epinephrine (EpiPen, EpiPen Jr, Adrenaclick, Auvi-Q, Adrenalin)
Classes: Alpha/Beta Adrenergic Agonists; Alpha/Beta Agonists
Dosing and uses of EpiPen, EpiPen Jr (epinephrine)
Adult dosage forms and strengths
autoinjector (EpiPen, Twinject, Adrenaclick, Auvi-Q)
- 0.15mg/0.15mL
- 0.3mg/0.3mg
injectable solution
- 0.1mg/mL (1:10,000)
- 1mg/mL (1:1000)
Cardiac Arrest
1 mg IV/IO q3-5min PRN; may administer up to 0.2 mg/kg if no response
Dose >1 mg not shown to improve survival or neurological oucomes as compared to standard dosing; not recommended
ET: 2-2.5 mg q3-5min until IV/IO access established or spontaneous circulation restored
Asthma, Severe/Anaphylaxis
0.2-0.5 mg IM/SC q5-15min (1:1,000 solution; 1 mg/mL), clinician may shorten 5-min interval between injections for more frequent administration if deemed appropriate
0.1 mg (1:10,000 solution; 0.1mg/mL) IV at rate of 1-4 mcg/min over 5 min to prevent the need to repeat injections frequently OR may initiate with infusion at 5-15 mcg/min (with crystalloid administration); IV administration should only be done in patients who are profoundly hypotensive or are in cardiopulmonary arrest refractory to volume resuscitation and several epinephrine injections
Autoinjector: 0.3 mg (contents of 1 autoinjector) SC/IM once in anterolateral aspect of the thigh; may repeat dose after 5-15 minutes if symptoms persist
Symptomatic Bradycardia (Off-label)
Unresponsive to atropine or pacing: 2-10 mcg//min by IV infusion or 0.1-0.5 mcg/kg/min (7-35 mcg/min in 70 kg patient); titrate to patient response
Administration
Do not administer autoinjector IV; give only in outer thigh to ensure SC or IM administration
Discard remaining volume after dose has been administered
Pediatric dosage forms and strengths
autoinjector (EpiPen, Twinject, Adrenaclick, Auvi-Q)
- 0.15mg
- 0.3mg
injectable solution
- 0.1mg/mL (1:10,000)
- 1mg/mL (1:1000)
Asystole/Pulseless Arrest (Off-label)
1:10,000 solution: 0.01 mg/kg (0.1 mg/mL) IO/IV; not to exceed 1 mg; repeat q3-5min until return of spontaneous circulation
0.1 mg/kg (0.1 mL/kg of 1:1000 solution; 1 mg/mL) endotracheal; not to exceed 2.5 mg q3-5min until IO/IVP access established or spontaneous circulation achieved; flush with 5 mL of normal saline immediately after administration
Symptomatic Bradycardia (Off-label)
1:10,000 solution: 0.01 mg/kg IO/IV q3-5min; not to exceed 1 mg
1:1,000 solution: 0.1 mg/kg (0.1mL/kg) of endotracheal q3-5min if necessary; flush each dose with at least 5 mL isotonic sodium chloride injection
Neonates (<28 days old): 0.01-0.03 mg/kg IVP (1:10,000 solution) q3-5min; higher doses not recommended
Neonate IV access not available: 0.05-0.1 mg/kg endotracheal tube (1:10,000 soluiton); lower doses not effective; follow each dose with at least 5 mL isotonic sodium chloride injection
Asthma/Anaphylaxis
0.01 mg/kg (0.01 mL/kg of 1:1,000 solution; 1 mg/mL) IM/SC q5-15min , clinician may shorten 5-min interval between injections for more frequent administration if deemed appropriate
Autoinjector
- Weight <30 kg: 0.15 mg (contents of 1 autoinjector) SC/IM once; may repeat dose q5-15min
- Weight ≥30 kg: 0.3 mg (contents of 1 autoinjector) SC/IM once; may repeat dose q5-15min
Administration
When administering to a child, to minimize risk of injection related injury, hold leg firmly in place and limit movement prior to and during an injection; injection may be repeated every 5-10 min as necessary; for IM administration, use a needle long enough (at least 1/2 inch to 5/8 inch) to ensure injection is administered into muscle; monitor patient clinically for severity of allergic reaction and potential cardiac effects of drug, with repeat doses titrated to effect; do not administer repeated injections at same site, as resulting vasoconstriction may cause tissue necrosis
Do not administer autoinjector IV; give only in outer thigh to ensure SC or IM administration
Discard remaining volume after dose has been administered
EpiPen, EpiPen Jr (epinephrine) adverse (side) effects
Frequency not defined
Angina
Anxiety
Apprehensiveness
Cardiac arrhythmias
Dizziness
Dyspnea
Flushing
Headache
Hypertension
Nausea
Nervousness
Pallor
Palpitations
Respiratory difficulties
Restlessness
Sweating
Tachycardia
Tremor
Vasoconstriction
Vomiting
Weakness
Postmarketing Reports
Necrotizing fasciitis and myonecrosis caused by Clostridia (gas gangrene)
Warnings
Contraindications
There are no contraindications for life-threatening situations
Nonanaphylactic shock
Narrow-angle glaucoma
Coadministration during genral anesthesia with halogenated hydrocarbons or cyclopropane
Labor
Situations where vasopressors may be contraindicated, including thyrotoxicosis, diabetes
Maternal blood pressure in excess of 130/80 mm Hg in hypertension and other cardiovascular disorders
Cautions
