UK Guidelines

Guidelines covering the management of anaphylaxis recommend adrenaline as immediate first-line treatment.

Please find below summaries of the following key guidelines relevant to the UK:

MHRA guidelines - prescribing 2 AAIs1

Advice for healthcare professionals:

  • It is recommended that 2 adrenaline auto-injectors are prescribed, which patients should carry at all times.
  • Ensure that people with allergies and their carers have been trained to use the particular auto-injector that they have been prescribed - technique varies between injectors.
  • Encourage people with allergies and their carers to obtain and practise using a trainer device (available for free from the manufacturers’ websites).

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NICE guidelines2

Updated in 2020 to include a recommendation that a further 2 adrenaline auto-injectors are prescribed before discharge, which patients are advised to carry at all times. This should be provided as an interim measure before the specialist allergy service appointment and should accompany advice and information about anaphylaxis. After emergency treatment for suspected anaphylaxis, offer people (or, as appropriate, their parent and/or carer) an appropriate adrenaline injector as an interim measure before the specialist allergy service appointment.

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Resuscitation Council (UK) guidelines - clinical administration of adrenaline5

This guideline is for healthcare providers who are expected to deal with an anaphylactic reaction during their usual clinical role.

Recommended doses of adrenaline when administered by medical staff are different from AAI’s for self-administration. Standard practice for healthcare professionals, particularly in the hospital is to use a vial of adrenaline, syringe and needle.3 Resus Guidelines do not make needle length and does recommendations for AAIs.4

Adrenaline (give IM unless experienced with IV adrenaline).

IM doses of 1:1000 adrenaline (repeat after 5 min if no better).

  • Adult 500 micrograms IM (0.5 mL)
  • Child more than 12 years: 500 micrograms IM (0.5 mL)
  • Child 6 -12 years: 300 micrograms IM (0.3 mL)
  • Child less than 6 years: 150 micrograms IM (0.15 mL)

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BSACI guidelines on prescribing AAI3

Adrenaline is the first-line treatment for anaphylaxis. It should be used in patients with significant airway involvement or hypotension, occurring as part of an anaphylactic (IgE- or non IgE-mediated) reaction. An auto-injector allows early administration of adrenaline, improving outcome.

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Clinical trial data

There are no randomised controlled clinical trials in humans providing unequivocal evidence for the treatment of anaphylactic reactions; moreover, such evidence is unlikely to be forthcoming in the near future.2 This is the same for all AAIs. Adrenaline is accepted as the drug of choice and it should be administered intra muscularly. EpiPen® has been used successfully for over 20 years, 0.15mg is licensed for use in patients weighing 7.5kg - 25kg, 0.3mg is licensed for use in all patients weighing over 25kg.

The EpiPen® PK/PD study (carried out as part of the 2015 requested review of all AAIs by the EMA) showed adrenaline delivery via EpiPen® resulted in greater early systemic exposure to adrenaline vs intramuscular syringe injection as assessed by adrenaline plasma levels.6

In comparative PK/PD studies of AAIs, of the same strength but with different size needles, plasma adrenaline concentrations appear to be higher with devices that have shorter needles and higher propulsive force (such as EpiPen®) compared with devices with a longer needle.7

References

  • MHRA guidelines- https://www.gov.uk/drug-safety-update/adrenaline-auto-injectors-updated-advice-after-european-review Last access September 2020.
  • NICE guidelines- https://www.nice.org.uk/guidance/cg134/evidence/anaphylaxis-full-guideline-pdf-184946941 last accessed September 2020.
  • Ewan, P., 2016. BSACI guideline: prescribing an adrenaline auto‐injector. Clinical &   Experimental Allergy46(10), pp.1258-1280.
  • Resus Guidelines Statement- https://www.resus.org.uk/about-us/news-and-events/statement-anaphylactic-guidelines
  • Resuscitation Council (UK) Guidelines. January 2008. Available at https://www.resus.org.uk/anaphylaxis/emergency-treatment-of-anaphylactic-reactions/> Last accessed September 2018.
  • Worm, M., 2020. Epinephrine delivery via EpiPen® Auto-Injector or manual syringe across participants with a wide range of skin-to-muscle distances. Clinical and Translational Allergy10(1), pp.1-13.
  • Emerade®, 500mg SPC https://www.medicines.org.uk/emc/product/5279/smpc/history last accessed September 2020.

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