epinephrine (Rx)

Brand and Other Names:EpiPen, EpiPen Jr, more...Adrenaclick, Auvi-Q, Symjepi, Adrenalin
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Dosing & Uses

AdultPediatric

Dosage Forms & Strengths

SC/IM autoinjector (EpiPen, Adrenaclick, Auvi-Q, Symjepi)

  • 0.15mg/0.15mL
  • 0.3mg/0.3mg

injectable solution

  • 0.1mg/mL (1:10,000)
  • 1mg/mL (1:1000)
more...

Cardiac Arrest

1 mg IV/IO q3-5min PRN; may administer up to 0.2 mg/kg if no response

Dose >1 mg not shown to improve survival or neurological outcomes as compared to standard dosing; not recommended

ET: 2-2.5 mg q3-5min until IV/IO access established or spontaneous circulation restored

Hypotension Associated with Septic Shock

Indicated to increase mean arterial blood pressure in adults with hypotension associated with septic shock

Recommended dose: 0.05-2 mcg/kg/,om; titrate to desired mean arterial pressure (MAP); may adjust dose q10-15 min by 0.05-0.2 mcg/kg/minute to achieve desired blood pressure goal

After hemodynamic stabilization, may wean incrementally q30min over 12-24 hr

See also Administration

Anaphylaxis

Indicated in emergency treatment of allergic reactions (Type I) including anaphylaxis

0.1 mg (1:10,000 solution; 0.1mg/mL) IV at rate of 1-4 mcg/min over 5 min to prevent the need to repeat injections frequently OR may initiate with infusion at 5-15 mcg/min (with crystalloid administration); IV administration should only be done in patients who are profoundly hypotensive or are in cardiopulmonary arrest refractory to volume resuscitation and several epinephrine injections

1:1000 solution

  • 0.3-0.5 mg/kg (0.3-0.5 mL) SC/IM, may not to exceed 0.5 mg (0.5 mL) per injection, repeated q5-10 min as necessary

Autoinjector

  • 0.3 mg (contents of 1 autoinjector) SC/IM once in anterolateral aspect of the thigh; may repeat dose after 5-15 minutes if symptoms persist

Symptomatic Bradycardia

Unresponsive to atropine or pacing: 2-10 mcg//min by IV infusion or 0.1-0.5 mcg/kg/min (7-35 mcg/min in 70 kg patient); titrate to patient response

Mydriasis

Induction and maintenance of mydriasis during intraocular surgery

After dilution in an ophthalmic irrigating fluid, inject intracamerally as a bolus dos of 0.1 mL at dilution of 1:100,000 to 1:400,000 (10-2.5 mcg/mL)

See also Administration

Dosing Considerations

Anaphylaxis

  • With severe persistent anaphylaxis, repeat injections with an additional autoinjector may be necessary
  • More than two sequential doses of epinephrine should only be administered under direct medical supervision

Dosage Forms & Strengths

autoinjector (EpiPen, Twinject, Adrenaclick, Auvi-Q)

  • 0.1mg/0.1mL (Auvi-Q)
  • 0.15mg/0.15mL
  • 0.3mg/0.3mL

injectable solution

  • 0.1mg/mL (1:10,000)
  • 1mg/mL (1:1000)
more...

Anaphylaxis

Indicated in emergency treatment of allergic reactions (Type I) including anaphylaxis

1:1000 solution

  • <30 kg (66lbs): 0.01 mg/kg (0.01 mL/kg) SC/IM, may not to exceed 0.3 mg (0.3 mL) per injection, repeated q5-10 min as necessary 
  • ≥30 kg (66lbs): 0.3-0.5 mg/kg (0.3-0.5 mL) SC/IM, may not to exceed 0.5 mg (0.5 mL) per injection, repeated q5-10 min as necessary 

Autoinjector

  • May repeat dose after 5-15 minutes if symptoms persist
  • Infants weighing 7.5-15 kg (16.5-33 lb); Auvi-Q only: 0.1 mg SC/IM once
  • Weight <30 kg: 0.15 mg (contents of 1 autoinjector) SC/IM once; may repeat dose q5-15min
  • Weight ≥30 kg: 0.3 mg (contents of 1 autoinjector) SC/IM once; may repeat dose q5-15min

Asystole/Pulseless Arrest (Off-label)

1:10,000 solution: 0.01 mg/kg (0.1 mg/mL) IO/IV; not to exceed 1 mg; repeat q3-5min until return of spontaneous circulation  

0.1 mg/kg (0.1 mL/kg of 1:1000 solution; 1 mg/mL) endotracheal; not to exceed 2.5 mg q3-5min until IO/IVP access established or spontaneous circulation achieved; flush with 5 mL of normal saline immediately after administration

Symptomatic Bradycardia (Off-label)

1:10,000 solution: 0.01 mg/kg IO/IV q3-5min; not to exceed 1 mg 

1:1,000 solution: 0.1 mg/kg (0.1mL/kg) of endotracheal q3-5min if necessary; flush each dose with at least 5 mL isotonic sodium chloride injection

Neonates (aged <28 days): 0.01-0.03 mg/kg IVP (1:10,000 solution) q3-5min; higher doses not recommended

Neonate IV access not available: 0.05-0.1 mg/kg endotracheal tube (1:10,000 soluiton); lower doses not effective; follow each dose with at least 5 mL isotonic sodium chloride injection

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Interactions

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            Adverse Effects

            Frequency Not Defined

            Angina

            Anxiety

            Apprehensiveness

            Cardiac arrhythmias

            Dizziness

            Dyspnea

            Flushing

            Headache

            Hypertension

            Nausea

            Nervousness

            Pallor

            Palpitations

            Respiratory difficulties

            Restlessness

            Stress cardiomyopathy

            Sweating

            Tachycardia

            Tremor

            Vasoconstriction

            Vomiting

            Weakness

            Postmarketing Reports

            Necrotizing fasciitis and myonecrosis caused by Clostridia (gas gangrene)

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            Warnings

            Contraindications

            There are no contraindications for life-threatening situations

            Nonanaphylactic shock

            Narrow-angle glaucoma

            Coadministration during genral anesthesia with halogenated hydrocarbons or cyclopropane

            Labor

            Situations where vasopressors may be contraindicated, including thyrotoxicosis, diabetes

            Maternal blood pressure in excess of 130/80 mm Hg in hypertension and other cardiovascular disorders

            Cautions

            Use caution in patients with cardiac disease, angina (especially with history of CAD) or that are receiving drugs that sensitize the myocardium; treatment may induce cardiac arrhythmias

            Pulmonary edema may occur as the result of cardiac stimulation and peripheral constriction

            Decreased urine output may occur as the result of renal blood vessel constriction

            Use caution in cerebrovascular insufficiency

            Use with caution in patients with hypertension, diabetes mellitus, thyroid disease, prostatic hypertrophy, geriatric patients, pregnancy, and previous hospitalization for asthma

            Rapid IV administration, although necessary in pulesless arrest, may cause death from cerebrovascular hemorrhage or cardiac arrhythmias

            Patients that are sulfite-sensitive, should still be treated during a serious allergic reaction or other emergency even if products available contain sulfites

            May cause worsening of symptoms in patients with Parkinson disease

            Avoid extravasation; ensure proper needle or catheter placement prior to and during infusion

            Correct blood volume depletion before administering any vasopressor

            Rare cases of serious skin and soft tissue infections, including necrotizing fasciitis and myonecrosis caused by Clostridia (gas gangrene), reported at injection site following injection for anaphylaxis; to decrease risk, do not inject into buttock; advise patients to seek medical care if they develop signs or symptoms of infection, such as persistent redness, warmth, swelling, or tenderness, at epinephrine injection site; cleansing with alcohol does not kill bacterial spores, and therefore, does not lower risk of infection

            Multiple-dose vial not for ophthalmic use; contains chlorobutanol which may be harmful to corneal endothelium

            Solutions must be diluted prior to intraocular use; other epinephrine products containing sodium bisulfite have been associated with corneal endothelial damage when used in the eye at undiluted concentrations (1 mg/mL)

            Autoinjector is to be used in conjunction with immediate medical or hospital care; more than two sequential doses of epinephrine should only be administered under direct medical supervision

            Extravasation

            • Avoid extravasation; ensure proper needle or catheter placement prior to and during infusion
            • To prevent sloughing and necrosis in areas has extravasation, infiltrate the area with 10-15 mL of 0.9% NaCl solution containing phentolamine 5-10 mg
            • Use a syringe with a fine hypodermic needle, with solution being infiltrated liberally throughout the area, which has a cold, hard, and pallid appearance
            • Phentolamine may cause immediate and conspicuous local hyperemic changes if area is infiltrated within 12 hr

