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Mylan 0.3 mg EpiPen, epinephrine autoinjector.
ALK Pharma Jext300, adrenaline autoinjector, without its safety cover.

An epinephrine autoinjector is a medical device for injecting a measured dose or doses of epinephrine (adrenaline) by means of autoinjector technology. It is most often used for the treatment of anaphylaxis. The first epinephrine autoinjector was brought to market in the 1980s.

Medical uses

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Epinephrine autoinjectors are hand-held devices carried by those who have severe allergies; the epinephrine delivered by the device is an emergency treatment for anaphylactic reaction.[1][2]

When anaphylaxis is suspected, epinephrine solution should be injected into the thigh muscle as soon as possible. The injection may be repeated every 5 to 15 minutes if there is insufficient response.[3] A second dose is needed in 16–35% of episodes with more than two doses rarely required; in around 80% of the cases where a second dose is administered, it is by a medical professional.[3] It is not clear which are the people who might need a second injection at the outset.[3] The intramuscular route is preferred over subcutaneous administration because the latter may have delayed absorption.[3][4] Minor adverse effects from epinephrine include tremors, anxiety, headaches, and palpitations.[3]

The epinephrine in autoinjectors expires after one year.[2] A study in rabbits showed that intramuscular epinephrine works less well after it expires; that study also recommended that if the drug in an expired device has not started to precipitate (if the solution is not cloudy and has no particles in it) using the expired device is better than no injection at all in an emergency situation.[5]

Design

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EpiPen inner mechanism. 1. Four latch mechanisms that hold the plunger secure. 2. Loaded spring that drives the plunger and the needle (toward the right). 3. Plunger. 4. Adrenaline solution. 5. Outer body. When retracted upward (left) exposes the needle and triggers the latch mechanism. Later springs back to cover the needle after use. 6. Needle exits through a protective barrier when this is pressed against the skin.

The devices contain a fixed dose of epinephrine and a spring-loaded needle that exits the tip or edge of the device and penetrates the recipient's skin, to deliver the medication via intramuscular injection.[2]

People to whom epinephrine autoinjectors are prescribed need to be trained how to use the specific device prescribed.[1][3] The rate of unintentional injections using these devices is unknown but a 2009 review found that the rate is increasing.[6] Unintentional injections are delivered to a finger or thumb around 90% of the time; they cause intense pain locally but usually completely resolve.[6] The cause of unintentional injections has been attributed to design flaws, where the device is mistaken for a pen or the user mistakes which end of the device contains the needle.[6]

The European Medicines Agency conducted a review of the safety of devices then on the market and found several factors that determine whether the devices successfully deliver drug into muscle, including "needle length, the thickness of fat under the skin, the way the auto-injector works (e.g., if it is spring loaded or not), the angle at which the device is placed on the skin and the force used to activate the device as well as how well the user follows the instructions for injection."[7] It found that how well the user was trained was the most important factor determining successful delivery, and requested companies to develop better training materials for doctors and people to whom the devices are prescribed.[7]

History

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Autoinjectors were originally developed for the rapid administration of nerve gas antidotes in kits like the Mark I NAAK. The first modern epinephrine autoinjector, the EpiPen, was invented in the mid-1970s at Survival Technology in Bethesda, Maryland by Sheldon Kaplan[8][9] and was first approved for marketing by the FDA in 1987.[10]

In 1996, Survival Technology merged with a company called Brunswick Biomedical and the new company was called Meridian Medical Technologies Inc..[11] In 1997, Dey, a subsidiary of Merck KGaA, acquired the exclusive right to market and distribute the EpiPen.[12][13] In 1998 there was a recall of one million EpiPens, the second such recall in a year.[14]

In 2001 Meridian and Dey introduced a two-pack version of the EpiPen; at that time the device had $23.9 million in annual sales and accounted for 75% of the market in the United States.[15] In 2002 King Pharmaceuticals acquired Meridian for $247.8 million in cash;[16] the deal was completed in January 2003.[17] (King was later acquired by Pfizer in 2010 for $3.6 billion in cash.[18]) Kaplan continued to improve his designs over the years, filing for example US Patent 6,767,336 in 2003.[19]

