ASCIA Guidelines for adrenaline injector prescription 2024127.88 KB

This document has been developed by ASCIA, the peak professional body of clinical immunology/allergy specialists in Australia and New Zealand. ASCIA information is based on published literature and expert review, is not influenced by commercial organisations and is not intended to replace medical advice. For patient or carer support contact Allergy & Anaphylaxis Australia or Allergy New Zealand

The aim of these guidelines is to outline the appropriate prescription and dose of adrenaline (epinephrine) injectors for use in non-medical settings, for the emergency first aid treatment of potentially life-threatening severe allergic reactions (anaphylaxis). 

These guidelines should be used in conjunction with clinical judgement, with consideration of issues that include training on a new device and preference of device from the patient or their carer.

These guidelines include adrenaline injector devices that are currently available in Australia and New Zealand, and are based on published evidence regarding:

• Recommended doses of adrenaline injectors to treat severe symptoms, reduce the risk of serious morbidity (e.g. cerebrovascular damage) and prevent fatalities due to anaphylaxis.
• Epidemiology of allergic reactions triggers that may be difficult to avoid.
• Risk factors that have been associated with fatal anaphylaxis.

ASCIA Adrenaline Injector Recommendations

Adrenaline rapidly reverses the effects of anaphylaxis and adrenaline injector devices are considered to be first line emergency first aid treatment for anaphylaxis.

Each adrenaline injector device contains a single fixed dose of adrenaline that is administered intramuscularly into the outer mid-thigh, for safe and rapid absorption of adrenaline.

Adrenaline ampoules and syringes are not considered by ASCIA to be suitable for non-medical settings such as schools, children’s education/care centres and workplaces. 

ASCIA recommends the use of adrenaline as the first line treatment for anaphylaxis using either of the following two brands of adrenaline injectors:

• EpiPen^® Jr (150 microgram) and EpiPen^® (300 microgram) - TGA approved, available in Australia on the PBS (up to two devices per prescription), and New Zealand (Pharmac listed 2023).
• Anapen^® 500 (500 microgram) - TGA approved and available in Australia on the PBS (up to two devices per prescription).

It is important to specify brand and tick box on PBS prescription to ensure that brand is not substituted. EpiPen^® and Anapen^® are also available without prescription.

Both EpiPen^® and Anapen^® devices are widely used in other countries. Most countries have multiple brands of adrenaline injector devices available, and this is important for the following reasons:

• To ensure continued supply of life saving adrenaline, particularly if one brand has stock shortages.
• To provide doctors with a choice of dose, who may prefer to prescribe a higher dose (500 microgram device) for people over 50kg .
• A 500 microgram dose can potentially prevent the need for further doses of adrenaline (which is important due to increasing ambulance delays and many people only carrying one device).
• To encourage suppliers to provide devices with longer shelf life.
• To provide choice for consumers to access devices with points of difference to best suit their needs.

It is essential that patients and carers are trained to use the prescribed device (EpiPen^® or Anapen^®) and provided with an ASCIA Action Plan for Anaphylaxis, including the prescribed device instructions.

ASCIA Adrenaline Injector Dose Recommendations

ASCIA recommends the adrenaline injector doses listed below, based on expert consensus and standard practice by ASCIA members, which vary to the product information. These doses are consistent with the Acute Anaphylaxis Clinical Care Standard for Australia, Australian Prescriber Anaphylaxis Wallchart, Australian Immunisation Handbook and international recommendations from the World Allergy Organisation (WAO), Canada and the UK (refer to weblinks below).

Children 7.5-20kg (aged around one to five years): EpiPen^® Jr (150 microgram) 

Children over 20kg and adults: EpiPen^® (300 microgram) 

Children and adults over 50kg: Anapen^® 500 (500 microgram)* 

*The dose of adrenaline in Anapen 500 is consistent with the intramuscular injection (IMI) dose recommendations for people who weigh more than 50kg in the publications listed below:

https://www.safetyandquality.gov.au/standards/clinical-care-standards/acute-anaphylaxis-clinical-care-standard

https://www.nps.org.au/australian-prescriber/articles/anaphylaxis-emergency-management-for-health-professionals

https://immunisationhandbook.health.gov.au/resources/handbook-tables/doses-of-intramuscular-11000-adrenaline-for-anaphylaxis 

https://www.worldallergyorganizationjournal.org/article/S1939-4551(20)30375-6/fulltext

https://www.resuscitationjournal.com/article/S0300-9572(21)00150-7/fulltext

https://www.canada.ca/en/public-health/services/publications/healthy-living/canadian-immunization-guide-part-2-vaccine-safety/page-4-early-vaccine-reactions-including-anaphylaxis.html#shr-pg0

https://onlinelibrary.wiley.com/doi/full/10.1111/cea.14055

ASCIA Adrenaline Injector Prescription Guide

To access clinical definitions refer to the ASCIA Guidelines for Acute Management of Anaphylaxis on the ASCIA website www.allergy.org.au/hp/papers/acute-management-of-anaphylaxis-guidelines

Updated ASCIA Action Plans for Anaphylaxis, e-training courses and other resources which include EpiPen^® and Anapen^® instructions are available on the ASCIA website www.allergy.org.au/hp/anaphylaxis  

Anaphylaxis Management Plan

An adrenaline injector should only be prescribed within the context of a comprehensive Anaphylaxis Management Plan that includes the following:

1. Referral to a clinical immunology/allergy specialist

Review by a clinical immunology/allergy specialist should occur to:

• Ascertain if the correct trigger(s) have been identified.
• Determine whether the allergy persists.
• Advise on specific management, including suitability for allergen immunotherapy (if available).
• Advise on co-factors that may increase the risk of more serious reactions (e.g. use of beta blockers, NSAID, exercise, asthma control).

