TABLE 5

Pharmacologic Management of Anaphylaxis

With the exception of epinephrine as first-line treatment, these treatments often occur concomitantly and are not meant to be sequential.
In an outpatient setting
First-line treatment
    – Epinephrine, IM; auto-injector or 1:1000 solution
        ∘ Weight 10 to 25 kg: 0.15 mg epinephrine autoinjector, IM (anterior-lateral thigh)
        ∘ Weight >25 kg: 0.3 mg epinephrine autoinjector, IM (anterior-lateral thigh)
        ∘ Epinephrine (1:1000 solution) (IM), 0.01 mg/kg per dose; maximum dose, 0.5 mg per dose (anterior-lateral thigh)
    – Epinephrine doses may need to be repeated every 5–15 minutes
Adjunctive treatment
    – Bronchodilator (β2-agonist): albuterol
        ∘ MDI (child: 4–8 puffs; adult: 8 puffs) or
        ∘ Nebulized solution (child: 1.5 mL; adult: 3 mL) every 20 minutes or continuously as needed
    – H1 antihistamine: diphenhydramine
        ∘ 1 to 2 mg/kg per dose
        ∘ Maximum dose, 50 mg IV or oral (oral liquid is more readily absorbed than tablets)
        ∘ Alternative dosing may be with a less-sedating second generation antihistamine
    – Supplemental oxygen therapy
    – IV fluids in large volumes if patient presents with orthostasis, hypotension, or incomplete response to IM epinephrine
    – Place the patient in recumbent position if tolerated, with the lower extremities elevated
In a hospital-based setting
First-line treatment
    – Epinephrine IM as above, consider continuous epinephrine infusion for persistent hypotension (ideally with continuous non-invasive monitoring of blood pressure and heart rate); alternatives are endotracheal or intra-osseous epinephrine
Adjunctive treatment
    – Bronchodilator (β2-agonist): albuterol
        ∘ MDI (child: 4–8 puffs; adult: 8 puffs) or
        ∘ Nebulized solution (child: 1.5 mL; adult: 3 mL) every 20 minutes or continuously as needed
    – H1 antihistamine: diphenhydramine
        ∘ 1 to 2 mg/kg per dose
        ∘ Maximum dose, 50 mg IV or oral (oral liquid is more readily absorbed than tablets)
        ∘ Alternative dosing may be with a less-sedating second generation antihistamine
    – H2 antihistamine: ranitidine
        ∘ 1 to 2 mg/kg per dose
        ∘ Maximum dose, 75 to 150 mg oral and IV
    – Corticosteroids
        ∘ Prednisone at 1 mg/kg with a maximum dose of 60 to 80 mg oral or
        ∘ Methylprednisolone at 1 mg/kg with a maximum dose of 60 to 80 mg IV
    – Vasopressors (other than epinephrine) for refractory hypotension, titrate to effect
    – Glucagon for refractory hypotension, titrate to effect
        ∘ Child: 20–30 mcg/kg
        ∘ Adult: 1–5 mg
        ∘ Dose may be repeated or followed by infusion of 5–15 mcg/min
    – Atropine for bradycardia, titrate to effect
    – Supplemental oxygen therapy
    – IV fluids in large volumes if patients present with orthostasis, hypotension, or incomplete response to IM epinephrine
    – Place the patient in recumbent position if tolerated, with the lower extremities elevated
To instruct to patients at discharge
First-line treatment
    – Epinephrine auto-injector prescription (2 doses) and instructions
    – Education on avoidance of allergen
    – Follow-up with primary care physician
    – Consider referral to an allergist
Adjunctive treatment
    – H1 antihistamine: diphenhydramine every 6 hours for 2–3 days; alternative dosing with a non-sedating second generation antihistamine
    – H2 antihistamine: ranitidine twice daily for 2–3 days
    – Corticosteroid: prednisone daily for 2–3 days
  • IM indicates intramuscular; IV, intravenous; MDI, metered-dose inhaler.

  • Reproduced with permission from Elsevier Limited: NIAID-Sponsored Expert Panel; Boyce JA, Assa'ad A, Burks AW, et al. J Allergy Clin Immunol. 2010;126(suppl 6):S39.