Drugs List

Therapeutic Indications

Uses

Anaphylaxis acute - emergency treatment
Cardiopulmonary resuscitation

Administration

Emergency treatment of acute anaphylaxis where intramuscular injection has been ineffective
For slow intravenous injection

Cardiopulmonary resuscitation for the management of cardiac arrest
For intravenous injection. The intraosseous route may also be used where necessary.

Contraindications

None known

Precautions and Warnings

Elderly
Predisposition to narrow angle glaucoma
Arteriosclerosis
Asthma
Autonomic dysreflexia
Brain damage
Cardiac arrhythmias
Cardiomyopathy
Cardiovascular disorder
Cerebrovascular disorder
Diabetes mellitus
Hypercalcaemia
Hypertension
Hyperthyroidism
Hypokalaemia
Ischaemic heart disease
Narrow angle glaucoma
Occlusive peripheral vascular disorder
Parkinsonism
Phaeochromocytoma
Pregnancy
Prostate disorder
Psychoneurosis
Pulmonary emphysema
Severe angina
Severe renal impairment
Unstable pulmonary hypertension with advanced right ventricular failure

Sodium content of formulation may be significant
Advise patient not to drive or operate machinery until assessed
Not all available brands are licensed for all age groups
Not all available brands are licensed for all indications
Not all available brands are licensed for all routes of administration
Contains sodium metabisulfite. Caution,may cause allergic reactions
Do NOT inject into the extremities or penis
Avoid administration in the gluteal region
Monitor blood pressure
Monitor ECG
May affect results of some laboratory tests

Adrenaline is indicated in life threatening situations, therefore all precautions are relative.

When the 1 in 10,000 strength of adrenaline is required for this indication a "ready to use" preparation should be selected.

Adrenaline should not be injected in to the fingers, toes, ears, nose buttocks or genitalia due to the risk of ischaemic tissue necrosis. Repeated local injection can result in necrosis at sites of injection from vascular constriction. Accidental intravascular injection may result in cerebral haemorrhage due to a sudden rise in blood pressure.

Adrenaline should be used cautiously, if at all, during general anaesthesia with halogenated hydrocarbon anaesthetics.

Pregnancy and Lactation

Pregnancy

Use adrenaline with caution in pregnancy.

Briggs (2011) states that because adrenaline naturally occurs in the body, it is difficult to separate the effects of administration on the foetus compared that of endogenous adrenaline.

Many manufacturers strongly caution use in labour. Adrenaline usually inhibits spontaneous or oxytocin induced contractions. It may reduce the placental blood flow (anaphylactic shock will also have this effect) and delay the second stage of labour. Adrenaline may produce a prolonged period of uterine atony with haemorrhage and cause anoxia to the foetus.

There is some evidence of a slightly increased incidence of congenital abnormalities. However, according to Briggs (2011) this may reflect the indication for which it was administered to the mother.

Adrenaline is teratogenic in some animal species.

Schaefer comments that the systemic use of adrenaline is restricted to emergency.

The use of all medication in pregnancy should be avoided whenever possible; particularly in the first trimester. Non-drug treatments should also be considered. When essential, a medication with the best safety record over time should be chosen, employing the lowest effective dose for the shortest possible time. Polypharmacy should be avoided. Teratogens taken in the pre-embryonic period, often quoted as lasting until 14-17 days post-conception, are believed to have an all-or-nothing effect. Where drugs have a short half-life, and when the date of conception is certain, this may allow women to be reassured where drug exposure has occurred within this time frame. Further advice may be available from the UK National Teratology Information Service (NTIS) and through ToxBase, available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Licensed in pregnancy? - Yes as an emergency treatment

Crosses placenta? - Yes

Lactation

Adrenaline is considered safe for use in breastfeeding.

At the time of writing there is limited data available about use in breastfeeding.

Maternal status is likely to preclude breastfeeding and some manufacturers advise against use while breastfeeding.

According to LactMed due to the poor oral bioavailability and short half-life of adrenaline in milk it is considered unlikely to affect the infant. High intravenous doses may reduce milk production or milk let-down.

