What is the approach for reversing the effects of epinephrine (adrenaline)?

From the Guidelines

To reverse the effects of epinephrine (adrenaline), the primary approach is not to administer a specific antidote, but rather to manage the symptoms and supportive care, as most epinephrine effects are short-lived due to its brief half-life. The management of epinephrine's effects can be complex and depends on the clinical context, including the dose and route of administration, as well as the patient's underlying medical conditions.

• In cases where epinephrine is administered for anaphylaxis, the focus is on managing the anaphylactic reaction rather than reversing the epinephrine itself, with epinephrine being the first-line treatment for anaphylaxis 1.
• Supportive care is essential and may include continuous cardiac monitoring, blood pressure checks, and oxygen administration as needed.
• For patients with contraindications to epinephrine, such as those on beta-blockers, alternative treatments like glucagon may be considered, with a dose of 1 to 5 mg in adults administered intravenously over 5 minutes, which may be repeated or followed by an infusion of 5 to 15 μg/minute 1.
• It's also important to note that there is no absolute contraindication to epinephrine use in the treatment of anaphylaxis, and the benefits of prompt epinephrine administration outweigh the risks, with the mortality from anaphylaxis being remarkably low at <0.5% per episode of anaphylaxis 1. Key considerations in managing epinephrine's effects include:
• Monitoring for potential adverse effects, such as anxiety, fear, restlessness, headache, dizziness, palpitations, pallor, and tremor.
• Being aware of the potential for more severe adverse effects, such as ventricular arrhythmias, angina, myocardial infarction, pulmonary edema, sudden sharp increase in blood pressure, and intracranial hemorrhage, especially with overdose or in high-risk patients.
• Ensuring appropriate counseling of patients on the technique of epinephrine administration and the need for restraint in young children and infants to avoid inadvertent needle injuries.

From the FDA Drug Label

For preoperative reduction of elevated blood pressure, 5 mg of phentolamine mesylate (1 mg for children) is injected intravenously or intramuscularly 1 or 2 hours before surgery, and repeated if necessary During surgery, phentolamine mesylate (5 mg for adults, 1 mg for children) is administered intravenously as indicated, to help prevent or control paroxysms of hypertension, tachycardia, respiratory depression, convulsions, or other effects of epinephrine intoxication

The approach for reversing the effects of epinephrine (adrenaline) is to administer phentolamine mesylate intravenously, with a dose of 5 mg for adults and 1 mg for children, as indicated, to help prevent or control the effects of epinephrine intoxication 2.

From the Research

Reversal of Epinephrine Effects

The approach to reversing the effects of epinephrine (adrenaline) involves several considerations, including the management of anaphylaxis and the use of specific medications.

• Epinephrine is a life-saving medication in the management of anaphylaxis, acting rapidly to reverse symptoms and stabilize mast cells 3.
• The standard treatment for anaphylaxis involves the administration of intramuscular epinephrine, followed by supportive care and observation for potential biphasic reactions 4.
• In terms of reversing the effects of epinephrine, there are no specific medications that directly counteract its effects. However, medications such as beta-blockers may be used to manage certain symptoms or conditions associated with epinephrine use 5, 6.
• Phentolamine, an alpha-adrenergic antagonist, has been used in certain clinical settings, including the treatment of congestive heart failure and the management of shock 7.
• It is essential to note that the management of anaphylaxis and the reversal of epinephrine effects require prompt and proper medical attention, and patients at risk for anaphylaxis should carry epinephrine autoinjectors and be taught how to use them 3.

Medications Used in Reversal

Some medications that may be used in the management of anaphylaxis or the reversal of epinephrine effects include:

• Beta-blockers, such as labetalol, which may be used to manage certain symptoms or conditions associated with epinephrine use 5, 6.
• Phentolamine, an alpha-adrenergic antagonist, which has been used in certain clinical settings, including the treatment of congestive heart failure and the management of shock 7.
• Histamine H1 and H2 antagonists, corticosteroids, beta2 agonists, and glucagon, which may be used as adjunct medications in the management of anaphylaxis 4.