What is the recommended dose of Epinephrine (adrenaline) for acute asthma exacerbation?

From the Guidelines

The recommended dose of epinephrine for acute asthma exacerbations is 0.01 mg/kg of 1:1000 (1 mg/mL) solution administered subcutaneously, up to a maximum dose of 0.3-0.5 mg in adults and 0.15 mg in children, as supported by the most recent and highest quality study 1.

Key Points to Consider

• Epinephrine should be used only in emergency situations when standard treatments like inhaled beta-agonists have failed or are unavailable.
• The medication works rapidly by stimulating both alpha and beta-adrenergic receptors, causing bronchodilation, reducing airway inflammation, and decreasing mucosal edema.
• Side effects may include anxiety, tremors, palpitations, increased blood pressure, and headache.
• Patients should seek immediate medical attention after using epinephrine for asthma, as this represents a severe exacerbation requiring professional evaluation.

Evidence-Based Recommendations

• The systematic review and meta-analysis published in 2022 1 suggests that epinephrine and selective β2-agonists have similar efficacy in acute asthma, but the quality of evidence is low.
• The study highlights the need for high-quality double-blind RCTs to determine whether addition of intramuscular epinephrine to inhaled or nebulised selective β2-agonist improves outcome.
• The guidelines from 2007 1 and 2009 1 provide dosing recommendations for epinephrine in acute asthma exacerbations, but the most recent study 1 should be prioritized due to its recency and high quality.

Clinical Implications

• Regular use of controller medications and a proper asthma action plan are essential to prevent situations requiring emergency epinephrine use.
• Epinephrine auto-injectors (like EpiPen) are primarily designed for anaphylaxis but may be used in life-threatening asthma when no alternatives exist.
• Clinicians should be aware of the potential side effects of epinephrine and monitor patients closely after administration.

From the FDA Drug Label

2 DOSAGE & ADMINISTRATION

... Adults and Children 30 kg (66 lbs) or more: 0.3 to 0.5 mg (0.3 mL to 0. 5 mL) of undiluted Adrenalin® administered intramuscularly or subcutaneously in the anterolateral aspect of the thigh, up to a maximum of 0.5 mg (0.5 mL) per injection, repeated every 5 to 10 minutes as necessary. Children less than 30 kg (66 lbs): 0.01 mg/kg (0. 01 mL/kg) of undiluted Adrenalin® administered intramuscularly or subcutaneously in the anterolateral aspect of the thigh, up to a maximum of 0.3 mg (0.3 mL) per injection, repeated every 5 to 10 minutes as necessary.

The recommended dose of Epinephrine for acute asthma exacerbation is not explicitly stated in the provided drug label. The label provides dosing information for administration in general, but it does not specifically address acute asthma exacerbation. Therefore, no conclusion can be drawn regarding the recommended dose for this specific condition 2.

From the Research

Recommended Dose of Epinephrine for Acute Asthma Exacerbation

• The recommended dose of Epinephrine (adrenaline) for acute asthma exacerbation is not explicitly stated in the provided studies 3, 4, 5, 6, 7.
• However, study 6 mentions that subcutaneous and intramuscular β2 agonists such as terbutaline and epinephrine may be considered for children with severe asthma exacerbation who have poor air entry, are uncooperative with nebulized therapy, or have poor response to nebulized therapy.
• Study 3 describes a case report where nebulized racemic epinephrine was used successfully to treat severe acute asthma following failure of standard first-line therapies, but it does not provide a specific recommended dose.
• The other studies 4, 5, 7 do not mention the use of epinephrine as a treatment for acute asthma exacerbation.

Alternative Treatments

• The studies suggest that other treatments such as bronchodilators, corticosteroids, and ipratropium bromide are commonly used to treat acute asthma exacerbation 4, 5, 6, 7.
• Study 7 found that the addition of ipratropium bromide to albuterol improved pulmonary function and reduced hospital admissions in patients with acute asthma.
• Study 6 mentions that inhaled bronchodilators and systemic corticosteroids are the mainstay of therapy in the management of severe and status asthmaticus.