Neonates, infants born prematurely, those with low birth weight, those with an unstable gastrointestinal function or who have serious illnesses may require special consideration. For any infant, if a drug is prescribed to the nursing mother, it should be at the lowest practical dose and for the shortest time. When drug administration is unavoidable and breastfeeding is to continue, minimisation of exposure of the infant to the drug may sometimes be achieved by timing the maternal doses to just after a feeding episode. Infants exposed to drugs via breast milk should be monitored for unusual signs or symptoms. Interactions between the drug received by the infant from the mother's milk and medication prescribed for the infant should also be considered, for example, when the drug given to the infant may prevent metabolism of the drug received via breast milk.
Specialist advice is available from the UK Drugs in Lactation Advisory Service at https://www.midlandsmedicines.nhs.uk/content.asp?section=6&subsection=17&pageIdx=1

Side Effects

Allergic reaction
Anaphylaxis
Anginal pain
Anxiety
Bowel necrosis
Bronchospasm
Cardiac arrest
Cardiac arrhythmias
Cardiomyopathy
Cerebral haemorrhage
Cold extremities
Difficulty in micturition
Dizziness
Dry mouth
Dyspnoea
ECG changes
Glaucoma (closed angle)
Hallucinations
Headache
Hepatic necrosis
Hyperglycaemia
Hypersalivation
Hypertension
Hypokalaemia
Metabolic acidosis
Mydriasis
Myocardial infarction
Myocardial ischaemia
Nausea
Necrosis (injection site)
Pallor
Palpitations
Peripheral ischaemia
Pulmonary oedema
Renal medullary necrosis
Restlessness
Sweating
Syncope
T-wave changes
Tachycardia
Tremor
Urinary retention
Vasoconstriction
Ventricular fibrillation
Vomiting
Weakness
Worsening of Parkinson's disease

Presentation

Injections of adrenaline (1:10,000).

Drugs List

Therapeutic Indications

Uses

Anaphylaxis acute - emergency treatment
Cardiopulmonary resuscitation

Dosage

This monograph relates only to the specific use of the 1:10,000 strength adrenaline injections. Different strength preparations of adrenaline are available and the separate monographs for other strengths should be consulted for further information.

Adults

Elderly

Children

Additional Dosage Information

Administration

Emergency treatment of acute anaphylaxis where intramuscular injection has been ineffective
For slow intravenous injection

Cardiopulmonary resuscitation for the management of cardiac arrest
For intravenous injection. The intraosseous route may also be used where necessary.

Contraindications

None known

Precautions and Warnings

Elderly
Predisposition to narrow angle glaucoma
Arteriosclerosis
Asthma
Autonomic dysreflexia
Brain damage
Cardiac arrhythmias
Cardiomyopathy
Cardiovascular disorder
Cerebrovascular disorder
Diabetes mellitus
Hypercalcaemia
Hypertension
Hyperthyroidism
Hypokalaemia
Ischaemic heart disease
Narrow angle glaucoma
Occlusive peripheral vascular disorder
Parkinsonism
Phaeochromocytoma
Pregnancy
Prostate disorder
Psychoneurosis
Pulmonary emphysema
Severe angina
Severe renal impairment
Unstable pulmonary hypertension with advanced right ventricular failure

Sodium content of formulation may be significant
Advise patient not to drive or operate machinery until assessed
Not all available brands are licensed for all age groups
Not all available brands are licensed for all indications
Not all available brands are licensed for all routes of administration
Contains sodium metabisulfite. Caution,may cause allergic reactions
Do NOT inject into the extremities or penis
Avoid administration in the gluteal region
Monitor blood pressure
Monitor ECG
May affect results of some laboratory tests

Adrenaline is indicated in life threatening situations, therefore all precautions are relative.

When the 1 in 10,000 strength of adrenaline is required for this indication a "ready to use" preparation should be selected.

Adrenaline should not be injected in to the fingers, toes, ears, nose buttocks or genitalia due to the risk of ischaemic tissue necrosis. Repeated local injection can result in necrosis at sites of injection from vascular constriction. Accidental intravascular injection may result in cerebral haemorrhage due to a sudden rise in blood pressure.

Adrenaline should be used cautiously, if at all, during general anaesthesia with halogenated hydrocarbon anaesthetics.

Pregnancy and Lactation

Pregnancy

Use adrenaline with caution in pregnancy.

Briggs (2011) states that because adrenaline naturally occurs in the body, it is difficult to separate the effects of administration on the foetus compared that of endogenous adrenaline.

Many manufacturers strongly caution use in labour. Adrenaline usually inhibits spontaneous or oxytocin induced contractions. It may reduce the placental blood flow (anaphylactic shock will also have this effect) and delay the second stage of labour. Adrenaline may produce a prolonged period of uterine atony with haemorrhage and cause anoxia to the foetus.

There is some evidence of a slightly increased incidence of congenital abnormalities. However, according to Briggs (2011) this may reflect the indication for which it was administered to the mother.

Adrenaline is teratogenic in some animal species.

Schaefer comments that the systemic use of adrenaline is restricted to emergency.

