epinephrine injection

Generic Name: epinephrine injection (EP i NEF rin)
Brand names: Adrenaclick, Adrenaclick Two-Pack, Adrenalin, EpiPen 2-Pak, EpiPen Auto-Injector, EpiPen JR 2-Pak, EpiPen JR Auto-Injector, Twinject Auto-Injector, Twinject Auto-Injector Two Pack, ...show all 24 brand names.Ana-Guard, Sus-Phrine Injection, Bronitin, Micronefrin (obsolete), Asthmahaler, Nephron (obsolete), Primatene Mist Inhaler, Primatene Mist Suspension, S2 Inhalant (obsolete), Bronchial Mist with Pump, Epi EZ Pen, Medihaler-Epi, Asthmanefrin (obsolete), Bronkaid Mist, Primatene Mist Inhaler Refill

What is epinephrine injection?

Epinephrine is a chemical that narrows blood vessels and opens airways in the lungs. These effects can reverse severe low blood pressure, wheezing, severe skin itching, hives, and other symptoms of an allergic reaction.

Epinephrine injection is used to treat severe allergic reactions (anaphylaxis) to insect stings or bites, foods, drugs, and other allergens. Epinephrine is also used to treat exercise-induced anaphylaxis.

Epinephrine auto-injectors such as EpiPen and EpiPen Jr. may be kept on hand for self-injection by a person with a history of an severe allergic reaction.

Epinephrine injection may also be used for purposes not listed in this medication guide.

What is the most important information I should know about epinephrine injection?

Before using this medication, tell your doctor if you have heart disease or high blood pressure, a heart rhythm disorder, coronary artery disease, Parkinson's disease, diabetes, or a thyroid disorder.

Before using epinephrine, tell your doctor about all other medications you use, especially digoxin (digitalis, Lanoxin), heart or blood pressure medicine, heart rhythm medication, an antidepressant, a diuretic (water pill), thyroid medication, migraine headache medicine, cold or sleep medicine that contains an antihistamine, or an MAO inhibitor such as Marplan, Nardil, Azilect, Eldepryl, Emsam, or Parnate.

Seek emergency medical attention even after you use epinephrine to treat a severe allergic reaction. The effects of epinephrine may wear off after 10 or 20 minutes. You will need to receive further treatment and observation. Before using epinephrine a second time, tell your doctor if your first injection caused a serious side effect such as increased breathing difficulty, or dangerously high blood pressure (severe headache, blurred vision, buzzing in your ears, anxiety, confusion, chest pain, shortness of breath, uneven heartbeats, seizure).

What should I discuss with my healthcare provider before using epinephrine injection?

To make sure you can safely use epinephrine, tell your doctor if you have any of these other conditions:

• heart disease or high blood pressure;

• a heart rhythm disorder;

• coronary artery disease;

• Parkinson's disease;

• diabetes; or

• a thyroid disorder.

FDA pregnancy category C. It is not known whether epinephrine will harm an unborn baby. If possible before using this medicine, tell your doctor if you are pregnant. Do not use epinephrine without your doctor's advice if you are breast-feeding a baby. In an emergency situation, it may not be possible before you use epinephrine to tell your caregivers if you are pregnant or breast-feeding. Make sure any doctor caring for your pregnancy or your baby knows you have received this medication.

How should I use epinephrine injection?

Use exactly as prescribed by your doctor. Do not use in larger or smaller amounts or for longer than recommended. Follow the directions on your prescription label.

Seek emergency medical attention even after you use this medication to treat a severe allergic reaction. The effects of epinephrine may wear off after 10 or 20 minutes. You will need to receive further treatment and observation.

The auto-injector device this medicine comes in is a disposable single-use system that contains a spring-loaded needle. Epinephrine injection comes with patient instructions for safe and effective use. Follow these directions carefully. Ask your doctor or pharmacist if you have any questions.

Do not remove the safety cap until you are ready to use the auto-injector. Never put your fingers over the tip when removing the safety cap or after the safety cap has been removed.

To use an epinephrine auto-injector:

• Form a fist around the auto-injector with the black tip pointing down. Pull off the safety cap.

• Place the black tip against the fleshy portion of your outer thigh. You may give the injection directly through your clothing. Do not put your thumb over the end of the unit.

