Epinephrine

Pronunciation

Class: alpha- and beta-Adrenergic Agonists
VA Class: AU100
CAS Number: 51-43-4
Brands: Adrenalin Chloride, EpiPen Auto-Injector, EpiPen Jr., Primatene

Introduction

Epinephrine is an endogenous catecholamine that is the active principle of the adrenal medulla; epinephrine acts directly on both α- and β-adrenergic receptors.

Uses for Epinephrine

Bronchospasm

Has been used as a quick-relief bronchodilator for symptomatic treatment of acute symptoms and exacerbations of bronchial asthma and reversible bronchospasm associated with chronic bronchitis, emphysema, and other obstructive pulmonary diseases.a 160 162 166 168 However, generally should be used only when selective β2-agonists are not readily available, since excessive cardiac stimulation (e.g., increased heart rate, myocardial irritability, increased oxygen demand) can occur with nonselective agents, particularly at high doses.160 162 174 d

Orally inhaled selective β2-agonists currently are recommended for prehospital management of asthma exacerbations (e.g., in emergency medicine facilities and/or ambulances) and for acute asthma management in emergency rooms and hospitals.160 161 162 Reserve sub-Q epinephrine for severe exacerbations when selective agents are not readily available or are ineffective.160 161 162 174 d No proven advantage of systemically administered (e.g., sub-Q) epinephrine therapy over orally inhaled therapy for the acute management of asthma exacerbations.160 162 Parenteral epinephrine may be particularly useful in treating anaphylaxis and angioedema coexisting with asthma.174

Nebulized bronchodilator therapy generally should be reserved for patients who are unable to coordinate inhalation via an MDI because of their age, agitation, or exacerbation severity.160

Regular, daily use of a short-acting, inhaled β-agonist generally is no longer recommended for maintenance therapy of asthma.160 Current asthma guidelines emphasize long-term control with anti-inflammatory agents (e.g., corticosteroids), and concomitant anti-inflammatory therapy with an inhaled corticosteroid is recommended whenever inhaled β-agonist bronchodilators are used for maintenance.130 131 132 138 140 141 147 148

Slideshow: Flashback: FDA Drug Approvals 2013

Sensitivity Reactions

Drug of choice in the emergency treatment of severe acute anaphylactic reactions, including anaphylactic shock, which can be profound and life-threatening.a 161 163 164 d

May relieve anaphylactic symptoms (e.g., urticaria, pruritus, angioedema, wheezing, dyspnea, hypotension, swelling of the lips, eyelids, and tongue) caused by reactions to drugs, contrast media, sera, insect stings or bites, foods (e.g., milk, eggs, fish, shellfish, peanuts, tree nuts), latex, or other allergens as well as idiopathic or exercise-induced anaphylaxis.a 161 163 d

Give to all patients with signs of shock, airway swelling, or definite breathing difficulty.161 d Drug of choice for the treatment of both vasodilation/hypotension and cardiac arrest associated with anaphylaxis.161 d

Parenteral administration (IM route favored)d is preferred for the treatment of anaphylaxis.a d Administer IV if anaphylaxis appears to be severe with immediate life-threatening manifestations.161 d Absorption and subsequent achievement of peak plasma concentrations after sub-Q injection is slower and may be substantially delayed in patients with shock.161 d

High IV doses (i.e., rapid progression to high dose) should be used without hesitation in any patient in full cardiac arrest.161 d

If necessary, institute other measures for management of cardiac arrhythmias, laryngeal edema, or bronchospasm.a Once adequate ventilation is ensured, maintenance of BP in anaphylactic shock should be achieved with other pressor agents (e.g., norepinephrine, metaraminol).a

Close monitoring critical; fatal overdose of epinephrine reported.d

Risk of paradoxical response to epinephrine in patients receiving β-adrenergic blocking agents; consider glucagon and/or ipratropium for treatment of anaphylaxis in these patients.d Increased incidence and severity of anaphylaxis in patients receiving β-adrenergic blocking agents.d

CPR and Cardiac Arrhythmias

Used for its α-adrenergic stimulatory effects to increase blood flow in ACLS during CPR.a 161 d The principal beneficial effects in patients with cardiac arrest result from increases in aortic diastolic blood pressure and in myocardial and cerebral blood flow during resuscitation.a 161 d The value and safety of the β-adrenergic effects are controversial because they may increase myocardial work and reduce subendocardial perfusion.161 d

A drug of choice and a high priority for ACLS in cardiac arrest to facilitate return of spontaneous circulation (ROSC); generally used after failure of artificial ventilation, external or internal cardiac compression, and initial defibrillation to restore effective circulation.a 161 d

Cardiac arrest: May be administered IV, intraosseously, or intracardially or by direct instillation into the tracheobronchial tree via an endotracheal tube to restore cardiac rhythm as an adjunct in the management of cardiac arrest.a 161 169 170 d

Asystole: Restores cardiac electrical activity in asystole and, in some cases, restores myocardial contractility in electromechanical dissociation.a 161

Impending pulseless electrical activity: May produce beneficial vasopressor effects in patients who are not in cardiac arrest but who have other indications for vasopressor therapy161 (e.g., in those with severe bradycardia and hypotension who are close to pulseless electrical activity or even asystole).a

Bradycardia: Treatment of symptomatic bradycardia unresponsive to atropine, as a temporizing measure while awaiting availability of a pacemaker (e.g., out-of-hospital setting) or if pacing ineffective.d

Drug-induced cardiovascular emergencies or altered vital signs: May consider use in bradycardia or shock associated with β-adrenergic or calcium-channel blocking agent or tricyclic antidepressant toxicity.d

Anesthesia accidents: May be useful in treating cardiac arrest following anesthesia accidents, but should be used with extreme caution, if at all, in patients receiving cyclopropane or halogenated hydrocarbon general anesthetics.a (See General Anesthetics under Interactions.)

