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.