Should I administer Epinephrine (Epi) to someone with angioedema?

From the Guidelines

You should give epinephrine to someone with angioedema if they are experiencing a severe allergic reaction or if the angioedema affects the airway, as recommended by the most recent guidelines 1. The recommended dose is 0.3-0.5 mg of 1:1000 epinephrine administered intramuscularly in the mid-outer thigh, which can be repeated every 5-15 minutes if needed. For children, the dose is 0.01 mg/kg up to 0.3 mg. Epinephrine is the first-line treatment for severe angioedema, especially when associated with anaphylaxis or when there is involvement of the lips, tongue, uvula, or larynx that could compromise the airway. However, it's essential to note that for hereditary angioedema, epinephrine may not be efficacious and is not recommended as a primary treatment, as stated in the 2013 guidelines 1. Epinephrine works by constricting blood vessels to reduce swelling, relaxing smooth muscles in the lungs to improve breathing, and increasing heart rate and contractility. After administering epinephrine, the person should be placed in a position of comfort, typically lying flat with legs elevated unless they are having breathing difficulties, and emergency medical services should be called immediately. Some key points to consider when treating angioedema include:

• Administering epinephrine as the first-line pharmacotherapy for uniphasic and/or biphasic anaphylaxis 1
• Not delaying the administration of epinephrine for anaphylaxis, as doing so may be associated with higher morbidity and mortality 1
• Keeping patients under observation in a setting capable of managing anaphylaxis until symptoms have fully resolved 1
• Educating patients on anaphylaxis, including avoidance of identified triggers, presenting signs and symptoms, biphasic anaphylaxis, treatment with epinephrine, and the use of epinephrine auto-injectors 1

From the FDA Drug Label

Epinephrine also alleviates pruritus, urticaria, and angioedema and may relieve gastrointestinal and genitourinary symptoms associated with anaphylaxis because of its relaxer effects on the smooth muscle of the stomach, intestine, uterus and urinary bladder Yes, epinephrine (IM) can be given to someone with angioedema, as it alleviates angioedema, especially in the context of anaphylaxis 2.

• Key benefits: alleviates angioedema, pruritus, urticaria, and other symptoms associated with anaphylaxis.

From the Research

Administration of Epinephrine in Angioedema

• The decision to administer epinephrine (Epi) to someone with angioedema depends on the underlying cause of the angioedema 3.
• Histamine-mediated angioedema should be treated with epinephrine intramuscularly, antihistaminergic medications, and steroids 3.
• However, for bradykinin-mediated angioedema, epinephrine and other medications typically used for anaphylaxis are not effective 3, 4.
• In cases of angioedema secondary to an ACE-inhibitor, the primary focus is on airway management, and no specific medication therapy is recommended in the absence of high-quality evidence 4.

Considerations for Airway Management

• Airway management is crucial in cases of angioedema, especially when there is a risk of airway compromise 5, 3, 4.
• The approach to airway management may involve fiberoptic or video laryngoscopy, with preparation for cricothyrotomy if necessary 3.
• The choice of treatment and airway management strategy should be guided by the severity of the angioedema and the patient's overall clinical condition 6, 7.