Delinking Epinephrine Use From Mandatory ED Visits

Part 2 of the special report focuses on one of the most practice-changing elements of the 2024 anaphylaxis guideline update: whether patients must automatically go to the emergency department after using epinephrine.

David Golden, MD, explained that for decades, patients were universally instructed to seek emergency care after any epinephrine use, a message reinforced by package inserts and clinical dogma. However, during early COVID-19, patients and clinicians were reluctant to send otherwise stable individuals to emergency departments. Interim guidance developed during that period prompted a careful re-review of the evidence, ultimately leading to a permanent change in the 2024 practice parameters.

The updated guidance states that if epinephrine is administered promptly, the reaction is not severe, symptoms resolve, and the patient remains well, an emergency department visit is not always necessary. Golden emphasized that most anaphylaxis cases are mild to moderate, that approximately 90% respond to a single dose of epinephrine, and that biphasic reactions are uncommon, generally occurring in 5% to 10% of cases and often associated with delayed treatment.

By delinking epinephrine use from automatic emergency care, clinicians can reduce fear that delays treatment. Golden stressed that patients should focus on the reaction itself, not on meeting strict diagnostic criteria or worrying about the consequences of using epinephrine. The updated parameters explicitly note that epinephrine can be given even if anaphylaxis criteria are not fully met, and that giving epinephrine does not retrospectively confirm that the reaction was anaphylaxis.

The experts said factors such as patient comfort, access to emergency care, availability of a second epinephrine dose, presence of a caregiver, and individual risk factors all influence whether observation at home is appropriate. Severe presentations, such as hypotension, loss of consciousness, or significant respiratory distress, still warrant urgent medical evaluation.

The discussion concludes by reinforcing that the goal of the updated guidance is not to discourage emergency care, but to remove barriers to early epinephrine use. By shifting control to patients and families and tailoring decisions to individual circumstances, the 2024 update aims to improve outcomes while reducing unnecessary fear and hesitation.

Experts include:

Brian Schroer, MD, of Cleveland Clinic Children’s Hospital

Jay Lieberman, MD, of the University of Tennessee Health Science Center

David Golden, MD, of Johns Hopkins University

Disclosures include Novartis Pharmaceuticals, Regeneron Pharmaceuticals, BioCryst, GlaxoSmithKline, Amgen, GENZYME Corporation, AstraZeneca Pharmaceuticals, and LEO Pharma for Schroer; Novartis Pharmaceuticals, ABBVIE, Genentech, Aquestive Therapeutics for Lieberman; and Phadia US and Genentech USA for Golden.

References

Golden DBK, Wang J, Waserman S, et al. Anaphylaxis: A 2023 practice parameter update. Ann Allergy Asthma Immunol. 2024;132(2):124-176. doi:10.1016/j.anai.2023.09.015