Guidelines covering the management of anaphylaxis generally recommend adrenaline as immediate first-line treatment. Doses of adrenaline, where recommended, reflect what is considered to be safe and practical for healthcare providers to inject in a clinical setting.1 For example, the Resuscitation Council UK recommend 0.5 mg IM in adults, but this does not apply to patients and carers using adrenaline auto-injectors, nor for rescuers, where the use of an auto-injector (0.3 mg or 0.15 mg) is recommended when no other adrenaline for IM administration is available.1,2
BSACI Auto-injector Guidelines, 20167
Drug Safety Update. May 2014.3
Resuscitation Council (UK).1,2
Royal College Paediatrics and Child Health 2011.5
Guidelines in Emergency Medicine Network (GMENet) 2009.6
BSACI Auto-injector Guidelines, 2016.
This guidance for the prescription of an adrenaline auto-injector has been prepared by the Standards of Care Committee (SOCC) of the British Society for Allergy and Clinical Immunology (BSACI). There is insufficient quality evidence-based data in some areas, including the question of how often a second dose is required, and the optimal dose and absorption after subcutaneous vs. intramuscular injection. Thus, indications for adrenaline(which are partly opinion based) in guidelines from different countries vary slightly. The guideline is based on evidence as well as on expert opinion and is for use by both adult physicians and paediatricians practising allergy. During the development of these guidelines, all BSACI members were included in the consultation process using a web-based system.Their comments and suggestions were carefully considered by the SOCC. Evidence from randomized controlled trials is lacking in anaphylaxis for ethical reasons. Consensus was reached by the experts on the committee. Included in this guideline are aetiology, risk of recurrence and management of anaphylaxis (after treatment of the acute episode), including allergen avoidance and written treatment plans. There are sections on dose and absorption of adrenaline, and adrenaline auto-injectors, including indications for their prescription, risk assessment for the number required and training in their use. The guidelines are not intended to be prescriptive, and clinicians should use their clinical judgement.
Drug Safety Update. May 2014.
People who have been prescribed an adrenaline auto-injector because of the risk of anaphylaxis should carry two with them at all times for emergency, on-the-spot use.3
After every use of an adrenaline auto-injector, an ambulance should be called (even if symptoms are improving), the individual should lie down with their legs raised and, if at all possible, should not be left alone.3
These guidelines are for staff in primary, secondary and tertiary settings who care for people with suspected anaphylaxis.
NICE recommended that adults and young people aged 16 years or older who have emergency treatment for suspected anaphylaxis should be observed for 6-12 hours from the onset of symptoms, depending on their response to emergency treatment. In people with reactions that are controlled promptly and easily, a shorter observation period may be considered provided that they receive appropriate post-reaction care prior to discharge. Children younger than 16 who have emergency treatment for suspected anaphylaxis should be admitted to hospital under the care of a paediatric medical team.4
They also recommend that all patients are referred to a specialist allergy service for assessment and be offered an adrenaline auto-injector as an interim measure, along with training on how to use it, what to do during an anaphylactic episode and how to avoid triggers.
Resuscitation Council (UK)1,2
Intended for healthcare professionals who are expected to recognise and treat an anaphylactic reaction as part of their clinical role:
- Early treatment with IM adrenaline is the treatment of choice for patients having an anaphylactic reaction
- Dose of adrenaline:
- ≤6 years: 150 μg; 6 to 12 years: 300 μg; adults and adolescents (>12 years): 500 μg
- Patients should be observed in a clinical area for at least 6 hours, reviewed and potentially observed for longer periods before discharge
- An auto-injector is an appropriate treatment for patients at increased risk of an idiopathic anaphylactic reaction, or for anyone at continued high risk of reaction e.g.to triggers such as venom stings and food-induced reactions (unless easy to avoid)
- An auto-injector is not usually necessary for patients who have suffered drug induced anaphylaxis, unless it is difficult to avoid the drug
- Guidance for auto-injector use must allow a greater degree of safety in terms of dose and recommended dosing interval
- Individuals provided with an auto-injector on discharge from hospital must be given instructions and training and have appropriate follow-up including contact with the patient’s general practitioner.
Royal College Paediatrics and Child Health 20115
The Anaphylaxis Working Group has made four key recommendations for healthcare professionals involved the management of children and young people aged 0 to 18 years with anaphylaxis, and the patients/carers themselves:
- Prompt administration of adrenaline by intramuscular injection is the cornerstone of therapy both in the hospital and in the community.
- Children and young people at risk of anaphylaxis should be referred to clinics with specialist competence in paediatric allergies.
- Risk analysis should be performed for all patients with suspected anaphylaxis.
- Provision of a management plan may reduce the frequency and severity of further reactions and is a recommended part of anaphylaxis management.
The basic prevention and treatment package should include an adrenaline injector, training for the use of adrenaline injector, basic avoidance advice and patient group information.
Guidelines in Emergency Medicine Network (GMENet) 20096
The guidelines are intended to be used by healthcare professionals working within the Emergency Department. Recommendations include:
- Prompt treatment is essential as it improves prognosis in severe anaphylactic reactions
- Administer adrenaline IM into the lateral thigh at a dose of 500 μg every 5 minutes if necessary
- IM route is preferred over the SC route
- Adrenaline auto-injectors should be used in the community at an early stage for severe reactions
- Patients, parents and carers should be educated regarding injection technique
- Auto-injectors should be available to at risk patients at all times
Listed below are key papers for further reading.
McLean-Tooke APC et al.
Adrenaline in the treatment of anaphylaxis: what is the evidence?
Kemp SF et al.
Epinephrine: the drug of choice for anaphylaxis. A statement of the World Allergy Organization.
Allergy 2008: 63: 1061–1070
Schwirtz A, Seeger H.
Are adrenaline auto-injectors fit for purpose? A pilot study of the mechanical and injection performance characteristics of a cartridge versus a syringe-based auto-injector.
J Asthma Allergy 2010;3:159-67.
What are the ‘ideal’ features of an adrenalin (epinephrine) auto-injector in the treatment of anaphylaxis?
Lieberman P et al.
The diagnosis and management of anaphylaxis practice parameter: 2010 Update.
J Allergy Clin Immunol 2010;126:477-80.
Anaphylaxis: Recent advances in assessment and treatment.
J Allergy Clin Immunol 2009;124:625-36.
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