Epinephrine and emergency medical services activation recommendations during acute allergic reactions in community settings: International consensus report

Timothy E Dribin¹, Hugh A Sampson², Aikaterini Anagnostou³, Carlos A Camargo Jr⁴, Adam T Fox⁵, David B K Golden⁶, Kenneth A Michelson⁷, Marcus S Shaker⁸, Julie Wang², Waleed Alqurashi⁹, Amal H Assa'ad¹⁰, David C Brousseau¹¹, Dianne E Campbell¹², Ronna L Campbell¹³, Thomas B Casale¹⁴, Derek K Chu¹⁵, Ashley Lynn Devonshire¹⁰, Motohiro Ebisawa¹⁶, Matthew Greenhawt¹⁷, David M Lang¹⁸, Jay A Liebermann¹⁹, Stephanie Leonard²⁰, Douglas P Mack²¹, Antonella Muraro²², Mark I Neuman²³, Kimberly A Risma¹⁰, Graham Roberts²⁴, Nicholas Sargant²⁵, Scott H Sicherer², Jonathan M Spergel²⁶, Dana Wallace²⁷, Susan Waserman²⁸, Margitta Worm²⁹, Hannah R Bush³⁰, Barbara K Giambra³¹, Lisa M Vaughn³², Vincetta Kahmann³³, Brad Sobolewski³⁴, Yin Zhang³⁵, Stephanie Boyd³³, Sanaz Eftekhari¹⁷, Hannah Jaffee¹⁷, Melanie Carver¹⁷, Rob Keefer³⁶, Lisa Douglas³⁶, Caroline Nickels³⁶, Ryan A Moore³⁷, David Schnadower³⁸

Affiliations

¹ Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio. Electronic address: Timothy.Dribin@cchmc.org.
² Elliot and Roslyn Jaffe Food Allergy Institute, Serena and John Liew Division of Allergy and Immunology, Kravis Children's Hospital, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY.
³ Department of Pediatrics, Division of Immunology, Allergy and Retrovirology, Baylor College of Medicine, Houston, Tex; Division of Allergy, Immunology & Retrovirology, Baylor College of Medicine, Houston, Tex.
⁴ Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
⁵ Evelina London Children's Hospital, London, UK & King's College London, London, United Kingdom.
⁶ Johns Hopkins University School of Medicine, Baltimore, Md.
⁷ Ann & Robert Lurie Children's Hospital of Chicago, Chicago, Ill.
⁸ Dartmouth Hitchcock Medical Center, Section of Allergy and Clinical Immunology, Lebanon, NH; Dartmouth Geisel School of Medicine, Departments of Medicine and of Pediatrics, Hanover, NH.
⁹ Department of Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada.
¹⁰ Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
¹¹ Department of Pediatrics, Nemours Children's Health Delaware, Wilmington, Del; Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pa.
¹² Faculty of Medicine and Health, University of Sydney, Sydney, Australia; National Allergy Centre of Excellence (NACE), Parkville, Australia; Allergy and Immunology, Children's Hospital at Westmead, Sydney, Australia.
¹³ Department of Emergency Medicine, Mayo Clinic, Rochester, Minn.
¹⁴ Department of Medicine and Pediatrics, University of South Florida Morsani College of Medicine, Tampa, Fla.
¹⁵ Department of Medicine, McMaster University, Hamilton, Canada; Department of Pediatrics, McMaster University, Hamilton, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada.
¹⁶ Clinical Research Center for Allergy and Rheumatology, NHO Sagamihara National Hospital, Sagamihara, Japan.
¹⁷ Asthma and Allergy Foundation of America, Arlington, Va.
¹⁸ Department of Allergy and Clinical Immunology, Cleveland Clinic, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio.
¹⁹ The University of Tennessee Health Science Center, Department of Pediatrics, Memphis, Tenn.
²⁰ University of California, San Diego, San Diego, Calif.
²¹ Department of Pediatrics, McMaster University, Hamilton, Canada.
²² Food Allergy Centre, Department of Woman and Child Health, Padua University Hospital, Padua, Italy.
²³ Division of Emergency Medicine, Boston Children's Hospital, Boston, Mass.
²⁴ University of Southampton Faculty of Medicine, David Hide Asthma and Allergy Centre, St Mary's Hospital, Isle of Wight, and National Institute for Health Research Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom.
²⁵ Bristol Royal Hospital for Children, Bristol, United Kingdom.
²⁶ Division of Allergy and Immunology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pa.
²⁷ Dr Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Fort Lauderdale, Fla.
²⁸ Division of Clinical Immunology and Allergy, Department of Medicine, McMaster University, Hamilton, Canada.
²⁹ Charité-Universitätsmedizin Berlin, Department of Dermatology, Venereology and Allergology, Berlin, Germany.
³⁰ Qualitative Methods & Analysis Collaborative, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
³¹ Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; Qualitative Methods & Analysis Collaborative, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
³² Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Qualitative Methods & Analysis Collaborative, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
³³ Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
³⁴ Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.
³⁵ Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
³⁶ POMIET LLC, Cincinnati, Ohio.
³⁷ Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
³⁸ Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio.