Heart block: Has been used in the treatment of syncope and/or bradycardia resulting from AV nodal block, but has largely been replaced by isoproterenol.a Electrical cardiac pacemakers have largely replaced drug therapy in third-degree AV nodal block (complete heart block).a

Radiographic Uses

Has been given intra-arterially as an adjunct to radiographic contrast media in arteriography.a

GI and Renal Hemorrhage

Has been administered intra-arterially via the celiac artery, inferior mesenteric artery, or superior mesenteric artery to control hemorrhage in patients with severe GI bleeding.a

Has been administered intra-arterially via the renal artery to control hemorrhage in patients with renal arterial bleeding.a

Radiation Nephritis

Has been injected into a renal artery prior to and during irradiation of the abdominal area to protect the kidney from radiation nephritis.a

Adjunct to Local Anesthesia

May be added to solutions of some local anesthetics to decrease the rate of their vascular absorption (to localize and prolong the duration of anesthesia and decrease the risk of systemic toxicity).a

Superficial Bleeding

May be applied topically to control superficial bleeding from arterioles or capillaries in the skin, mucous membranes, or other tissues.a Bleeding from larger vessels is not controllable by topical application.a

Cardiogenic, Hemorrhagic, and Traumatic Shock

Should not be used in cardiogenic shock (because it increases myocardial oxygen demand) or in hemorrhagic or traumatic shock.a

Premature Labor

Has been used to relax uterine musculature and inhibit uterine contractions in premature labor (tocolysis); however, the cardiovascular and other adverse effects limit its usefulness.a (See Pregnancy under Cautions.) Other β-agonists (e.g., terbutaline) preferred.165 173

Hypoglycemia

Has been used parenterally to correct hypoglycemia in insulin shock; however, dextrose and/or glucagon is more effective.a

Epinephrine Dosage and Administration

Administration

Administer by sub-Q, IM, or IV injection or by IV infusion.a 160 161 162 163 164 169 d Also may be administered intra-arterially (e.g., for radiography, for local control of bleeding).a

In extreme cardiac emergencies, may be administered intracardially, via an endotracheal tube, or by intraosseous infusion.a 161 169 170 Although endotracheal administration of epinephrine is possible, IV or intraosseous administration is preferred because of more predictable drug delivery and pharmacologic effect.d

Rapid IV injection (bolus dose) or endotracheal administration of epinephrine may cause failure of exhaled carbon dioxide detectors (used to confirm endotracheal tube placement in the trachea during cardiac arrest) despite adequate placement (i.e., false-negative reading).d Use a second method to confirm tube placement.d

For bronchodilation, administer by oral inhalation via a metered-dose inhaler (MDI), nebulization, or intermittent positive-pressure breathing (IPPB) apparatus or inject sub-Q or IM.a 160 162 166 168

Apply topically to the skin and mucous membranes for local hemostasis.a

Sub-Q Injection

Injections containing 1 mg/mL preferably are administered sub-Q.a 160 162 169 However, absorption and subsequent achievement of peak plasma concentrations is slower and may be substantially delayed if shock is present.a 161 d

IM Injection

Injections containing 1 mg/mL also may be injected IM, but IM injection into the buttocks should be avoided.a 160 161 162 169 172 d

For self-medication, instruct patients and their caregivers about proper administration techniques using the auto-injector provided by the manufacturer.163 164 d First aid providers should be familiar with the auto-injector in order to assist patients having an anaphylactic reaction with self-medication, and they should be able to administer the auto-injector, if a patient is unable to self-administer, provided that state law permits it and valid prescription exists.d

Technique for Using Auto-injector

Inject the age-appropriate dose IM only into the anterolateral aspect of the thigh.163 164

The patient should grasp the prefilled auto-injector with the black tip pointed downward; the grey activation cap should be removed.164 Point the black tip toward the outer thigh, swing and jab it firmly into the outer thigh so that the auto-injector is perpendicular (90° angle) to the thigh, and hold firmly in the thigh for several seconds until the dose is delivered.164 Administer through clothing if necessary.163 Massage injection area for several seconds.164 If the needle is not exposed at the black tip, repeat administration.164

Never put thumb, fingers, or hand over the black tip.164

Do not remove the grey activation cap until ready to use.164

The auto-injector is overfilled and most of the solution (90%) will remain after injection of the age-appropriate dose and cannot be reused.164

After use, bend the needle back against a hard surface.164 Then, deliver the used auto-injector to a health-care provider for proper disposal.164

IV Administration

For solution and drug compatibility information, see Compatibility under Stability.

Emergency situations: Inject very slowly IV as a dilute solution or infuse slowly IV.a When injected peripherally, 1–2 minutes generally are required to reach central circulation.161 d

Severe asthma or anaphylaxis: IV therapy may be necessary (e.g., for severe anaphylactic shock with immediate life-threatening manifestations) when drug absorption from sub-Q or IM injection is likely to be impaired.a d

CPR: When a vein has not been cannulated prior to the arrest, a peripheral vein (antecubital or external jugular in adults and the largest most accessible vein that does not interrupt resuscitation in pediatric patients) is preferred since central venous access requires interruption of chest compressions, is technically more difficult, and is associated with an increased risk of complications.161 Venous access can be challenging in infants and children during an emergency, whereas intraosseous access can be easily achieved.d Limit the time attempting venous access; if reliable access cannot be achieved quickly, establish intraosseous access.d

If a central venous catheter is already in place at the time of arrest, it can be used because of more rapid onset (in adults), more secure access to circulation, and avoidance of tissue infiltration.161 d Tissue infiltration may lead to local ischemia, tissue injury, and ulceration.d Avoid central venous line placement in patients who are candidates for pharmacologic reperfusion (e.g., with thrombolytic therapy).161 d

Dilution

Prepare infusion solutions containing 2 or 4 mcg/mL by adding 1 mg to 500 or 250 mL of a compatible IV solution, respectively.a 101 d

Prepare solutions containing 0.05 mg/mL by adding 0.5 mg (0.5 mL of a 1:1000 injection) to 10 mL of 0.9% sodium chloride injection.169

Prepare a 1:10,000 solution (0.1 mg/mL) by diluting 1 mL of a commercially available 1:1000 injection (1 mg/mL) with 10 mL of water for injection or 0.9% sodium chloride injection.a Alternatively, a commercially available 1:10,000 (0.1 mg/mL) injection can be used.170

Prepare a 1:100,000 solution (0.01 mg/mL) by diluting 0.1 mL of a commercially available 1:1000 injection (1 mg/mL) with 10 mL of 0.9% sodium chloride injection.a

Rate of Administration

Severe asthma or anaphylaxis: Inject IV slowly (e.g., over 5–10 minutes) or administer by rapid IV injection (i.e., bolus).a 101

Alternatively in adults, infuse IV at an initial rate of 1 mcg/minute, increasing to 4 mcg/minute as needed.a

In children after an initial 1-mcg/kg IV bolus, infuse IV at an initial rate of 0.1 mcg/kg per minute, increasing gradually up to 1.5 mcg/kg per minute as needed.101

CPR: Inject doses by IV push in adults, repeating at 3- to 5-minute intervals as needed;161 170 d follow each dose injected peripherally with a 20-mL flush of IV fluid to ensure distribution into the central compartment;161 d if injected IV in an extremity, elevate the extremity for 10–20 seconds.d

