Epinephrine in Anaphylaxis: Too Little, Too Late

Jay Adam Lieberman; Julie Wang


Curr Opin Allergy Clin Immunol. 2020;20(5):452-458. 

In This Article

Abstract and Introduction


Purpose of Review: Epinephrine is the agreed-upon first line treatment for anaphylaxis, yet it continues to be underused by patients/caregivers and providers alike.

Recent Findings: There are unfortunately limited data on how epinephrine can best be utilized in anaphylaxis, which hinders how best to inform patients and providers. Studies reporting underuse suggest various barriers and themes on why this may happen.

Summary: Continued education of patients, caregivers, and providers is needed; however, is not likely to be enough to close the gap. Thus, novel studies on how to increase use; increase availability in a cost-effective manner; and newer, effective delivery routes are still needed.


There is no accepted, single definition of anaphylaxis. In fact, amongst recent anaphylaxis guidelines, the only words that consistently appear in anaphylaxis definitions are 'life-threatening, systemic reaction'.[1] Despite the lack of uniformity in the definition of anaphylaxis, all major anaphylaxis guidelines state that epinephrine is the only first-line therapy for the treatment of anaphylaxis.[2–6] This is based mainly on two factors. First, via its effects as a nonselective adrenergic agonist, the pharmacologic action of epinephrine is thought to reverse key physiologic consequences of anaphylaxis (e.g. vasodilation, mucosal edema, hypotension, and bronchoconstriction).[5] Second, is that lack of use or a delay in epinephrine administration has been associated with anaphylaxis fatalities,[7] Despite this, data continue to suggest that epinephrine is underutilized.[7] In this review, we discuss data supporting the use of epinephrine in anaphylaxis, available data on timing of administration and outcomes, data suggesting poor adherence to guidelines and possible reasons why, and hopeful strategies to mitigate these issues.