PMID: 41386477
PMCID: PMC12812044 (available on 2026-12-10)
DOI: 10.1016/j.jaci.2025.11.008

Epinephrine and emergency medical services activation recommendations during acute allergic reactions in community settings: International consensus report

Timothy E Dribin et al. J Allergy Clin Immunol. 2026 Feb.

. 2026 Feb;157(2):429-441.

doi: 10.1016/j.jaci.2025.11.008. Epub 2025 Dec 10.

Authors

Affiliations

¹ Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio. Electronic address: Timothy.Dribin@cchmc.org.
² Elliot and Roslyn Jaffe Food Allergy Institute, Serena and John Liew Division of Allergy and Immunology, Kravis Children's Hospital, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY.
³ Department of Pediatrics, Division of Immunology, Allergy and Retrovirology, Baylor College of Medicine, Houston, Tex; Division of Allergy, Immunology & Retrovirology, Baylor College of Medicine, Houston, Tex.
⁴ Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass.
⁵ Evelina London Children's Hospital, London, UK & King's College London, London, United Kingdom.
⁶ Johns Hopkins University School of Medicine, Baltimore, Md.
⁷ Ann & Robert Lurie Children's Hospital of Chicago, Chicago, Ill.
⁸ Dartmouth Hitchcock Medical Center, Section of Allergy and Clinical Immunology, Lebanon, NH; Dartmouth Geisel School of Medicine, Departments of Medicine and of Pediatrics, Hanover, NH.
⁹ Department of Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada.
¹⁰ Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
¹¹ Department of Pediatrics, Nemours Children's Health Delaware, Wilmington, Del; Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pa.
¹² Faculty of Medicine and Health, University of Sydney, Sydney, Australia; National Allergy Centre of Excellence (NACE), Parkville, Australia; Allergy and Immunology, Children's Hospital at Westmead, Sydney, Australia.
¹³ Department of Emergency Medicine, Mayo Clinic, Rochester, Minn.
¹⁴ Department of Medicine and Pediatrics, University of South Florida Morsani College of Medicine, Tampa, Fla.
¹⁵ Department of Medicine, McMaster University, Hamilton, Canada; Department of Pediatrics, McMaster University, Hamilton, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada.
¹⁶ Clinical Research Center for Allergy and Rheumatology, NHO Sagamihara National Hospital, Sagamihara, Japan.
¹⁷ Asthma and Allergy Foundation of America, Arlington, Va.
¹⁸ Department of Allergy and Clinical Immunology, Cleveland Clinic, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio.
¹⁹ The University of Tennessee Health Science Center, Department of Pediatrics, Memphis, Tenn.
²⁰ University of California, San Diego, San Diego, Calif.
²¹ Department of Pediatrics, McMaster University, Hamilton, Canada.
²² Food Allergy Centre, Department of Woman and Child Health, Padua University Hospital, Padua, Italy.
²³ Division of Emergency Medicine, Boston Children's Hospital, Boston, Mass.
²⁴ University of Southampton Faculty of Medicine, David Hide Asthma and Allergy Centre, St Mary's Hospital, Isle of Wight, and National Institute for Health Research Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom.
²⁵ Bristol Royal Hospital for Children, Bristol, United Kingdom.
²⁶ Division of Allergy and Immunology, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pa.
²⁷ Dr Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Fort Lauderdale, Fla.
²⁸ Division of Clinical Immunology and Allergy, Department of Medicine, McMaster University, Hamilton, Canada.
²⁹ Charité-Universitätsmedizin Berlin, Department of Dermatology, Venereology and Allergology, Berlin, Germany.
³⁰ Qualitative Methods & Analysis Collaborative, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
³¹ Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; Qualitative Methods & Analysis Collaborative, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
³² Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Qualitative Methods & Analysis Collaborative, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
³³ Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
³⁴ Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.
³⁵ Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
³⁶ POMIET LLC, Cincinnati, Ohio.
³⁷ Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
³⁸ Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio.

