Governor, had appointed her to the West Virginia board of education. In December 2012, the Association announced an "epinephrine policy initiative" designed to "help state boards of education as they develop student health policies regarding anaphylaxis and epinephrine auto-injector access and use." The EpiPen was the only auto-injector available.
Family matters: EpiPens had high-level help getting into schools Jayne O'Donnell
September 21, 2016

Unless there's a good objection, I'm going to put it in. --Nbauman (talk) 13:57, 25 September 2016 (UTC)

Again you have some inaccurate things here. It is not true that "EpiPen was the only auto-injector available. " As the article says it was about the only one in 2012; if you read our article you can see that by that time Auvi-Q was on the market (and that the Adrenaclick products were briefly off the market in 2012 and part of 2013).
The content in the USA today article about her mom was new to me, and wow, and not in the article now. (the otherwise excellent and thorough Bloomberg article completely missed that) Thanks for bringing that. (the header should really be about Gayle not Joe). Yes the lobbying by the association of school boards definitely needs to be here. The article carefully notes that Joe appointed Gayle in 2007 and that she became president in 2010 and started working on autoinjector policy. It is careful not to say that this was actually coordinated with Mylan. (we need to be careful not to say that as well per WP:BLP). The juxtaposition is powerful and extremely suggestive for sure but we cannot say that it was coordinated until a reliable source says that. Sure we can add mention of Joe along the same lines (that he was a senator when the federal law was passed); i have not seen a source that says he actually helped Mylan. I'll take a shot at adding the content about the parents now. Jytdog (talk) 19:41, 25 September 2016 (UTC)
done, here. Will add that to the Mylan article as well. Jytdog (talk) 19:56, 25 September 2016 (UTC)

Bloomberg: Why the $600 EpiPen Costs $69 in Britain[edit]

This article explains why the price of EpiPen and its competitors varies so much around the world, using the UK and US as the opposite sides of the spectrum. Particularly good for those of you who want an international perspective.
Why the $600 EpiPen Costs $69 in Britain
James Paton, Naomi Kresge
--Nbauman (talk) 17:10, 29 September 2016 (UTC)

so much great information there on pricing/availability in other countries. thanks! Jytdog (talk) 20:36, 29 September 2016 (UTC)
You're welcome. --Nbauman (talk)

EpiPen teardown[edit]

NBC News had a good story based on teardowns of EpiPens and a lot of other very specific information, including the fact that Pfizer sells the EpiPen to Mylan for $34.50. This addresses the question of what Mylan did to improve the EpiPen (and justify its price increase), with quotes from both Mylan and its critics.
Mylan's Upgraded EpiPen Torn Apart By Experts
by Ben Popken
Sep 30 2016
a medical technologies expert and a doctor have been physically taking apart Mylan's famed auto-injectors to find out exactly how — and where — that money was spent.
Mylan didn't invent the EpiPen, it acquired it in 2007, getting a drug that had been approved since 1987 and had 90 percent market dominance. Nor does it manufacture the EpiPen itself. Mylan buys it from a wholly owned Pfizer subsidiary for $34.50 per pen.
--Nbauman (talk) 15:38, 9 October 2016 (UTC)

yes as the article says, Mylan just markets it. Added content based on the ref above in these two diffs. Jytdog (talk) 03:07, 10 October 2016 (UTC)