In children, infuse IV at an initial rate of 0.1 mcg/kg per minute, increasing gradually to a maximum of 1 mcg/kg per minute as needed for CPR.a d

Bradycardia or hypotension (i.e., nonarrest rate): In adults, infuse IV at an initial rate of 1 mcg/minute, titrating to hemodynamic response at rates ranging from 2–10 mcg/minute.161 d Assess intravascular volume and support as needed.d

In children, infuse IV at a rate of 0.1–0.2 mcg/kg per minute for refractory bradycardia.161

Intra-arterial Administration

Injections have been administered intra-arterially for local effects (e.g., to control local bleeding, prevent radiation nephritis, as an adjunct to arteriography).a

Rate of Administration

GI hemorrhage: 8–20 mcg/minute infused into the celiac or inferior or superior mesenteric artery.a

Renal hemorrhage: 10 mcg/minute infused into the renal artery.a

Radiation nephritis: 3–7.6 mcg/minute infused into the renal artery.a

Adjunct to arteriography: 8–12 mcg/minute infused into the celiac or superior mesenteric artery.a

Intracardiac Injection

Limit intracardiac injection to personnel well trained in the technique and generally use only during open cardiac massage or when other routes of administration are persistently inaccessible.a 161 170

Inject into the left ventricular chamber.170

Follow intracardiac administration by external cardiac massage to ensure entry of the drug into the coronary circulation.a

Suspensions must not be administered intracardially.a

Administration Risks

Hazards include coronary artery laceration, cardiac tamponade, pneumothorax, and the need to interrupt external chest compressions and ventilation during the period of administration.a 161

Endotracheal Administration

Limit endotracheal administration to personnel well trained in the technique.a 161

In intubated patients, doses can be instilled directly into the bronchial tree via the endotracheal tube.170

Pass a catheter beyond the tip of the tracheal tube, stop chest compressions, inject the drug solution directly into the tracheal tube, follow immediately with several quick insufflations to create a rapidly absorbed aerosol, and then resume compressions.161 d

For pediatric patients, flush with a minimum of 5 mL of 0.9% sodium chloride injection after each dose.d

For pediatric patients, administration via a tracheal tube is preferred to a catheter or feeding tube because these latter 2 methods often are cumbersome and depend on finding the correct-size catheter to place through the tracheal tube.161

Dilution

Adults: Dilute dose in 5–10 mL of 0.9% sodium chloride or sterile water.a d Systemic absorption may be increased by diluting in sterile water instead of 0.9% sodium chloride;a d however, sterile water may have a more negative effect on arterial oxygen pressure (PaO2) than sodium chloride.a Alternatively, a commercially available 1:10,000 (0.1 mg/mL) injection may be administered undiluted via the endotracheal tube.170

Intraosseous Administration

When IV administration is not possible, epinephrine may be given by intraosseous administration for emergency uses such as CPR.161 d

Limit intraosseous administration to personnel well trained in the technique.a 161

Place a cannula in a noncollapsible marrow venous plexus; such access often can be achieved in 30–60 seconds.161

Use a rigid needle, preferably a specially designed intraosseous or Jamshidi-type bone marrow needle; a styleted needle is preferred to prevent obstruction of the needle with cortical bone.161

Insert the intraosseous needle into the anterior tibial bone marrow; alternatively, the distal femur, medial malleolus, or anterior superior iliac spine can be used.161

In older children and adults, intraosseous cannulas also have been inserted successfully into the distal radius or ulna as well as the proximal tibia.161

Successful intraosseous placement outside the hospital (e.g., by emergency medical services) generally is more difficult in older than in younger children.161

Onset of action and systemic concentrations are comparable to those achieved with central venous administration.161 d

Administration Risks

Complications are uncommon (less than 1% of patients), and include tibial fracture, lower-extremity compartment syndrome, extravasation, and osteomyelitis; careful technique can minimize the risk.161 Local effects on bone marrow and bone growth appear to be minimal.161 Risk of microscopic pulmonary fat and bone marrow emboli does not appear to be increased.161

Oral Inhalation

Epinephrine base or hydrochloride may be administered via oral inhalation using a nebulizer, aerosol (metered-dose inhaler [MDI]), or intermittent positive-pressure breathing (IPPB) apparatus.a 166 168

For nebulization, use a glass or plastic nebulizer capable of delivering a very fine mist and that works effectively with a very small volume of solution.168 Place the dose in the nebulizer reservoir and then place the nozzle just inside the partially opened mouth.168 Squeeze the bulb once or twice, inhaling deeply to draw the vaporized solution into the lungs.168 Rinse mouth with water immediately to prevent oropharyngeal dryness.168

Solutions intended for oral inhalation are more concentrated than those intended for injection and must not be administered parenterally.a 168

Do not administer oral inhalation solutions intranasally.168

Topical Administration

Apply solutions topically as a spray or on cotton or gauze to the skin, mucous membranes, or other tissues.a

Dosage

Available as epinephrine and epinephrine hydrochloride; dosage expressed in terms of epinephrine.a 163 166 168

Pediatric Patients

Bronchospasm
Treatment of Acute Exacerbations of Asthma
Oral Inhalation

Children ≥4 years of age: 220 mcg (1 inhalation) of epinephrine via an MDI, repeated once if necessary after at least 1 minute; do not administer subsequent doses for at least 3 hours.a 166

Children ≥4 years of age: After placing approximately 10 drops of 1% (1:100) epinephrine in the nebulizer reservoir, administer 1–3 deep inhalations via the hand-bulb.a 168 Do not repeat more often than every 3 hours; use the least number of inhalations producing relief.a 168

Sub-Q

For severe asthma, inject 0.01 mg/kg (0.01 mL/kg of a 1:1000 injection)a 160 162 or 0.3 mg/m2 (0.3 mL/m2 of a 1:1000 injection) sub-Q.a 169

Single pediatric doses should not exceed 0.3–0.5 mg every 20 minutes as needed for up to 3 consecutive doses.160 162 a 160 162 169

IV

Neonates: Inject 0.01 mg/kg IV.170 172

Infants: Inject 0.05 mg IV initially, repeated at 20- to 30-minute intervals as needed.170 172

Sensitivity Reactions
Anaphylaxis
IM

Inject 0.01 mg/kg (0.01 mL/kg of a 1:1000 injection) (up to 0.5 mg/dose), repeated every 10–20 minutes as needed for up to 3 consecutive doses.101

