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Patient education: Use of an epinephrine autoinjector (Beyond the Basics)

Scott H Sicherer, MD, FAAAAI
Section Editor
John M Kelso, MD
Deputy Editor
Anna M Feldweg, MD
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Allergic reactions can be triggered by foods, medications, exercise, latex, insect stings, or unknown triggers, and can cause a sudden, potentially life-threatening allergic reaction called anaphylaxis. Epinephrine (also known as adrenaline) is a medicine that treats the symptoms of serious allergic reactions. (See "Patient education: Anaphylaxis symptoms and diagnosis (Beyond the Basics)".)


A person with allergies, as well as his or her family, close friends, teachers, and coworkers, should learn to use an epinephrine autoinjector before it is needed. Anaphylaxis is unpredictable, and while a person may have a mild reaction one time, a serious or even life-threatening reaction can occur the next time. A person suffering with anaphylaxis may panic and be unable to assist with his/her own injection. In addition, a quick response is necessary to prevent serious complications of anaphylaxis.

An epinephrine autoinjector prescription should be filled immediately. People who are at risk of anaphylaxis should keep at least one epinephrine autoinjector with them at all times. Most allergy specialists recommend having at least two doses of epinephrine available, and some prescribe more. The reason for this is that more than one dose of epinephrine may be needed to treat a more severe anaphylactic reaction.

After filling the prescription, patients/caregivers should practice using the autoinjector. Many manufacturers include a practice autoinjector (that does not have a needle or actual medicine). A video (on the internet or DVD) showing how the autoinjector is used is available from some manufacturers and should be reviewed periodically.

The autoinjector should always be available, including at school or work, when attending parties or traveling, during exercise, and while dining out. It should be kept in a place that can be easily located by others in an emergency, and family and friends should be informed about where the autoinjector is stored. It is also important to ensure that the autoinjector is not expired, although an expired autoinjector may be used if there is no alternative.

Epinephrine should be stored at normal room temperature, away from extreme cold and heat. Epinephrine autoinjectors are unlikely to be damaged by radiograph equipment at airport security.

The epinephrine cartridge window should be examined periodically to ensure that the solution is colorless and contains no floating particles. Solutions that are discolored or contain particles should be replaced. Autoinjectors that have expired should be replaced even if the solution still looks clear. Although far from ideal, if the only epinephrine available in an emergency is in an outdated autoinjector and the solution still looks clear and free of particles, that device can be used as it is better than not treating. Expired autoinjectors may still have some amount of active epinephrine.


Allergic reactions can produce symptoms throughout the body. The symptoms of anaphylaxis are discussed in detail in a separate topic. (See "Patient education: Anaphylaxis symptoms and diagnosis (Beyond the Basics)".)


Epinephrine is the best treatment for anaphylaxis and it works best if it is given within the first few minutes of a severe allergic reaction. Epinephrine rapidly treats all of the most dangerous symptoms of anaphylaxis, including throat swelling, difficulty breathing, and low blood pressure. However, epinephrine is not a perfect treatment, so allergic triggers should be avoided.

Other medicines that are used in the treatment of allergic reactions can help with some of the symptoms, but only epinephrine treats the entire reaction. Antihistamines (such as diphenhydramine and others) help with itching and hives, and asthma inhalers (such as albuterol) can help with coughing and wheezing, but these medications do not treat the dangerous symptoms of throat swelling and low blood pressure. In addition, antihistamines taken by mouth are too slow-acting to be effective in a rapidly-developing episode of anaphylaxis. In contrast, injected epinephrine works within a few minutes.

In short, antihistamines and asthma inhalers are useful in the treatment of anaphylaxis, but they are NOT substitutes for epinephrine. There is no substitute for epinephrine in anaphylaxis.


