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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.

Response:

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.

References: 

Rachid O, Rawas-Qalaji MM, Simons FE, Simons KJ. Epinephrine (adrenaline) absorption from new-generation, taste-masked sublingual tablets: a preclinical study. J Allergy Clin Immunol. 2013; 131(1):236–8. (doi:10.1016/j.jaci.2012.10.016).

Rawas-Qalaji M, Rachid O, Mendez BA, Losada A, Simons FE, Simons KJ. Adrenaline (epinephrine) microcrystal sublingual tablet formulation: enhanced absorption in a preclinical model. J Pharm Pharmacol. 2015; 67(1):20–5. (doi:10.1111/jphp.12312).

Rawas-Qalaji MM, Simons FE, Simons KJ. Sublingual epinephrine tablets versus intramuscular injection of epinephrine: dose equivalence for potential treatment of anaphylaxis. J Allergy Clin Immunol. 2006; 117(2):398–403. (doi:10.1016/j.jaci.2005.12.1310).

Rawas-Qalaji MM, Simons FE, Simons KJ. Epinephrine for the treatment of anaphylaxis: do all 40 mg sublingual epinephrine tablet formulations with similar in vitro characteristics have the same bioavailability? Biopharm Drug Dispos. 2006; 27(9):427–35. (doi:10.1002/bdd.519).

Rawas-Qalaji MM, Werdy S, Rachid O, Simons FE, Simons KJ. Sublingual Diffusion of Epinephrine Microcrystals from Rapidly Disintegrating Tablets for the Potential First-Aid Treatment of Anaphylaxis: In Vitro and Ex Vivo Study. AAPS PharmSciTech. 2015 Oct; 16(5):1203-12.

Simons FE, Ardusso LR, Bilò MB, Cardona V, Ebisawa M, El-Gamal YM, Lieberman P, Lockey RF, Muraro A, Roberts G, Sanchez-Borges M, Sheikh A, Shek LP, Wallace DV, Worm M. International consensus on (ICON) anaphylaxis. World Allergy Organ J. 2014 May 30; 7(1):9.

Vicky Cardona
Allergy Section, Department of Internal Medicine
Vall d'Hebron University Hospital
Barcelona, Spain


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