For self-administration using a prefilled auto-injector (e.g., EpiPen), inject 0.15 or 0.3 mg, depending on body weight; a dose of 0.01 mg/kg generally is recommended.163 Clinicians may recommend higher or lower doses depending on individual patient needs and considering the life-threatening nature of anaphylaxis.163 The 0.15-mg dose may be more appropriate for children <30 kg.163 If doses <0.15 mg are considered more appropriate, alternative injectable forms of the drug should be used.163 For severe persistent anaphylaxis, repeated doses may be needed.163

Sub-Q

Inject 0.01 mg/kg (0.01 mL/kg of a 1:1000 injection) or 0.3 mg/m2 (0.3 mL/m2 of a 1:1000 injection) sub-Q.a 169 Single pediatric doses should not exceed 0.5 mg, repeated as needed at 20-minute to 4-hour intervals depending on the severity of the condition and the response of the patient.a 169

IV

In severe anaphylactic shock, IV administration may be necessary since absorption may be impaired with sub-Q or IM administration.a 101

If necessary, inject an initial dose of 10 mcg/kg (0.1 mL/kg of a 1:10,000 dilution), followed by a continuous IV infusion at an initial rate of 0.1 mcg/kg per minute (using a diluted solution containing 4 mcg/mL); the infusion may be increased as necessary to a maximum of 1.5 mcg/kg per minute to maintain BP.101

Neonates, alternatively: Inject 0.01 mg (10 mcg)/kg.170 172

Infants, alternatively: Inject 0.05 mg (50 mcg) initially, repeated at 20- to 30-minute intervals as needed.170 172

CPR and Cardiac Arrhythmias
Bradycardia and Pediatric Advanced Life Support
IV

Neonates: The usual dose is 0.01–0.03 mg/kg (0.1–0.3 mL/kg of a 1:10,000 injection),d repeated every 3–5 minutes if necessary for CPR or bradycardia.a 161 Higher IV doses are not recommended161 d because of risk of exaggerated hypertension, decreased myocardial function, and worsening neurologic function.d

Pediatric Patients: The usual initial dose is 0.01 mg/kg (0.1 mL/kg of a 1:10,000 injection), up to a maximum single dose of 1 mg, for CPR or bradycardia,a 161 d e repeated every 3–5 minutes as needed.161 d Higher IV doses not recommended; use a standard dose for the first and subsequent doses.d No survival benefit from routine use of high-dose epinephrine; may be harmful, particularly in asphyxia.d Risk of exaggerated hypertension, decreased myocardial function, and worsening neurologic function with high doses.d May consider high-dose epinephrine in certain circumstances (e.g., β-adrenergic blocking agent overdose).d

Pediatric Patients: Alternatively, infuse at an initial rate of 0.1 mcg/kg per minute; increase the rate in increments of 0.1 mcg/kg per minute, if necessary, to a maximum of 1 mcg/kg per minute.a d Low-dose infusions (<0.3 mcg/kg per minute) generally produce predominantly β-adrenergic effects,161 while higher-dose infusions (>0.3 mcg/kg per minute) generally result in α-adrenergic vasoconstriction, but there is substantial interindividual variation in catecholamine response, and infusion dosage should be titrated to the desired effect.d

Pediatric patients: For refractory bradycardia, consider continuous infusiond at a rate of 0.1–0.2 mcg/kg per minute.161

Intraosseous

Pediatric patients: The usual initial dose is 0.01 mg/kg (0.1 mL/kg of a 1:10,000 injection), up to a maximum single dose of 1 mg, for CPR or bradycardia,a 161 d e repeated every 3–5 minutes as needed.161 d Higher intraosseous doses are not recommended; use a standard dose for the first and subsequent doses.d No survival benefit from routine use of high-dose epinephrine; may be harmful, particularly in asphyxia.d Risk of exaggerated hypertension, decreased myocardial function, and worsening neurologic function with high doses.d May consider high-dose epinephrine in certain circumstances (e.g., β-adrenergic blocking agent overdose).d

Endotracheal

Optimum dose not established.a 161 d

Neonates: IV administration (of 0.01–0.03 mg/kg per dose [0.1–0.3 mL/kg of a 1:10,000 injection])161 is the preferred route.a d If the endotracheal route is used, doses of 0.01 or 0.03 mg/kg will likely be ineffective.d Although safety and efficacy have not been established, consider endotracheal administration of a higher dose (up to 0.1 mg/kg) while access is being obtained.a d

Pediatric patients: The usual initial dose is 0.1 mg/kg (0.1 mL/kg of a 1:1000 injection), up to a maximum single dose of 10 mg, for CPR or bradycardia,a 161 d e repeated every 3–5 minutes as needed.161 d

Generally flush the dose with a minimum of 5 mL of 0.9% sodium chloride injection followed by 5 assisted manual ventilations to promote absorption.161 a d

Intracardiac

Pediatric patients: 0.005–0.01 mg/kg (0.05–0.1 mL/kg of a 1:10,000 injection).a

Adults

Bronchospasm
Treatment of Acute Exacerbations of Asthma
Oral Inhalation

220 mcg (1 inhalation) of epinephrine via an MDI, repeated once if necessary after at least 1 minute; do not administer subsequent doses for at least 3 hours.a 166

After placing approximately 10 drops of 1% (1:100) epinephrine in the nebulizer reservoir, administer 1–3 deep inhalations via the hand-bulb.a 168 Do not repeat more often than every 3 hours; the least number of inhalations producing relief should be used.a 168

Sub-Q

For severe asthma, the usual initial dose is 0.1–0.5 mg (0.1–0.5 mL of a 1:1000 injection).a Initial doses should be small and may be increased if necessary, but single doses should not exceed 1 mg.a

May give at 20-minute to 4-hours intervals depending on the severity of the condition and patient response.a

Alternatively, may administer 0.01 mg/kg (concentration of 1:1000) divided into 3 doses of approximately 0.3 mg, given at 20-minute intervals.a d

IM

For severe asthma, the usual initial dose is 0.1–0.5 mg (0.1–0.5 mL of a 1:1000 injection).a Initial doses should be small and may be increased if necessary, but single doses should not exceed 1 mg.a

IV

0.1–0.25 mg injected slowly.170

Sensitivity Reactions
Anaphylaxis
IM

The usual initial dose is 0.1–0.5 mg (0.1–0.5 mL of a 1:1000 injection).a

For the treatment of reactions caused by drugs that were given IM, epinephrine may be administered at the site of injection of the other drug to minimize further absorption.a

Initial doses should be small and may be increased if necessary, but single doses should not exceed 1 mg.a

Alternatively, inject 0.3–0.5 mg (0.3–0.5 mL of a 1:1000 injection),161 repeated every 15–20 minutes, as needed.d

