How to prescribe an EpiPen (Epinephrine)

From the Guidelines

To prescribe an EpiPen, write a prescription for "EpiPen Auto-Injector" or "EpiPen Jr Auto-Injector" based on patient weight, with clear directions for use and storage, and consider additional units for different locations, as recommended by the most recent guidelines 1. When prescribing an EpiPen, it is essential to consider the patient's weight to determine the correct dosage.

• For patients weighing 30 kg (66 lbs) or more, prescribe the standard EpiPen 0.3 mg.
• For those under 30 kg, prescribe EpiPen Jr 0.15 mg, as suggested by previous guidelines 1. Always prescribe two auto-injectors to ensure the patient has a backup in case of an emergency.
• Include clear directions: "Inject intramuscularly into outer thigh at first sign of severe allergic reaction. May repeat once after 5-15 minutes if symptoms persist. Seek immediate medical attention after use." The prescription should specify "dispense as written" to prevent substitution with generic versions if brand-name is preferred. Epinephrine works by constricting blood vessels, relaxing airway muscles, and reducing inflammation during anaphylaxis, as explained in the guidelines 1. Patients should be educated on proper administration technique, storage at room temperature, checking the solution for clarity, and the importance of replacing expired devices, as emphasized in the recent guidelines 1. Consider prescribing additional units for different locations (home, school, work) to ensure immediate access during emergencies, and provide training on how to recognize anaphylaxis and use an EA, as recommended by the guidelines 1.

From the Research

Epinephrine Administration

• Epinephrine is the mainstay of acute pharmacotherapy for anaphylaxis, and its administration often eliminates all manifestations of anaphylaxis 2.
• The method of choice for administering epinephrine is by intramuscular injection with an autoinjector, mainly done to treat reactions of intermediate severity 2.
• The injection is given in the lateral portion of the thigh and can be repeated every 10-15 minutes until there is a response 2.
• The dose to be administered is 300-600 µg for an adult or 10 µg/kg for a child 2.

Prescribing Epinephrine Autoinjectors

• Patients at risk of anaphylaxis should be supplied with autoinjectable epinephrine and instructed on its use 3.
• They should keep the device with them at all times and be taught the signs and symptoms of anaphylaxis 3.
• International guidelines stipulate that intramuscular epinephrine is the first-line treatment for anaphylaxis, with an established good safety profile 4.
• However, key areas of uncertainty remain around epinephrine usage, including variations in prescribing epinephrine autoinjectors and what symptoms should prompt epinephrine administration 4.

Management of Anaphylaxis

• Acute management of anaphylaxis involves removal of the trigger, early administration of intramuscular epinephrine, supportive care for the patient's airway, breathing, and circulation, and a period of observation for potential biphasic reactions 5.
• Only after epinephrine administration should adjunct medications be considered, including histamine H1 and H2 antagonists, corticosteroids, beta2 agonists, and glucagon 5.
• Patients should be monitored for a biphasic reaction for four to 12 hours, depending on risk factors for severe anaphylaxis 5.
• Following an anaphylactic reaction, management should focus on developing an emergency action plan, referral to an allergist, and patient education on avoidance of triggers and appropriate use of an epinephrine auto-injector 5.