Should you choose a nasal over an injectable adrenaline device for the treatment of anaphylaxis?

Choosing between the devices is best achieved through a thorough, well-informed decision-making process. Having a choice is a wonderful privilege, but it can prove stressful for some. Herewith some info to help facilitate this decision:

For decades, managing severe allergic reactions (anaphylaxis) in children and young adults has relied exclusively on intramuscular adrenaline auto-injectors (AAIs), such as EpiPens or Jext. In less well-resourced settings, patients and their families have needed to be trained in drawing up adrenaline from an ampule for injection. Whilst cost-effective, this is a complex task to do in an acute medical setting.

Whilst the allergy community has grown used to the concept of carrying an injectable emergency device, the mere fact that it contains a needle has created a significant barrier to the timely and effective administration of adrenaline. However, a major shift in emergency allergy care has arrived.

The Medicines and Healthcare products Regulatory Agency (MHRA) recently approved the first needle-free adrenaline nasal spray, EURneffy. Originally launched for adults and older children, a lower 1 mg dose has now been approved for younger children aged four and over (weighing 15 kg to 30 kg).

The needle-free adrenaline nasal spray device. Source: ALK Pro UK / EURneffy® | For UK HCPs

Traditional adrenaline auto-injectors. Source: React First / How to use adrenaline auto-injectors like EpiPen, or Jext

Why the Shift to Nasal Adrenaline Matters

Surveys show that over half of adults at risk of anaphylaxis carry their auto-injectors irregularly, and roughly one-third fail to use them during an emergency due to needle anxiety or hesitation. It is hoped that the nasal alternative will address these behavioural and physiological hurdles.

Key Advantages of Nasal Adrenaline

• Zero Needles: Eliminates needle phobia, which frequently delays life-saving care in panicked settings. AAI needles can result in lacerations if the patient kicks while the needle is still embedded; this is not uncommon in vigorous young children.
• Temperature Stability: Unlike liquid injectables, the nasal device remains stable at temperatures up to 50°C and is not ruined by accidental freezing.
• Longer Shelf Life: Offers a shelf life of 24 to 30 months, reducing the frequency of costly device replacements.
• Rapid Absorption: Clinical trials show that adrenaline absorption through the nasal lining is at least as effective as a standard intramuscular thigh injection, even in patients with a cold or nasal congestion.

Direct Comparison: Nasal Spray vs Injectable AAIs

Important Clinical Considerations

While the nasal spray is a groundbreaking alternative, experts from the British Society for Allergy and Clinical Immunology (BSACI) emphasise that it may not be suitable for everyone right away.

Critical Safety Rule: Patients who have historically required multiple doses of adrenaline to control severe anaphylaxis, or those with severe venom allergies causing dangerous blood pressure drops, should continue to rely on traditional intramuscular auto-injectors.

It is exciting for us as Allergists to now be able to offer a choice of adrenaline administration devices; we certainly have enjoyed a lot of choice with regard to other allergy medicines such as antihistamines and asthma sprays.

It may also be that the nasal device leads to earlier administration of adrenaline, which interrupts the immune cascade that occurs in anaphylaxis. It has been shown that adrenaline acts as an allergy cell stabiliser, so this should provide additional protection during reactions.

Whichever device you select as a family, the baseline emergency protocol remains unchanged.

In the UK, the devices are beginning to be rolled out nationwide in the NHS.

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