New Guidelines: When to Use Epinephrine

Epinephrine should be first treatment choice in all severe allergic emergencies, including anaphylaxis

/ Author:  / Reviewed by: Joseph V. Madia, MD Beth Bolt, RPh

(RxWiki News) Getting the right treatment in an allergy emergency can be the difference between life and death. An expert panel weighed in on these emergencies.

The American College of Allergy, Asthma and Immunology (ACAAI) issued some new guidelines this month on epinephrine use for severe allergic reactions, including anaphylaxis.

According to the new guidelines, epinephrine should be the first treatment choice in an emergency situation.

"Our emergency medicine colleagues told us that if patients don't fit established guidelines for anaphylaxis, there may be a reluctance in the emergency room to treat with epinephrine," said lead study author, allergist and past president of the ACAAI Stanley M. Fineman, MD, in a press release. "Because epinephrine is the first line of defense in treating anaphylaxis, the panel agreed it should be used — even if a patient's reaction may not meet all the established criteria. The consequences for not using epinephrine when it's needed are much more severe than using it when it might not be necessary."

Anaphylaxis is a potentially life-threatening emergency that can occur within seconds of exposure to an allergen, such as a peanut or a bee sting.

The flood of chemicals released by the immune system during anaphylaxis can cause a sudden drop in blood pressure and a narrowing of the airways. The patient may also go into shock.

This type of reaction requires immediate medical attention and usually an injection of the hormone epinephrine, sometimes known as adrenaline.

Anaphylaxis is not always easily diagnosed, however.

Steven Cole, DO, of Baylor University Medical Center, told dailyRx News that it can be difficult to diagnose anaphylaxis in the emergency room.

"Some cases are obvious, but others are far from it," Dr. Cole said. "At times, there is a hidden allergen that patients are exposed to at a restaurant or the patient ate multiple foods, such as a buffet. Some patients are misdiagnosed as anaphylaxis because they have hives which leads to a panic attack or the sensation of shortness of breath."

Symptoms of a severe allergic reaction may include severe swelling, hives, itching, nausea, vomiting and shortness of breath.

With each reaction, the risk for future attacks also goes up.

Epinephrine works by immediately counteracting the swelling and raising a patient’s blood pressure.

The ACAAI guidelines noted several areas where treatment of allergic emergencies could be improved.

The ACAAI recommends doctors use epinephrine first before using antihistamines or corticosteroids to treat an allergy emergency. Epinephrine should also be used if the patient is at risk for anaphylaxis. An at-risk patient is one with a history of the condition. Doctors should also prescribe epinephrine injectors — sometimes known as EpiPens — to patients at risk of anaphylaxis before discharge from the emergency room.

"We want emergency medical personnel, as well as people who have had, or are at risk for having severe allergic reactions to know there is no substitute for epinephrine as the most important tool for combating anaphylaxis," said panel member and allergist Paul Dowling, MD, in the press release.

According to the ACAAI, the risks of using epinephrine are much less than the risks of not using it.

The new guidelines were published in the August issue of the journal Annals of Allergy, Asthma and Immunology.

Review Date: 
August 4, 2015
Last Updated:
August 9, 2015