In 2003, Hollister-Stier received approval from the FDA to market an epinephrine autoinjector called Twinject that could deliver two shots of epinephrine, which it had spent ten years developing.[20][21][22] In 2005, it sold the product to Verus Pharmaceuticals,[20] which launched the product the same year.[23] In March 2008, Sciele Pharma acquired Twinject from Verus[24] and later that year, Sciele was acquired by Shionogi.[25]

In 2007, Mylan acquired the right to market the EpiPen from Merck KGaA as part of a larger transaction.[26] At that time annual sales were around $200 million[27] and the EpiPen had about 90% of the market.[28]

In 2009, Teva Pharmaceuticals filed an ANDA to market a generic EpiPen in collaboration with Antares Pharma Inc, a maker of injection systems; Pfizer and King sued them for infringing US Patent 7,449,012 that was due to expire in 2025;[29] Pfizer, Mylan, and Teva settled in April 2012 in a deal that allowed Teva to start selling the device in mid-2015, pending FDA approval.[30]

In 2009, Intelliject, a US startup developing a new epinephrine autoinjector, licensed their product to Sanofi.[31]

In 2010, Sciele/Shionogi faced a recall of Twinject devices[32] and launched Adrenaclick, a modified version of the Twinject that could deliver only one dose.[33][34]

In 2010, European regulators approved Twinject,[35] and also approved a new epinephrine autoinjector made by ALK and sold under the brand name Jext.[36][37] Jext was launched in the European Union in September 2011.[38][39]

Also in 2010, Shionogi authorized Greenstone, the authorized generics division of Pfizer,[40][41]to begin selling an authorized generic of Adrenaclick.[42][43] The media noted that Pfizer, through Greenstone, was marketing a generic epinephrine autoinjector when Pfizer acquired King later that year.[44] At that time, King and Mylan's EpiPen had 91% of the global market share for epinephrine autoinjectors and 96% of the US market.[44]

In 2010, Pfizer and King sued Novartis' Sandoz generic unit for patent infringement after Sandoz submitted an ANDA to sell a generic EpiPen.[45] In response, Sandoz challenged the validity of the patents, and as of July 2016 this litigation was ongoing.[46]

In 2011, Pfizer and King sued Intelliject and Sanofi after the companies filed a 505(b)(2)[47] New Drug Application for the product, then known as "e-cue";[48] Pfizer, Mylan and Sanofi settled in 2012 under a deal that allowed the device to enter the market no earlier than November 2012, pending FDA approval.[49] In August 2012, the FDA approved the autoinjector, called "Auvi-Q" after the FDA required a name change from "e-cue".[50] The device is equipped with a sound chip to provide electronic voice instructions to guide the user in the proper use of the device.[51][52]

In 2012, Mylan launched a program called EpiPen4Schools to sell EpiPens in bulk and with discounts to schools; to participate in the program schools had to agree not to buy epinephrine autoinjectors from any other company for a year.[53]

In December 2012, the National Association of State Boards of Education launched a policy initiative designed to "help state boards of education as they develop student health policies regarding anaphylaxis and epinephrine auto-injector access and use," and advocated for state laws protecting school from legal liability for stocking and using epinephrine autoinjectors. Gayle Manchin, the mother of Mylan's CEO, Heather Bresch, had become president of the association in 2010, and shortly after had discussed donations from her "daughter's company" to the association. Manchin had been appointed to the West Virginia state school board by her husband Joe Manchin, then-governor of the state, in 2012.[54]

In 2012, Shionogi, the manufacturer of Adrenaclick and Twinject, announced it would stop making them;[31] it had sold the rights to the NDA to a company called Amedra Pharmaceuticals.[55][56]

In June 2013, Amedra relaunched Adrenaclick.[57] and at the same time, Lineage Therapeutics launched its authorized generic version of Adrenaclick.[58] Lineage was a wholly owned subsidiary of Amedra that had acquired the rights to the Adrenaclick authorized generic from Greenstone/Pfizer.[59]

After successful lobbying from Mylan,[27] in 2013, the "School Access to Emergency Epinephrine Act" became law after passing Congress with broad and bipartisan support; it protected anyone from liability if they administered epinephrine to a child in a school (previously, only trained professionals or the affected person were allowed to administer the drug, and were open to liability), and it provided some financial incentives for schools that didn’t already stock epinephrine autoinjector to start stocking them.[60] Joe Manchin, the father of Mylan's CEO, was a senator at that time.[54]

