Summary of New Guidelines Clarifying When to Use Epinephrine and Call EMS for Allergic Reactions

For years, patients and caregivers managing food allergies have faced a terrifying dilemma during a reaction: “Is this bad enough for epinephrine?” and “Do I have to call 911 every single time I use it?”

A new report, published as an International Consensus Report in The Journal of Allergy and Clinical Immunology, provides clearer, unified answers. An international panel of 34 anaphylaxis experts and community advisors has developed specific criteria for administering epinephrine and activating Emergency Medical Services (EMS) in community settings like homes and schools.

Here is a breakdown of the new consensus recommendations.

When to Administer Epinephrine

The panel agreed that the decision to use epinephrine should primarily be based on symptom severity. They reached a consensus that epinephrine should be administered in the following scenarios:

• Any Respiratory Symptoms: Trouble breathing, repetitive coughing, wheezing, gasping, or a tight chest.
• Any Cardiovascular/Neurologic Symptoms: Fainting, dizziness, lightheadedness, inability to stand, or unresponsiveness.
• Severe Skin/Mouth Symptoms: Tongue swelling or drooling.
• Severe Gastrointestinal (GI) Symptoms: Vomiting two or more times or severe abdominal pain.
• Multi-System Symptoms: A combination of symptoms involving two different body systems. For example:
  • Mild skin symptoms (a few hives) PLUS mild GI symptoms (vomiting once).
  • Respiratory symptoms PLUS skin symptoms.

When to Hold Off Administering Epinephrine

In an effort to prevent the unnecessary use of epinephrine, the panel agreed that epinephrine is NOT recommended for:

• Isolated Mild Skin Symptoms: Itchy skin, a few hives, or a runny nose with no other symptoms;
• Isolated Mild GI Symptoms: Nausea or a single episode of vomiting with no other symptoms.

The “Grey Area” for Epinephrine Administration

One scenario was less clear for the experts: Isolated Moderate Skin Symptoms (e.g., hives all over the body or a tight throat, but no other organ involvement). Initially, there was no consensus on whether to treat this with epinephrine.

However, the panel agreed that specific patient history — called “modifiers” — should tip the scale. Experts recommend administering epinephrine for isolated moderate skin symptoms IF the patient has:

• A history of requiring two or more doses of epinephrine for a single reaction -or-
• A history of a mast cell disorder (e.g., systemic mastocytosis).

Surprisingly, having a history of asthma or living far from a hospital did not change the recommendation for this specific scenario.

When to Call Emergency Medical Services (911)

The most significant shift in these guidelines is the move away from the “always call 911” rule. While EMS activation is still critical in many cases, the panel introduced a “watch and wait” approach for specific situations.

You MUST activate EMS if:

• Severe Signs are Present: The patient shows severe respiratory (gasping, blue skin) or cardiovascular (unconscious, fainting) signs either before or after epinephrine;
• Symptoms Persist: The patient still feels dizzy, lightheaded, or has a tight throat/chest after epinephrine;
• Resource Limitations: You should always call if the patient is alone, requires a second dose of epinephrine, does not have a backup device available, or is more than 30 minutes from a hospital.

You MAY be able to “Watch and Wait” if:

The symptoms resolve completely after one dose of epinephrine,

AND you have a backup epinephrine device on hand,

AND you are within 30 minutes of emergency care,

AND the patient is not alone.

Why This Matters

These recommendations are designed to be integrated into apps and digital decision-support tools to help patients make real-time decisions. By clarifying when to treat — and when not to — these guidelines aim to empower caregivers, reduce fear-based hesitation, and prevent unnecessary emergency room visits while ensuring safety for severe reactions.

How do you feel about these recommendations? Let us know in the comments section below.