PMID: 41386477
PMCID: PMC12812044 (available on 2026-12-10)
DOI: 10.1016/j.jaci.2025.11.008

Abstract

Background: Limited research exists on when to administer epinephrine (adrenaline) or activate emergency medical services (EMS) during acute allergic reactions in community settings. This contributes to suboptimal patient care, including both the underuse and overuse of epinephrine, as well as potentially unnecessary emergency department visits.

Objective: We developed consensus recommendations for administering epinephrine and activating EMS during acute allergic reactions.

Methods: From January 2024 to May 2025, we assembled a 34-member international panel of experts to develop clinical scenarios reflecting varying severity levels within and across organ systems, candidate modifiers that may lower the threshold for epinephrine administration (eg, history of asthma), and candidate EMS activation recommendations. In phase 1, the panel engaged in a modified Delphi process to reach consensus on these outputs. In phase 2, we tested each consensus modifier by embedding it into scenarios where epinephrine was not recommended or lacked consensus, to assess potential impacts on treatment decisions.

Results: The expert panel developed 24 clinical scenarios, 9 candidate modifiers, and 12 candidate EMS activation recommendations. During the first phase, 21 statements reached consensus to recommend epinephrine, 2 reached consensus not to recommend it, and 1 did not reach a consensus. There were 5 consensus modifiers and 10 consensus EMS activation recommendations. In the second phase, 2 of the 15 clinical scenarios reached consensus to recommend epinephrine administration.

Conclusion: We developed consensus recommendations for administering epinephrine and activating EMS during acute allergic reactions in community settings. Integrating them into technology-based decision support tools may enhance reaction management, improve patient outcomes, optimize health care utilization, and empower patient and caregiver self-efficacy.

Keywords: Acute allergic reactions; adrenaline; anaphylaxis; anaphylaxis action plans; emergency department; emergency medical services; epinephrine; epinephrine delivery devices.

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Conflict of interest statement