In January 2015 Mylan filed a citizen petition with the FDA raising concerns about TEVA's ANDA application to market a generic EpiPen and filed an additional supplement later in May; the FDA rejected the petition in June.[61][62]

In March 2015, Impax Laboratories acquired the parent company of Amedra and Lineage, and placed Amedra and the Adrenaclick in its Impax Specialty Pharma division; at the same time it acquired Lineage, which it placed, along with its generic version of Adrenaclick, in its Impax Generics division.[63][64]

In May 2015, the Emerade epinephrine autoinjector developed by the Swedish company Medeca was approved in Sweden and Germany;[65] it had been approved in the UK in 2013.[66] Also in 2015 Valeant, which had licensed the rights from Medeca, abandoned its efforts to get Emerade approved in the US.[67]

In October 2015, Auvi-Q devices were voluntarily recalled by Sanofi in North America.[68][69] The reason stated by Sanofi was that the products had been found to potentially have inaccurate dosage delivery, which may include failure to deliver drug.[70] In February 2016, Sanofi terminated its license to manufacture and market the Auvi-Q, leaving Kaléo (Intelliject was renamed) to consider how and whether to re-introduce the device.[71][72]

The EpiPen had 89% of the market for epinephrine autoinjectors in 2015;[53] in the first half of the year it had about 85% share and Auvi-Q had about 10% share.[27]

In March 2016, Teva's ANDA for a generic EpiPen, which had already faced several delays, was rejected by the FDA.[73]

In 2015 Mylan had about had about $1.5B in sales of EpiPens and those sales accounted for 40% of Mylan's profit.[27] Mylan had maintained about a 90% market share since it had acquired the product, and had continually raised the price of EpiPens starting in 2009: in 2009, the wholesale price of two EpiPens was about $100; by July 2013, the price was about $265; in May 2015, it was around $461; and in May 2016, the price rose again to around $609,[26] around a 500% jump from the price in 2009.[74] In the summer of 2016, as parents prepared to send their children back to school and went to pharmacies to get new EpiPens, people began to express outrage at the cost of the EpiPen and Mylan was widely and harshly criticized.[75][76] In September 2016, the New York State Attorney General began an investigation into Mylan's EpiPen4Schools program in New York to determine if the program's contracts violated antitrust law[77] and the West Virginia State Attorney General opened an investigation into whether Mylan had given the state the correct discount under the Medicaid Drug Rebate Program and subpoenaed the company when it refused to provide the documentation the state requested.[78]

Society and culture

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Brands

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As of 2015, the following epinephrine autoinjectors were available in various parts of Europe: Adrenalina WZF, Adrenaline (epinephrine) 1 in 1000 solution for injection BP auto-injector, Altellus, Anapen, Emerade, EpiPen, Fastjekt, FastPen, and Jext.[79] As of 2014, three branded products were available in the US: Adrenaclick, Auvi-Q, and EpiPen,[5] but as of October 2015 Auvi-Q was no longer available.[71] As of 2005, epinephrine autoinjectors were not available in most of the developing world.[5]

Price

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Europe

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As of September 2016, In France two EpiPens cost around $100 and cost around $200 in Germany.[39]

As of September 2016, two Jext autoinjectors cost people in Britain about £8.5, and the National Health Service pays around £48 (US$65.75) in order to make them available; that price was about 17 percent less than 2013.[39]

US

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The devices deliver about $1 worth of drug.[27]

In the United States, one brand of autoinjector, the EpiPen, manufactured by King, a subsidiary of Pfizer, and marketed by Mylan, has dominated the market.[53] In 2007 when Mylan acquired the rights to market the product, annual sales of all epinephrine autoinjectors were about $200M and EpiPen had around 90% of the market; in 2015 the market size was around $1.5B and Mylan still had about 90% of the market.[28][53] Mylan raised the price from around $100 for a package of two EpiPens in 2007 to around $600 in 2016.[74] In the United Kingdom, an EpiPen costs £26.45 as of 2015.[80] In Canada they are about 120 CAD each.[81]

