What is the recommended dose of epinephrine (adrenaline) for treating anaphylaxis?

Epinephrine Dosing for Anaphylaxis

For adults and children ≥30 kg, administer 0.3 to 0.5 mg of epinephrine (1:1000 concentration) intramuscularly into the anterolateral thigh, repeated every 5 to 15 minutes as needed; for children <30 kg, give 0.01 mg/kg (maximum 0.3 mg) intramuscularly. 1, 2, 3

Adult Dosing

• Administer 0.3 to 0.5 mg (0.3 to 0.5 mL of 1:1000 concentration) intramuscularly into the anterolateral aspect of the thigh as recommended by the American Heart Association and FDA labeling 1, 2, 3
• Repeat doses every 5 to 15 minutes based on patient response, with approximately 6-19% of patients requiring a second dose 1, 2
• The FDA label specifies every 5 to 10 minutes for repeat dosing 3

Pediatric Dosing

Children ≥30 kg (66 lbs)

• Use the same adult dose: 0.3 to 0.5 mg intramuscularly 2, 3

Children <30 kg (66 lbs)

• Administer 0.01 mg/kg (0.01 mL/kg of 1:1000 concentration) up to a maximum of 0.3 mg intramuscularly 1, 2, 3
• For autoinjector selection: 0.15 mg autoinjector for children weighing 7.5 to 25 kg, and 0.3 mg autoinjector for children ≥25 kg 2
• Repeat every 5 to 15 minutes as necessary 1, 2

Route of Administration

Intramuscular injection into the anterolateral thigh (vastus lateralis muscle) is the preferred first-line route, producing rapid peak plasma concentrations compared to subcutaneous administration 1, 2

When to Use IV Epinephrine

• Reserve intravenous epinephrine for patients in anaphylactic shock when IV access is already established, or for cardiac arrest or profound hypotension unresponsive to IM epinephrine and fluid resuscitation 1, 2
• IV dose: 0.05 to 0.1 mg (0.5 to 1 mL of 1:10,000 solution) 2
• For continuous IV infusion: add 1 mg (1 mL of 1:1000) to 1000 mL of 0.9% normal saline, starting at 2 μg/min (120 mL/h) and titrating up to 10 μg/min (600 mL/h) based on blood pressure, heart rate, and oxygenation 1, 2

Critical Safety Points

No Absolute Contraindications

• There are no absolute contraindications to epinephrine use in anaphylaxis, even in elderly patients with cardiovascular disease or other comorbidities, as the benefits far outweigh the risks according to the American Academy of Allergy, Asthma, and Immunology 1, 2, 4, 3
• Common adverse effects include transient pallor, tremor, anxiety, palpitations, sweating, and headache 1, 3
• Mortality from anaphylaxis is remarkably low at less than 0.5% per episode when treated appropriately with epinephrine 4

Common Pitfalls to Avoid

Do not withhold epinephrine due to fear of adverse effects—delay in administration is associated with increased morbidity and mortality 1, 4

Do not inject into buttocks, digits, hands, or feet as specified by FDA labeling 3

Avoid dosing errors: The most dangerous error is administering the cardiac arrest dose (1 mg IV push) instead of the anaphylaxis dose (0.3-0.5 mg IM), which can cause severe cardiac complications including ventricular dysfunction 5

Recognize the concentration difference:

• IM/subcutaneous use requires 1:1000 concentration (1 mg per 1 mL) 2
• IV use requires 1:10,000 concentration to avoid overdose 2

Special Population Considerations

• Fixed autoinjector doses may lead to potential overdosing in small children (<15 kg) or underdosing in larger adolescents and obese adults 4, 6, 7
• Patients requiring more than one dose are more likely to require hospital admission 4
• Elderly patients and pregnant women may be at greater risk of adverse reactions but should still receive epinephrine without hesitation 3