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September 27, 2016

Epinephrine for Anaphylaxis

Question

In the recent times, anaphylaxis frequency is increasing and management is difficult. Epipen is not available in India. Adrenalin Injection self-administration is difficult.

Alternate routes of administration of Adrenalin by sublingual route 40 mgs appears promising, do you recommend for routine use in our patients? Please let us know its efficacy in the management of anaphylaxis.

Answer

From the Editor: Epinephrine or adrenalin is the cornerstone of anaphylaxis treatment.  Access to auto-injectors has been hindered by cost or availability. This question addresses the state of epinephrine/adrenalin self-treatment alternatives.

By Prof Vicky Cardona

Several publications have reported the use of sublingual adrenaline in anaphylaxis. Nevertheless, as can be seen in the referenced publications below, this route has been initially assessed for tablets, and not for the conventional liquid formulation. Currently, according to the available information, sublingual epinephrine tablets may be a promising alternative, but they have not yet been approved or commercialized. Therefore, currently, intramuscular epinephrine remains the treatment of choice for anaphylaxis, recommended by all international Allergy societies. In countries where auto-injectors are not available, injection with a syringe and an intramuscular needle is still the preferred form of administration, despite limitations inherent to the difficulties involved with this administration form.

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By Prof Margitta Worm

Yes, several studies in the last years indicated an increase of anaphylaxis in countries like the United States, Europe and Australia (1, 2, 3). According to the WAO, but also the American and European anaphylaxis management guidelines adrenaline given intramuscular is the treatment of choice (4, 5, 6). Several auto-injectors for self-administration by patients and their relatives are currently on the market, but their availability is limited in some countries worldwide, e.g. India. In these countries, the adrenaline application should be given by doctors or trained person.

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