How to Write an EpiPen Order for an Adult
For adults weighing ≥30 kg (66 lbs), prescribe epinephrine auto-injector 0.3 mg, administered intramuscularly into the anterolateral thigh (vastus lateralis), with instructions to repeat every 5-10 minutes as needed if symptoms persist or worsen, and always prescribe two auto-injectors. 1
Standard Adult Prescription Components
Medication and Dose:
- Epinephrine auto-injector 0.3 mg (for adults ≥30 kg/66 lbs) 1
- Alternative: Epinephrine 1:1000 solution, 0.3-0.5 mg (0.3-0.5 mL) if prescribing vials instead of auto-injectors 1
Route and Site:
- Intramuscular injection into the anterolateral aspect of the mid-thigh (vastus lateralis muscle) 2
- This site achieves peak plasma concentrations in 8±2 minutes, compared to 34±14 minutes with subcutaneous deltoid injection 2
- Can be administered through clothing if necessary 2, 1
Frequency:
- Repeat every 5-10 minutes as necessary if symptoms fail to resolve or worsen 1, 3
- There is no maximum number of doses—continue until symptoms resolve 3
- Approximately 10-20% of patients require more than one dose 3, 4
Quantity:
- Always prescribe TWO auto-injectors 3
- This ensures availability of a second dose, as 6-28% of patients require repeat dosing 3, 4
Critical Patient Instructions to Include
Administration Technique:
- Inject into the outer thigh (vastus lateralis), never into buttocks, digits, hands, or feet 1
- Hold the leg firmly in place during injection to minimize movement 1
- Do not inject repeatedly at the same site, as vasoconstriction may cause tissue necrosis 1
When to Use:
- Administer immediately upon recognition of anaphylaxis symptoms (hives with respiratory difficulty, hypotension, or gastrointestinal symptoms after allergen exposure) 2, 3
- Call 911 immediately after administering epinephrine 4, 3
- Position patient supine with legs elevated; never allow standing or walking, as this increases mortality risk 3
Repeat Dosing Instructions:
- If symptoms persist or worsen after 5-10 minutes, administer second dose 1, 3
- Continue dosing every 5 minutes as needed until emergency medical services arrive 3, 4
Sample Order Format
Prescription:
- Drug: Epinephrine auto-injector 0.3 mg
- Indication: Emergency treatment of anaphylaxis
- Directions: Inject 0.3 mg intramuscularly into outer thigh at first sign of anaphylaxis. May repeat every 5-10 minutes if symptoms persist. Call 911 immediately after first dose.
- Quantity: 2 auto-injectors
- Refills: As appropriate for patient's risk level
Special Considerations
No Absolute Contraindications:
- There are no absolute contraindications to epinephrine use in anaphylaxis, even in elderly patients or those with cardiovascular disease 1, 3, 4
- The risk of death from untreated anaphylaxis far exceeds the risk of epinephrine-related adverse effects 3, 4
Needle Length Concerns:
- Standard auto-injector needles (15.2 mm for EpiPen) may be inadequate for intramuscular delivery in obese patients, particularly women 5, 6
- In obese adults, consider prescribing epinephrine vials with longer needles (at least 1/2 to 5/8 inch) to ensure intramuscular delivery 1, 6
Storage and Inspection:
- Instruct patients to inspect epinephrine visually before use—do not use if solution is colored, cloudy, or contains particulate matter 1
- Protect from light 1
Common Pitfalls to Avoid
Delayed Administration:
- Fatalities are associated with delayed epinephrine administration, not with giving multiple doses 3, 4, 7
- Epinephrine is grossly underused in anaphylaxis management 8
Wrong Route or Site:
- Subcutaneous administration has delayed onset (34 minutes vs. 8 minutes for intramuscular thigh injection) 2
- Deltoid injection is inferior to anterolateral thigh 2
Inadequate Quantity:
- Prescribing only one auto-injector leaves patients without backup when repeat dosing is needed 3
Substituting Other Medications:
- Antihistamines and corticosteroids are NOT substitutes for epinephrine and should only be used as adjunctive therapy 4