A person who is having an allergic reaction should use his/her epinephrine autoinjector immediately if he/she:

Is having trouble breathing

Feels tightness in the throat

Feels lightheaded or thinks that he/she might pass out

If treating a child with an allergic reaction, also use the autoinjector if the child:

Is not responding, seems groggy, or passes out during an allergic reaction.

Has food allergies and is vomiting repeatedly shortly after eating, especially if these symptoms are accompanied by flushing or hives.

Is coughing repeatedly during an allergic reaction.

Had previous anaphylaxis and develops widespread hives after possibly eating a trigger food.

Has definitely eaten a trigger food that previously caused very severe anaphylaxis. In this case, use the autoinjector before symptoms appear.


The patient and a family member should review instructions provided with the autoinjector each time a refill is obtained in case there are changes. Instructions may differ from one autoinjector to another. Patients/families should watch videos or review pictures of administration of the autoinjector(s) they are prescribed. Although the EpiPen manufacturer suggests "swinging" the device, another option is simply to press the unit firmly against the leg to activate it. Swinging can result in missing the intended location or twisting the device.

EpiPen or EpiPen Jr — These epinephrine autoinjectors contain one dose per autoinjector. They are available in two different doses, one intended for older children and adults and the other for use in young children.

Stay with other people if possible. There is no need to undress, because the injector works through clothing. However, when possible, lift the edge of a skirt or lower pants to avoid hitting a buckle, zipper, or contents of the pockets.

(1) Flip open the cap and remove the pen from its carrier tube.

(2) Hold the autoinjector in your dominant hand, making a fist. Keep fingers away from both ends to avoid sticking them. The end with the orange tip contains the needle and should be facing down. Use your other hand to pull off the blue safety release. If you are giving the injection to a child or someone who might not be able to stay still, hold his/her leg firmly in place so he/she does not move.

(3) Hold the orange tip near the outer thigh. Swing and firmly push against the outer thigh until it clicks so that the unit is perpendicular (90 degree angle) to the thigh. Hold in place for three seconds to allow all the medicine to be injected (picture 1). The cartridge window will become obscured.

(4) Remove the pen from the thigh. The orange needle cover will extend to automatically cover the needle.

(5) Massage the injected area for 10 seconds.

(6) Call 911 and get to the nearest emergency department immediately (patients should not drive themselves). Allergic reactions sometimes come back.

(7) Take the used autoinjector with you to the hospital emergency department so that it can be disposed of safely.

The EpiPen is available in packages of two, in case a second dose is needed. Large-sized adults may need to repeat the dose. A second dose may also be needed if symptoms are not improving or getting worse after about five minutes, or if symptoms come back before reaching the emergency department.

Auvi-Q — Auvi-Q epinephrine autoinjectors were recalled in the United States in 2015 because they might not deliver the right dose. If you have an Auvi-Q (or the Canadian version, Allerject), let your doctor or pharmacy know right away. They can have it switched to a different type of autoinjector

Adrenaclick — This autoinjector contains one dose of epinephrine. It is available in two different strengths, one intended for use in children and the other for use in adolescents and adults. Adrenaclick is not available in the United States, although it may be again in the future.

Stay with other people if possible. There is no need to undress, because the injector works through clothing. However, when possible, lift the edge of a skirt or lower pants to avoid hitting a buckle, zipper, or contents of the pockets.

(1) Remove the autoinjector from its gray case.

(2) Pull off the gray cap, labeled "1." This will reveal a red tip, which contains a needle inside. Do not place your finger or hand over the red tip.

(3) Pull off the gray cap, labeled "2."

(4) Form a fist around the autoinjector with the red tip pointing down.

(5) Place the red tip against the upper, outer thigh, and press down hard until the autoinjector fires (picture 1). Hold in place for 10 seconds to allow all the medicine to be injected.

(6) Remove the autoinjector and check the red cap. If the needle is visible, epinephrine was given. If the needle is not present, repeat steps 4 through 5 again.

(7) Massage the injected area for 10 seconds.

