Underutilization of Guideline-Recommended Epinephrine in Anaphylaxis Management: New Study

A retrospective study analyzing anaphylactic reactions treated by emergency medical services (EMS) showed that guideline-recommended first-line therapy with epinephrine was underutilized, despite its association with improved patient outcomes.¹

“The literature published to date and the data presented here suggest that there is some uncertainty among prehospital health care professionals about how to recognize and treat anaphylactic reactions,” investigators, led by Theresa Lüdke, from Technische Universität Dresden in Germany, wrote in the study published online in Prehospital and Disaster Medicine.¹

Given the life-threatening nature of anaphylaxis, guidelines advocate for prompt diagnosis and intervention. Intramuscular epinephrine is recommended in severe cases due to its rapid effect and potential to prevent biphasic reactions.¹ Despite these recommendations, previous research has indicated inconsistent adherence to treatment protocols.^2,3

Lüdke and colleagues conducted a retrospective study assessing anaphylaxis cases managed by Dresden’s Emergency Medical Services (EMS) from 2012 to 2016. The study excluded air rescue cases and classified reactions based on the Ring and Messmer severity scale (Grades I-IV). Researchers analyzed the severity, treatment, hospitalization rates, and outcomes of 1131 adults (mean age, 50.5 years) and 223 children (mean age, 7.4 years).¹

Severe anaphylaxis (Grade II or higher) was observed in 591 adults and 102 children, which was mostly triggered by medication (33%) in adults and food (61%) in children. The average time between the alert and the arrival of the EMS was 6 minutes (range: 1–47 minutes) for children and 7 minutes (range: 1–60 minutes) for adults.¹

Investigators reported that epinephrine was administered in only 7% of adults and 8% of children experiencing Grade II or higher reactions. A statistically significant correlation was observed between epinephrine use and patient improvement in adults (P < .001) and children (P = .016).¹

Among pediatric patients, 61.4% received treatment, including glucocorticoids (50.7%), H1-receptor antagonists (45.3%), H2-receptor antagonists (24.2%), and epinephrine (4.9%). Medication use increased with severity: for Grade I reactions, 59.5% received treatment (2.5% with epinephrine); for Grade II, 61.6% received treatment (5.8% with epinephrine); and for Grade III, 75% received treatment (18.8% with epinephrine).¹

In adults, 75.2% received emergency medication, including glucocorticoids (68.3%), H1-receptor antagonists (69.2%), H2-receptor antagonists (57.4%), and epinephrine (4.5%). Among them, 47.7% had Grade I reactions (70.2% received treatment; 1.9% with epinephrine), 40.5% had Grade II reactions (79.7% received treatment; 4.4% with epinephrine), and 11.8% had Grade III reactions (80.5% received treatment; 15.8% with epinephrine).¹

Most patients with severe reactions were hospitalized, including 66% of adults and 83% of children. However, 21% of adults and 13% of children with severe reactions did not receive further medical observation. A strong correlation between severity and hospitalization was found in adults (P < .001), whereas a non-significant trend was observed in children (P = .179).¹

“Further studies could help to close the existing medical care gap,” researchers concluded.¹ “However, in the case of emergency treatment of anaphylaxis, double-blind, placebo-controlled, randomized trials are hardly feasible, even though they are needed.”

References:

1. Lüdke T, Günther S, Cuevas M, Haacke W, Frank M. Treatment and outcome of anaphylactic reactions in emergency medical services of Dresden/Germany: A 5-year analysis. Prehosp Disaster Med. 2025;40:12-20. doi:10.1017/S1049023X25000184

2. Clark, S, Bock, SA, Gaeta, TJ, et al. Multicenter study of emergency department visits for food allergies. J Allergy Clin Immunol. 2004;113:347–352. doi:10.1016/j.jaci.2003.10.053

3. Helbling, A, Fricker, M, Bircher, A, et al. Notfallbehandlung beim allergischen Schock. Swiss Med Forum – Schweiz Med-Forum. 2011;11:206-212. doi:10.5167/uzh-55545