• With a quick motion, push the auto-injector firmly against your thigh. This will release the spring-loaded needle that injects the dose of epinephrine. Hold the auto-injector in place for a few seconds after activation.

• Remove the auto-injector from your thigh. Carefully re-insert the used device needle-first into the carrying tube. Re-cap the tube and take it with you to the emergency room so that anyone who treats you will know how much epinephrine you have received.

• Use each auto-injector only one time. Throw away after one use, even if there is still some medicine left in it.

Do not use the medication if it has changed colors or has any particles in it, or if the expiration date on the label has passed. Call your doctor for a new prescription. Store at room temperature away from moisture, heat, and light. Do not refrigerate this medication, and do not store it in a car.

What happens if I miss a dose?

Since epinephrine is normally used only as needed in an emergency, you are not likely to be on a dosing schedule. Do not use repeat doses of epinephrine without a doctor's advice.

What happens if I overdose?

Seek emergency medical attention or call the Poison Help line at 1-800-222-1222.

Overdose symptoms may include fast or pounding heartbeats, sudden and severe headache, sudden numbness or weakness, feeling like you might pass out, wheezing, trouble breathing, chest pain, or sudden problems with vision, speech, or balance.

What should I avoid while using epinephrine injection?

Do not inject epinephrine into a vein or into the muscles of your buttocks, or it may not work as well. Inject it only into the fleshy outer portion of the thigh. Accidentally injecting epinephrine into your hands or feet may result in a loss of blood flow to those areas, and resulting numbness. If this occurs, seek emergency medical attention.

Epinephrine injection side effects

Before using epinephrine a second time, call your doctor if your first injection caused a serious side effect such as increased breathing difficulty, or dangerously high blood pressure (severe headache, blurred vision, buzzing in your ears, anxiety, confusion, chest pain, shortness of breath, uneven heartbeats, seizure).

Less serious side effects may include:

• sweating;

• nausea and vomiting;

• pale skin;

• feeling short of breath;

• dizziness;

• weakness or tremors;

• headache; or

• feeling nervous or anxious.

This is not a complete list of side effects and others may occur. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

Epinephrine injection Dosing Information

Usual Adult Dose for Shock:

IV: 2 to 10 mcg/min (1 mg in 250 mL of D5W or 4 mcg/mL). May increase as necessary to establish an adequate heart rate and blood pressure. Rarely doses as high as 20 mcg/min are required.

Endotracheal: 1 mg (10 mL of 1:10,000) once, followed by 5 quick insufflations.

Intracardiac: 0.3 to 0.5 mg (3 to 5 mL of 1:10,000) by direct injection into the left ventricular chamber once.

Usual Adult Dose for Asystole:

IV: 0.5 to 1 mg (5 to 10 mL of 1:10,000) once.
May be repeated every 3 to 5 minutes as necessary.
If there is inadequate response to 1 mg, then high dose therapy (2 to 5 mg) every 3 to 5 minutes, escalating 1, 3, then 5 mg every 3 minutes, or 0.1 mg/kg every 3 to 5 minutes, has been used.

Endotracheal: 1 mg (10 mL of 1:10,000) once, followed by 5 quick insufflations.

Intracardiac: 0.3 to 0.5 mg (3 to 5 mL of 1:10,000) by direct injection into the left ventricular chamber once.

Usual Adult Dose for Electromechanical Dissociation:

IV: 0.5 to 1 mg (5 to 10 mL of 1:10,000) once.
May be repeated every 3 to 5 minutes as necessary.
If there is inadequate response to 1 mg, then high dose therapy (2 to 5 mg) every 3 to 5 minutes, escalating 1, 3, then 5 mg every 3 minutes, or 0.1 mg/kg every 3 to 5 minutes, has been used.

Endotracheal: 1 mg (10 mL of 1:10,000) once, followed by 5 quick insufflations.

Intracardiac: 0.3 to 0.5 mg (3 to 5 mL of 1:10,000) by direct injection into the left ventricular chamber once.

Usual Adult Dose for AV Heart Block:

IV: 0.5 to 1 mg (5 to 10 mL of 1:10,000) once.
May be repeated every 3 to 5 minutes as necessary.
If there is inadequate response to 1 mg, then high dose therapy (2 to 5 mg) every 3 to 5 minutes, escalating 1, 3, then 5 mg every 3 minutes, or 0.1 mg/kg every 3 to 5 minutes, has been used.

