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Clinical Review Lesson of the week

Adrenaline given outside the context of life threatening allergic reactions

BMJ 2003; 326 doi: (Published 15 March 2003) Cite this as: BMJ 2003;326:589
  1. Sarah L Johnston, specialist registrar, immunology and general internal medicine (,
  2. Joe Unsworth, consultant clinical immunologist,
  3. Mark M Gompels, consultant clinical immunologist
  1. Department of Immunology and Immunogenetics, Southmead Hospital, Bristol BS10 5NB
  1. Correspondence to: S L Johnston
  • Accepted 21 October 2002

Adrenaline can be life saving in true systemic anaphylaxis but can be hazardous when used out of context

The true incidence of anaphylaxis is unknown. A study in an accident and emergency department suggested an incidence of between 1 in 2300 and 1 in 1500 attendances.1 Fatal anaphylaxis is rare but probably underestimated. A register established in 1992, recording fatal reactions, gave an incidence of only 20 cases a year in the United Kingdom.2 Using adrenaline (epinephrine) in the context of acute severe anaphylaxis characterised by hypotension or marked respiratory difficulty is not contentious.3 Adrenaline, however, is not a treatment without risk2—especially in patients with cardiovascular comorbidity or who are taking an interacting medication.4 Despite the low incidence of life threatening anaphylaxis, over 100 000 adrenaline syringes have been prescribed throughout the United Kingdom for community use.5 We report two cases with serious outcomes as a direct result of adrenaline treatment, highlighting the dangers of this drug outside the context of acute severe anaphylaxis.

Case reports

Case 1—A 64 year old man was referred to our clinic for investigation of a 15 year history of benign idiopathic angio-oedema, mainly affecting his face and tongue. An EpiPen (ALK-Abelló, Hungerford, Berkshire) for self administration of adrenaline had already been prescribed. His medical history included hypertension and type II diabetes. The hypertension had been treated with an angiotensin converting …

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