How do I order an EpiPen (epinephrine auto-injector)?

How to Order an EpiPen

Prescribe self-injectable epinephrine (EpiPen or equivalent autoinjector) for any patient with a history of anaphylaxis involving respiratory or cardiovascular symptoms, or for those with generalized acute urticaria after insect stings, as these patients face significant risk of life-threatening reactions upon re-exposure. 1, 2

Who Needs a Prescription

Primary indications for prescribing:

• Any patient with previous anaphylaxis characterized by respiratory compromise (wheezing, throat tightness, difficulty breathing) or cardiovascular symptoms (hypotension, syncope, shock) to a trigger that may be re-encountered outside medical settings 1, 2
• Patients with generalized acute urticaria after insect stings, who carry approximately 10% risk of more severe reactions from future stings 1, 2
• Patients with idiopathic anaphylaxis, though this is uncommon in children 2

High-risk factors that strengthen the indication:

• Concurrent asthma (significantly increases risk of severe or fatal anaphylaxis) 2
• Previous reactions to high-risk foods including peanut, tree nut, seafood, milk, or egg 2
• History of reaction to trace allergen exposure 1
• Use of nonselective β-blockers 1
• Living in remote areas away from immediate medical care 1

Dosing and Device Selection

For children weighing less than 30 kg (66 lbs): Prescribe EpiPen Jr 0.15 mg 1, 2

For patients weighing 30 kg (66 lbs) or more: Prescribe EpiPen 0.3 mg 1, 2

Critical dosing considerations for infants and small children (10-15 kg):

• Most pediatricians (80-100%) prescribe the 0.15 mg autoinjector despite the 1.5-fold overdose, because the certainty of delivery outweighs the risk of modest overdose in healthy children 1, 2
• Do not prescribe ampule/syringe/needle combinations for infants under 15 kg unless absolutely necessary—parents take 142±13 seconds to draw up doses (versus 29 seconds for emergency nurses), and dosing accuracy ranges from 0.004 to 0.151 mL (nearly 40-fold variation) 1, 2

Prescription Specifics

Always prescribe two autoinjectors, as approximately 10-20% of patients require more than one dose during a single anaphylactic episode 2

Include a written anaphylaxis action plan with clear instructions on when and how to use the device 1

Ensure the prescription includes:

• Two autoinjectors of the appropriate dose
• Instructions to carry both devices at all times
• Replacement prescription when devices expire (typically 12-18 months from dispensing)
• School/daycare authorization forms if applicable 1

Patient Education Requirements

When to use the EpiPen:

• Immediately for ANY severe symptoms (difficulty breathing, throat tightness, severe wheezing, hypotension, collapse) after suspected or known allergen exposure 1, 3
• Immediately if the allergen was definitely eaten and previously caused anaphylaxis with cardiovascular collapse, even if no symptoms are present yet 1
• For generalized acute urticaria in the context of known exposure to an allergen that previously triggered anaphylaxis 1

How to use the device (provide demonstration with trainer):

• Remove EpiPen from plastic carrying case
• Pull off blue safety release cap
• Hold orange tip near outer thigh (can inject through clothing if necessary) 1, 4, 2
• Swing and firmly push orange tip against outer thigh
• Hold in place for approximately 10 seconds 1, 4
• Remove and massage injection area for 10 more seconds 1, 4

Critical actions after injection:

• Call 911 immediately, even if symptoms improve 4, 2, 3
• Keep patient lying on back with legs raised 1, 4
• Note the time epinephrine was administered 1, 4
• Administer second dose after 5 minutes if symptoms persist or recur 1, 4, 3
• Never rely on antihistamines or inhalers as primary treatment—only epinephrine addresses life-threatening cardiovascular and respiratory manifestations 1, 2, 3

Common Pitfalls to Avoid

Underprescribing: Only 46% of patients refill their epinephrine autoinjectors, and only 11% refill consistently at expected intervals 5. Emphasize the importance of maintaining unexpired devices at all times.

Inadequate education: Only 2% of doctors can correctly demonstrate all 6 administration steps, and 16% accidentally inject their own thumb during demonstration 6. Use a trainer device during every patient encounter to ensure proper technique.

Underuse during actual reactions: The EpiPen is only used in 29% of recurrent anaphylactic reactions, despite being prescribed 7. Emphasize that when used appropriately, it reduces subsequent hospital admissions and need for additional epinephrine in the emergency department 7.

Delayed administration: Delay in administering epinephrine is associated with anaphylaxis fatalities and increased risk of biphasic reactions 3. Instruct patients that there are no absolute contraindications to epinephrine in anaphylaxis, even in patients with cardiac disease, advanced age, or frailty 3.