Version July 2025
Dosage guidance:
Safety: Epinephrine injectable dosage form concentrations are no longer labeled as ratio expressions (eg, 1:1,000); however, a ratio expression of 1:1,000 is equivalent to 1 mg/mL and 1:10,000 is equivalent to 0.1 mg/mL (Ref).
Anaphylaxis and other severe immediate hypersensitivity reactions:
Note: IM administration in the anterolateral aspect of the middle third of the thigh is preferred; early administration (including before hospital arrival) is essential to prevent progression to life-threatening manifestations (Ref).
IM: 0.3 or 0.5 mg (use 0.5 mg in patients >50 kg unless patient is rapidly deteriorating, then may use 0.3 mg via autoinjector) using the 1 mg/mL solution; may repeat every ~5 to 15 minutes (or sooner if clinically indicated) if patient does not adequately respond. Most patients respond to the first or second dose; if inadequate response, additional measures should be instituted (eg, IV fluids and continuous IV epinephrine infusion) (Ref).
IV, intraosseous (alternative routes): Note: In general, reserve IV administration for patients who are unresponsive (eg, profoundly hypotensive) after several epinephrine IM injections. Only use intraosseous when IV access is not readily available; dosing is the same as IV route (Ref).
Continuous infusion (off label): IV: Initial: 0.1 to 0.2 mcg/kg/minute (or 8 to 16 mcg/minute for an 80 kg patient) administered with fluid resuscitation; starting dose is dependent on severity of anaphylaxis; titrate every 2 to 3 minutes by 0.05 mcg/kg/minute (or 4 mcg/minute) to response; usual dosing range: 0.01 to 0.2 mcg/kg/minute (or ~1 to 16 mcg/minute for an 80 kg patient) (Ref).
Slow IV bolus (off label): Note: Only consider in impending cardiopulmonary arrest when continuous infusion epinephrine is not immediately available; IV bolus administration may be associated with cardiac arrhythmias and cardiac ischemia (Ref).
Initial: 0.05 to 0.1 mg using the 0.1 mg/mL solution (further diluted in 10 mL of NS) administered over 1 to 10 minutes; may repeat once after 3 minutes if patient remains unresponsive to initial dose. If inadequate response, additional measures should be instituted (eg, IV fluids and continuous IV epinephrine infusion) (Ref). If patient develops cardiopulmonary arrest, use higher IV/intraosseous bolus doses (ie, 1 mg [using the 0.1 mg/mL solution] every 3 to 5 minutes) administered rapidly (see "Sudden Cardiac Arrest due to Asystole, Pulseless Electrical Activity, Ventricular Fibrillation, or Pulseless Ventricular Tachycardia [off-label use]") (Ref).
Self-treatment using auto-injector or nasal spray for severe allergic reactions (eg, insect stings, food):
Note: For outpatient use, prescribe at least 2 doses for patients who have a prior anaphylactic reaction and for those at risk for severe anaphylaxis (Ref).
Auto-injector: IM (preferred route), SUBQ: 0.3 or 0.5 mg (if available, 0.5 mg dose may be used or prescribed for patients with more severe symptoms or who weigh >60 kg); may repeat every ~5 to 15 minutes (or sooner if clinically indicated) if patient does not adequately respond to initial dose; more than 2 sequential doses should only be administered under direct medical supervision; IM administration is preferred to SUBQ due to more rapid absorption and higher peak concentrations, especially when administered in the thigh (Ref).
Nasal spray: Intranasal: One spray (2 mg) into one nostril; if response is inadequate, administer a second dose in the same nostril 5 minutes after the first dose.
Asthma, acute severe (off-label use):
Note: May use in patients who are unable to use inhaled beta-agonists. Although rare and without formal supportive data, may consider in patients who are refractory to standard therapy and are in impending respiratory arrest (Ref).
IM (preferred route), SUBQ: 0.3 to 0.5 mg using the 1 mg/mL concentration; if severe symptoms persist after initial dose, may repeat every 20 minutes for a total of 3 doses (Ref). Note: IM administration is preferred to SUBQ due to more rapid absorption and higher peak concentrations when administered in the thigh (Ref).
Atrioventricular block, symptomatic and/or hemodynamically unstable (off-label use):
Note: Should only be used as a temporizing measure until a permanent pacemaker can be placed, if clinically indicated. In most cases, pharmacologic agents will not be effective and temporary transcutaneous or transvenous pacing is necessary as a bridge to permanent pacemaker placement (Ref).
Continuous infusion:
Weight-based dosing: IV: Initial: 0.03 to 0.1 mcg/kg/minute; dosage range: 0.03 to 0.5 mcg/kg/minute; titrate to desired effect (Ref).
Non-weight-based dosing: IV: Initial: 2 to 10 mcg/minute; dosage range: 2 to 40 mcg/minute; titrate to desired effect (doses calculated and rounded for an 80 kg patient based on weight-based dosing using the referenced sources) (Ref).
Bradycardia, symptomatic and/or hemodynamically unstable (unresponsive to atropine) (off-label use):
Continuous infusion:
Weight-based dosing: IV: Initial: 0.03 to 0.1 mcg/kg/minute; dosage range: 0.03 to 0.5 mcg/kg/minute; titrate to desired effect (Ref).
Non-weight- based dosing: IV: Initial: 2 to 10 mcg/minute; dosage range: 2 to 40 mcg/minute; titrate to desired effect (doses calculated and rounded for an 80 kg patient based on weight-based dosing using the referenced sources) (Ref).
Hypotension or shock:
Cardiogenic shock (alternative agent) (off-label use):
Note: Typically, not the preferred initial agent in cardiogenic shock; consider other options. Optimal goal of therapy is not well established, but typically titrate to maintain end-organ perfusion (Ref). Institutional protocols may vary with weight-based or non-weight-based dose regimens.
Continuous infusion:
Weight-based dosing:
IV: Usual dosage range: 0.01 to 0.5 mcg/kg/minute; titrate based on clinical end point (eg, BP, end-organ perfusion) (Ref).
Non-weight-based dosing:
IV: Usual dosage range: 1 to 40 mcg/minute; titrate based on clinical end point (eg, BP, end-organ perfusion) (doses calculated and rounded for an 80 kg patient based on weight-based dosing using the referenced sources) (Ref).
Post–cardiac arrest shock (off-label use):
Note: Optimal goal of therapy is not well established, but typically titrate to mean arterial blood pressure (MAP) >65 mm Hg and preferably 80 to 100 mm Hg to optimize cerebral and end-organ perfusion (Ref). Institutional protocols may vary with weight-based or non-weight-based dose regimens.
Continuous infusion:
Weight-based dosing:
IV: Usual dosage range: 0.01 to 1 mcg/kg/minute; titrate based on clinical end points (eg, MAP, end-organ perfusion); maximum dose for refractory shock: 2 mcg/kg/minute (Ref).
Non-weight-based dosing:
IV: Usual dosage range: 1 to 80 mcg/minute; titrate based on clinical end points (eg, MAP, end-organ perfusion); maximum dose for refractory shock: 160 mcg/minute (doses calculated and rounded for an 80 kg patient based on weight-based dosing using the referenced sources) (Ref).