Mylan acquired the right to market the EpiPen line of epinephrine autoinjector devices from Merck KGaA as part of their 2007 deal.[26] Heather Bresch, Mylan's CEO, saw an opportunity to increase sales in the US through marketing and advocacy, and the company launched a marketing campaign to increase awareness of the dangers of anaphylaxis for people with severe allergies that made the EpiPen brand as identified with epinephrine autoinjectors as Kleenex is for facial tissue; the company also successfully lobbied the FDA to broaden the label to include risk of anaphylaxis and in parallel, successfully lobbied Congress to generate legislation making EpiPens available in public places like defibrillators are, and hired the same people that Medtronic had worked with on defibrillator legislation to do so.[27]

Mylan's efforts to maintain its market dominance were aided when Sanofi's competing product was recalled in November 2015 and further when Teva's generic competitor was rejected by the FDA in March 2016.[82] By the first half of 2015, sales of EpiPen accounted for 40% of Mylan's profit.[27] Those profits were also due in part to Mylan's continually raising the price of EpiPens starting in 2009: in 2007, the wholesale price of two EpiPens was about $100; the price was about the same in 2009; by July 2013, the price was about $265; in May 2015, it was around $461; and in May 2016, the price rose again to around $609,[26] around a 500% jump from the price in 2009.[74] The last price increase sparked widespread outrage in the late summer as parents prepared to send their children back to school and went to pharmacies to get new EpiPens.[75][76] Some Americans responded to the high price by buying EpiPens online from pharmacies outside the US,[83][84] forgoing new EpiPens and relying on their expired EpiPen,[83] or forgoing an autoinjector altogether and having their children carry pre-loaded syringes.[85][86]

In response to criticism, Mylan increased financial assistance available for some patients to purchase EpiPens,[87] a gesture that was called a "classic public relations move" by Harvard Medical School professor Aaron Kesselheim.[88] The up to $300 saving cards can only be used by a small number of people who need the drug, and no one on Medicaid. They do nothing about the high price which is still being paid by insurers, who ultimately pass the cost onto consumers.[88]

As of August 2016, the authorized generic of Adrenaclick cost $142 at retail stores.[86][89]

In September 2016, a group of hackers called the Four Thieves Vinegar published a video and documents describing what they call an EpiPencil, an autoinjector which can be built using off-the-shelf parts, for a claimed price tag of about $30.[90][91] However the releasing of the schematics was criticised by others, as the device has not been subject to any validation by regulatory agencies.[90]

