EpiPen Prescribing Guidelines
Prescribe an epinephrine autoinjector (2 doses) to any patient with a previous systemic allergic reaction, food allergy with asthma, or known allergy to peanut, tree nuts, fish, or crustacean shellfish. 1
Clear Indications for EpiPen Prescription
High-Risk Patients (Mandatory Prescription)
- Previous systemic allergic reaction of any severity 1
- Food allergy combined with asthma (highest risk for fatal anaphylaxis) 1
- Known allergy to high-risk foods: peanuts, tree nuts, fish, or crustacean shellfish 1
Strong Consideration (Recommended)
- All patients with IgE-mediated food allergies, even without the above risk factors 1
Dosing by Weight
Weight-based dosing is critical to ensure therapeutic efficacy while minimizing adverse effects. 1
Pediatric Dosing
The 25 kg threshold represents the point where the 0.15 mg dose becomes inadequate (only 0.006 mg/kg), making the 0.3 mg dose (0.012 mg/kg) preferable despite slight overdosing. 2 For children with asthma or other high-risk features, consider switching to the higher dose at lower weights. 2
Adult Dosing
- Standard dose: 0.3 mg autoinjector 1
- Maximum single dose: 0.5 mg when using 1:1000 solution with syringe 1
Prescription Specifications
Always prescribe TWO autoinjectors to ensure availability for:
- Repeat dosing if symptoms persist or recur (doses may be repeated every 5-15 minutes) 1
- Biphasic reactions occurring up to 72 hours later 1, 2
- Device malfunction or accidental discharge 1
Administration Site
The anterolateral thigh (vastus lateralis muscle) is the only recommended injection site. 1, 3
Critical Pitfalls to Avoid
- Never inject into the buttock: risk of Clostridial infections (gas gangrene) and ineffective treatment 3
- Never inject into deltoid: inadequate muscle size and blood flow 3
- Never inject into digits, hands, or feet: risk of tissue necrosis from vasoconstriction 3
Patient Education Requirements
When prescribing, ensure patients receive:
- Anaphylaxis emergency action plan with clear instructions on when to use the device 1
- Demonstration of proper technique until patient can self-administer correctly 4
- Plan for monitoring expiration dates and timely replacement 1
- Instructions to call 911 immediately after using the autoinjector and proceed to emergency facility for 4-6 hour observation 1
- Referral for allergy evaluation if not already established 1
Special Populations
Patients with Cardiovascular Disease
Do not withhold epinephrine based on cardiac history, advanced age, or frailty—there are no absolute contraindications to epinephrine for anaphylaxis. 2 The risk of untreated anaphylaxis exceeds the risk of epinephrine-related cardiac effects. 5
Patients on Beta-Blockers
These patients may require higher or repeated doses of epinephrine and are at risk for refractory hypotension. 1 Still prescribe the autoinjector, but counsel about potential need for additional medical interventions. 1
Infants <10 kg
While no autoinjector is specifically designed for infants under 10 kg, the 0.15 mg dose may be used as the risk of untreated anaphylaxis outweighs concerns about relative overdosing. 1, 2 Do not prescribe ampule/syringe/needle combinations for home use—studies show parents take 2-4 minutes to draw up doses with 40-fold variation in accuracy. 1
Pregnant Patients
Prescribe without hesitation—epinephrine is life-saving and appropriate for use in pregnancy. 3
Common Prescribing Errors to Avoid
- Prescribing only one autoinjector instead of two 1
- Failing to provide written action plan with specific triggers for use 1
- Not verifying patient can demonstrate proper technique before leaving the office 4
- Prescribing 0.15 mg dose for children ≥25 kg (underdosing) 2
- Delaying prescription while awaiting formal allergy testing in high-risk patients 1
Documentation
Document in the medical record: