Dosing & Uses
Dosage Forms & Strengths
prefilled autoinjector or syringe for SC/IM use
- 0.3mg/0.3mL (EpiPen, Auvi-Q, Symjepi)
injectable solution
- 0.1mg/mL (1:10,000)
- 1mg/mL (1:1000)
Cardiac Arrest
1:10,000 solution
- IV
- Recommended dose: 0.5-1.0 mg (5-10 mL)
- During a resuscitation effort, 0.5 mg (5 mL) IV q5min
- Intracardiac
- Intracardiac injection if there has not been sufficient time to establish an IV route
- Usual dose ranges from 0.3-0.5 mg (3-5 mL)
- Endotracheal tube
- Alternatively, if the patient has been intubated, epinephrine can be injected via the endotracheal tube directly into the bronchial tree at the same dosage as for IV injection
- 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/minute IV infusion; 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
1:10,000 solution
- 0.1 mg (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 (0.3-0.5 mL) of undiluted epinephrine IM/SC once in anterolateral aspect of the thigh, not to exceed 0.5 mg (0.5 mL) per injection, repeated every 5-10 minutes as necessary
- Monitor clinically for reaction severity and cardiac effects
Prefilled autoinjector or syringe
- 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
See also Administration
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
1:1000 solution
- After dilution in an ophthalmic irrigating fluid, inject intracamerally as a bolus dose 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
prefilled autoinjector or syringe for SC/IM use
- 0.1mg/0.1mL (Auvi-Q)
- 0.15mg/0.15mL (EpiPen Jr, Auvi-Q, Symjepi)
- 0.3mg/0.3mL (EpiPen, Auvi-Q, Symjepi)
injectable solution
- 0.1mg/mL (1:10,000)
- 1mg/mL (1:1000)
Anaphylaxis
Indicated in emergency treatment of allergic reactions (Type I) including anaphylaxis
1:1000 solution
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 15 to <30 kg: 0.15 mg (contents of 1 autoinjector/prefilled syringe) SC/IM once; may repeat dose q5-15min
- Weight ≥30 kg: 0.3 mg (contents of 1 autoinjector/prefilled syringe) 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
Interactions
Interaction Checker
No Results
Contraindicated
Serious - Use Alternative
Significant - Monitor Closely
Minor
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)
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
Pregnancy & Lactation
Pregnancy
Epinephrine crosses the placenta
During pregnancy, anaphylaxis can be catastrophic and can lead to hypoxic-ischemic encephalopathy and permanent central nervous system damage or death in the mother and, more commonly, in the fetus or neonate; the prevalence of anaphylaxis occurring during pregnancy is reported to be approximately 3 cases per 100,000 deliveries; epinephrine is first-line medication of choice for treatment of anaphylaxis during pregnancy in humans; epinephrine should be used for treatment of anaphylaxis during pregnancy in same manner as it is used in non-pregnant patients
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
There is no information on presence of epinephrine in human milk, effects on breastfed infants, or on milk production; epinephrine is first line-medication of choice for treatment of anaphylaxis; it should be used in same manner in breastfeeding and non- breastfeeding patients
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.
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
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
Images
Patient Handout
Formulary
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.
