Quandaries in prescribing an emergency action plan and self-injectable epinephrine for first-aid management of anaphylaxis in the community

Anaphylaxis often occurs in the community in the absence of a health care professional. Prompt administration or self-injectable epinephrine as first-aid treatment in the context of a personalized emergency action plan is the key to survival. There is little argument that physicians should prescribe self-injectable epinephrine for individuals who have already experienced anaphylaxis involving respiratory distress or shock triggered by allergens that might be encountered in the community. A quandary faced by physicians is that additional individuals with identified allergy who have no recognized prior history of anaphylaxis or who have a history of mild symptoms after exposure to a known trigger might also be at risk for subsequent life-threatening anaphylaxis and might also warrant prescription of self-injectable epinephrine. Prescribing for the latter individuals requires considerable clinical judgment and has led to controversy regarding possible overprescription or underprescription of self-injectable epinephrine. A second quandary for physicians occurs with regard to the advice they should give to at-risk individuals about actual use of their self-injectable epinephrine. It is difficult for health care professionals, let alone persons with no health care training, to predict whether anaphylaxis symptoms will occur in an at-risk individual after exposure to a known trigger. Moreover, at the onset of an acute allergic reaction, it is difficult to predict the symptoms that will ultimately develop. We examine these 2 common quandaries and provide examples of clinical scenarios and potential pitfalls in the management of persons identified as being at risk for anaphylaxis in the community. Additional studies of the recognition and treatment of anaphylaxis in the community are needed to develop comprehensive, evidence-based recommendations for its management in this setting.