Timothy E. Dribin, from the division of emergency medicine, at Cincinnati Children’s Hospital Medical Center.

Timothy E. Dribin, MD

International Consensus on Epinephrine Use, With Timothy E. Dribin, MD

Uncertainty around when patients should administer epinephrine for 

 in community settings prompted an international expert panel to develop consensus-based recommendations.

 The resulting report aims to reduce persistent variation in anaphylaxis action plans.

 spoke with first author Timothy E. Dribin, MD, from the division of emergency medicine, at Cincinnati Children’s Hospital Medical Center, on what clinical gap prompted this international consensus on epinephrine and EMS activation, and how this report addresses both underuse and overuse of epinephrine in community settings.

“The number one question that I get when patients leave our emergency departments, when we prescribe them an autoinjector, is: when should I administer epinephrine? What symptoms should I administer epinephrine for? It's a very complicated answer because there's no consensus on what symptoms warrant epinephrine and what symptoms do not warrant epinephrine,” Dribin said.

He continued by saying that different organizations have their own action plans. Recommendations differ from country to country.

“To address that gap, we said, ‘look, it'd be really helpful if we could have some international recommendations based on the views of an expert panel to try to resolve that variation and come up with consensus around…when…patients [should] administer epinephrine,’” Dribin said. “It is important to note, though, that in clinical practice, we always say if in doubt, patients and caregivers should just err on the side of giving epinephrine, given that it's a very, very safe medicine.”

Although early intramuscular epinephrine remains the first-line treatment for anaphylaxis, real-world studies suggest it is underused. Dribin noted that only approximately 21% of children and 7% of adults with anaphylaxis receive epinephrine before arriving at the emergency department. Delayed or absent epinephrine has been associated with worse outcomes, including increased hospitalization risk.

To address this variability, investigators convened a 34-member international panel from January 2024 through May 2025 and used a modified Delphi process to develop structured clinical scenarios reflecting differing severities and organ system involvement.

The panel categorized reactions across 4 organ systems: cutaneous or mucosal, respiratory, cardiovascular, and gastrointestinal. They generated 24 clinical scenarios representing isolated and combined system involvement, along with 9 candidate modifiers that could lower the threshold for epinephrine administration, such as comorbid asthma, and 12 potential EMS activation recommendations.

In phase 1 of the Delphi process, 21 of 24 scenarios reached consensus recommending epinephrine administration. Two scenarios reached consensus against epinephrine use, and one did not achieve consensus.

Agreement was strongest when reactions involved ≥ 2 organ systems. Isolated but severe respiratory symptoms, such as wheezing or dyspnea, and cardiovascular symptoms, including dizziness or hypotension, also generated high agreement for immediate epinephrine administration.

In contrast, isolated mild cutaneous symptoms, such as limited urticaria, or mild gastrointestinal symptoms, did not warrant epinephrine according to panel consensus. The single scenario that failed to reach consensus involved moderate mucocutaneous symptoms without other organ involvement. Dribin emphasized that this reflects real-world variability in clinician and caregiver risk tolerance.

The panel achieved consensus on 5 modifiers and 10 EMS activation recommendations. In phase 2, investigators embedded consensus modifiers into scenarios that initially did not recommend epinephrine or lacked consensus. Only 2 of 15 reassessed scenarios subsequently reached consensus for epinephrine administration, suggesting that modifiers did not broadly shift decision thresholds.

Dribin acknowledged that although underuse remains the larger public health concern, overuse carries implications. Administration of epinephrine typically prompts EMS activation or emergency department evaluation, which can result in healthcare expenditures, missed school or work, and patient anxiety.

For clinicians, Dribin advised contextual interpretation of the consensus statements, particularly in scenarios where agreement was not reached. He cautioned against viewing the recommendations as prescriptive mandates, noting that shared decision-making and individualized counseling remain central.

“Ultimately, what we are doing right now is we're trying to build a smartphone application that can incorporate these algorithms, so that in real time, patients and caregivers can receive prescriptive advice about whether to administer epinephrine,” Dribin said. “…it will also spur them to observe their symptoms and either re-dose epinephrine, or for those reactions where they didn't initially administer epinephrine, if their reactions were to get worse, it would make sure that they're checking their symptoms and then administering that device.”

Dribin TE, Sampson HA, Anagnostou A, et al. Epinephrine and emergency medical services activation recommendations during acute allergic reactions in community settings: International consensus report. 

Golden DBK, Wang J, Waserman S, et al. Anaphylaxis: A 2023 practice parameter update. 

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Timothy E. Dribin, MD

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