References

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  1. ^ a b "Anaphylaxis". National Institute of Allergy and Infectious Diseases. April 23, 2015. Retrieved 4 February 2016.
  2. ^ a b c Dinakar, C (December 2012). "Anaphylaxis in children: current understanding and key issues in diagnosis and treatment". Current Allergy and Asthma Reports. 12 (6): 641–9. doi:10.1007/s11882-012-0284-1. PMC 3492692. PMID 22815131.
  3. ^ a b c d e f Muraro, A; The EAACI Food Allergy and Anaphylaxis Guidelines Group; et al. (August 2014). "Anaphylaxis: guidelines from the European Academy of Allergy and Clinical Immunology". Allergy. 69 (8): 1026–45. doi:10.1111/all.12437. PMID 24909803. S2CID 11054771. {{cite journal}}: Explicit use of et al. in: |first1= (help)
  4. ^ Simons, KJ; Simons, FE (August 2010). "Epinephrine and its use in anaphylaxis: current issues". Current Opinion in Allergy and Clinical Immunology. 10 (4): 354–61. doi:10.1097/ACI.0b013e32833bc670. PMID 20543673. S2CID 205435146.
  5. ^ a b c Song, TT; Worm, M; Lieberman, P (August 2014). "Anaphylaxis treatment: current barriers to adrenaline auto-injector use". Allergy. 69 (8): 983–91. doi:10.1111/all.12387. PMID 24835773. S2CID 7156705.
  6. ^ a b c Simons, FE; Lieberman, PL; Read EJ, Jr; Edwards, ES (April 2009). "Hazards of unintentional injection of epinephrine from autoinjectors: a systematic review". Annals of Allergy, Asthma & Immunology : Official Publication of the American College of Allergy, Asthma, & Immunology. 102 (4): 282–7. doi:10.1016/S1081-1206(10)60332-8. PMID 19441598.
  7. ^ a b European Medicines Agency (June 26, 2015). "Better training tools recommended to support patients using adrenaline auto-injectors".
  8. ^ Smetana, Kevin (September 24, 2009). "EpiPen inventor helped millions and died in obscurity". St. Petersburg Times. Archived from the original on February 1, 2013. Retrieved 2010-07-07.
  9. ^ National Inventors Hall of Fame Kaplan Sheldon
  10. ^ FDA Approval history for NDA 019430 - EpiPen Page accessed Aug 30, 2016
  11. ^ Meridian Medical Technologies 10-K Filing For the fiscal year ended July 31, 1997
  12. ^ Dey, Inc. Amendment No. 3 to Form S-1 Registration Statement under The Securities Act Of 1933. Filed April 30, 1999
  13. ^ King Pharmaceuticals Oct 21, 2002. Press Release: King Pharmaceuticals to Acquire Meridian Medical Technologies
  14. ^ Chase, Marilyn (18 May 1998). "EpiPen Recall PointsTo Broader Concerns". Wall Street Journal.
  15. ^ Meridian Medical Technologies, Merck KGaA. April 03, 2001 Press Release: Meridian Announces Launch Of New EpiPen 2-Pak
  16. ^ King Pharmaceuticals Oct 21, 2002. Press Release: King Pharmaceuticals to Acquire Meridian Medical Technologies
  17. ^ King Pharmaceuticals Form 11K filed For the fiscal year ended December 31, 2003.
  18. ^ "Pfizer Completes Acquisition Of King Pharmaceuticals, Inc.; Pfizer and King begin joint operations on March 1, 2011" (press release). Pfizer. March 1, 2011.
  19. ^ US Patent 6,767,336, cited in Steve Brachmann for IPWatchdog June 28, 2016 EpiPen gives doses of life-saving epinephrine for nearly 50 years
  20. ^ a b Jennifer Sudick for the Spokane Spokesman-Review. July 20, 2005 Spokane firm sells rights to auto-injector
  21. ^ FDA Twinject Approval Package
  22. ^ FDA Approval History NDA 020800 - Twinject and Adrenaclick Page accessed August 25, 2016
  23. ^ "Verus Pharmaceuticals Announces U.S. Launch of Twinject for Anaphylaxis". veruspharm.com. Archived from the original on 2005-12-22.
  24. ^ Sciele Pharma. March 13, 2008. Press Release: Sciele Pharma Acquires Twinject® Epinephrine Auto-Injector from Verus Pharmaceuticals
  25. ^ Z+Kazuhiro Shimamua for The Wall Street Journal. Sept. 1, 2008 Shionogi to Buy Sciele Pharma
  26. ^ a b c d Tara Parker-Pope and Rachel Rabkin Peachman for the New York Times. Aug 22, 2016 EpiPen Price Rise Sparks Concern for Allergy Sufferers
  27. ^ a b c d e f g Cynthia Koons and Robert Langreth for Bloomberg Businessweek. September 23, 2015 How Marketing Turned the EpiPen Into a Billion-Dollar Business
  28. ^ a b Johnson, Carolyn Y.; Ho, Catherine (August 25, 2016). "How Mylan, the EpiPen company, maneuvered to create a virtual monopoly". The Washington Post via The Chicago Tribune.