Septic shock and other vasodilatory shock states (adjunctive agent):
Note: Considered as adjunctive use when goal MAP not achieved with initial vasopressor or need for inotropic therapy. In general, maintain goal MAP (eg, ~65 mm Hg); consider use if patient is in shock during or after fluid resuscitation (Ref). Institutional protocols may vary with weight-based or non-weight-based dose regimens.
Continuous infusion:
Weight-based dosing:
IV: Initial: 0.01 to 0.2 mcg/kg/minute; titrate to goal MAP or end-organ perfusion; usual dose range: 0.01 to 0.5 mcg/kg/minute; maximum dose range for refractory shock: 0.5 to 2 mcg/kg/minute (Ref).
Non-weight-based dosing:
IV: Initial: 1 to 15 mcg/minute; titrate to goal MAP or end-organ perfusion; usual dose range: 1 to 40 mcg/minute; maximum dose range for refractory shock: 40 to 160 mcg/minute (doses calculated and rounded for an 80 kg patient based on weight-based dosing using the referenced sources) (Ref).
Inotropic support (off-label use):
Note: Inotropic actions predominate at lower doses and vasoconstrictive actions predominate at higher doses (Ref). Institutional protocols may vary with weight-based or non-weight-based dose regimens.
Continuous infusion:
Weight-based dosing:
IV: Usual dosage range: 0.01 to 0.5 mcg/kg/minute; titrate based on clinical end point (eg, BP, end-organ perfusion) (Ref).
Non-weight-based dosing:
IV: Usual dosage range: 1 to 40 mcg/minute; titrate based on clinical end point (eg, BP, end-organ perfusion) (doses calculated and rounded for an 80 kg patient based on weight-based dosing using the referenced sources) (Ref).
Mydriasis (induction and maintenance) during intraocular surgery (product specific):
Note: Must only use preservative-free vials without tartaric acid. Not all formulations of epinephrine injection are suitable for intraocular use; consult the prescribing information for formulation details (Ref). Protocols may vary with concentrations and dose.
Intraocular: Prior to use, must dilute 1 mL of a 1 mg/mL single-use solution to a concentration of 1 to 10 mcg/mL or if using for intracameral injection, 2.5 to 10 mcg/mL.
Irrigating solution (using 1 to 10 mcg/mL): Use as needed during the procedure (Ref).
Intracameral injection (using 2.5 to 10 mcg/mL): Injection volume: 0.1 mL (Ref).
Sudden cardiac arrest due to asystole, pulseless electrical activity, ventricular fibrillation, or pulseless ventricular tachycardia (off-label use):
IV, Intraosseous: 1 mg (using the 0.1 mg/mL solution) every 3 to 5 minutes until return of spontaneous circulation (Ref).
Endotracheal (alternative route): 2 to 2.5 mg every 3 to 5 minutes until IV/intraosseous access established or return of spontaneous circulation; before administration, dilute in 5 to 10 mL NS or sterile water (using the 1 mg/mL solution) and use hyperventilation or manual ventilation after administration (Ref). Note: May cause false-negative reading with exhaled CO2 detectors; use second method to confirm tube placement if CO2 is not detected (Ref).
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
The renal dosing recommendations are based upon the best available evidence and clinical expertise. Senior Editorial Team: Bruce Mueller, PharmD, FCCP, FASN, FNKF; Jason A. Roberts, PhD, BPharm (Hons), B App Sc, FSHP, FISAC; Michael Heung, MD, MS.
Altered kidney function: Endotracheal, Intranasal, Intraocular, Parenteral: No dosage adjustment likely to be necessary for any degree of kidney impairment (limited excretion in urine as unchanged drug) (Ref).
Hemodialysis, intermittent (thrice weekly): Endotracheal, Intranasal, Intraocular, Parenteral: Not significantly dialyzed (Ref): No supplemental dose or dosage adjustment necessary (Ref).
Peritoneal dialysis: Endotracheal, Intranasal, Intraocular, Parenteral: No dosage adjustment necessary (Ref).
CRRT: Endotracheal, Intranasal, Intraocular, Parenteral: Unlikely to be significantly dialyzable (Ref): No dosage adjustment necessary (Ref).
PIRRT (eg, sustained, low-efficiency diafiltration): Endotracheal, Intranasal, Intraocular, Parenteral: No dosage adjustment necessary (Ref).
There are no dosage adjustments provided in the manufacturer's labeling.
The recommendations for dosing in patients with obesity are based upon the best available evidence and clinical expertise. Senior Editorial Team: Jeffrey F. Barletta, PharmD, FCCM; Manjunath P. Pai, PharmD, FCP; Jason A. Roberts, PhD, BPharm (Hons), B App Sc, FSHP, FISAC.
Class 1, 2, and 3 obesity (BMI ≥30 kg/m2):
Continuous infusion: IV: If institution uses weight-based dosing, use ideal body weight for initial weight-based dosing calculations, then titrate to hemodynamic effect and clinical response (Ref). If institution uses nonweight-based dosing for vasoactive agents, continue with this approach. During therapy, clinicians should not change dosing weight from one weight metric to another (ie, ideal body weight to/from actual body weight or weight-based dosing to/from nonweight-based dosing) (Ref). Refer to adult dosing for indication-specific doses.
Intermittent dosing: IM, SUBQ, intraosseous, endotracheal: Use nonweight-based dosing (Ref). Refer to adult dosing for indication specific doses.
Rationale for recommendations:
There is a paucity of studies evaluating the influence of obesity on epinephrine dosing or pharmacokinetics. Observational studies, including epinephrine, phenylephrine, and norepinephrine, suggest nonweight-based dosing strategies may result in lower overall cumulative dose requirements and increased drug exposure to second-line agents in some patients and may not be advantageous in time to achieving hemodynamic stability (Ref); however, it is difficult to show outcome differences between weight-based and nonweight-based dosing because of dose titration to target BP, particularly in the context of retrospective studies. Furthermore, there is substantial variability in response in critically ill patients, irrespective of weight. Due to the short onset of action and small Vd, rapid titration to clinical effect after initial dosing is possible (Ref).
In terms of IM administration, there are few pharmacokinetic studies in patients with obesity; however, the data do not demonstrate differences compared to patients without obesity (Ref). An observational, multicenter study in patients presenting with allergic reactions to the emergency room did not find differences in the need for repeat IM dosing between patients with obesity and those without obesity (Ref). Some experts recommend use of a longer 1.5-inch needle to penetrate the subcutaneous fat to maximize effectiveness in patients with obesity, although use of a fixed 0.3 mg dose via autoinjector is recommended in a rapidly deteriorating patient (Ref).
Refer to adult dosing.
(For additional information see "Epinephrine (adrenaline) (systemic): Pediatric drug information")
Dosage guidance:
Safety: Epinephrine dosage form concentrations are no longer labeled as ratio expressions (eg, 1:1,000); however, a ratio expression of 1:1,000 is equivalent to 1 mg/mL and 1:10,000 is equivalent to 0.1 mg/mL (Ref). Epinephrine dosing varies by route of administration; use caution.