            Injection related complications

            • Injection into buttock may not provide effective treatment of anaphylaxis
            • Accidental injection into hands, digits, or feet may result in local reactions including injection site coldness, pallor, and hypoesthesia or injury resulting in bruising, discoloration, erythema, bleeding, or skeletal injury
            • To minimize the risk of injection-related injury when administering autoinjector to children or infants, instruct caregivers to firmly hold child’s leg in place and limit movement prior to and during injection

            Drug interactions overview

            • Coadministration with cardiac glycosides, diuretics, or anti-arrhythmics should be observed carefully for the development of cardiac arrhythmias
            • Effects of epinephrine may be potentiated by tricyclic antidepressants, monoamine oxidase inhibitors, levothyroxine sodium, and certain antihistamines, notably chlorpheniramine, tripelennamine, and diphenhydramine
            • Cardiostimulating and bronchodilating effects of epinephrine are antagonized by beta-adrenergic blocking drugs, such as propranolol
            • Vasoconstricting and hypertensive effects of epinephrine are antagonized by alpha-adrenergic blocking drugs, such as phentolamine
            • Ergot alkaloids may reverse the pressor effects of epinephrine
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            Pregnancy & Lactation

            Pregnancy

            Epinephrine crosses the placenta

            Administration of epinephrine used during pregnancy only if the potential benefit justifies the potential risk to the fetus (fetal anoxia, spontaneous abortion, or both) Epinephrine is teratogenic in rabbits, mice, and hamsters dosed during organogenesis

            Use with caution during labor and delivery; although epinephrine improves maternal hypotension associated with anaphylaxis, it may result in uterine vasoconstriction, decreased uterine blood flow, and fetal anoxia

            Avoid epinephrine during second stage of labor; in dosage sufficient to reduce uterine contractions, the drug may cause a prolonged period of uterine atony with hemorrhage; avoid epinephrine in obstetrics when maternal blood pressure exceeds 130/80 mmHg

            Lactation

            Unknown whether epinephrine is excreted in human milk

            Because many drugs are excreted in human milk, caution should be exercised when epinephrine is administered to a nursing woman

            Pregnancy Categories

            A:Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

            B:May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

            C:Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

            D:Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

            X:Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

            NA:Information not available.

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            Pharmacology

            Mechanism of Action

            Strong alpha-adrenergic effects, which cause an increase in cardio output and HR, a decrease in renal perfusion and PVR, and a variable effect on BP, resulting in systemic vasoconstriction and increased vascular permeability

            Strong beta1- and moderate beta2-adrenergic effects, resulting in bronchial smooth muscle relaxation

            Secondary relaxation effect on smooth muscle of stomach, intestine, uterus, and urinary bladder

            Absorption

            Onset: 5-10 min (SC); 1 min (inhalation)

            Duration: 4 hr

            Metabolism

            Metabolized by MAO and COMT in adrenergic neuron

            Metabolites: Metadrenaline, sulfate conjugates, and hydroxy derivatives of mandelic acid (inactive)

            Elimination

            Excretion: Urine

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            Administration

            IV Incompatibilities

            Solution: Na-bicarbonate 5%, Ionosol PSL, Ionosol T/D5

            Additive: Aminophylline, hyaluronidase, mephentermine, Na-bicarbonate

            Syringe: Na-bicarbonate(?)

            Y-site: Ampicillin, thiopental

            Not specified: Atropine, carbenicillin, diazepam, erythromycin, lidocaine

            IV Compatibilities

            Solution: D5W, D10W, dextrose-Ringer's, dextrose-saline, NS, LR, Ringer's

            Additive: Amikacin, cimetidine, dobutamine, floxacillin, furosemide, metaraminol, ranitidine, verapamil

            Syringe: Caffeine, doxapram, heparin, milrinone

            Y-site: Amiodarone, atracurium, bivalirudin, CaCl2, Ca gluconate, cefpirome, cisatracurium, dexmedetomidine, diltiazem, dobutamine, dopamine, famotidine, fenoldopam, fentanyl, furosemide, heparin, Hextend, hydrocortisone Na succinate, hydromorphone, inamrinone, labetalol, levofloxacin, lorazepam, midazolam, milrinone, morphine SO4, nicardipine, nitroglycerin, norepinephrine, pancuronium, phytonadione, KCl, propofol, ranitidine, remifentanil, nitroprusside, tirofiban, vasopressin, vecuronium, vitamin B/C, warfarin