Usual Adult Dose for Adams-Stokes Syndrome:

IV: 0.5 to 1 mg (5 to 10 mL of 1:10,000) once.
May be repeated every 3 to 5 minutes as necessary.
If there is inadequate response to 1 mg, then high dose therapy (2 to 5 mg) every 3 to 5 minutes, escalating 1, 3, then 5 mg every 3 minutes, or 0.1 mg/kg every 3 to 5 minutes, has been used.

Usual Adult Dose for Asthma -- Acute:

Subcutaneous: 0.1 to 0.5 mg (0.1 to 0.5 mL of 1:1000 solution). May be repeated every 20 minutes to once every 4 hours as needed.

Subcutaneous suspension: 0.5 mg (0.1 mL of 1:200 suspension) once. An additional dose of 0.5 to 1 mg may be given as needed but not more frequently than every 6 hours.

IM: 0.1 to 0.5 mg (0.1 to 0.5 mL of 1:1000 solution). May be repeated every 20 minutes to once every 4 hours as needed.

Inhalation aerosol: 160 to 220 mcg (1 inhalation) once. An additional inhalation may be used after at least one minute. It is recommended that subsequent doses not be administered for at least three hours.

Nebulized: 1 to 3 inhalations (8 to 10 drops of a 1% 1:100 solution) once. If relief does not occur within 5 minutes, the dose may be repeated once. It is recommended that subsequent doses not be repeated more often than every 3 hours.

Intermittent positive pressure breathing: 0.3 mg (0.03 mL of a 1:100 solution) once. The least amount of tolerated inhalations required to provide relief is the recommended dose. Most patients respond within 15 minutes. This dose may be repeated once every 3 to 4 hours as needed.

Usual Adult Dose for Chronic Obstructive Pulmonary Disease -- Acute:

Subcutaneous: 0.3 mg (0.3 mL of 1:1000) every 20 minutes for up to 3 doses. May be repeated once every 2 hours as needed.

IM: 0.1 to 0.5 mg (0.1 to 0.5 mL of 1:1000) once. May be repeated every 20 minutes to 4 hours as needed.

Inhalation aerosol: 160 to 220 mcg (1 inhalation) once. An additional inhalation may be used after at least one minute. It is recommended that subsequent doses not be administered for at least three hours.

Nebulized: 1 to 3 inhalations (8 to 15 drops of a 1% 1:100 solution or 2.25% racepinephrine solution) once. If relief does not occur within 5 minutes, the dose may be repeated once. It is recommended that subsequent doses not be repeated more often than every 3 hours.

Intermittent positive pressure breathing: 0.3 mg (0.03 mL of a 1:100 solution) once. The least amount of tolerated inhalations required to provide relief is the recommended dose. Most patients respond within 15 minutes. This dose may be repeated once every 3 to 4 hours as needed.

Usual Adult Dose for Allergic Reaction:

Subcutaneous: 0.1 to 0.5 mg (0.1 to 0.5 mL of 1:1000 solution). May be repeated every 20 minutes to once every 4 hours as needed.

Subcutaneous suspension: 0.5 mg (0.1 mL of 1:200 suspension) once. An additional dose of 0.5 to 1 mg may be given as needed but not more frequently than every 6 hours.

IM: 0.1 to 0.5 mg (0.1 to 0.5 mL of 1:1000 solution). May be repeated every 10 to 15 minutes.

IV: 0.1 to 0.25 mg (1 to 2.5 mL of a 1:10,000 solution) once slowly and cautiously over 5 to 10 minutes. The dose may be repeated every 5 to 15 minutes as needed and tolerated. In some cases of severe anaphylaxis, an intravenous infusion of epinephrine (1 mg in 250 mL of D5W, or 4 mcg/mL) can be started to run at 1 to 4 mcg/min (15 to 60 mL/hour).

Usual Pediatric Dose for Asystole:

Neonates:
IV or Intratracheal: 0.01 to 0.03 mg/kg (0.1 to 0.3 mL/kg of 1:10,000) every 3 to 5 minutes as needed. Dilute intratracheal dose in 1 to 2 mL of normal saline.

Infants and children:
IV: Initial dose: 0.01 mg/kg (0.1 mL/kg of 1:10,000). May be repeated every 3 to 5 minutes. Maximum dose: 1 mg or 10 mL.