Asystole or pulseless arrest (Ref):
Infants, Children, and Adolescents:
IV, Intraosseous (preferred routes of administration): 0.01 mg/kg (0.1 mL/kg of 0.1 mg/mL solution) immediately after initiating CPR (within 5 minutes of starting chest compressions), maximum dose: 1 mg/dose; repeat every 3 to 5 minutes until return of spontaneous circulation.
Endotracheal: 0.1 mg/kg (0.1 mL/kg of 1 mg/mL solution) immediately after initiating CPR (within 5 minutes of starting chest compressions), maximum dose: 2.5 mg/dose; repeat every 3 to 5 minutes until return of spontaneous circulation or IV/intraosseous access established. Note: Recent clinical studies suggest that lower epinephrine concentrations delivered by endotracheal administration may produce transient beta 2-adrenergic effects which may be detrimental (eg, hypotension, lower coronary artery perfusion pressure). IV or intraosseous are the preferred methods of administration.
Bradycardia (Ref):
Infants, Children, and Adolescents:
IV, Intraosseous: 0.01 mg/kg (0.1 mL/kg of 0.1 mg/mL solution) (maximum dose: 1 mg/dose or 10 mL/dose); may repeat every 3 to 5 minutes as needed.
Endotracheal: 0.1 mg/kg (0.1 mL/kg of 1 mg/mL solution) (maximum dose: 2.5 mg/dose); doses as high as 0.2 mg/kg may be effective; may repeat every 3 to 5 minutes as needed until IV/intraosseous access established. Note: Recent clinical studies suggest that lower epinephrine concentrations delivered by endotracheal administration may produce transient beta 2-adrenergic effects which may be detrimental (eg, hypotension, lower coronary artery perfusion pressure). IV or intraosseous are the preferred methods of administration.
Cardiac output increase or maintenance/post resuscitation stabilization: Infants, Children, and Adolescents: Continuous IV or intraosseous infusion: 0.05 to 1 mcg/kg/minute; doses <0.3 mcg/kg/minute generally produce beta-adrenergic effects and higher doses (>0.3 mcg/kg/minute) generally produce alpha-adrenergic vasoconstriction; titrate dosage to desired effect (Ref).
Hypersensitivity reaction/anaphylaxis: Note: With parenteral administration, the preferred route of administration is IM administration in the anterolateral aspect of the middle third of the thigh; SUBQ administration results in slower absorption and is less reliable (Ref).
General dosing or health care settings: Infants, Children, and Adolescents: IM: 0.01 mg/kg/dose (0.01 mL/kg/dose of 1 mg/mL solution) not to exceed: Prepubertal child: 0.3 mg/dose; adolescent: 0.5 mg/dose; administered every 5 to 15 minutes; usual practice is to administer up to 3 doses, but more doses may be needed in some cases (Ref).
Self-/caregiver-administration following type I allergic reactions (eg, insect stings, food):
Autoinjector: Note: If anaphylactic symptoms persist after first dose, may repeat dose in 5 to 15 minutes (Ref).
Manufacturer's labeling (eg, Adrenaclick, Auvi-Q, EpiPen Jr, EpiPen):
Infants, Children, and Adolescents:
7.5 to <15 kg: IM, SUBQ: 0.1 mg; if anaphylactic symptoms persist, dose may be repeated based on severity and response to initial dose; more than 2 sequential doses should only be administered under direct medical supervision.
15 to <30 kg: IM, SUBQ: 0.15 mg; if anaphylactic symptoms persist, dose may be repeated based on severity and response to initial dose; more than 2 sequential doses should only be administered under direct medical supervision.
≥30 kg: IM, SUBQ: 0.3 mg; if anaphylactic symptoms persist, dose may be repeated based on severity and response to initial dose; more than 2 sequential doses should only be administered under direct medical supervision.
Alternate dosing: AAP Recommendations (Ref): Limited data available:
Infants, Children, and Adolescents:
7.5 to <25 kg: IM: 0.15 mg.
≥25 kg: IM: 0.3 mg.
Intranasal : Note: Each Neffy spray is an individual unit (either 1 mg dose or 2 mg dose); a patient should be prescribed or have access to 2 dosing units appropriate for their weight.
Children ≥4 years and Adolescents:
≥15 kg to <30 kg: Neffy 1 mg/0.1 mL spray: Intranasal: 1 spray (1 mg) in one nostril once; if symptoms persist or worsen after first dose, may repeat dose in 5 minutes in the same nostril.
≥30 kg: Neffy 2 mg/0.1 mL spray: Intranasal: 1 spray (2 mg) in one nostril once; if symptoms persist or worsen after first dose, may repeat dose in 5 minutes in the same nostril.
Refractory cases:Infants, Children, and Adolescents: Continuous IV infusion: Prepared 1 mcg/mL solution: Initial: 0.1 mcg/kg/minute; titrate dose to response. Usual range: 0.1 to 1 mcg/kg/minute; maximum dose: 10 mcg/minute (Ref). Note: Suggested concentration of initial solution is more dilute than those typically utilized in other clinical conditions; evaluate infusion concentration with continued therapy and patient fluid status.
Hypotension/Shock, fluid resistant: Infants, Children, and Adolescents: Continuous IV or intraosseous infusion: 0.1 to 1 mcg/kg/minute; rates >0.3 mcg/kg/minute associated with vasopressor activity (Ref).
Mydriasis during intraocular surgery, induction, and maintenance (product specific):
Note: Not all formulations of epinephrine injection are suitable for intraocular use; consult product labeling prior to use.
Infants, Children, and Adolescents: Intraocular: Must dilute 1 mL of a 1 mg/mL preservative-/sulfite-free, single-use solution to a concentration of 1 mcg/mL to 10 mcg/mL prior to intraocular use: May use as an irrigation solution as needed during the procedure or may administer intracamerally (ie, directly into the anterior chamber of the eye) with a bolus dose of 0.1 mL of a 2.5 mcg/mL to 10 mcg/mL dilution.
Dosage adjustment for concomitant therapy: Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
There are no dosage adjustments provided in the manufacturer's labeling.
There are no dosage adjustments provided in the manufacturer's labeling.
The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.
Injection:
Frequency not defined:
Cardiovascular: Acute myocardial infarction, angina pectoris, cardiac arrhythmia, cardiomyopathy (stress), chest pain, hypertension, increased cardiac work, ischemic heart disease, palpitations, peripheral vasoconstriction, supraventricular tachycardia, tachyarrhythmia, tachycardia, vasoconstriction, ventricular arrhythmia, ventricular ectopy, ventricular fibrillation
Dermatologic: Diaphoresis, gangrene of skin and/or subcutaneous tissue (at injection site), pallor, piloerection
Endocrine & metabolic: Hyperglycemia, hypoglycemia, hypokalemia, insulin resistance, lactic acidosis
Gastrointestinal: Nausea, vomiting
Local: Localized blanching, tissue necrosis at injection site
Nervous system: Anxiety, apprehension, asthenia, cerebral hemorrhage, cerebrovascular accident, disorientation, dizziness, drowsiness, exacerbation of Parkinson disease, headache, memory impairment, panic, paresthesia, psychomotor agitation, restlessness, tingling sensation, tremor
Neuromuscular & skeletal: Limb ischemia
Renal: Kidney impairment
Respiratory: Dyspnea, pulmonary edema, rales
Nasal spray:
Adverse reactions reported in adults unless otherwise indicated.
