What medications are recommended for acute management via intramuscular (IM) administration?

From the Guidelines

Epinephrine is the first-line treatment for anaphylaxis and should be administered intramuscularly (IM) at a dose of 0.01 mg/kg of 1:1000 solution, up to 0.5 mg in adults and 0.3 mg in children and teenagers, as recommended by the most recent guidelines 1. For acute management via IM administration, the following medications are commonly recommended:

• Epinephrine (0.3-0.5 mg of 1:1000 solution for adults, 0.15 mg for children) for anaphylaxis, administered in the mid-outer thigh 1
• Other medications such as ketorolac, opioids, antipsychotics, benzodiazepines, and antibiotics may be used for acute pain management, psychosis, agitation, anxiety, or infections, but epinephrine remains the primary treatment for anaphylaxis 1 Key considerations for IM administration include:
• Rapid medication delivery when intravenous access is difficult or unavailable
• Medication absorption typically occurring within 10-30 minutes depending on the specific drug and patient factors
• Importance of administering epinephrine promptly and correctly in cases of anaphylaxis to prevent severe consequences 1 It is essential to note that while other medications may be used for various acute conditions, epinephrine is the most critical medication for anaphylaxis treatment, and its administration should be prioritized accordingly 1.

From the FDA Drug Label

Ketorolac Tromethamine Injection, USP is available for intravenous (IV) or intramuscular (IM) administration as: 15 mg in 1 mL (1.5%) and 30 mg in 1 mL (3%) in sterile solution; 60 mg in 2 mL (3%) of ketorolac tromethamine in sterile solution is available for intramuscular administration only. Midazolam Injection, USP CIV 2 mg per 2 mL* (1 mg per mL*) For Intravenous or Intramuscular Use

The following medications are recommended for acute management via intramuscular (IM) administration:

• Ketorolac (IM) 2
• Midazolam (IM) 3

From the Research

Acute Management via Intramuscular (IM) Administration

• The recommended medication for acute management via IM administration is epinephrine (adrenaline) 4, 5, 6.
• Epinephrine is universally recommended as the initial drug of choice for the treatment of anaphylaxis, with no other medication having similar life-saving pharmacologic effects 4.
• The initial recommended adult dose is 0.3-0.5 mg, injected intramuscularly in the anterolateral aspect of the mid-thigh 4, 6.
• IM epinephrine administration is considered the first-line treatment for anaphylaxis, with no absolute contraindications to its use 5.
• Alternative routes of epinephrine administration, such as intranasal, sublingual, inhaled, and needle-free intramuscular administration, are being investigated 5.

Safety and Efficacy of IM Epinephrine Administration

• IM epinephrine administration has a satisfactory therapeutic window, with a faster onset of action compared to subcutaneous injection 4.
• The risk of adverse cardiovascular events and overdose is significantly higher with intravenous bolus epinephrine administration compared to IM epinephrine administration 7.
• IM epinephrine administration is considered safe, with a low risk of adverse events 7.

Management of Refractory Anaphylaxis

• In cases of refractory anaphylaxis, where patients do not respond to IM adrenaline treatment, intravenous infusion of adrenaline may be considered 8.
• A framework for escalation of treatment in such cases, using intravenous infusion of adrenaline, has been proposed 8.