            Not specified: Meperidine

            IV Preparation

            Dilute epinephrine in D5W or D5W 0.9% NaCl

            Administration in saline solution alone is not recommended

            Add 1 mL (1 mg) of epinephrine from its ampule to 1000 mL of a D5W containing solution

            Each mL of this dilution contains 1 mcg of epinephrine

            Solution: 1 mg in 250 mL D5W or NS (4 mcg/mL) to make up concentration of 15-60 mL/hr (1-4 mcg/min)

            IV Administration

            Correct blood volume depletion as fully as possible prior to administering any vasopressor

            When, as an emergency measure, intraaortic pressures must be maintained to prevent cerebral or coronary artery ischemia, epinephrine can be administered before and concurrently with blood volume replacement

            Whenever possible, administer epinephrine infusions into a large vein

            Avoid using a catheter tie-in technique, because the obstruction to blood flow around the tubing may cause stasis and increased local concentration of the drug

            Central line; infusion pump required

            Do not mix with alkaline solutions

            Discard after 24 hours or if solution is discolored or contains precipitate

            Store in light-resistant container

            Intraocular Preparation

            Epinephrine must be diluted prior to intraocular use

            Dilute 1 mL of epinephrine 1 mg/mL (1:1000) in 100 to 1000 mL of an ophthalmic irrigation fluid to create an epinephrine concentration of 1:100,000 to 1:1,000,000 (10-1 mcg/mL)

            Use the irrigating solution as needed for the surgical procedure

            Intraocular Administration

            After dilution in an ophthalmic irrigating fluid, inject intracamerally

            SC/IM Administration

            SC or IM administration only

            Inject IM or SC into the anterolateral aspect of the thigh, through clothing if necessary

            Do not administer autoinjector IV; administer only in outer thigh to ensure SC or IM administration

            Do not inject into buttock, or into digits, hands, or feet

            To minimize the risk of injection-related injury, instruct caregivers to hold the child's leg firmly in place and limit movement prior to and during injection when administering to young children

            Discard remaining volume after dose has been administered

            In conjunction with use, seek immediate medical or hospital care

            Storage

            Injection

            • Unused vials
              • Store at room temperature, 20-25°C (68-77°F)
              • Protect from light until ready to use; do not refrigerate; protect from freezing
              • Protect from alkalis and oxidizing agents
            • Diluted solutions
              • Store at room temperature (25°C) or refrigeration (4°C) is 24 hr

            Autoinjector

            • Store at room temperature 20-25°C (68-77°F); excursions permitted to 15-30°C (59-86°F; do not refrigerator
            • The trainer for AUVI-Q should not be used at temperatures <50ºF (10ºC) or >104ºF (40ºC)
            • Store the trainer for AUVI-Q in its outer case; keep away from dirt, chemicals, and water
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            Images

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            Formulary

            FormularyPatient Discounts

            Adding plans allows you to compare formulary status to other drugs in the same class.

            To view formulary information first create a list of plans. Your list will be saved and can be edited at any time.

            Adding plans allows you to:

            • View the formulary and any restrictions for each plan.
            • Manage and view all your plans together – even plans in different states.
            • Compare formulary status to other drugs in the same class.
            • Access your plan list on any device – mobile or desktop.

            The above information is provided for general informational and educational purposes only. Individual plans may vary and formulary information changes. Contact the applicable plan provider for the most current information.

            Tier Description
            1 This drug is available at the lowest co-pay. Most commonly, these are generic drugs.
            2 This drug is available at a middle level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs.
            3 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs.
            4 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            5 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            6 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            NC NOT COVERED – Drugs that are not covered by the plan.
            Code Definition
            PA Prior Authorization
            Drugs that require prior authorization. This restriction requires that specific clinical criteria be met prior to the approval of the prescription.
            QL Quantity Limits
            Drugs that have quantity limits associated with each prescription. This restriction typically limits the quantity of the drug that will be covered.
            ST Step Therapy
            Drugs that have step therapy associated with each prescription. This restriction typically requires that certain criteria be met prior to approval for the prescription.
            OR Other Restrictions
            Drugs that have restrictions other than prior authorization, quantity limits, and step therapy associated with each prescription.
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