For self-administration using a prefilled auto-injector (e.g., EpiPen), inject 0.3 mg.163 Clinicians may recommend higher or lower doses depending on individual patient needs and considering the life-threatening nature of anaphylaxis.163

For severe persistent anaphylaxis, repeated doses may be needed.163

Sub-Q

Consider the possibility that drug absorption from sub-Q injection may be inadequate in anaphylaxis, particularly with shock.161 d

The usual initial dose is 0.1–0.5 mg (0.1–0.5 mL of a 1:1000 injection).a For the treatment of reactions caused by drugs that were given sub-Q, epinephrine may be administered at the site of injection of the other drug to minimize further absorption.a

Initial doses should be small and may be increased if necessary, but single doses should not exceed 1 mg.a

May be given at 20-minute to 4-hours intervals depending on the severity of the condition and patient response.a

Alternatively, inject 0.3–0.5 mg every 20 minutes as needed for up to 3 doses.160 162

IV

In severe or life-threatening anaphylaxis, IV administration may be necessary since absorption may be impaired with sub-Q or IM administration.a 101 161 d

If necessary, inject 0.1–0.25 mga 161 172 d (e.g., 1–2.5 mL of a 1:10,000 injection or dilution) slowly and cautiously (e.g., over 5–10 minutes), and repeat every 5–15 minutes as necessary or follow by a continuous infusion at an initial rate of 1 mcg/minute, increasing the rate to up to 4 mcg/minute as necessary.a 161 d Individual doses up to 0.5 mg also have been used.161

To optimally control administration, some clinicians recommend an initial dose of 0.1 mg (10 mL of a 1:100,000 injection or dilution) given over 5–10 minutes, followed by a continuous infusion as necessary.100

Alternatively, 0.025–0.05 mg (0.25–0.5 mL of a 1:10,000 injection) be given every 5–15 minutes following initial sub-Q or IM administration of 0.5 mg.a

CPR and Cardiac Arrhythmias

The optimum dose of epinephrine during CPR remains controversial.103 104 115 116 117 118 119 120 121 122 123 125 126 127 The usual dose of 0.5–1 mg has been questioned since it is not based on body weight103 104 117 119 120 and may be lower than necessary for optimum cardiovascular effects.103 104 117 119 121 127

CPR (Cardiac Arrest)
IV

Inject 1 mg every 3–5 minutes.161 d

Has been infused at an initial rate of 1 mcg/minute and, increased to 3–4 mcg/minute as needed, via a central line to reduce the risk of extravasation and ensure good bioavailability.161

Higher (>1-mg) doses may be indicated in certain circumstances, (e.g., β-adrenergic or calcium-channel blocking agent overdose).d

Intraosseous

Intraosseous doses generally are the same as those administered IV.a d

Usually, 1 mg every 3–5 minutes.d

Endotracheal

Optimum dose not established.a 161 d

If IV or intraosseous access is delayed or cannot be established,d endotracheal doses 2–2.5 times those administered IV (i.e., 2–2.5 mg) are recommended.a 161 d

Intracardiac

Inject 0.1–1 mg (usually as 1–10 mL of a 1:10,000 injection) into the left ventricular chamber.a 161 170 172

Sub-Q

Following initial IV administration, 0.3 mg may be injected sub-Q.a

Persistent or Recurrent Ventricular Fibrillation/Tachycardia
IV

Inject 1 mg by rapid injection (IV push) every 3–5 minutes.161 d

Pulseless Electrical Activity
IV

Inject 1 mg by rapid injection (IV push) every 3–5 minutes.161 d

Asystole
IV

Inject 1 mg by rapid injection (IV push) every 3–5 minutes.161 d

Bradycardia:
IV

For symptomatic bradycardia without cardiac arrest, infuse at an initial rate of 1 mcg/minute; subsequent dosage is adjusted according to the patient’s response and generally ranges from 2–10 mcg/minute.a 161 d

Radiographic Use
Arteriography
IV

As an adjunct in arteriography, 16–24 mL of sodium chloride injection containing 1 mcg of epinephrine per mL has been infused into the celiac or superior mesenteric artery over 2 minutes; the radiographic contrast medium was administered 7–10 minutes later.

Hemorrhage
GI
Intra-arterial

To control GI bleeding, infuse into the celiac artery, inferior mesenteric artery, or superior mesenteric artery at a rate of 8–20 mcg/minute for 4 minutes to 3 hours.

Renal
Intra-arterial

To control bleeding from the kidney, infuse into the renal artery at a rate of 10 mcg/minute for 10 minutes.a

Radiation Nephritis
Abdominal Irradiation
Intra-arterial

To prevent radiation nephritis, infuse into the renal artery at a rate of 3–7.6 mcg/minute for 4–10 minutes prior to and continued during the period of abdominal irradiation.a

Adjunct to Local Anesthesia
Local Injection

To localize and prolong the duration of local anesthesia, epinephrine may be used in concentrations of 1:500,000 to 1:50,000; 1:200,000 is used most commonly.a 172

Superficial Bleeding
Topical

As a topical hemostatic, solutions concentrations of 1:50,000 (0.002%) to 1:1000 (0.1%) may be sprayed or applied with cotton or gauze to the skin, mucous membranes, or other tissues.

Prescribing Limits

Pediatric Patients

Bronchospasm
Treatment of Acute Exacerbations of Asthma
Oral Inhalation

Maximum for children ≥4 years of age: 1 or 2 doses 1 minute apart, repeated no more frequently than every 3 hours.a 166

Sub-Q

Maximum for pediatric patients: 0.5 mg repeated no more frequently than every 20 minutes up to 3 times.a 160 162

Sensitivity Reactions
Anaphylaxis
IM or Sub-Q

Maximum for pediatric patients: 0.5 mg repeated no more frequently than every 10 minutes up to 3 times.a 101

IV

Up to 1.5 mcg/kg per minute.

CPR and Cardiac Arrhythmias
Bradycardia and Pediatric Advanced Life Support
IV

Maximum for neonates: 0.03 mg/kgd repeated no more frequently than every 3–5 minutes.161 Higher IV doses are not recommended.161 d (See Bradycardia and Pediatric Advanced Life Support under Dosage and Administration.)