>10%:
Nervous system: Headache (6% to 18%), jitteriness (children, adolescents, adults: 1% to 11%), paresthesia (children, adolescents: 10%; nose: 19%)
Respiratory: Nasal congestion (children, adolescents: 19%; adults: 2%), nasal discomfort (children, adolescents: 19%; adults: 10% to 13%), respiratory congestion (upper tract: children, adolescents: 14%), rhinorrhea (children, adolescents: 19%; adults: 3% to 7%), sneezing (children, adolescents: 14%; adults: 4%), throat irritation (2% to 19%)
1% to 10%:
Dermatologic: Pruritus of nose (4%)
Gastrointestinal: Abdominal pain (1% to 4%), gingival pain (4%), nausea (2% to 3%), oral hypoesthesia (4%), vomiting (2%)
Nervous system: Dizziness (2% to 3%), fatigue (children, adolescents: 10%), tremor (8%)
Respiratory: Dry nose (children, adolescents: 10%), dry throat (children, adolescents: 10%), epistaxis (children, adolescents: 10%), nasal cavity pain (children, adolescents: 10%)
There are no absolute contraindications to the use of intranasal (Neffy) or injectable epinephrine (including Adrenaclick, Auvi-Q, EpiPen, EpiPen Jr, Symjepi, Allerject [Canadian product], and Twinject [Canadian product]) in a life-threatening situation. The manufacturer’s labeling for some injectable products include the following contraindications: Hypersensitivity to sympathomimetic amines; general anesthesia with halogenated hydrocarbons (eg, halothane) or cyclopropane; narrow angle glaucoma; nonanaphylactic shock; in combination with local anesthesia of certain areas such as fingers, toes, and ears; use in situations where vasopressors may be contraindicated (eg, thyrotoxicosis, diabetes, in obstetrics when maternal blood pressure is in excess of 130/80 mm Hg and in hypertension and other cardiovascular disorders).
Significant drug interactions exist, requiring dose/frequency adjustment or avoidance. Consult drug interactions database for more information.
Injectable solution (Adrenalin, Epinephrine injection, USP): There are no contraindications listed in the manufacturer's labeling.
Concerns related to adverse effects:
• Cardiac effects: May precipitate or aggravate angina pectoris or induce cardiac arrhythmias; use with caution especially in patients with cardiac disease or those receiving drugs that sensitize the myocardium.
• Extravasation: IV administration: Vesicant; ensure proper needle or catheter placement prior to and during infusion. Avoid extravasation.
• Pulmonary edema: Due to peripheral constriction and cardiac stimulation, pulmonary edema may occur.
• Renal effects: Due to renal blood vessel constriction, decreased urine output may occur.
Disease-related concerns:
• Cardiovascular disease: Use with caution in patients with cardiovascular diseases (eg, arrhythmias, cerebrovascular disease, coronary artery disease, heart disease, hypertension).
• Diabetes: Use with caution in patients with diabetes mellitus; may transiently increase blood glucose levels.
• Hypovolemia: Correct blood volume depletion before administering any vasopressor.
• Parkinson disease: Use with caution in patients with Parkinson disease; psychomotor agitation or temporary worsening of symptoms may occur.
• Pheochromocytoma: Use with caution in patients with pheochromocytoma.
• Thyroid disease: Use with caution in patients with thyroid disease.
Special populations:
• Older adults: Use with caution in older adults.
• Pediatric: Lacerations, bent needles, and embedded needles have been reported in young children who are uncooperative during injection for hypersensitivity reaction using parenteral formulations. To minimize risk, hold the child's leg firmly in place and limit movement prior to and during injection. Although the manufacturers of auto-injectors recommend varying lengths of time for holding the device in the thigh (range: 2 to 10 seconds), longer times have occasionally resulted in injury. For all devices, the needle should remain in the thigh for the least amount of time as possible (~3 seconds) (Brown 2016) (also see "Administration").
Dosage form specific issues:
• Accidental injection: Accidental injection into digits, hands, or feet may result in local reactions including injection-site pallor, coldness, and hypoesthesia or injury resulting in bruising, bleeding, discoloration, erythema, or skeletal injury. Patient should seek immediate medical attention if this occurs.
• Intraocular use: Not all formulations of epinephrine injection are suitable for intraocular use; consult the prescribing information prior to selecting a product. Appropriate products should have an indication for induction and maintenance of mydriasis during intraocular surgery and should not contain any sulfites or preservatives (ISMP 2017). Prior to intraocular use of an appropriate product, must dilute single-use 1 mg/mL (1 mL) solution to a concentration of 1 mcg/mL to 10 mcg/mL. Corneal endothelial damage has occurred when products containing sodium bisulfite have been used undiluted; therefore, dilution is advised prior to any intraocular use. In addition, products containing chlorobutanol must also not be used intraocularly (may be harmful to corneal endothelium).
• Nasal spray: Absorption may be affected in patients with underlying structural and anatomical nasal conditions (eg, polyps, history of nasal fractures, injuries, or nasal surgery); consider use of injectable epinephrine products in these patients. Nasal mucosa may be altered for up to 2 weeks following intranasal epinephrine administration, which may enhance systemic absorption of intranasally administered medications; risk of adverse effects may be increased.
• Sulfites: Some products may contain sulfites as preservatives. The presence of sulfites in some products should not deter administration during a serious allergic or other emergency situation even if the patient is sulfite-sensitive.
Other warnings/precautions:
• Appropriate use: Hypersensitivity reactions: Do not inject into the buttock; may not effectively treat anaphylaxis and has been associated with Clostridial infections (gas gangrene). Serious skin and soft tissue infections, including necrotizing fasciitis and myonecrosis caused by Clostridia (gas gangrene), have been reported rarely at the injection site. Cleansing skin with alcohol may reduce bacteria at the injection site, but alcohol cleansing does not kill Clostridium spores. Preferred injection site is anterolateral aspect of the thigh. Do not administer repeated injections at the same site (tissue necrosis may occur). Monitor for signs/symptoms of injection-site infection.