Disclosure statement Supported in part by the Cincinnati Children’s Hospital Medical Center Place Outcomes Research Award (to T.E.D.); and by the National Institute of Allergy and Infectious Diseases of the National Institutes of Health (NIH; award K23AI175525). The K23 award provided T.E.D. with the time to execute the study. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. Disclosure of potential conflict of interest: T. E. Dribin reports receiving funding from the National Institutes of Health (NIH) and the Cincinnati Children’s Hospital Medical Center. H. A. Sampson reports grants from Immune Tolerance Network, National Institute of Allergy and Infectious Diseases (NIAID)/NIH, and Food Allergy Research and Education (FARE); personal fees from N-Fold and DBV Technologies, Alpina Biotech, and RAPT Therapeutics; and stock options from N-Fold and DBV Technologies. A. Anagnostou reports receipt of institutional funding from Novartis, Asthma and Allergy Foundation of America (AAFA), Aquestive, and ALK; advisory board member for Novartis, Genentech, Bryn, ALK, and ARS; and consultation/speaker fees from ALK, EPG Health, MJH, Adelphi, DBV Technologies, Genentech, Medscape, ARS, FARE, Innovation Horizons, and Stallergenes. C. A. Camargo Jr has served on scientific advisory boards and/or consulted for ALK-Abelló, Aquestive, ARS, Bryn, and Hikma. A. T. Fox reports consultancy for ALK-Abelló and Viatris; and service as chair of the National Allergy Strategy Group, United Kingdom. D. B. K. Golden reports consulting for Novartis, Aquestive, ARS, Thermo Fisher Scientific, Blueprint, Orexo, and Kokua. J. Wang reports clinical trial support via her institution from NIH, DBV Technologies, and Siolta outside the current report; consulting fees from DBV Technologies and Novartis outside the current report; and royalties from UpToDate. W. Alqurashi reports funding from the Canadian Institute for Health Research and the Children’s Hospital of Eastern Ontario Research Institute. A. H. Assa’ad reports funding NIH, FARE, Novartis, ARS, AbbVie, Abbott, Sanofi, DBV Technologies, and Siolta. D. E. Campbell reports employment and shares from DBV Technologies; personal fees/honoraria from Westmead Fertility Centre; and grants from National Health and Medical Research Council of Australia and FARE outside the current report. R. L. Campbell has received royalties from UpToDate; and has been a consultant for Bryn Pharma and Aquestive. T. B. Casale is an advisor and speaker for ARS. A. L. Devonshire reports grants or contracts from the NIH, Sanofi, GlaxoSmithKline, OM Pharma, Abbott, The Gerber Foundation, and FARE; consulting fees from Genentech; and support for meeting attendance and/or travel from the American Academy of Allergy, Asthma & Immunology (AAAAI) and FARE. M. Ebisawa reports lecture fees from SAB, Viatris, ARS, Sanofi, and Novartis. M. Greenhawt reports being an employee of the AAFA; consultant for Aquestive; member of physician/medical advisory boards for DBV Technologies, Takeda, Griffols, Nutricia, Novartis, Aquestive, Allergy Therapeutics, AstraZeneca, ALK-Abelló, Bryn, Genentech, and Prota; speaker for Genentech and ARS; unpaid member of the scientific advisory council for the International Food Protein Induced Enterocolitis Syndrome Association; member of the Brighton Collaboration Criteria Vaccine Anaphylaxis 2.0 working group; senior associate editor for the Annals of Allergy, Asthma & Immunology; and member of the Joint Taskforce on Allergy Practice Parameters. D. M. Lang has carried out clinical research with, received honoraria from, and/or served as a consultant for Celldex, Genentech, Novartis, and Sanofi-Regeneron. J. A. Liebermann reports being an advisor/consultant for Aquestive, ARS, and Bryn Research; and, via his institution, DBV Adjudication, AbbVie, and Amgen. D. P. Mackreports being an investigator for Aquestive, ALK, DBV, and RAPT Therapeutics; and speaker and consultant for Viatris and Bausch Health, ALK, and DBV. A. Muraro reports speaker’s fee for Aimmune, DVB Technologies, Sanofi, Viatris; and advisory board for Sanofi, Regeneron, Novartis, and Viatris. G. Roberts reports receipt of consultancy fees by his institution from ALK-Abelló; and performing consultancy work for Viatris. S. H. Sicherer reports royalty payments from UpToDate and from Johns Hopkins University Press; grants to his institution from NIAID, FARE, Pfizer, and Regeneron; and personal fees from the AAAAI as deputy editor of the Journal of Allergy and Clinical Immunology: In Practice, outside of the current report. J. M. Spergel reports consulting agreements with ARS; grant support from the NIH, ARS, Regeneron, Sanofi, Novartis, Genetech, and FARE; and royalites from UpToDate. D. Wallace reports being an advisor for Bryn, Genetech, ARS, and Kaléo. S. Waserman reports receipt of support from Pfizer Canada, ALK, Viatris, GlaxoSmithKline, AstraZeneca, Novartis, Sanofi, Takeda, CSL Behring, AbbVie, MiravoHealth, and Medexus Pharma; and service on the board of directors for Asthma Canada and the Canadian Hereditary Angioedema Network, medical advisor for Food Allergy Canada, and president of the Canadian Allergy Asthma Immunology Foundation. M. Worm declares the receipt of honoraria or consultation fees from AbbVie, Aimmune Therapeutics, ALK-Abelló, Allergopharma, Almirall Hermal, Amgen, AstraZenceca, Bayer, Bencard Allergy, Bioprojet Pharma, Boehringer Ingelheim Pharma, Bristol Myers Squibb, KGaA, Galderma Laboratorium, GlaxoSmithKline, Infectopharm Arzneimittel und Consilium, LEO Pharma, Lilly Deutschland, Mylan Germany (a Viatris Company), Novartis, Octapharm, Pfizer Pharma, and Sanofi-Aventis Deutschland/Genzyme Europe. S. Eftekhari, H. Jaffee, and M. Carver are employed by the AAFA, a nonprofit patient organization, which has received food allergy– and anaphylaxis-related funding from ARS, Aquestive, DBV Technologies, Genentech, Kaléo, and Viatris. The rest of the authors declare that they have no relevant conflicts of interest.

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Epinephrine and emergency medical services activation recommendations during acute allergic reactions in community settings: International consensus report

Affiliations

Epinephrine and emergency medical services activation recommendations during acute allergic reactions in community settings: International consensus report

Authors

Affiliations

Abstract

Conflict of interest statement

References

MeSH terms

Substances

Grants and funding

LinkOut - more resources

Full Text Sources

Medical