  29. ^ US Patent 7,449,012, cited in PatentDoc's September 07, 2009 Court Report
  30. ^ Phil Milford for Bloomberg News April 26, 2012 Mylan, Pfizer Reach Epinephrine-Pen Settlement With Teva
  31. ^ a b Katie Thomas for the New York Times. Feb 1, 2013 Brothers Develop New Device to Halt Allergy Attacks
  32. ^ Recalls.org December 2010
  33. ^ Staff, Monthly Prescribing Reference. January 07, 2010 Adrenaclick Auto-injector launched for anaphylaxis
  34. ^ FDA/Shionogi Adrenaclick original label 2009
  35. ^ Shionogi. August 31, 2010 Press Release: Shionogi Announces Positive Outcome to the Decentralized Procedure For The European Approval Of Twinject (Epinephrine Auto-Injector)
  36. ^ "ALK media release (07 October 2010)". Retrieved 2014-04-08.
  37. ^ "ALK media release (13 October 2010)". Retrieved 2014-04-08.
  38. ^ "ALK media release (06 September 2011)". Retrieved 2014-04-08.
  39. ^ a b c Paton, James; Kresge, Naomi (29 September 2016). "Why the $600 EpiPen Costs $69 in Britain". Bloomberg News.
  40. ^ Staff (August 1, 2008). "Greenstone LLC - A Successful Business Model". Pharmacy Times.
  41. ^ Hensley, Scott (29 June 2006). "Pfizer to Make Generic Version of Its Zoloft". Wall Street Journal.
  42. ^ Tucker, Janna. "Generic Epinephrine Injector May Cause Confusion". American College of Allergy, Asthma & Immunology. Retrieved August 30, 2016.
  43. ^ "EPINEPHRINE injection [Greenstone LLC]". FDA via DailyMed. 16 May 2010. Marketing Category: NDA Authorized Generic; Application Number Or Monograph: NDA020800; Marketing Start Date: 03/31/2010
  44. ^ a b Edwards, Jim (Oct 12, 2010). "In $3.6B King Deal, Pfizer Gets a Small but Important EpiPen Monopoly". CBS MoneyWatch.
  45. ^ Julie Zeveloff for Law360. July 16, 2010. King Pharma Sues Sandoz Over Generic EpiPen
  46. ^ Pfizer Quarterly Report (Form 10-Q) for the quarterly period ended July 3, 2016
  47. ^ Note - a "505(b)(2)" is a kind of new drug application that allows the applicant to rely in part on someone else's drug approval data - this pathway is used for example to get approval for an existing drug for a new indication. The information about the drug itself is someone else's, but the applicant has to generate the data showing the drug works for the new indication. In the case of Intelliject, it is the generic drug in a new device. For an explanation see Kenneth V. Phelps for Drug Discovery & Development Magazine. Aug 9, 2012 Taking the 505(b)(2) Route
  48. ^ Sherri Oslick for PatentDocs. Court Report January 23, 2011
  49. ^ Mylan. Feb 16, 2012 Press Release: Mylan and Pfizer Announce Epinephrine Auto-injector Settlement Agreement
  50. ^ John Reid Blackwell for the Richmond Times-Dispatch. August 14, 2012 FDA approves Intelliject's life-saving device for allergy sufferers
  51. ^ "Auvi-Q Fact Sheet" (PDF). Retrieved 18 August 2012.
  52. ^ Sanofi August 13, 2012 Press Release: Sanofi Announces FDA Approval for Auvi-Q
  53. ^ a b c d Swetlitz, Ike; Silverman, Ed (August 26, 2016). "Mylan may have violated antitrust law in its EpiPen sales to schools". PBS Newshour.
  54. ^ a b O'Donnell, Jayne (September 21, 2016). "Family matters: EpiPens had high-level help getting into schools". USA Today.
  55. ^ National Council for Prescription Drug Programs May 2013 QUIC FORM 201313 Adrenaclick Auto-Injector, NDC 59630-0803-02 And 59630-0804-02 Resolution. Indexed here
  56. ^ Shionogi FY2011 Financial Results: Supplement See note in the margin of page 6
  57. ^ Amedra Pharmaceutical June 14th, 2013 Press Release: Amedra Pharmaceuticals Markets Adrenaclick Auto-Injector
  58. ^ Lineage Therapeutics. Jun 14, 2013 Press Release: Lineage Therapeutics Markets Authorized Generic Epinephrine Auto-Injector
  59. ^ "Clinical Alert" (PDF). Magellan Medical. July 2013. Archived from the original (PDF) on September 9, 2016.
  60. ^ Novak, Matt (August 23, 2016). "How Congress, the FDA, and Sarah Jessica Parker Helped EpiPen Become a $1 Billion Business". Gizmodo.
  61. ^ Gibney, Michael (September 1, 2016). "Could EpiPen's plastic cap be Mylan's secret weapon?". FiercePharma.