Neffy 1 mg/0.1 mL: FDA approved March 2025; current availability anticipated in May 2025. Information pertaining to this monograph is under revision. Neffy 1 mg/0.1 mL nasal solution is intended for use in pediatric patients aged 4 years and older weighing 15 kg to less than 30 kg. Consult the product label for more information.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Kit, Injection:
Adyphren Amp: 1 mg/mL [DSC] [contains sodium metabisulfite]
Adyphren Amp II: 1 mg/mL [DSC] [contains sodium metabisulfite]
Adyphren II: 1 mg/mL [DSC] [contains sodium metabisulfite]
Epinephrine Professional: 1 mg/mL [contains edetate (edta) disodium dihydrate, sodium metabisulfite]
EPINEPHrinesnap: 1 mg/mL [contains edetate (edta) disodium dihydrate, sodium metabisulfite]
EpinephrineSnap-EMS: 1 mg/mL [contains edetate (edta) disodium dihydrate, sodium metabisulfite]
Epinephrinesnap-v: 1 mg/mL [contains sodium metabisulfite]
EPIsnap: 1 mg/mL [DSC] [contains sodium metabisulfite]
Kit, Injection [preservative free]:
Adyphren: 1 mg/mL [DSC] [contains sodium metabisulfite]
Epinephrinesnap-v: 1 mg/mL [contains edetate (edta) disodium dihydrate, sodium metabisulfite]
Solution, Injection:
Adrenalin: 30 mg/30 mL (30 mL) [contains chlorobutanol (chlorobutol), disodium edta, sodium metabisulfite]
Generic: 1 mg/mL (1 mL, 10 mL, 30 mL); 10 mg/10 mL (10 mL); 30 mg/30 mL (30 mL)
Solution, Injection [preservative free]:
Adrenalin: 1 mg/mL (1 mL) [contains edetate (edta) disodium dihydrate, sodium metabisulfite]
Generic: 1 mg/mL (1 mL)
Solution, Intravenous:
Adrenalin: 5 mg/250 mL NaCl 0.9% (250 mL); 8 mg/250 mL in NaCl 0.9% (250 mL) [contains edetate (edta) disodium dihydrate]
Adrenalin-NaCl: 4 mg/250 mL in NaCl 0.9% (250 mL) [contains edetate (edta) disodium]
Solution, Nasal:
Neffy: 1 mg/0.1 mL (2 ea); 2 mg/0.1 mL (2 ea) [contains benzalkonium chloride, edetate (edta) disodium, sodium metabisulfite]
Solution Auto-injector, Injection:
Auvi-Q: 0.1 mg/0.1 mL (2 ea); 0.15 mg/0.15 mL (2 ea); 0.3 mg/0.3 mL (2 ea) [contains sodium bisulfite]
EpiPen 2-Pak: 0.3 mg/0.3 mL (1 ea, 2 ea) [contains sodium metabisulfite]
EpiPen Jr 2-Pak: 0.15 mg/0.3 mL (2 ea) [contains sodium metabisulfite]
Generic: 0.15 mg/0.3 mL (1 ea, 2 ea); 0.15 mg/0.15 mL (1 ea, 2 ea); 0.3 mg/0.3 mL (1 ea, 2 ea)
Solution Auto-injector, Injection [preservative free]:
Generic: 0.15 mg/0.3 mL (1 ea, 2 ea)
Solution Prefilled Syringe, Injection [preservative free]:
Symjepi: 0.15 mg/0.3 mL (1 ea [DSC], 2 ea [DSC]); 0.3 mg/0.3 mL (1 ea [DSC], 2 ea [DSC]) [latex free; contains sodium metabisulfite]
Generic: 1 mg/10 mL (10 mL [DSC])
Solution Prefilled Syringe, Intravenous [preservative free]:
Generic: 1 mg/10 mL (10 mL)
Yes
Kit (EPINEPHrinesnap Injection)
1 mg/mL (per each): $148.80
Kit (EpinephrineSnap-EMS Injection)
1 mg/mL (per each): $104.40
Kit (Epinephrinesnap-v Injection)
1 mg/mL (per each): $109.20
Solution (Adrenalin Injection)
1 mg/mL (per mL): $17.95
30 mg/30 mL (per mL): $10.02
Solution (Adrenalin Intravenous)
5MG/250ML 0.9% (per mL): $0.24
8MG/250ML 0.9% (per mL): $0.38
Solution (Adrenalin-NaCl Intravenous)
4MG/250ML 0.9% (per mL): $0.19
Solution (EPINEPHrine (Anaphylaxis) Injection)
1 mg/mL (per mL): $17.95
30 mg/30 mL (per mL): $8.00 - $9.00
Solution (EPINEPHrine Injection)
1 mg/mL (per mL): $14.98 - $16.16
Solution (EPINEPHrine PF Injection)
1 mg/mL (per mL): $17.50
Solution (Neffy Nasal)
1MG/0.1ML (per each): $426.00
2MG/0.1ML (per each): $426.00
Solution Auto-injector (Auvi-Q Injection)
0.1MG/0.1ML (per each): $373.15
0.15 mg/0.15 mL (per each): $373.15
0.3 mg/0.3 mL (per each): $373.15
Solution Auto-injector (EPINEPHrine Injection)
0.15 mg/0.15 mL (per each): $247.01
0.15 mg/0.3 mL (per each): $187.50 - $346.91
0.3 mg/0.3 mL (per each): $187.50 - $346.91
Solution Auto-injector (EpiPen 2-Pak Injection)
0.3 mg/0.3 mL (per each): $365.17
Solution Auto-injector (EpiPen Jr 2-Pak Injection)
0.15 mg/0.3 mL (per each): $365.17
Solution Prefilled Syringe (EPINEPHrine Intravenous)
1 mg/10 mL (per mL): $1.23 - $1.65
Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling. [DSC] = Discontinued product
Solution, Injection:
Adrenalin: 1 mg/mL (1 mL, 30 mL) [contains chlorobutanol (chlorobutol), sodium metabisulfite]
Generic: 1 mg/10 mL (10 mL); 1 mg/mL (1 mL, 10 mL)
Solution Auto-injector, Intramuscular:
Allerject: 0.15 mg/0.15 mL (1 ea); 0.3 mg/0.3 mL (1 ea) [contains sodium metabisulfite]
Anapen: 0.3 mg/0.3 mL ([DSC]) [contains sodium metabisulfite]
Anapen Junior: 0.15 mg/0.3 mL ([DSC]) [contains sodium metabisulfite]
Emerade: 0.5 mg/0.5 mL (1 ea) [contains edetate (edta) disodium, sodium metabisulfite]
EpiPen: 0.3 mg/0.3 mL (2 mL) [contains sodium metabisulfite]
EpiPen Jr: 0.15 mg/0.3 mL (2 mL) [contains sodium metabisulfite]
Epinephrine solutions for injection can be administered IM, intraosseous, endotracheally, IV, or SUBQ. Note: Adrenaclick, Allerject [Canadian product], Auvi-Q, EpiPen, EpiPen Jr, and Symjepi contain a single, fixed-dose of epinephrine and may only be administered IM (preferred) or SUBQ. Twinject Auto-Injectors [Canadian product] contain two doses; the first fixed-dose is available for auto-injection; the second dose is available for manual injection following partial disassembly of device.
IV : IV infusions require an infusion pump. When administering as a continuous infusion, central line administration is preferred; extravasation may cause severe ischemic necrosis. If central line is not available, may administer for a short duration (<72 hours) through a peripheral IV catheter placed in a large vein, at a proximal site (eg, in or proximal to antecubital fossa). Frequent monitoring of the IV catheter site is recommended to rapidly identify extravasation (Ref). Refer to institutional policies and procedures; catheter placement/size and vasopressor concentration may vary depending on institution. Administration through midline catheters may also be an option (Ref).
Vesicant; ensure proper needle or catheter placement prior to and during infusion; avoid extravasation.
Extravasation management: If extravasation occurs, stop infusion immediately; leave cannula/needle in place temporarily but do NOT flush the line; gently aspirate extravasated solution, then remove needle/cannula; elevate extremity; apply dry warm compresses; initiate phentolamine (or alternative antidote) (Ref).
