Adrenaline (epinephrine) for the treatment of anaphylaxis with and without shock.
BACKGROUND
Anaphylaxis is a serious hypersensitivity reaction that is rapid in onset and may cause death. Adrenaline is recommended as the initial treatment of choice for anaphylaxis.


OBJECTIVE
To assess the benefits and harms of adrenaline (epinephrine) in the treatment of anaphylaxis.


METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 1), MEDLINE (1966 to March 2007), EMBASE (1966 to March 2007), CINAHL (1982 to March 2007), BIOSIS (to March 2007), ISI Web of Knowledge (to March 2007) and LILACS (to March 2007). We also searched websites listing ongoing trials: http://clinicaltrials.gov/, http://www.controlledtrials.com and http://www.actr.org.au/; and contacted pharmaceutical companies and international experts in anaphylaxis in an attempt to locate unpublished material.


METHODS
Randomized and quasi-randomized controlled trials comparing adrenaline with no intervention, placebo or other adrenergic agonists were eligible for inclusion.


METHODS
Two authors independently assessed articles for inclusion.


RESULTS
We found no studies that satisfied the inclusion criteria.


CONCLUSIONS
Based on this review, we are unable to make any new recommendations on the use of adrenaline for the treatment of anaphylaxis. Although there is a need for randomized, double-blind, placebo-controlled clinical trials of high methodological quality in order to define the true extent of benefits from the administration of adrenaline in anaphylaxis, such trials are unlikely to be performed in individuals with anaphylaxis. Indeed, they might be unethical because prompt treatment with adrenaline is deemed to be critically important for survival in anaphylaxis. Also, such studies would be difficult to conduct because anaphylactic episodes usually occur without warning, often in a non-medical setting, and differ in severity both among individuals and from one episode to another in the same individual. Consequently, obtaining baseline measurements and frequent timed measurements might be difficult, or impossible, to obtain. In the absence of appropriate trials, we recommend, albeit on the basis of less than optimal evidence, that adrenaline administration by intramuscular (i.m.) injection should still be regarded as first-line treatment for the management of anaphylaxis.
Division of Community Health Sciences: GP Section, University of Edinburgh, 20 West Richmond Street, Edinburgh, UK, EH8 9DX. Aziz.Sheikh@ed.ac.uk
Aziz
A
Sheikh
Yasser A
YA
Shehata
Simon Ga
SG
Brown
F Estelle R
FE
Simons
D000322:Adrenergic Agonists / Q000627:therapeutic use*; D000707:Anaphylaxis / Q000150:complications / Q000188:drug therapy*; D004837:Epinephrine / Q000627:therapeutic use*; D006801:Humans; D012769:Shock / Q000150:complications / Q000188:drug therapy*; D014662:Vasoconstrictor Agents / Q000627:therapeutic use
D000322:Adrenergic Agonists; D014662:Vasoconstrictor Agents; D004837:Epinephrine