Pediatric patients: Maximum 1 mg, as a single dose.d e

Intraosseous

Pediatric patients: Maximum 1 mg, as a single dose.d e

Endotracheal

Neonates: IV administration is the preferred route.d Although safety and efficacy have not been established, consider an endotracheal dose up to 0.1 mg/kg, while access is being obtained.a d d

Pediatric patients: Maximum 10 mg as a single dose.d e

Adults

Bronchospasm
Treatment of Acute Exacerbations of Asthma
Oral Inhalation

Maximum 1 or 2 doses 1 minute apart, repeated no more frequently than every 3 hours.a 166

Sub-Q

Single doses should not exceed 1 mg.a

Sensitivity Reactions
Anaphylaxis
IM

Single doses should not exceed 1 mg.a

Sub-Q

Single doses should not exceed 1 mg.a

Cautions for Epinephrine

Contraindications

  • No absolute contraindications to use in life-threatening conditions.163

  • Relative contraindications include shock (other than anaphylactic shock), organic heart disease, coronary insufficiency, or cardiac dilatation, as well as use in most patients with angle-closure glaucoma, arrhythmias, organic brain damage, or cerebral arteriosclerosis.a 169 170 172 Contraindicated for use during general anesthesia with chloroform, trichloroethylene, or cyclopropane, and should be used cautiously, if at all, with other halogenated hydrocarbon anesthetics such as halothane.a 169 170 172

  • Contraindicated in conjunction with local anesthetics for use in fingers, toes, ears, nose, or genitalia.a

Warnings/Precautions

Warnings

High BP Induction

Inadvertent induction of high arterial BP can cause angina pectoris, aortic rupture, or cerebral hemorrhage.170 172

Hypertension and Hyperthyroidism

Adverse reactions most likely to occur in hypertensive or hyperthyroid patients; use with extreme caution, if at all.a

Cardiac Arrhythmias

Can induce serious cardiac arrhythmias in patients without heart disease, in those with organic heart disease, and in those with drug-induced myocardial sensitization.170 172

General Anesthetics

Can convert asystole to VF in anesthetic cardiac accidents since many anesthetics sensitize the myocardium to epinephrine.170

Cyclopropane or halogenated hydrocarbon general anesthetics that increase cardiac irritability and seem to sensitize the myocardium to epinephrine may cause arrhythmias including VPC, VT, or VF.a 170 172 (See Contraindications under Cautions.)

Sensitivity Reactions

Sulfites

Some formulations contain sulfites, which may cause allergic-type reactions (including anaphylaxis and life-threatening or less severe asthmatic episodes) in certain susceptible individuals.a 163 169 170 172

Presence of sulfites in a parenteral epinephrine preparation and the possibility of allergic-type reactions should not deter use of the drug when indicated for the treatment of serious allergic reactions or for other emergency situations.102 170 172 Epinephrine is the preferred treatment for such conditions, and currently available alternatives to epinephrine may not be optimally effective.102 170 172

Consider that sulfites may be responsible for paradoxical worsening of respiratory function in asthmatics or for worsening symptoms or decreased bronchodilatory response with increasing use of the drug.a

Sympathomimetic Amines

Caution in those with a history of sensitivity to sympathomimetic amines.a

General Precautions

Regular Inhalation Therapy

Concerns about the safety of regular use of inhaled β-agonist bronchodilators have been raised.133 135 143 149 150 151 Therefore, regular, daily use of a short-acting, inhaled β-agonist generally is no longer recommended for maintenance therapy of asthma, and use more than twice weekly or more than one canister monthly may indicate the need to initiate or increase long-term control therapy for asthma.160

Cardiovascular Effects

Can cause VF, but beneficial effects in restoring electrical activity and enhancing defibrillation are well documented.170 172

May cause tachycardia, ventricular ectopy, tachyarrhythmias, hypertension, and vasoconstriction in patients with a perfusing rhythm.d

Caution in patients with underlying cardiovascular disease (e.g., angina pectoris, tachycardia, MI).a

Extreme caution in patients with prefibrillatory rhythm because of excitatory cardiac activity.170

Overdosage or inadvertent IV administration may cause cerebrovascular hemorrhage secondary to a marked increase in BP.163 169

Respiratory Disease and Effects

Caution in patients with long-standing bronchial asthma and substantial emphysema who may also have degenerative heart disease.a

Can cause pulmonary edema secondary to peripheral vasoconstriction and cardiac stimulation.169

Diuretics

May decrease vascular vasopressor response.170 172

MAO Inhibitors

Use vasopressors cautiously with MAO inhibitors according to one manufacturer.170

Specific Populations

Pregnancy

Category C.163 169 170 172

Some manufacturers state that epinephrine injection is contraindicated during the second stage of labor or when maternal BP is >130/80 mm Hg.a 169 170

When administered in ACLS, may decrease blood flow to the uterus; however, the woman must be resuscitated for survival of the fetus.d

Lactation

Risk unknown.171

Pediatric Use

Used in pediatric patients of all ages, dosing according to body weight or surface area.a 101 160 161 162 163 169 170 172 d

Oral inhalation aerosols are not recommended for children <4 years of age.a 166

Geriatric Use

Use with caution.a 169

Common Adverse Effects

Fear, anxiety, tenseness, restlessness, headache, tremor, dizziness, lightheadedness, nervousness, sleeplessness, excitability, and weakness.a Increased rigidity and tremor in patients with parkinsonian syndrome. May aggravate or induce psychomotor agitation, disorientation, impaired memory, assaultive behavior, panic, hallucinations, suicidal or homicidal tendencies, and psychosis characterized by clear consciousness with schizophrenic-like thought disorder and paranoid delusions.a Nausea, vomiting, sweating, pallor, respiratory difficulty, or respiratory weakness and apnea.a

ECG changes including a decrease in T-wave amplitude in all leads in normal individuals.a Disturbances of cardiac rhythm and rate may result in palpitation and tachycardia.a Aggravation or precipitation of angina pectoris by increasing cardiac work and accentuating the insufficiency of the coronary circulation.a Potentially fatal ventricular arrhythmias including fibrillation, especially in patients with organic heart disease or those receiving other drugs that sensitize the heart to arrhythmias.a

Hypertension secondary to overdosage or inadvertent IV injection of usual sub-Q doses.a Subarachnoid hemorrhage and hemiplegia have resulted from hypertension, even following usual sub-Q doses.a

Necrosis from repeated injections because of vascular constriction at the injection site.a Tissue necrosis in the extremities, kidneys, and liver.a

Severe metabolic acidosis from prolonged use or overdosage because of elevated blood concentrations of lactic acid.a

Absorption from the respiratory tract following large orally inhaled doses may result in adverse effects similar to those occurring after parenteral administration.a Rebound bronchospasm may occur when the effects of epinephrine end.a Further reductions in arterial oxygen tension.a Dryness of pharyngeal membranes may follow oral inhalation.a