Phentolamine: SUBQ: Dilute 5 to 10 mg in 10 mL NS and administer into extravasation site as soon as possible after extravasation; if IV catheter remains in place, administer initial dose intravenously through the infiltrated catheter; may repeat in 60 minutes if patient remains symptomatic (Ref).
For accidental digital epinephrine injection, inject phentolamine 0.5 to 4.5 mg (diluted in 5 mL NS) divided into multiple SUBQ injections along the area of accidental injury as soon as possible after the injury (Ref).
Alternatives to phentolamine:
Nitroglycerin topical 2% ointment: Apply a 1-inch strip to the site of ischemia to cover the affected areas; may repeat every 8 hours as necessary (Ref).
Terbutaline:
Large extravasations: SUBQ: Infiltrate affected extravasation area with terbutaline 1 mg using a solution of terbutaline 1 mg diluted in 10 mL NS; may repeat dose after 15 minutes (Ref).
Small extravasations: SUBQ: Infiltrate affected extravasation area with 0.5 mg using a solution of terbutaline 1 mg diluted in 1 mL NS; may repeat dose after 15 minutes (Ref).
SUBQ: SUBQ administration results in slower absorption and lower peak concentrations (Ref). IM administration is preferred (Ref).
IM: IM administration in the anterolateral aspect of the middle third of the thigh is preferred in the setting of anaphylaxis (Ref). Administer through clothing if necessary. Although the manufacturers of auto-injectors recommend varying lengths of time for holding the device in the thigh (range: 2 to 10 seconds), longer times have occasionally resulted in injury. For all devices, the needle should remain in the thigh for the least amount of time as possible. With nearly every device, the full dose is delivered within 3 seconds. For EpiPen, holding the device against the leg followed by removing the cap and then compressing has been described for easier administration. Never reinsert needles (Ref). Do not administer repeated injections at the same site. Do not inject into the buttocks or into digits, hands, or feet. Adrenaclick, Adrenalin, Allerject [Canadian product], Auvi-Q, EpiPen, EpiPen Jr, Symjepi, and Twinject [Canadian product] should only be injected into the anterolateral aspect of the thigh.
Obesity: For adults with obesity experiencing anaphylaxis, administer recommended dose using a 1.5-inch needle or if patient is rapidly deteriorating, use a fixed-dose autoinjector, if available (Ref). In overweight or obese children, because skin surface to muscle depth is greater in the upper half of the thigh, administration into the lower half of the thigh may be preferred. In very obese children, injection into the calf will provide an even greater chance of intramuscular administration (Ref).
Intranasal: Insert the nozzle of the nasal spray fully into one nostril until fingers touch the nose. Hold the nasal spray straight into the nose; do not angle the nasal spray toward the septum or outer wall of the nose. Use right hand for self-administration into the right nostril or left hand for self-administration into the left nostril. Press the plunger firmly to activate. Do not sniff during or after administration. Neffy product contains a single, fixed dose of epinephrine. Do not prime or reuse for more than one administration. If a second dose is needed, administer into the same nostril via a new nasal spray 5 minutes after the first dose.
Intraocular (product specific): May administer diluted solution (concentration: 1 to 10 mcg/mL) as an irrigation solution as needed during the procedure or may administer intracamerally (ie, directly into the anterior chamber of the eye). Note: Must only use preservative free vials without tartaric acid. Not all formulations of epinephrine injection are suitable for intraocular use; consult the prescribing information. Appropriate products should have mydriasis during intraocular surgery as an approved indication (Ref).
Endotracheal (cardiac arrest): Dilute in NS or sterile water (using the 1 mg/mL epinephrine solution). Absorption may be greater with sterile water (Ref). Stop compressions, spray drug quickly down tube. Follow immediately with several quick insufflations and continue chest compressions. May cause false-negative reading with exhaled CO2 detectors; use second method to confirm tube placement if CO2 is not detected (Ref).
Endotracheal:
Neonates: Use 0.1 mg/mL solution.
Infants, Children, and Adolescents: Use 1 mg/mL solution; administer and flush with a minimum of 5 mL NS, followed by 5 manual ventilations.
Intranasal: Spray: Neffy: Administration is into a single nostril only; a single Neffy device contains 1 dose; do not prime device.
Insert the nozzle of the nasal spray fully into one nostril until fingers touch the nose. Hold the nasal spray straight into the nose; do not angle the nasal spray toward the septum or outer wall of the nose. Press the plunger firmly to activate. Do not sniff during or after administration. Do not reuse for more than one administration. If a second dose is needed, acquire a new device and administer into the same nostril via a new nasal spray 5 minutes after the first dose.
Intraocular: Administer as a diluted solution (concentration: 1 to 10 mcg/mL) as an irrigation solution as needed during the procedure or may administer intracamerally (ie, directly into the anterior chamber of the eye). Note: Not all formulations of epinephrine injection are suitable for intraocular use; consult the product labeling prior to use. Appropriate products should have mydriasis during intraocular surgery as an approved indication and should not contain any sulfites or preservatives (Ref).
Parenteral:
Direct IV or intraosseous: If using 0.1 mg/mL concentration, no dilution is necessary; the 1 mg/mL concentration must be further diluted.
Continuous IV infusion: Administer as a continuous infusion via an infusion pump. Must be diluted prior to administration. Central line administration is preferred; extravasation may cause severe ischemic necrosis. If central line not available, may administer for a short duration through a peripheral IV catheter placed in a large vein or via intraosseous access using a more dilute solution or with a second carrier fluid (Ref); frequent monitoring of the IV catheter site is recommended to rapidly identify extravasation (Ref). Note: Refer to institutional policies and procedures; catheter placement/size and vasopressor concentration may vary depending on institution. Avoid use of ankle veins (due to potential for gangrene), leg veins in those with occlusive vascular diseases (eg, diabetic endarteritis, Buerger disease, arteriosclerosis, atherosclerosis).
Rate of infusion (mL/hour) = dose (mcg/kg/minute) × weight (kg) × 60 minutes/hour divided by the concentration (mcg/mL)
Vesicant; ensure proper needle or catheter placement prior to and during infusion; avoid extravasation. If extravasation occurs, stop infusion immediately; leave cannula/needle in place but do NOT flush the line; gently aspirate extravasated solution, then remove needle/cannula; elevate extremity; apply dry warm compresses. Initiate phentolamine (or alternative antidote) (Ref).
IM, Autoinjectors (eg, Auvi-Q, EpiPen, EpiPen Jr): Intramuscularly into anterolateral aspect of the middle third of the thigh is preferred in the setting of anaphylaxis (Ref). Administer through clothing if necessary. Before administering to a child, immobilize leg to prevent laceration or other injury and consider restraining children who are likely to move during administration. Although the manufacturers of auto-injectors recommend varying lengths of time for holding the device in the thigh (range: 2 to 10 seconds), longer times have occasionally resulted in injury. For all devices, the needle should remain in the thigh for the least amount of time as possible. With nearly every device, the full dose is delivered within 3 seconds. For EpiPen, holding the device against the leg followed by removing the cap and then compressing has been described for easier administration. Never reinsert needles (Ref). Do not administer repeated injections at the same site. Do not inject into the buttocks or into digits, hands, or feet. Some products are single-use products and a new device should be used for each dose; consult product-specific labeling. Note: In children who are overweight or obese, because skin surface to muscle depth is greater in the upper half of the thigh, administration into the lower half of the thigh may be preferred. In children who are very obese, injection into the calf will provide an even greater chance of intramuscular administration (Ref).