(8) Call 911 and get to the nearest emergency department immediately. Patients should not drive themselves. Allergic reactions sometimes come back.

(9) Place the used autoinjector back into the carrying case needle end first, and close the case by putting the light gray case top over the non-needle end and close the case. Take the case to the hospital for disposal.

Other devices — Other devices may be available around the world.

Immediately after using the autoinjector — After using an autoinjector, it is important to immediately seek care in an emergency department. The reaction may initially improve, but then come back. When possible, ask someone else to call for help. If alone, treat with the autoinjector first and then call or walk for help. The reason for seeking medical attention is because of the allergic reaction, NOT because epinephrine was used. Epinephrine is safe, but symptoms of the allergic reaction could return, which is why medical attention is needed.

If the person experiencing anaphylaxis begins to feel weak or dizzy, have him/her lie down and elevate the knees or feet. If he/she feels faint or has fainted, leave him/her in the lying down position. NEVER prop him/her up because this can prevent blood from reaching the heart and brain.

Side effects of epinephrine — The benefits of epinephrine are FAR GREATER than the risk of side effects. However, epinephrine can cause short-lived side effects in some patients. The most common side effects include the following:

Heart – Fast and/or pounding heartbeat, fleeting chest pain

Nervous system – Nervousness, trembling, feeling cold, anxiety, headache, dizziness

Digestive system – Nausea, dry throat

Lungs – Fleeting shortness of breath

Autoinjector disposal — The autoinjector should not be thrown away in the normal trash. Instead, patients should take their used or expired autoinjector (inside the case) to a hospital or health care provider for proper disposal.


People have varying responses to a severe allergic reaction. Some people have symptoms that will resolve rapidly and completely with treatment. These people may feel tired, but otherwise normal afterwards. Other people have symptoms that take longer to resolve. For most people, facial swelling and asthma symptoms resolve completely after 24 to 48 hours.

Some people experience a second reaction after the initial allergic reaction, although this is not common. Second reactions can occur hours to a day later, although most second reactions happen within eight hours. For this reason, it is important to stay at the emergency department for several hours of observation after a reaction.

A health care provider may prescribe additional medications for treatment after a reaction, such as antihistamines or oral glucocorticoids (eg, prednisone). It is possible (but not proven) that these medications can help to prevent a second reaction.


Your health care provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Epinephrine autoinjectors (The Basics)
Patient education: Anaphylaxis (The Basics)
Patient education: Angioedema (The Basics)
Patient education: Insect allergy (The Basics)
Patient education: Allergy skin testing (The Basics)
Patient education: Peanut allergy (The Basics)
Patient education: Drug allergy (The Basics)
Patient education: Allergy shots (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Anaphylaxis symptoms and diagnosis (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Anaphylaxis: Emergency treatment
Bee, yellow jacket, wasp, and other Hymenoptera stings: Reaction types and acute management
Hereditary angioedema: Epidemiology, clinical manifestations, exacerbating factors, and prognosis
Clinical manifestations of food allergy: An overview
Diagnosis of Hymenoptera venom allergy
Diagnostic evaluation of food allergy
Drug eruptions
Fatal anaphylaxis
Food allergy in schools and camps
Food-induced anaphylaxis
History and physical examination in the patient with possible food allergy
Laboratory tests to support the clinical diagnosis of anaphylaxis
Pathophysiology of anaphylaxis
Prescribing epinephrine for anaphylaxis self-treatment
Hereditary angioedema: Treatment of acute attacks
Anaphylaxis in infants

The following organizations also provide reliable health information.

Food Allergy Research and Education (FARE)

American Academy of Allergy, Asthma, and Immunology

American College of Allergy, Asthma and Immunology

Anaphylaxis Foundation and Anaphylaxis Network of Canada

The Anaphylaxis Campaign

American Academy of Pediatrics


Literature review current through: Jan 2017. | This topic last updated: Fri Jul 01 00:00:00 GMT 2016.
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