Interactions for Epinephrine

Specific Drugs

Drug

Interaction

Comments

α-Adrenergic blocking agents (e.g., phentolamine)

High-dose epinephrine vasoconstriction and hypertension antagonizeda

Anesthetics, general (e.g., halogenated hydrocarbons [e.g., halothane], cyclopropane)

Increased cardiosensitivity to epinephrinea

Use with caution, if at all; increased risk of ventricular arrhythmias such as VPCs, VT, or VF; contraindicated with chloroform, trichloroethylene, or cyclopropanea

May not be absorbed rapidly enough with topical hemostatic use to present a problem in short proceduresa

Prophylactic lidocaine or procainamide may provide some protectiona

IV propranolol may reverse arrhythmiasa

Antidepressants, MAO inhibitors

MAO is one enzyme involved in epinephrine metabolisma

Marked potentiation of epinephrine effects by MAO inhibitors does not occur

Antidepressants, tricyclic

Potentiation of epinephrine effects (especially on heart rate and rhythm)a

Antidiabetic agents (e.g., insulin, oral hypoglycemics)

Epinephrine-induced hyperglycemiaa

May require increased antidiabetic dosagea

Antihistamines, first generation (especially diphenhydramine, dexchlorpheniramine, tripelennamine)

Potentiation of epinephrine effects (especially on heart rate and rhythm)a

β-Adrenergic blocking agents

Antagonism of cardiac and bronchodilating effectsa

Digoxin

Increased cardiosensitivity to epinephrinea

Avoid epinephrine with high digoxin dosages

Ergot alkaloids

α-Adrenergic antagonisma

Possible reversal of pressor responsea

Phenothiazines

Reversal of epinephrine's vasopressor effecta

Do not use to treat phenothiazine-induced hypotension

Sympathomimetic amines

Additive effects and toxicitya

Avoid concomitant usea

Epinephrine Pharmacokinetics

Absorption

Bioavailability

Rapidly metabolized in the GI tract and liver after oral ingestion; pharmacologically active concentrations are not reached when given orally.a

Well absorbed after sub-Q or IM injection; absorption can be hastened by massaging the injection site.a

Absorbed rapidly through the lung capillary bed following endotracheal administration;170 serum concentrations achieved only 10% of those with an equivalent IV dose.161

Absorption is slight and the effects are restricted mainly to the respiratory tract after usual orally inhaled doses; absorption somewhat increased when larger doses are inhaled, and systemic effects may occur.a

Onset

Rapid onset of action when solutions are administered parenterally or by oral inhalation.a 163

Sub-Q injection in asthmatic attacks may produce bronchodilation within 5–10 minutes and maximal effects in about 20 minutes.a

After oral inhalation, bronchodilation usually occurs within 1 minute.a

Duration

Short duration of action when solutions are administered parenterally or by oral inhalation.a 163

Distribution

Extent

Epinephrine crosses the placenta but not the blood-brain barrier.a

Distributed into milk.a

Elimination

Metabolism

Pharmacologic actions are terminated mainly by uptake and metabolism in sympathetic nerve endings.a

Circulating drug is metabolized in the liver and other tissues by a combination of reactions involving the enzymes catechol-O-methyltransferase (COMT) and MAO.a

Elimination Route

40% excreted in urine, mainly as inactive metabolites.a

Stability

Storage

Epinephrine, epinephrine salts, and preparations containing the drug gradually darken on exposure to light and air and must be stored in tight, light-resistant containers.a 167

Discard solutions with a color that is pinkish or darker than slightly yellow or that contain a precipitate.a 167

Commercially available preparations vary in stability, depending on the form in which epinephrine is present and on the preservatives used.a Follow the manufacturer’s directions with respect to storage requirements for each product.a

Oral Inhalation

Aerosol

20–25°C.166

Contents under pressure; do not puncture or throw into an incinerator.166

Use or storage near an open flame or temperature >49°C can cause the canister to burst.166

Inhalation Solution

15–25°C in small, well-filled, tight containers; protect from light and freezing.167 168

Parenteral

Injection

15–25°C; protect from light and freezing.167 169 172

In some commercially available injections, air has been replaced with nitrogen to avoid oxidation.a

Withdrawal of doses from multiple-dose vials introduces air into the vials, subjecting the remaining epinephrine to oxidation.a Oxidation of epinephrine imparts first a pink, then a brown color.a

Auto-injector (e.g., EpiPen): 15–30°C; protect from light (dark place) and do not refrigerate or freeze.163 164 Manufacturer's plastic carrying case provides added UV light protection.164 Avoid exposure to extreme heat or cold.164

Compatibility

For information on systemic interactions resulting from concomitant use, see Interactions.

Parenteral

Incompatible with sodium bicarbonate and other alkaline solutions.d

Solution CompatibilityHID

Compatible

Dextrose–Ringer’s injection combinations

Dextrose–Ringer’s injection, lactated, combinations

Dextrose 5% in Ringer’s injection, lactated

Dextrose–saline combinations

Dextrose 5% in sodium chloride 0.9%

Dextrose 2.5, 5, or 10% in water

Ionosol products (except as noted below)

Ringer’s injection

Ringer’s injection, lactated

Sodium chloride 0.9%

Sodium lactate (1/6) M

Incompatible

Ionosol T in dextrose 5%

Sodium bicarbonate 5%

Drug Compatibility
Admixture CompatibilityHID

Compatible

Amikacin sulfate

Dobutamine HCl

Furosemide

Metaraminol bitartrate

Ranitidine HCl

Verapamil HCl

Incompatible

Aminophylline

Y-Site CompatibilityHID

Compatible

Amiodarone HCl

Anidulafungin

Atracurium besylate

Bivalirudin

Calcium chloride

Calcium gluconate

Caspofungin acetate

Ceftazidime

Cisatracurium besylate

Clonidine HCl

Dexmedetomidine HCl

Diltiazem HCl

Dobutamine HCl

Dopamine HCl

Famotidine

Fenoldopam mesylate

Fentanyl citrate

Furosemide

Heparin sodium

Hetastarch in lactated electrolyte injection (Hextend)

Hydrocortisone sodium succinate

Hydromorphone HCl

Labetalol HCl

Levofloxacin

Lorazepam

Midazolam HCl

Milrinone lactate

Morphine sulfate

Nicardipine HCl

Nitroglycerin

Norepinephrine bitartrate

Pancuronium bromide

Pantoprazole sodium

Phytonadione

Potassium chloride

Propofol

Ranitidine HCl

Remifentanil HCl

Sodium nitroprusside

Tigecycline

Tirofiban HCl

Vasopressin

Vecuronium bromide

Warfarin sodium

Incompatible

Ampicillin sodium

Hydroxyethyl starch 130/0.4 in sodium chloride 0.9%

Micafungin sodium

Actions

  • An endogenous catecholamine.a

  • Acts directly on both α- and β-adrenergic receptors of tissues innervated by sympathetic nerves except the sweat glands and arteries of the face.a