SUBQ: Use only 1 mg/mL solution. Although not preferred, if used for treatment of anaphylaxis, administer into the anterolateral aspect of the middle third of the thigh (Ref).
IV infusion: 1 mg in 250 mL (concentration: 4 mcg/mL) or 4 mg in 250 mL (concentration: 16 mcg/mL) of D5W or NS; 1 mg in 1,000 mL (concentration: 1 mcg/mL) in D5W, D5NS, or NS.
IV infusion: 10 mcg/mL, 20 mcg/mL, 32 mcg/mL, 40 mcg/mL, or 64 mcg/mL.
Anaphylaxis and other severe immediate hypersensitivity reactions: Treatment of type I allergic reactions, including anaphylactic reactions.
Hypotension or shock: Treatment of hypotension associated with septic shock in adults (to increase mean arterial BP).
Mydriasis during intraocular surgery (product specific): Induction and maintenance of mydriasis during intraocular surgery. Note: Not all formulations of epinephrine injection are suitable for intraocular use; consult the prescribing information.
Asthma, acute severe; Atrioventricular block, symptomatic and/or hemodynamically unstable; Bradycardia, symptomatic and/or hemodynamically unstable (unresponsive to atropine); Cardiogenic shock; Inotropic support; Post–cardiac arrest shock; Sudden cardiac arrest due to asystole, pulseless electrical activity, ventricular fibrillation, or pulseless ventricular tachycardia
Adrenalin may be confused with Akovaz
EPINEPHrine may be confused with ePHEDrine
Epifrin may be confused with ephedrine, EpiPen
Neffy (nasal spray) may be confused with nalaxone (nasal sprays [Kloxxado, Narcan, Rextovy, ReVive])
The Institute for Safe Medication Practices (ISMP) includes this medication (IM, SUBQ administration) and also this drug class (adrenergic agonist, IV) among its list of drugs/classes which have a heightened risk of causing significant patient harm when used in error (High-Alert Medications in Acute Care, Community/Ambulatory Care, and Long-Term Care Settings).
Medication errors have occurred due to confusion with epinephrine products expressed as ratio strengths (eg, 1:1000 vs 1:10,000).
Epinephrine 1:1000 = 1 mg/mL and is most commonly used IM
Epinephrine 1:10,000 = 0.1 mg/mL and is used IV
Medication errors have occurred when topical epinephrine 1 mg/mL (1:1000) has been inadvertently injected. Vials of injectable and topical epinephrine look very similar. Epinephrine should always be appropriately labeled with the intended administration.
EpiPen 0.3 mg and EpiPen Jr 0.15 mg auto-injectors, and authorized generic versions, may potentially have delayed injection or be prevented from properly injecting due to device failure from spontaneous activation caused by using sideways force to remove the blue safety release, device failure from inadvertent or spontaneous activation due to a raised blue safety release, difficulty removing the device from the carrier tube, and user errors. Health care providers, patients, and caregivers should periodically review the EpiPen user instructions and practice using the EpiPen trainer to ensure proper understanding and utilization of the EpiPen auto-injector. Patients and caregivers should inspect their epinephrine autoinjector prior to needing it to ensure the blue safety release is not raised and that the device can be easily removed from the carrier tube (FDA 2020).
EpiPen [US, Canada, and multiple international markets] may be confused with Epigen brand name for glycyrrhizinic acid [Argentina, Mexico, Russia] and Epopen brand name for epoetin alfa [Spain] and Epigent brand name for gentamicin [multiple international markets]
Substrate of COMT;
Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the drug interactions program by clicking on the “Launch drug interactions program” link above.
Alpha1-Blockers: May decrease therapeutic effects of Alpha-/Beta-Agonists. Risk C: Monitor
Antidiabetic Agents: Hyperglycemia-Associated Agents may decrease therapeutic effects of Antidiabetic Agents. Risk C: Monitor
Atomoxetine: May increase hypertensive effects of Sympathomimetics. Atomoxetine may increase tachycardic effects of Sympathomimetics. Risk C: Monitor
Azosemide: May decrease therapeutic effects of EPINEPHrine (Systemic). Risk C: Monitor
Benperidol: May decrease therapeutic effects of EPINEPHrine (Systemic). Risk C: Monitor
Benzylpenicilloyl Polylysine: Coadministration of Alpha-/Beta-Agonists and Benzylpenicilloyl Polylysine may alter diagnostic results. Management: Consider use of a histamine skin test as a positive control to assess a patient's ability to mount a wheal and flare response. Risk D: Consider Therapy Modification
Beta-Blockers (Beta1 Selective): May decrease therapeutic effects of EPINEPHrine (Systemic). Risk C: Monitor
Beta-Blockers (Nonselective): May increase hypertensive effects of EPINEPHrine (Systemic). Risk C: Monitor
Beta-Blockers (with Alpha-Blocking Properties): May decrease therapeutic effects of EPINEPHrine (Systemic). Risk C: Monitor
Blonanserin: May decrease therapeutic effects of EPINEPHrine (Systemic). Risk X: Avoid
Bornaprine: Sympathomimetics may increase anticholinergic effects of Bornaprine. Risk C: Monitor
Bretylium: May increase therapeutic effects of Alpha-/Beta-Agonists (Direct-Acting). Risk C: Monitor
Bromocriptine: May increase hypertensive effects of Alpha-/Beta-Agonists. Management: Consider alternatives to this combination when possible. If combined, monitor for hypertension and tachycardia, and do not coadminister these agents for more than 10 days. Risk D: Consider Therapy Modification
Bromperidol: May decrease therapeutic effects of EPINEPHrine (Systemic). Risk X: Avoid
Cannabinoid-Containing Products: May increase tachycardic effects of Sympathomimetics. Risk C: Monitor
Cardiac Glycosides: EPINEPHrine (Systemic) may increase arrhythmogenic effects of Cardiac Glycosides. Risk C: Monitor
Chloroprocaine (Systemic): May increase hypertensive effects of Alpha-/Beta-Agonists. Risk C: Monitor
Chlorprothixene: May increase adverse/toxic effects of EPINEPHrine (Systemic). Specifically, paradoxical hypotension and tachycardia may be increased. EPINEPHrine (Systemic) may increase therapeutic effects of Chlorprothixene. Risk C: Monitor
CloZAPine: May decrease therapeutic effects of Alpha-/Beta-Agonists. Risk C: Monitor
Cocaine (Topical): May increase hypertensive effects of Sympathomimetics. Management: Consider alternatives to use of this combination when possible. Monitor closely for substantially increased blood pressure or heart rate and for any evidence of myocardial ischemia with concurrent use. Risk D: Consider Therapy Modification
COMT Inhibitors: May increase serum concentration of COMT Substrates. Risk C: Monitor
Dihydralazine: Sympathomimetics may decrease therapeutic effects of Dihydralazine. Risk C: Monitor
Diuretics: May increase arrhythmogenic effects of EPINEPHrine (Systemic). Diuretics may decrease vasopressor effects of EPINEPHrine (Systemic). Risk C: Monitor
Doxofylline: Sympathomimetics may increase adverse/toxic effects of Doxofylline. Risk C: Monitor
