Table II. Summary of the pharmacologic management of anaphylaxis (modified).

Note: These treatments often occur concomitantly, and are not meant to be sequential, with the exception of epinephrine as first-line treatment.

In the outpatient setting

First-line treatment: –Epinephrine, IM; auto-injector or 1:1,000 solution 10 to 25 kg: 0.15 mg epinephrine autoinjector, IM (anterior-lateral thigh) >25 kg: 0.3 mg epinephrine autoinjector, IM (anterior-lateral thigh) Epinephrine (1:1,000 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 the 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 μg/kg Adult: 1-5 mg Dose may be repeated or followed by infusion of 5-15 μg/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

Therapy for the patient 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, Intramuscular; IV, intravenous; MDI, metered-dose inhaler.

Note: This table is presented as Table VI in the Guidelines.