2. Identification of anaphylaxis trigger(s)

This should include a comprehensive history, clinical examination, appropriate use and interpretation of allergy testing and under some circumstances, deliberate challenge to prove or disprove allergy.

3. Education on the avoidance of trigger(s)

This is particularly important with food allergy induced anaphylaxis.

4. Provision of an ASCIA Action Plan for Anaphylaxis (emergency response plan)

This plan includes:

• Personal details - patient’s photo, name, confirmed allergens and family/emergency contact.
• Symptoms and signs indicating when to use the adrenaline injector.
• Instructions on how to use the adrenaline injector.

5. Appropriate follow-up 

Review by a patient’s medical practitioner (normally their GP) approximately 12-18 monthly should occur to:

• Review any allergic reactions that have occurred since their last review.
• Examine co-factors (such as poorly controlled or persistent asthma) that may increase the risk of more serious reactions.
• Prescribe adrenaline injectors. If you do not want brand substitution, it is important to specify brand and tick box on PBS prescription. 
• Provide re-education on adrenaline injector use (using a trainer device of the prescribed brand) and positioning (e.g. not standing or walking when experiencing anaphylaxis).
• Renew ASCIA Action Plan for Anaphylaxis - the general version includes instructions for EpiPen^® and Anapen^®..
• Provide ASCIA Travel Plan if required.
• Determine if specialist review is required to ascertain if the allergy persists, new allergies have developed or if more detailed revi4ew is required.

© ASCIA 2024

Content and weblinks updated July 2024

For more information go to www.allergy.org.au/hp/anaphylaxis

To support allergy and immunology research go to www.allergyimmunology.org.au/donate

The ASCIA travel plan and checklist have been developed to assist people at risk of anaphylaxis, who need to carry adrenaline (epinephrine) injectors (EpiPen^® or Anapen^®) when travelling.

The travel plan should be used in conjunction with a red ASCIA Action Plan for Anaphylaxis and both plans need to be completed by a doctor or nurse practitioner.

ASCIA Travel Plan Anaphylaxis 2023184.47 KB

ASCIA PC Checklist Anaphylaxis Travel 2024135.08 KB

ASCIA Checklist - Travel 

This document has been developed by ASCIA, the peak professional body of clinical immunology/allergy specialists in Australia and New Zealand. ASCIA information is based on published literature and expert review, is not influenced by commercial organisations and is not intended to replace medical advice.        

For patient or carer support contact Allergy & Anaphylaxis Australia or Allergy New Zealand.

Plan ahead

You may need to request the following from your doctor or nurse practitioner:

• Prescriptions to cover your trip.
• Letter about medications you need to take.
• Special vaccinations.
• Updated ASCIA Action Plan for Anaphylaxis and ASCIA Travel Plan if you are carrying an adrenaline (epinephrine) injector (EpiPen^® or Anapen^®). You may wish to photograph these onto your mobile phone together with your prescriptions.
• Medical report for your travel insurance policy, if required.

Medication

• Take enough for your trip, and some spare in case you get delayed, lose it or need a higher dose.
• Make sure medicines have not expired or will not expire whilst you are travelling.
• If you have been prescribed adrenaline injectors, you should always carry these with you, including when travelling. You should check if it is possible to replace the adrenaline injectors if they are used.
• Take medication in original packaging. This reduces the risk of having problems with security and customs when leaving Australia or New Zealand as there are regulations about exporting government subsidised medicines. There may also be problems with security and customs when entering other countries.
• Carry essential medicines in your hand luggage. Adrenaline injectors should not be packed into checked-in luggage or in overhead lockers. They must be easily accessible at all times.

Vaccination

• Respiratory infections can trigger asthma so it is advised to consider influenza and other available vaccination. If egg allergic, the influenza vaccine can usually be given safely. For more information go to the ASCIA website www.allergy.org.au/patients/food-allergy/egg-allergy-flu-vaccine.
• If you need other egg-containing vaccines, you will need specialist advice.

Travel Plan for Anaphylaxis

• Download an ASCIA Travel Plan for people at risk of anaphylaxis (severe allergic reaction) from the ASCIA website wwww.allergy.org.au/hp/ascia-plans-action-and-treatment#r3 and have it completed by your doctor or nurse practitioner. This helps if you are carrying adrenaline injectors in hand luggage and through security and customs.

