Are There Alternatives to an EpiPen? neffy? Primatene Mist?

Several years ago, there was quite a fuss about high prices and shortages affecting EpiPen emergency allergy injections. This epinephrine shot is used to avert anaphylactic shock that can be life threatening. Without rapid access to epinephrine (adrenaline), an affected person’s airways could constrict and she might collapse and even die. That is why doctors prescribe epinephrine auto-injectors for people to use themselves if they have known allergies like those to bee stings, peanuts or shellfish. There’s also a nasal spray on the market called neffy. Readers want to know more about it. Some readers have suggested inhaled epinephrine (Primatene Mist). It’s surprisingly controversial!

Anaphylaxis Is a Life-threatening Allergic Reaction

Q. In the UK, my daughter is prescribed Primatene Mist inhaler for anaphylaxis (life threatening allergic reaction). She also has an EpiPen injector, but the inhaler is a vital part of her emergency medical kit. I am glad that this medicine can be purchased without a prescription in the United States.

A. Inhaled epinephrine (adrenaline) was a mainstay of asthma treatment for almost a century. Primatene Mist was marketed in the US starting in the 1960s.

Doctors also use epinephrine to counteract severe allergic reactions such as anaphylactic shock. They administer it by injection to achieve a fast response.

People who are highly allergic to stings, peanuts or other allergens often get a prescription for a self-injector such as an EpiPen or AUVI-Q. There is another option. Neffy is epinephrine in a nasal spray. It is available only by prescription for severe allergic reactions. Anyone experiencing anaphylaxis must also seek immediate medical attention!

Problem with Neffy Pricing

Q. I have read that there is now an epinephrine nasal spray called neffy for severe allergic reactions or even anaphylaxis. It requires a prescription and is pricey. Why not use over-the-counter Primatene Mist instead? It’s far less expensive.

A. Anaphylaxis is a life-threatening allergic reaction. It must always be treated as a medical emergency!

Epinephrine auto-injectors such as EpiPen deliver a specified dose of epinephrine quickly into the bloodstream. German scientists studied Primatene Mist to see if it could be used as a substitute treatment for anaphylaxis and found it is not suitable (Journal der Deutschen Dermatologischen Gesellschaft, May 2009).

Neffy, on the other hand, was developed specifically to immediately provide an appropriate dose of epinephrine. Experimenting with a money-saving alternative may not be wise when the outcome could be death. We acknowledge, however, that it is very expensive. According to GoodRx (at the time of this writing), the retail price of neffy is over $900 for a carton of 2 nasal sprays. The GoodRx price with a coupon is $399.

What About Primatene Mist?

The 2009 article in the German medical journal made it clear that inhaled epinephrine (Primatene Mist) would not be suitable for anaphylaxis treatment.

A more recent analysis in the Annals of Allergy, Asthma & Immunology (March, 2024) offers additional insights.

“…could there be utility for inhaled epinephrine for treating allergic reactions? It is a reasonable question, particularly given its broad OTC availability and likely cost-effectiveness at its current retail price if such an option was to be proven effective (a $35 canister contains 160 actuations and could presumably be used to treat 10 severe reactions).

“However, is someone really going to use 15 to 20 pumps? What if they lose count? There may be a high potential for such an approach to backfire, inadvertently delaying more definitive treatment, unless the device is reformulated somehow to reduce pump number and some of the unpleasant adverse effects. Still, given a more rapid onset of effect, in which repeated doses are not limited by cumulative toxicity, it may be worth exploring inhaled epinephrine as an initial treatment for early intervention and symptom de-escalation of anaphylaxis. Having more choices to match individual values and preferences may ensure that patients will use epinephrine early and effectively. As we inch closer to having a number of noninjectable epinephrine options available as welcomed additions to the market, perhaps further studies of this simple, convenient, and presently accessible OTC “bird in the hand” option are warranted for a second look at another tool in the anaphylaxis armamentarium.”

Neffy Is Epinephrine as a Nose Spray

In 2024, FDA approved an entirely new form of epinephrine for treating severe allergic reactions. It is called neffy and is administered as a nasal spray. When we first wrote about it, we noted that people in the trial had not had anaphylactic (life-threatening) reactions. One reader thinks that was an oversight.

Q. A few months ago, you wrote about a new form of epinephrine for treating severe allergic reactions. It’s a nasal spray called neffy.

I am curious: how can “neffy” be approved to treat anaphylactic reactions although it has not been tested in people experiencing anaphylactic shock?

A. The FDA approved neffy in August 2024 to provide an alternative for people with allergies and fear of injections. Some people also have difficulty using an auto-injector correctly.

You are right that this new way of administering epinephrine was tested in healthy people, not in those suffering an anaphylactic reaction. FDA officials explained that it would be unethical to provoke a life-threatening crisis to test the effectiveness of the drug.

Regardless of the form of epinephrine used, the patient should always call 911. Reactions can come back quickly and may require a second dose. They always demand emergency medical treatment.

Please share your own experience with severe allergic reactions in the comment section below.