International recommendations on epinephrine auto-injector doses often differ from standard weight-based guidance: a review and clinical proposals

Abstract

Background In anaphylaxis, the dosing of injectable epinephrine in medical settings has been arbitrarily recommended to be 0.01 mg/kg of body weight. For ethical reasons, there have been no dose–response studies or double-blind studies performed on patients with active anaphylaxis. Intramuscular delivery of epinephrine has been the standard. Auto-injectors for use in the treatment of anaphylaxis are available in four strengths (0.1, 0.15, 0.3, and 0.5 mg). However, in many countries, only the 0.15 and 0.3 mg strengths are available. Consequently, many adult, heavy patients are prescribed the 0.3 mg dose, which may result in only one-fifth to one-third of the recommended weight-based dose being administered in heavy patients experiencing anaphylaxis. Underdosing may have therefore contributed to mortality in anaphylaxis. Objective To review the doses of epinephrine recommended for the treatment of anaphylaxis in the community, and assess whether recommendations should be made to increase dosing for heavy adult patients in hopes of avoiding future deaths from anaphylaxis. Methods We reviewed multiple national and international recommendations for the dosing of epinephrine. We also reviewed the literature on adverse drug reactions from epinephrine, lethal doses of epinephrine, and epinephrine dose-finding studies. Results The majority of national and regional professional societies and authorities recommend epinephrine delivered by auto-injectors at doses far lower than the generally accepted therapeutic dose of 0.01 mg/kg body weight. Furthermore, we found that the recommendations vary even within regions themselves. Conclusions We suggest prescribing more appropriate doses of epinephrine auto-injectors based on weight-based recommendations. There may be some exceptions, such as for patients with heart disease. We hypothesize that these recommendations will lead to improved outcomes of anaphylaxis.

Knowledge and Attitude towards Anaphylaxis Reaction by Local Anesthesia among Dental Practitioners

“…Patients' body weights are used to determine the optimal epinephrine dosage. Children and adults weighing 30 kg or more often take 0.3 mg. To treat adults and children between 15 and 30 kilograms (kg), the recommended daily dosage is 0.15 mg. (23)(24)(25) The study findings also shows that most medical facilities are inadequately prepared to deal with unexpected medical emergencies. A dentist is ultimately responsible for addressing any emergency circumstances at a dental clinic, therefore their inexperience and unfamiliarity with doing so might have unfavorable results and lead to legal lawsuits by patients (3)(4)(5)(6) .…”

Prescribing propranolol for infants at risk of anaphylaxis

“…Propranolol is also usually stopped at around 1 year of age due to the natural involution seen after this point, 1 conveniently as children become more independent and inquisitive, and at higher risk of inadvertent exposure to allergens 7 . In Europe the recommended dose of epinephrine for infants weighing between 7.5 and 15 kg is 150 mcg, while in the United States the recommended dose is 100 mcg 9 …”

“…7 In Europe the recommended dose of epinephrine for infants weighing between 7.5 and 15 kg is 150 mcg, while in the United States the recommended dose is 100 mcg. 9 Propranolol is an exceptionally effective treatment for IH, and even more so when considering alternative treatments. Topical timolol has no effect on deep IH and is ineffective in treating proliferative IH.…”