  • Main effects of therapeutic parenteral doses are relaxation of smooth muscle of the bronchial tree, cardiac stimulation, and dilation of skeletal muscle vasculature.a

  • Relaxes bronchial smooth muscle by stimulation of β2-adrenergic receptors and constricts bronchial arterioles by stimulation of α-adrenergic receptors.a Relieves bronchospasm, reduces congestion and edema, and increases tidal volume and vital capacity.a

  • Inhibits histamine release and antagonizes the effect of the mediator on end organs.a As a result, may reverse histamine-induced bronchiolar constriction, vasodilation, and edema.a

  • Acts on β1-adrenergic receptors in the heart, producing a positive chronotropic effect through the SA node and a positive inotropic effect on the myocardium.a d Cardiac output, oxygen consumption, and the work of the heart are increased.a

  • Constricts arterioles in the skin, mucous membranes, and viscera by its effect on α-adrenergic receptors and reduces cutaneous blood flow, especially in the hands and feet.a Produces local vasoconstriction and hemostasis in bleeding from small vessels when applied topically but does not control bleeding from larger vessels.a

  • Increases glycogenolysis in the liver, reduces glucose uptake by tissues, and inhibits insulin release in the pancreas, resulting in hyperglycemia.a

Advice to Patients

  • Do not use solutions that are pinkish or darker than slightly yellow or if they contain a precipitate.a 167 168

  • For asthma, proper techniques for storage, use, care, and disposal of the metered-dose inhaler (MDI).166 Give patients a copy of the manufacturer’s patient instructions.166

  • For asthma, importance of discontinuing oral inhalation therapy and contacting a clinician if symptoms are not relieved within 20 minutes or they become worse.a 166 168

  • For asthma, importance of allowing at least 3 hours to elapse between orally inhaled doses.a 166 168

  • For asthma, importance of advising clinician if quick-relief use is more frequent than twice weekly or one canister monthly.160

  • For asthma, advise that oral inhalation therapy should be self-administered (OTC use) only if asthma was previously diagnosed by a clinician.166 168 Before considering self-administration therapy, inform clinician of any history of hospitalization for asthma.166 168

  • For asthma, importance of advising parents and caregivers to supervise children during oral inhalation therapy.166 168

  • Importance of not exceeding recommended dosages or frequency of administration because of the risk of adverse systemic effects (e.g., nervousness, tachycardia, other cardiac problems).166 168

  • Advise that certain oral inhalation aerosols contain chlorofluorocarbons, which may harm public health and environment by destroying ozone in the upper atmosphere.166

  • For self-administration in anaphylaxis, proper techniques for storage, attention to expiration dating (replacing before expiration), use, and disposal of the prefilled auto-injector (e.g., EpiPen) and for IM administration of the dose.163 164

  • Importance of going to the nearest emergency room after self-administration for anaphylaxis since further medical attention may be needed.164 Advise clinician that epinephrine was self-administered (show injection site) and give them the used auto-injector for proper disposal.164

  • Give patients a copy of the manufacturer’s patient instructions.163 164

  • Importance of not injecting the dose via the auto-injector into the thumb, finger, or hand since loss of blood flow may occur in these areas.164 Importance of seeking immediate medical attention if this occurs.164

  • For anaphylaxis, importance of remaining vigilant for possible recurrence despite an asymptomatic period;161 d length of observation time not established.d Symptoms may recur within 1–36 hours after initial reaction.d May discharge patient if asymptomatic for 4 hours after therapy; severity of reaction or other problems may require longer periods of observation.d

  • Importance of informing clinicians of underlying heart disease, hypertension, thyroid disease, diabetes mellitus, or prostatic enlargement that causes difficulty urinating.166 168

  • Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs.a 166 168 Importance of avoiding MAO inhibitors and allowing at least 2 weeks to elapse after discontinuing these antidepressants.166

  • Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.a 166 168

  • Importance of informing patients of other important precautionary information.a (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Epinephrine

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Bulk

Powder*

Oral Inhalation

Aerosol

220 mcg/metered spray

Epinephrine Mist

Alpharma

Primatene Mist

Wyeth

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Epinephrine Hydrochloride

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Oral Inhalation

Solution, for nebulization

1% (1:100) (of epinephrine)

Adrenalin Chloride Solution

Monarch

Parenteral

Injection

0.1 mg/mL (1:10,000) (of epinephrine)*

Epinephrine Hydrochloride Injection

0.5 mg/mL (1:2000) (of epinephrine)

EpiPen Jr. Auto-Injector (delivers a single 0.15-mg dose [0.3 mL])

Dey

1 mg/mL (1:1000) (of epinephrine)*

Adrenalin Chloride Solution

Monarch

Epinephrine Injection

EpiPen Auto-Injector (delivers a single 0.3-mg dose [0.3 mL])

Dey

Comparative Pricing

This pricing information is subject to change at the sole discretion of DS Pharmacy. This pricing information was updated 02/2014. Actual costs to patients will vary depending on the use of specific retail or mail-order locations and health insurance copays.

Adrenaclick 0.3MG/0.3ML Device (SHIONOGI PHARMA): 1/$99.91 or 2/$189.83

Adrenaclick 0.3MG/0.3ML Device (SHIONOGI PHARMA): 2/$179.84 or 4/$349.67

EpiPen 2-Pak 0.3 MG/0.3ML(1:1000) Device (DEY LABS): 2/$215.99 or 6/$620.96

EpiPen Jr 2-Pak 0.15 MG/0.3ML(1:2000) Device (DEY LABS): 2/$215.99 or 6/$616.00

Twinject 0.15MG/0.15ML Device (SHIONOGI PHARMA): 2/$299.00 or 6/$881.99

Twinject 0.3MG/0.3ML Device (SHIONOGI PHARMA): 2/$302.98 or 6/$892.99

AHFS DI Essentials. © Copyright, 2004-2014, Selected Revisions July 8, 2013. American Society of Health-System Pharmacists, Inc., 7272 Wisconsin Avenue, Bethesda, Maryland 20814.

† Use is not currently included in the labeling approved by the US Food and Drug Administration.

References

Only references cited for selected revisions after 1984 are available electronically.

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