Intratracheal: 0.1 mg/kg (0.1 mL of 1:1,000 solution). Doses as high as 0.2 mg/kg may be effective. May be repeated every 3 to 5 minutes.

Usual Pediatric Dose for Shock:

Neonates:
IV or Intratracheal: 0.01 to 0.03 mg/kg (0.1 to 0.3 mL/kg of 1:10,000) every 3 to 5 minutes as needed. Dilute intratracheal dose in 1 to 2 mL of normal saline.

Infants and children:
IV: Initial dose: 0.01 mg/kg (0.1 mL/kg of 1:10,000). May be repeated every 3 to 5 minutes. Maximum dose: 1 mg or 10 mL.

Intratracheal: 0.1 mg/kg (0.1 mL of 1:1,000 solution). Doses as high as 0.2 mg/kg may be effective. May be repeated every 3 to 5 minutes.

Usual Pediatric Dose for Allergic Reaction:

Infants to 2 years: 0.05 to 0.1 mL IM or subcutaneously of 1:1000 solution. If after 10 minutes from the first injection symptoms are not noticeably improved, administer a second dose.

Children:
2 to 5 years: 0.15 mL IM or subcutaneously
6 to 11 years: 0.2 mL IM or subcutaneously
12 years older: 0.3 mL IM or subcutaneously
If after 10 minutes from the first injection symptoms are not noticeably improved, administer a second dose.

Alternative subcutaneous dosing: 0.01 mg/kg (0.01 mL/kg/dose of 1:1000 solution) not to exceed 0.5 mg.

Subcutaneous suspension: 0.025 mg/kg (0.005 mL/kg of 1:200) once. Not to exceed 0.15 mL every 8 to 12 hours.

Usual Pediatric Dose for Asthma -- Acute:

Infants to 2 years: 0.05 to 0.1 mL IM or subcutaneously of 1:1000 solution. If after 10 minutes from the first injection symptoms are not noticeably improved, administer a second dose.

Children:
2 to 5 years: 0.15 mL IM or subcutaneously
6 to 11 years: 0.2 mL IM or subcutaneously
12 years or older: 0.3 mL IM or subcutaneously
If after 10 minutes from the first injection symptoms are not noticeably improved, administer a second dose.

Alternative subcutaneous dosing: 0.01 mg/kg (0.01 mL/kg/dose of 1:1000 solution) not to exceed 0.5 mg.

Subcutaneous suspension: 0.025 mg/kg (0.005 mL/kg of 1:200 suspension) not to exceed 0.15 mL every 8 to 12 hours.

4 years or older:
Inhalation aerosol: 220 mcg (1 inhalation) once. An additional inhalation may be used after at least one minute. It is recommended that subsequent doses not be administered for at least three hours.

What other drugs will affect epinephrine injection?

Tell your doctor about all other medicines you use, especially:

• digoxin (digitalis, Lanoxin, Lanoxicaps);

• a diuretic (water pill);

• levothyroxine (Levothroid, Levoxyl, Synthroid, Unithroid);

• chlorpheniramine or diphenhydramine (antihistamines that a commonly contained in cold, allergy, or over-the-counter sleep medications);

• an antidepressant such as amitriptyline (Elavil, Etrafon), doxepin (Sinequan), imipramine (Janimine, Tofranil), nortriptyline (Pamelor), and others;

• a beta-blocker such as atenolol (Tenormin, Tenoretic), carvedilol (Coreg), labetalol (Normodyne, Trandate), metoprolol (Lopressor, Toprol), nadolol (Corgard), propranolol (Inderal, InnoPran), sotalol (Betapace), and others;

• ergot medicine such as ergotamine (Ergomar), dihydroergotamine (D.H.E. 45, Migranal Nasal Spray), ergonovine (Ergotrate), or methylergonovine (Methergine);

• heart rhythm medication such as quinidine (Quin-G); or

• an MAO inhibitor such as furazolidone (Furoxone), isocarboxazid (Marplan), phenelzine (Nardil), rasagiline (Azilect), selegiline (Eldepryl, Emsam, Zelapar), or tranylcypromine (Parnate).

This list is not complete and other drugs may interact with epinephrine. Tell your doctor about all medications you use. This includes prescription, over-the-counter, vitamin, and herbal products. Do not start a new medication without telling your doctor.

Where can I get more information?

• Your doctor or pharmacist can provide more information about epinephrine injection.