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. 2012 Aug 15;2012(8):CD008935.
doi: 10.1002/14651858.CD008935.pub2.

Adrenaline auto-injectors for the treatment of anaphylaxis with and without cardiovascular collapse in the community

Aziz Sheikh  1 , F Estelle R Simons, Victoria Barbour, Allison Worth
Affiliations

Adrenaline auto-injectors for the treatment of anaphylaxis with and without cardiovascular collapse in the community

Aziz Sheikh et al. Cochrane Database Syst Rev. .

Abstract

Background: Anaphylaxis is a serious hypersensitivity reaction that is rapid in onset and may cause death. Adrenaline (epinephrine) auto-injectors are recommended as the initial, potentially life-saving treatment of choice for anaphylaxis in the community, but they are not universally available and have limitations in their use.

Objectives: To assess the effectiveness of adrenaline (epinephrine) auto-injectors in relieving respiratory, cardiovascular, and other symptoms during episodes of anaphylaxis that occur in the community.

Search methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 1), MEDLINE (Ovid SP) (1950 to January 2012), EMBASE (Ovid SP) (1980 to January 2012 ), CINAHL (EBSCO host) (1982 to January 2012 ), AMED (EBSCO host) (1985 to January 2012 ), LILACS, (BIREME) (1980 to January 2012 ), ISI Web of Science (1950 to January 2012 ). We adapted our search terms for other databases. We also searched websites listing on-going trials: the World Health Organization International Clinical Trials Registry Platform, the UK Clinical Research Network Study Portfolio, and the meta Register of Controlled Trials; and contacted pharmaceutical companies who manufacture adrenaline auto-injectors in an attempt to locate unpublished material.

Selection criteria: Randomized and quasi-randomized controlled trials comparing auto-injector administration of adrenaline with any control including no intervention, placebo, or other adrenergic agonists were eligible for inclusion.

Data collection and analysis: Two authors independently assessed articles for inclusion.

Main results: None of the 1328 studies that were identified satisfied the inclusion criteria.

Authors' conclusions: Based on this review, we cannot make any new recommendations on the effectiveness of adrenaline auto-injectors for the treatment of anaphylaxis. Although randomized, double-blind, placebo-controlled clinical trials of high methodological quality are necessary to define the true extent of benefits from the administration of adrenaline in anaphylaxis via an auto-injector, such trials are unlikely to be performed in individuals experiencing anaphylaxis because of ethical concerns associated with randomization to placebo. There is, however, a need to consider trials in which, for example, auto-injectors of different doses of adrenaline and differing devices are compared in order to provide greater clarity on the dose and device of choice. Such trials would be practically challenging to conduct. In the absence of appropriate trials, we recommend that adrenaline administration by auto-injector should still be regarded as the most effective first-line treatment for the management of anaphylaxis in the community. In countries where auto-injectors are not commonly used, it may be possible to conduct trials to compare administration of adrenaline via auto-injector with adrenaline administered by syringe and ampoule, or comparing the effectiveness of two different types of auto-injector.

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Conflict of interest statement

Aziz Sheikh and Allison Worth: we have obtained funding from ALK‐Abello to support conference attendance by members of our research group. Aziz Sheikh has acted as a consultant to ALK‐Abello and Phadia.

F Estelle R. Simons: I have published more than 90 papers on epinephrine (adrenaline) and on anaphylaxis. This research has been funded mostly by the Manitoba Institute of Child Health, with the exception of one pharmaceutical grant totaling $23,000. I serve on Anaphylaxis Advisory Boards for ALK‐Abello, Pfizer, and Sanofi. I also serve on the US NIH National Institute of Allergy and Infectious Diseases Food Allergy Guidelines Expert Panel and on the Medical Advisory Board of the Food Allergy and Anaphylaxis Network. One of my roles on these Boards is to advocate for better treatment of anaphylaxis in community settings, including development of user‐friendly adrenaline auto‐injectors with a wider range of doses and improved safety features.

Victoria Barbour: none known.

Figures

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Study flow diagram.
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  • doi: 10.1002/14651858.CD008935

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References to other published versions of this review

Sheikh 2011
    1. Sheikh A, Simons FER, Worth A. Adrenaline auto‐injectors for the treatment of anaphylaxis with and without cardiovascular collapse in the community. Cochrane Database of Systematic Reviews 2011, Issue 1. [DOI: 10.1002/14651858.CD008935] - DOI - PMC - PubMed

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