Editor—We agree that adrenaline can be life saving in severe allergic reactions. In our lesson of the week we carefully stated that using adrenaline as firstline treatment in true systemic anaphylaxis is not disputed.
We also agree that identifying allergens and subsequently avoiding them are key issues in managing allergy. The incidence of life threatening anaphylaxis is, however, influenced by allergen exposure rather than adrenaline use, and we support the use of adrenaline in this context.
The message we want to convey is that adrenaline can be life saving in true systemic anaphylaxis but can be hazardous when used out of context. Correct management of localised angioedema not affecting the larynx and without hypotension or bronchospasm includes antihistamines and steroids, with careful observation for the development of systemic features, which require adrenaline. Indiscriminate use of adrenaline for non-life threatening features in patients with contraindications to treatment with adrenaline has to be questioned.
The medical emergency in case 1 was a result of adrenaline (precipitation of angina) rather than localised angioedema. Adrenaline is not a recognised treatment for urticaria and facial angioedema in the absence of systemic features. Intravenous adrenaline should be reserved for patients with immediately life threatening profound shock where appropriate monitoring facilities exist. Case 2 therefore had a life threatening complication from unnecessary adrenaline.
Both cases highlight the importance of appropriate education for and supervision of medical staff. In a study of senior house officers at the start of their accident and emergency post, 10-56% would be prepared to administer adrenaline inappropriately.1 The series of deaths reported by Pumphrey support our concerns.2
We have advised withdrawal of EpiPens only when a diagnosis of acute systemic anaphylaxis could not be substantiated and adrenaline had caused dangerous side effects.
Competing interests: None declared.
References
- 1.Gompels LL, Bethune C, Johnston SL, Gompels MM. Proposed use of adrenaline (epinephrine) in anaphylaxis and related conditions: a study of senior house officers starting accident and emergency posts. Postgrad Med J 2002;78: 416-18. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Pumphrey RSH. Lessons for management of anaphylaxis from a study of fatal reactions. Clin Exp Allergy 2000;30: 1144-50. [DOI] [PubMed] [Google Scholar]