The use of all medication in pregnancy should be avoided whenever possible; particularly in the first trimester. Non-drug treatments should also be considered. When essential, a medication with the best safety record over time should be chosen, employing the lowest effective dose for the shortest possible time. Polypharmacy should be avoided. Teratogens taken in the pre-embryonic period, often quoted as lasting until 14-17 days post-conception, are believed to have an all-or-nothing effect. Where drugs have a short half-life, and when the date of conception is certain, this may allow women to be reassured where drug exposure has occurred within this time frame. Further advice may be available from the UK National Teratology Information Service (NTIS) and through ToxBase, available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Licensed in pregnancy? - Yes as an emergency treatment

Crosses placenta? - Yes

Lactation

Adrenaline is considered safe for use in breastfeeding.

At the time of writing there is limited data available about use in breastfeeding.

Maternal status is likely to preclude breastfeeding and some manufacturers advise against use while breastfeeding.

According to LactMed due to the poor oral bioavailability and short half-life of adrenaline in milk it is considered unlikely to affect the infant. High intravenous doses may reduce milk production or milk let-down.

Neonates, infants born prematurely, those with low birth weight, those with an unstable gastrointestinal function or who have serious illnesses may require special consideration. For any infant, if a drug is prescribed to the nursing mother, it should be at the lowest practical dose and for the shortest time. When drug administration is unavoidable and breastfeeding is to continue, minimisation of exposure of the infant to the drug may sometimes be achieved by timing the maternal doses to just after a feeding episode. Infants exposed to drugs via breast milk should be monitored for unusual signs or symptoms. Interactions between the drug received by the infant from the mother's milk and medication prescribed for the infant should also be considered, for example, when the drug given to the infant may prevent metabolism of the drug received via breast milk.
Specialist advice is available from the UK Drugs in Lactation Advisory Service at https://www.midlandsmedicines.nhs.uk/content.asp?section=6&subsection=17&pageIdx=1

Side Effects

Allergic reaction
Anaphylaxis
Anginal pain
Anxiety
Bowel necrosis
Bronchospasm
Cardiac arrest
Cardiac arrhythmias
Cardiomyopathy
Cerebral haemorrhage
Cold extremities
Difficulty in micturition
Dizziness
Dry mouth
Dyspnoea
ECG changes
Glaucoma (closed angle)
Hallucinations
Headache
Hepatic necrosis
Hyperglycaemia
Hypersalivation
Hypertension
Hypokalaemia
Metabolic acidosis
Mydriasis
Myocardial infarction
Myocardial ischaemia
Nausea
Necrosis (injection site)
Pallor
Palpitations
Peripheral ischaemia
Pulmonary oedema
Renal medullary necrosis
Restlessness
Sweating
Syncope
T-wave changes
Tachycardia
Tremor
Urinary retention
Vasoconstriction
Ventricular fibrillation
Vomiting
Weakness
Worsening of Parkinson's disease

Overdosage

It is strongly recommended that the UK National Poisons Information Service be consulted on cases of suspected or actual overdose where there is doubt over the degree of risk or about appropriate management.

The following number will direct the caller to the relevant local centre (0844) 892 0111

Information may be obtained if you have access to ToxBase the primary clinical toxicology database of the National Poisons Information Service. This is available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Further Information

Last Full Review Date: November 2013

Reference Sources

Drugs During Pregnancy and Lactation: Treatment Options and Risk Assessment, 2nd edition (2007) ed. Schaefer, C., Peters, P. and Miller, R. Elsevier, London.

Drugs in Pregnancy and Lactation: A Reference Guide to Fetal and Neonatal Risk, 9th edition (2011) ed. Briggs, G., Freeman, R. and Yaffe, S. Lippincott Williams & Wilkins, Philadelphia.

Summary of Product Characteristics: Epinephrine (Adrenaline) Injection 1:10,000. IMS Ltd. Revised August 2016.
Summary of Product Characteristics: Dilute Adrenaline/Epinephrine Injection 1;10,000 and Adrenaline (Epinephrine) Injection 1:10,000 (ampoules). Aurum Pharmaceuticals. Revised March 2011.
Summary of Product Characteristics: Dilute Adrenaline/Epinephrine Injection 1;10,000 (ampoules). Martindale Pharmaceuticals. Revised March 2011.
Summary of Product Characteristics: Adrenaline (epinephrine) Injection 1:10,000 (prefilled syringes). Aurum Pharmaceuticals. Revised April 2013.

NICE - Evidence Services
Available at: www.nice.org.uk
Last accessed: 20 June 2017

US National Library of Medicine. Toxicology Data Network. Drugs and Lactation Database (LactMed).
Available at: https://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT
Epinephrine Last revised: September 7, 2013
Last accessed: November 25, 2013

Resuscitation Council (UK)
Available at: https://www.resus.org.uk/pages/mediMain.htm
Last revised: October, 2010
Last accessed: November 26, 2013