Ergot Derivatives (Vasoconstrictive CYP3A4 Substrates): May increase vasoconstricting effects of Alpha-/Beta-Agonists. Risk X: Avoid
Esketamine (Injection): May increase adverse/toxic effects of Sympathomimetics. Specifically, the risk for elevated heart rate, hypertension, and arrhythmias may be increased. Risk C: Monitor
Guanethidine: May increase hypertensive effects of Sympathomimetics. Guanethidine may increase arrhythmogenic effects of Sympathomimetics. Risk C: Monitor
Haloperidol: May decrease vasoconstricting effects of EPINEPHrine (Systemic). Management: Consider alternatives to this combination and monitor for reduced epinephrine efficacy, and possible paradoxical effects (ie, hypotension), when combined. Use of alternative vasopressor agents (eg, phenylephrine, metaraminol, norepinephrine) is preferred. Risk D: Consider Therapy Modification
Hexoprenaline: May increase adverse/toxic effects of Alpha-/Beta-Agonists. Risk X: Avoid
Hyaluronidase: May increase vasoconstricting effects of Alpha-/Beta-Agonists. Management: Do not use hyaluronidase to enhance the dispersion or absorption of alpha-/beta-agonists. Use of hyaluronidase for other purposes in patients receiving alpha-/beta-agonists may be considered as clinically indicated. Risk D: Consider Therapy Modification
Inhalational Anesthetics: May increase arrhythmogenic effects of EPINEPHrine (Systemic). Management: Administer epinephrine with added caution in patients receiving, or who have recently received, inhalational anesthetics. Use lower than normal doses of epinephrine and monitor for the development of cardiac arrhythmias. Risk D: Consider Therapy Modification
Isoproterenol: May increase therapeutic effects of EPINEPHrine (Systemic). Risk X: Avoid
Kratom: May increase adverse/toxic effects of Sympathomimetics. Risk X: Avoid
Levothyroxine: May increase therapeutic effects of Sympathomimetics. Sympathomimetics may increase therapeutic effects of Levothyroxine. Levothyroxine may increase adverse/toxic effects of Sympathomimetics. Specifically, the risk of coronary insufficiency may be increased in patients with coronary artery disease. Risk C: Monitor
Linezolid: May increase hypertensive effects of Sympathomimetics. Management: Consider initial dose reductions of sympathomimetic agents, and closely monitor for enhanced blood pressure elevations, in patients receiving linezolid. Risk D: Consider Therapy Modification
Lisuride: May increase hypertensive effects of Alpha-/Beta-Agonists. Risk X: Avoid
Melperone: May increase adverse/toxic effects of EPINEPHrine (Systemic). Risk C: Monitor
Monoamine Oxidase Inhibitors: May increase hypertensive effects of EPINEPHrine (Systemic). Risk C: Monitor
Pergolide: May increase hypertensive effects of Alpha-/Beta-Agonists. Risk C: Monitor
Promethazine: May decrease vasoconstricting effects of EPINEPHrine (Systemic). Management: Avoid epinephrine and consider norepinephrine or phenylephrine when treating hypotension due to promethazine overdose. Consider alternative vasocontrictors in patients treated with promethazine. This combination may be indicated in anaphylaxis treatment. Risk D: Consider Therapy Modification
Serotonin/Norepinephrine Reuptake Inhibitor: May increase tachycardic effects of Alpha-/Beta-Agonists. Serotonin/Norepinephrine Reuptake Inhibitor may increase vasopressor effects of Alpha-/Beta-Agonists. Management: If possible, avoid coadministration of direct-acting alpha-/beta-agonists and serotonin/norepinephrine reuptake inhibitors. If coadministered, monitor for increased sympathomimetic effects (eg, increased blood pressure, chest pain, headache). Risk D: Consider Therapy Modification
Solriamfetol: Sympathomimetics may increase hypertensive effects of Solriamfetol. Sympathomimetics may increase tachycardic effects of Solriamfetol. Risk C: Monitor
Spironolactone: May decrease vasoconstricting effects of Alpha-/Beta-Agonists. Risk C: Monitor
Sympathomimetics: May increase adverse/toxic effects of Sympathomimetics. Risk C: Monitor
Tedizolid: May increase adverse/toxic effects of Sympathomimetics. Specifically, the risk for increased blood pressure and heart rate may be increased. Risk C: Monitor
Tricyclic Antidepressants: May increase vasopressor effects of Alpha-/Beta-Agonists. Management: Avoid, if possible, the use of alpha-/beta-agonists in patients receiving tricyclic antidepressants. If combined, monitor for evidence of increased pressor effects and consider reductions in initial dosages of the alpha-/beta-agonist. Risk D: Consider Therapy Modification
Vasopressin: Alpha-/Beta-Agonists (Direct-Acting) may increase hypertensive effects of Vasopressin. The effect of other hemodynamic parameters may also be enhanced. Risk C: Monitor
Epinephrine crosses the placenta (Sandler 1964).
Epinephrine is recommended for the treatment of anaphylaxis in pregnant women. Specific dosing is not available; use with caution and monitor hemodynamic response (Hepner 2013). Medications used for the treatment of cardiac arrest in pregnancy are the same as in the non-pregnant woman. Doses and indications should follow current Advanced Cardiovascular Life Support guidelines. Appropriate medications should not be withheld due to concerns of fetal teratogenicity (AHA [Jeejeebhoy 2015]).
It is not known if epinephrine is present in breast milk.
Epinephrine is generally considered compatible in breastfeeding and is recommended for the treatment of anaphylaxis in breastfeeding women (WHO 2002).
Heart rate, blood pressure (invasive blood pressure monitoring recommended while receiving continuous infusion); monitor site of infusion for blanching/extravasation; continuous cardiac monitoring required during continuous infusion. If using to treat hypotension, assess intravascular volume prior to and during therapy; support as needed; monitor for cardiac arrhythmias, hyperlactatemia, and hyperglycemia.
Consult individual institutional policies and procedures.
Stimulates alpha-, beta1-, and beta2-adrenergic receptors resulting in relaxation of smooth muscle of the bronchial tree, cardiac stimulation (increasing myocardial oxygen consumption), and dilation of skeletal muscle vasculature; small doses can cause vasodilation via beta2-vascular receptors; large doses may produce constriction of skeletal and vascular smooth muscle
Onset of action: Bronchodilation: SUBQ: ~5 to 10 minutes
Absorption: Orally ingested doses are rapidly metabolized in GI tract and liver; pharmacologically active concentrations are not achieved
Distribution: Does not cross blood-brain barrier
Metabolism: Taken up into the adrenergic neuron and metabolized by monoamine oxidase and catechol-o-methyltransferase; circulating drug hepatically metabolized
Half-life elimination: IV: <5 minutes
Excretion: Urine (as inactive metabolites, metanephrine, and sulfate and hydroxy derivatives of mandelic acid, small amounts as unchanged drug)