  62. ^ "FDA-2015-P-0181: Requests that the FDA take certain actions with respect to abbreviated new drug application (ANDA) 90-589, submitted by Teva Pharmaceuticals (Teva), for an epinephrine auto-injector". US Government Dockets Repository. Retrieved September 10, 2016.
  63. ^ "Impax 2014 Annual Report" (PDF).
  64. ^ Impax March 10, 2015 Press Release: Impax Completes Acquisition Of Tower Holdings, Inc. And Lineage Therapeutics Inc.
  65. ^ "Epinephrine self-injectable - Medeca Pharma AB - AdisInsight". Adis Insight. Retrieved 3 October 2016.
  66. ^ "Emerade, 500 micrograms, solution for injection in pre-filled pen - Summary of Product Characteristics (SPC) - (eMC)". UK Electronic Medicines Compendium. Retrieved 3 October 2016.
  67. ^ "Valeant Form 10-K For the fiscal year ended December 31, 2015". SEC Edgar.
  68. ^ Tammie Smith (October 29, 2015). "Auvi-Q auto injector being recalled". Richmond Times-Dispatch.
  69. ^ "Allerject epinephrine auto-injectors recalled by drugmaker Sanofi". Canadian Broadcasting Company. Associated Press. 30 October 2015.
  70. ^ "Updated: Sanofi US Issues Voluntary Nationwide Recall of All Auvi-Q® Due to Potential Inaccurate Dosage Delivery". Food and Drug Administration.
  71. ^ a b Spiers, Jonathan (21 March 2016). "French pharma giant vacates deal with Shockoe Slip firm". Richmond BizSense.
  72. ^ Stanton, Dan (February 26, 2016). "Sanofi abandoning Auvi-Q after dosage problems led to total recall". in-Pharma Technologist.
  73. ^ Staff, The Pharma Letter. March 3, 2016 Teva suffers setback over EpiPen generic
  74. ^ a b c Bartolotta, Devin (18 August 2016). "Cost Jumps Nearly 500-Percent For Life-Saving EpiPens". CBS Baltimore. Retrieved 19 August 2016.
  75. ^ a b Goldberg, Kenny. "People With Food Allergies Say Life-Saving Drug Too Expensive". KPBS Public Media. Retrieved 8 June 2016.
  76. ^ a b Walker, Joseph; Winslow, Ron; Steele, Anne (30 August 2016). "Mylan to Launch Cheaper Generic EpiPen Alternative". Wall Street Journal.
  77. ^ Larson, Erik; Hopkins, Jared S. (September 6, 2016). "Mylan's EpiPen School Sales Trigger N.Y. Antitrust Probe". Bloomberg. Retrieved September 7, 2016.
  78. ^ Feeley, Jef; Langreth, Robert (20 September 2016). "Mylan Investigations Mount as West Virginia Opens Fraud Probe". Bloomberg News.
  79. ^ EMA. Annex I: List of the names, pharmaceutical form(s), strength(s) of the medicinal product(s), route(s) of administration, marketing authorisation holder(s) in the Member States. Published April 25, 2014; Updated August 26, 2015. See Index page for EMA Review of Adrenaline auto-injectors
  80. ^ British National Formulary (BNF) 69 (69 ed.). Joint Formulary Committee. 2015. p. 215. ISBN 9780857111562.
  81. ^ "Canadians users of EpiPen not subject to price hike as U.S. consumers". Aug 26, 2016. Retrieved 6 September 2016.
  82. ^ Carly Helfand for FiercePharma Mar 1, 2016 FDA swats down Teva's EpiPen copy, putting Mylan in cruise control
  83. ^ a b Tuttle, Brad (Aug 22, 2016). "5 Signs That EpiPen Prices Are Completely Out of Control". Time/Money.
  84. ^ Lamble, Kate (25 August 2016). "Drug company stung by criticism of 'outrageous' EpiPen price rises". BBC.
  85. ^ Khazan, Olga (August 24, 2016). "Have You Ever Tried to Buy an EpiPen?". The Atlantic.
  86. ^ a b Ginger Skinner (August 11, 2016). "Can You Get A Cheaper EpiPen?". Consumer Reports.
  87. ^ "Mylan to provide EpiPen cost assistance as CEO is asked to testify on price hike | Business | The Guardian". TheGuardian.com.
  88. ^ a b Carolyn Y. Johnson (August 25, 2016). "Why Mylan's 'savings card' won't make EpiPen cheaper for all patients". Washington Post.
  89. ^ Lack of competition leads to EpiPen pricing woes, Adam Rubenfire, Modern Healthcare, March 28, 2016
  90. ^ a b Eliza Strickland (19 September 2016). "Hackers Offer a DIY Alternative to the $600 EpiPen". IEEE Spectrum. Retrieved 22 September 2016.
  91. ^ "Introducing the EpiPencil". Four Thieves Vinegar. 19 September 2016. Retrieved 22 September 2016..

Further reading

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[[Category:First aid]] [[Category:Drug delivery devices]] [[Category:Type I hypersensitivity]] [[Category:Pricing controversies]]

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