Notify travel agent and airline/s about food allergy

• Contact the airline/s to determine their food allergy policies well in advance of travel and before you book tickets.
• Tell your travel agent and airline/s about your food allergy in advance.

Insurance

• Have adequate travel insurance.
• Ensure the policy covers your medical condition. Special approval may be required.
• Check if there are any special conditions, such as a medical certificate or an additional fee to cover anaphylaxis.

Hospital and other medical facilities

• At your travel destination/s determine the location and contact details of emergency facilities and have these details available in case they are needed.
• Ensure that you have a way of contacting emergency services, such as your mobile phone.

Accommodation

• For food allergy, consider self-catering accommodation, which gives you the option of safely preparing food for yourself.
• When booking, enquire about relevant inhalant allergen risk (such as pets) if you have significant asthma or allergic rhinitis (hay fever) symptoms.
• Speak with your doctor if you often become unwell when away from home. Some people have medications increased or commenced for the time of the travel.

When boarding (airline or ship)

• Notify ship or airline attendants when you board about your allergies and indicate the location of your ASCIA Action Plan and adrenaline injector (if prescribed).
• If an allergic reaction occurs while travelling, follow your ASCIA Action Plan and notify travel attendants so they can assist if needed.
• You may also wish to notify passengers around you, particularly to reduce the likelihood that food may be offered to young children with food allergy.
• Consider taking your own supply of food, bearing in mind restrictions on liquids for international flights. This is particularly important when considering the bottle size of antihistamine liquid or baby formula.
• Consider wiping down tables and armrests to remove possible residual food allergens (contact can sometimes trigger mild allergic symptoms).
• While fumes or dust from inhaled food allergen might cause allergic rhinitis (hay fever) or mild asthma symptoms, the risks of severe allergic reactions is very low unless the food is actually eaten.
• Some airlines offer “exclusion zones” (not serving allergenic food within a few rows of the allergic person). While this can be requested, availability cannot be guaranteed. Since the effectiveness of ‘exclusion zones’ has not yet been researched, it is unknown whether this is an effective strategy to reduce the risk of allergen exposure.
• Keep emergency medication with you in hand luggage. If you are travelling with adrenaline injectors, keep these with you or under the seat in front of you and NOT in the overhead locker. You need to be able to access your adrenaline injectors with your seatbelt fastened.

Language cards

• If travelling to non-English speaking countries and eating out, consider purchasing foreign language travel cards that warn about your allergy to show to food service staff. 

© ASCIA 2024

Content updated March 2024

For more information go to www.allergy.org.au/patients/about-allergy 

To support allergy and immunology research go to www.allergyimmunology.org.au/donate 

Anaphylaxis is the most severe type of allergic reaction and should always be treated as a medical emergency. Anaphylaxis requires immediate treatment with adrenaline (epinephrine). If treatment with adrenaline is delayed, this can result in fatal anaphylaxis. 

ASCIA First Aid Plan Anaphylaxis General 2023

MILD TO MODERATE ALLERGIC REACTIONS

SIGNS

• Swelling of lips, face, eyes
• Hives or welts
• Tingling mouth
• Abdominal pain, vomiting - these are signs of anaphylaxis for insect allergy

ACTIONS

• Stay with person, call for help
• Locate adrenaline device
• Phone family/emergency contact
• Insect allergy - flick out sting if visible
• Tick allergy - seek medical help or freeze tick and allow to drop off

SIGNS OF ANAPHYLAXIS (SEVERE ALLERGIC REACTIONS)

Watch for ANY ONE of the following signs:

• Difficult or noisy breathing
• Swelling of tongue
• Swelling or tightness in throat
• Wheeze or persistent cough
• Difficulty talking or hoarse voice
• Persistent dizziness or collapse
• Pale and floppy (young children)

ACTIONS FOR ANAPHYLAXIS 

2 GIVE ADRENALINE DEVICE

3 Phone ambulance - 000 (AU) or 111 (NZ)

4 Phone family/emergency contact

5 Further adrenaline may be given if no response after 5 minutes

6 Transfer person to hospital for at least 4 hours of observation

IF IN DOUBT GIVE ADRENALINE DEVICE
Commence CPR at any time if person is unresponsive and not breathing normally

© ASCIA 2023

This document has been developed for use as a poster, or to be stored with general use adrenaline devices. 

Adrenaline device instructions are available on the ASCIA website:

www.allergy.org.au/hp/anaphylaxis/how-to-give-injector

ASCIA First Aid Plan for Anaphylaxis Pictorial

MILD TO MODERATE ALLERGIC REACTIONS

SIGNS

ACTIONS

ANAPHYLAXIS (SEVERE ALLERGIC REACTIONS)

WATCH FOR ANY ONE OF THE FOLLOWING SIGNS

ACTIONS

1. LAY PERSON FLAT - do NOT allow them to stand or walk
• If unconscious or pregnant, place in recovery position - on left side if pregnant       

• If breathing is difficult allow them to sit with legs outstretched

• Hold young children flat, not upright

 

  

2. GIVE ADRENALINE INJECTOR as shown on the device label

ASCIA Action Plans for First Aid - Quick links

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