Use caution in patients with cardiac disease, angina (especially with history of CAD) or that are receiving drugs that sensitize the myocardium; treatment may induce cardiac arrhythmias
Pulmonary edema may occur as the result of cardiac stimulation and peripheral constriction
Decreased urine output may occur as the result of renal blood vessel constriction
Use caution in cerebrovascular insufficiency
Use with caution in patients with hypertension, diabetes mellitus, thyroid disease, prostatic hypertrophy, geriatric patients, pregnancy, and previous hospitalization for asthma
Use caution when administering in conjunction with anesthesia in fingers, toes, ears, nose, or genitalia, due to potential for ischemia due to vasoconstriction
Use caution in concomitant use of digitalis, mercurial diuretics, quinidine, or drugs that may sensitize the heart to arrhythmias
Accidental injection into hands, digits, or feet may result in local reactions including injection site coldness, pallor, and hypoesthesia or injury resulting in bruising, discoloration, erythema, bleeding, or skeletal injury
Rapid IV administration, although necessary in pulesless arrest, may cause death from cerebrovascular hemorrhage or cardiac arrhythmias
Patients that are sulfite-sensitive, should still be treated during a serious allergic reaction or other emergency even if products available contain sulfites
May cause worsening of symptoms in patients with Parkinson disease
Avoid extravasation; ensure proper needle or catheter placement prior to and during infusion
Correct blood volume depletion before administering any vasopressor
Injection into buttock may not provide effective treatment of anaphylaxis
Rare cases of serious skin and soft tissue infections, including necrotizing fasciitis and myonecrosis caused by Clostridia (gas gangrene), reported at injection site following injection for anaphylaxis; to decrease risk, do not inject into buttock; advise patients to seek medical care if they develop signs or symptoms of infection, such as persistent redness, warmth, swelling, or tenderness, at epinephrine injection site; cleansing with alcohol does not kill bacterial spores, and therefore, does not lower risk of infection
Multiple-dose vial not for ophthalmic use; contains chlorobutanol which may be harmful to corneal endothelium
Pregnancy and lactation
Pregnancy category: C
Lactation: Unknown if excreted into breast milk; use caution
Pregnancy categories
A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.
B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.
C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.
D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.
X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.
NA: Information not available.
Pharmacology of EpiPen, EpiPen Jr (epinephrine)
Mechanism of action
Strong alpha-adrenergic effects, which cause an increase in cardio output and HR, a decrease in renal perfusion and PVR, and a variable effect on BP, resulting in systemic vasoconstriction and increased vascular permeability
Strong beta1- and moderate beta2-adrenergic effects, resulting in bronchial smooth muscle relaxation
Secondary relaxation effect on smooth muscle of stomach, intestine, uterus, and urinary bladder
Absorption
Onset: 5-10 min (SC); 1 min (inhalation)
Duration: 4 hr
Metabolism
Metabolized by MAO and COMT in adrenergic neuron
Metabolites: Metadrenaline, sulfate conjugates, and hydroxy derivatives of mandelic acid (inactive)
Elimination
Excretion: Urine
Administration
IV Incompatibilities
Solution: Na-bicarbonate 5%, Ionosol PSL, Ionosol T/D5
Additive: Aminophylline, hyaluronidase, mephentermine, Na-bicarbonate
Syringe: Na-bicarbonate(?)
Y-site: Ampicillin, thiopentaL
Not specified: Atropine, carbenicillin, diazepam, erythromycin, lidocaine
IV Compatibilities
Solution: D5W, D10W, dextrose-Ringer's, dextrose-saline, NS, LR, Ringer's
Additive: Amikacin, cimetidine, dobutamine, floxacillin, furosemide, metaraminol, ranitidine, verapamiL
Syringe: Caffeine, doxapram, heparin, milrinone
Y-site: Amiodarone, atracurium, bivalirudin, CaCl2, Ca gluconate, cefpirome, cisatracurium, dexmedetomidine, diltiazem, dobutamine, dopamine, famotidine, fenoldopam, fentanyl, furosemide, heparin, Hextend, hydrocortisone Na succinate, hydromorphone, inamrinone, labetalol, levofloxacin, lorazepam, midazolam, milrinone, morphine SO4, nicardipine, nitroglycerin, norepinephrine, pancuronium, phytonadione, KCl, propofol, ranitidine, remifentanil, nitroprusside, tirofiban, vasopressin, vecuronium, vitamin B/C, warfarin
Not specified: Meperidine
IV Preparation
Solution: 1 mg in 250 mL D5W or NS (4 mcg/mL) to make up concentration of 15-60 mL/hr (1-4 mcg/min)
IV Administration
Central line; infusion pump required
Do not mix with alkaline solutions
Discard after 24 hours or if solution is discolored or contains precipitate
Store in light-resistant container