Adrenaline in anaphylaxis treatment. Balancing benefits and harms

Introduction: Although anaphylaxis is a relatively common disorder, clinicians and scientists have debated on how to best define and manage this condition. The current recommendations are focused on the central role of adrenaline, but evidence in support of this therapeutic approach is modest, mainly for the lack of well-designed trials. Conversely, serious adverse effects are commonly reported following adrenaline use, especially when given intravenously. These include hypertension, ventricular arrhythmias, myocardial infarction, pulmonary edema. Areas covered: Anaphylaxis treatment, with special focus on adrenaline utilization, both in pre-hospital and in-hospital settings. Aim is to examine in depth the balance between benefits and harms of this important drug. Expert opinion: Due to the lack of solid evidence supporting the use of adrenaline in patients with anaphylaxis, except in severe cases, the strength of recommendations should be readdressed, limiting administration to selected categories of patients. Caregivers should promptly act in pre-hospital setting, given the shortness of time and lack of technology. In the hospital setting, and more specifically in the ED, clinicians should consider the prompt use of adrenaline in severe anaphylaxis cases, but they should also be able to judiciously wait in the vast majority of milder anaphylactic reactions, which may resolve spontaneously.