Epinephrine First: Closing the Anaphylaxis Gap in Primary Care Practice

Anaphylaxis remains a time-critical emergency that is frequently first encountered in the primary care setting, including pediatric practices, urgent care centers, and family medicine clinics.

Despite advances in the understanding of anaphylaxis pathophysiology and treatment, gaps persist between guideline recommendations and real-world practice, particularly regarding first-line therapy and post event disposition.

Updated practice parameters emphasize earlier recognition of anaphylaxis, including in infants and toddlers with atypical or nonverbal presentations, and reinforce that intramuscular epinephrine is the cornerstone of acute management. These updates also clarify the limited role of antihistamines and corticosteroids in treating acute anaphylaxis and refine which patients truly require emergency department evaluation after an epinephrine-treated event.

Recent guideline updates, including the 2020 focused parameter on anaphylaxis and the broader 2024 practice parameter update, synthesize nearly a decade of new evidence to guide clinicians in everyday decision-making.

For primary care clinicians, key practice implications include recognizing high-risk populations (such as patients with a history of severe anaphylaxis, those requiring multiple epinephrine doses, or those with uncontrolled asthma or mast cell disorders), understanding the impact of cofactors such as exercise, stress, and use of beta-blockers or angiotensin-converting enzyme inhibitors, and adopting a low threshold for epinephrine use when anaphylaxis is suspected. The guidance underscores that timely administration of epinephrine can halt progression of the reaction at multiple physiologic levels, improve outcomes, and in selected mild or moderate cases, when treated promptly, may obviate the need for automatic emergency department referral.

In an upcoming panel discussion, David Golden, MD, clinical associate professor of medicine at Johns Hopkins University School of Medicine, and Jay Lieberman, MD, professor of medicine at the University of Tennessee, will review these evolving recommendations and translate them into practical strategies for busy primary care practices.

Drawing on the latest practice parameters, Golden will focus on the underlying evidence, risk stratification, and emergency treatment algorithms, while Lieberman will highlight real-world implementation, including redesign of anaphylaxis order sets, emergency action plans for families, and communication strategies that lower barriers to epinephrine use. Together, Golden and Lieberman will offer an actionable framework to help clinicians recognize anaphylaxis early, reach for epinephrine first, and make informed decisions about observation, referral, and follow-up.

Disclosures include Novartis Pharmaceuticals, ABBVIE, Genentech, Aquestive Therapeutics for Lieberman; and Phadia US and Genentech USA for Golden.

References:

1. 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

2. ARS Pharma. ARS Pharmaceuticals Announces FDA Approval of neffy® 1 mg (epinephrine nasal spray) for Type I Allergic Reactions, Including Anaphylaxis, in Pediatric Patients Weighing 15 to < 30 Kilograms - ARS Pharmaceuticals. ARS Pharmaceuticals. Published March 5, 2025. Accessed February 20, 2026. https://ir.ars-pharma.com/news-releases/news-release-details/ars-pharmaceuticals-announces-fda-approval-neffyr-1-mg

3. Aquestive Therapeutics. Aquestive Therapeutics Announces FDA Issuance of Complete Response Letter for Anaphylm^TM - Aquestive Therapeutics. Aquestive Therapeutics. Published February 6, 2026. Accessed February 20, 2026. https://investors.aquestive.com/news-releases/news-release-details/aquestive-therapeutics-announces-fda-issuance-complete-response