Friday, March 10, 2017

1981: Sus-Phrine: The greatest asthma medicine ever

"When we vacationed to California in 1976.
Dr. Gunderson gave us this to take along." Mom wrote
I think that the world's greatest medicine was Sus-Phrine (brand of epinephrine). It was actually a long acting version of epinephrine. It gave you your breath back within five minutes. I was given this medicine many times in the emergency room. It was a lifesaver.

A few years ago, as I began my quest to learn more about this medicine, a doctor told me that he liked it because a person would come in with status asthmaticus (asthma non-responsive to treatment), and he would prescribe a Sus-Phrine shot followed by a shot of a systemic corticosteroid.

The steroid would take 1-2 hours to reduce airway inflammation. In the meantime, the Sus-Phrine started working within minutes, and would last up from 6-10 hours. So, he said, the Sus-Phrine would keep airways open long enough for the steroid to take effect. Patients would have to stay in the hospital at least an hour after the shot so they could be monitored for potential side effects. Then they'd be sent home feeling good.

I would surely be feeling good. I would be wired. Sus-Phrine was essentially adrenaline. It's a medicine that essentially mimics the sympathetic (flight or fight) nervous system (sympathomimetic). It narrowed blood vessels to speed up the flow of blood to increase blood pressure. It increased the rate and speed of your heart. It caused palpitations. It made you excited. It made you jittery. It kept you awake for hours. But you didn't care, because it felt so good to be able to breathe.

Since 1901, epinephrine was available to be used for asthma. It started working in 3-5 minutes, but only lasted a few hours. This meant that repeat shots were often needed. It had to be given into the muscles, and this was most frequently the gluteal muscle (the butt). It also had to be given with a very large needle, which made the butt a good spot for injection. And kids were not keen to seeing a large needle, let alone having to drop their drawer and getting poked in the butt.

An An ampule of Sus-Phrine (1)
Sus-Phrine was first introduced to the market in the 1950s. Apparently, according to Emergency Medicine PharmD, it was the first medicine that didn't have to be given by intramuscular injection with a large needle. It was available in a concentration of 1:1200 (aqueous solution), which (if you are a nurse and I am not) can be delivered with any gauge needle and introduced to the body subcutaneously (meaning into the fat), meaning you could just get the shot in the arm with a small needle.

I only mention this because I started getting this shot in the mid-1970s and early 1980s when I would have been 5-10 range. Even though they would always assure me they had seen many naked butts before, it was always better to pull down my sleeve than to pull down my drawers. I'm sure this is the same for any kid.

Sus-Phrine (8)
Sus-Phrine became standard for asthmatics who presented to the emergency room during the 1970s to about the mid-1980s. This would have been about the time albuterol entered the mainstream of asthma treatments. It must have been discovered about this time that albuterol was just as effective as epinephrine in opening airways and ending asthma attacks. Giving 2-3 albuterol breathing treatments would also prove to offer the patient fewer side effects as a bonus.

I must have been given Sus-Phrine many times early on in my life. I know this, because, in 1976, my parents decided to take us to California. It was a three day car ride. This would have occurred just after I finished Kindergarten in June. My mom had my doctor write a note to any random doctor who might have to take care of me in case my asthma acted up. The note, written on a prescription pad, said:
Sus-Phrine (8)
"This boy is a known asthmatic undergoing hypersensitization program. If he has severe asthmatic attack without a fever he will respond well to 0.2cc Susphrine sub-q. Stat & observe 20 minutes."
By the late 1980s, and particularly between 1981 and January 1985, I made regular trips to the emergency room. I remember sitting on the hospital bed. I remember my dad saying, "In five minutes you will feel better."

Of course, they always had to give me an Alupent nebulizer treatment first. After a while I knew this wasn't going to work, but they always did it. As I inhaled the mist, I watched as a nurse would prepare the shot. When the treatment neared completion, the shot was given to me on my left or right arm.

Then I watched the clock. It was an oval clock on the wall right in front of me. It was 8 p.m.  I watched the red second hand go round and round as my shoulders dug deep into the mattress I was sitting on. I'd concentrate on my breathing. At first my breath would only go in half way. My chest was tight. I must have been near panic, or I wouldn't have asked mom or dad to take me.

Five minutes would go slow. But, right on cue: at the five minute mark my breath would start coming back. Each subsequent breath would go in deeper and deeper. Then I'd take in a deep breath and it would be easy. Then I'd take several deep breaths just because I could.

I can tell you with complete honesty that there is nothing better than all of a sudden being able to breathe after several hours of struggling to do so. It is just a great feeling. In fact, it usually created a feeling of euphoria. And, quite frankly, in retrospect, I'm not sure if that euphoria was the result of all of a sudden being able to breathe, or a side effect of the medicine. I imagine it was a little of both.

Nearly all of my ER visits were at West Shore Hospital. I remember going to the emergency room at West Shore Hospital in 1991 for an asthma attack. This was the first time I did this since 1985. I requested Sus-Phrine. The nurse never heard of it. The doctor had a vague memory of it, and consulted the pharmacist. The pharmacist and doctor talked about it for a while, and the pharmacist decided he had a cabinet that might have the medicine I requested.

This was the last time I was given the shot. It was discontinued within the next few years. A study published in 1991 in the Journal of the National Medical Association conclude that "Subcutaneous, long-acting epinephrine (Sus-Phrine) provides no additional benefit to a beta-2 agonist (albuterol) by nebulization for children with acute asthma." (6)

To be honest, I have never been given an epinephrine shot since then either, which spotlights the changing times as far as we asthmatics are concerned.

Further reading and references:
  1. Emergency Medicine Pharm D: Throwback Drug Thursday: Sus-Phrine, An Aqueous Formulation of Epinephrine
  2. Naterman HL. Ephinephrine base suspended in water with thioglycolate. J Allergy 1953; 24:60.
  3. Unger AH, Unger L. Prolonged epinephrine action. Ann Allergy 1952; 10:128-130
  4. Ben-Zvi Z, Lam C, Hoffman J, et al. An evaluation of the initial treatment of acute asthma. Pediatrics 1982; 70:348-353.
  5. Ben-Zvi Z, Lam C, Spohn WA, et al. An evaluation of repeated injections of epinephrine for the initial treatment of acute asthma. Am Rev Respir Dis 1983; 127:101-105.
  6. Kornberg AE, Zuckerman S, Welliver JR, et al. Effect of injected long-acting epinephrine in addition to aerosolized albuterol in the treatment of acute asthma in children. Pediatr Emerg Care 1991; 7:1-3.
  7. Jenkens, Charles M, "A Clinical Study of 'Sus-Phrine,' an Aqueous Epinephrine Suspensionfor Sustained Action," Journal of the National Medical Association, March, 1953, 45, pages 120-122
  8. Bezzant, John L., "Epinephrine: Comparison of short vs long acting," http://library.med.utah.edu/kw/derm/pages/ni18_3.htm, accessed 3/10/17
  9. "Sus-Phrine (brand of epinephrine), Physician's Desk Reference," 1991, page 1006
  10. Feldman, B. Robert, "The Complete Book of Children's Alergies: A Guide for Parents," 1986, Times Books
  11. Brenner, Barry E., editor, "Emergency Asthma," 1999, New York, Marcel Dekker, Inc., page 322

1 comment: