Epinephrine remains the drug of choice for managing food-induced anaphylaxis. In addition to updated guidelines, a newer delivery system (in the form of the recently US Food and Drug Administration [FDA]–approved intranasal epinephrine) may help some parents and patients overcome their reluctance to administer epinephrine for the management of anaphylaxis.

Epinephrine remains the drug of choice for the treatment of anaphylaxis, although many cases of anaphylaxis do not get treated with epinephrine because parents do not want to give their child an injection. These parents may use an antihistamine instead, which takes 30 to 60 minutes to work. Fortunately, fatalities related to food-induced anaphylaxis are really low. In addition to the intramuscular and subcutaneous formulations, noninjectable intranasal epinephrine is now available, and a sublingual epinephrine film is being studied. So, we have a noninvasive way to administer epinephrine, and, hopefully, anaphylaxis will be treated more quickly. However, the fear of using epinephrine is still a big issue.

The most recent practice parameter update on anaphylaxis recommendations states that if patients have already received epinephrine plus an antihistamine and are stable and comfortable, with no history of a severe reaction requiring multiple doses, 911 does not always need to be called, and patients do not have to go to the Emergency Department. Hopefully, these new anaphylaxis recommendations, together with the availability of a noninvasive epinephrine delivery system, will increase the rate of anaphylaxis treatment.

All these issues should be discussed with patients and incorporated into a food allergy anaphylaxis action plan, which is now, for the most part, standardized in the United States. The action plan should include how and when to use the epinephrine delivery device. For example, patients with only mild symptoms (ie, a few hives, localized lip swelling, and/or a runny nose) can just use an antihistamine. With coughing and wheezing, ongoing vomiting, or generalized hives, epinephrine should be used quickly. It depends on the symptoms, and this is delineated in the action plan.

We tell families that they cannot go wrong by giving epinephrine if they feel that the child needs it based on symptoms. It is better to give epinephrine than not to give it if there is a question. Its effects are very transient, and it has demonstrated safety. After using epinephrine or watching us use it in the clinic during an oral food challenge, families often are empowered to use it the next time it is needed with less hesitation because they see how quickly it works. With respect to the appropriate age for the self-injection of epinephrine, we generally wait until patients are teenagers, although there is no set age. It depends, in part, on the patient’s level of maturity.

Intranasal epinephrine is now available, but getting it on formulary may be difficult, and parents often ask whether it will work. It was approved by the FDA based on nonclinical pharmacokinetic and pharmacodynamic studies comparing it with injectable epinephrine, although a study from Japan of 15 pediatric patients showed intranasal epinephrine’s efficacy in treating oral food challenge–induced anaphylactic symptoms. Additionally, a survey of patients who used it found that 10% required a second dose, which is consistent with injectable epinephrine. If approved by the FDA, I think that the availability of sublingual epinephrine may offer another helpful, convenient, noninvasive delivery option.