Anaphylaxis is a potentially life-threatening allergic reaction that can present in primary care. General practitioners play a critical role in identifying patients at risk, managing emergencies, and prescribing adrenaline auto-injectors to mitigate future risks. This guide provides a structured approach to risk assessment, prescribing, and patient education, ensuring safe and effective management in line with RCGP curriculum competencies.

Key Points for GPs: Adrenaline Auto-Injectors (AAIs)

• AAIs are the first-line emergency treatment for anaphylaxis.

• Risk assessment is guided by clinical history, not solely allergy testing.

• Prescribe two devices for patients at significant risk and refer to an allergy specialist for further evaluation.

• Ensure patients and carers receive training on AAI administration and have a written anaphylaxis action plan.

STEP 1- when to consider

Indication	Examples / Notes
Previous anaphylaxis of unknown cause	Idiopathic anaphylaxis
Anaphylaxis with unavoidable trigger	Bee/wasp stings, common food allergens (e.g., nuts, shellfish)
Allergy to high-risk allergens + additional risk factors	Peanuts, tree nuts + asthma, poorly controlled asthma, adolescence (higher risk group)
Reaction to trace amounts of allergen	Highly sensitive individuals
Co-morbidities increasing risk	Asthma, mastocytosis, ↑ baseline tryptase
Post-emergency treatment for anaphylaxis	After hospital/ED discharge for anaphylaxis
High risk of exposure to known allergens	Occupational, environmental, or dietary exposure risks
On Specialist Recommendation	AAI prescribed following allergy clinic advice or consultant letter
Persistent parental/patient anxiety despite low clinical risk	Consider AAI if anxiety impacts quality of life (per BSACI guidance)

STEP 2 - Choosing the Adrenaline Auto-Injector (AAI)

• Confirm Patient Weight:
  Select the correct dose based on current weight:

  • 0.15 mg: 15–30 kg

  • 0.3 mg: >30 kg

  • Seek specialist advice if <15 kg

  • 
    

• Write Clear Prescription Instructions:
  Example:
  “EpiPen 0.3 mg, two devices, to be carried at all times.”

• 
  

• Check for Drug Interactions:

  • Beta-blockers: May reduce the effectiveness of adrenaline.

  • Consider risks if the patient is on tricyclic antidepressants or monoamine oxidase inhibitors (MAOIs).

  • 
    

• Review Expiry Dates:

  • Advise patients to check expiry dates regularly.

  • Issue repeat prescriptions proactively — most devices expire after 12–18 months.

  • 
    

• • Document all education and prescription details in records.

  • 
    

Consideration	Details
Brands	EpiPen, Jext, EmeradeAvailability may vary — check local formulary
Dosing	- Adults & children >30 kg: 0.3 mg- Children 15–30 kg: 0.15 mg- Children <15 kg: Seek specialist advice
Number of Devices	Always prescribe 2 devices to ensure access at multiple locations (e.g., home, school, work)

Step 3: Essential Patient Education

Key Education Points	Details
When to Use the AAI	- Use immediately if signs of anaphylaxis appear (e.g., difficulty breathing, throat swelling, dizziness, collapse).- Administer even if unsure — adrenaline is generally safe.
How to Use the AAI	- Demonstrate with trainer devices (available from manufacturers).- Steps:1. Remove safety cap2. Hold device firmly3. Inject into outer thigh (through clothing if needed)4. Hold for 3–5 seconds5. Call 999 immediately
Written Instructions & Videos	- Provide written instructions.- Direct patients to manufacturer websites and videos:• EpiPen Instructions• Jext Instructions• Emerade Instructions
Storage and Disposal	- Store at room temperature, away from heat/sunlight.- Check expiry dates regularly.- Return expired devices to the pharmacy for disposal.
Emergency Action Plan	- Provide a written anaphylaxis action plan (e.g., via BSACI or Anaphylaxis UK).- Advise carrying the AAI at all times and informing family, school, and employers.
Follow-Up	- Arrange periodic reviews to assess understanding, adherence, and to refresh training.- Refer to an allergy specialist for complex cases, diagnostic uncertainty, or recurrent anaphylaxis.

Practical Tip: Use a pre-formatted prescribing template in your practice system (e.g., SystmOne, EMIS) to ensure consistency and compliance with local guidelines.

Step 4: Ongoing Management and Referral

1. Monitor Risk Factors:

• Regularly review patient’s:

  • Allergen exposure risks (e.g., dietary, environmental, occupational)

  • Co-morbidities (e.g., asthma control, mastocytosis)

  • Medication changes (e.g., new beta-blockers)

  • 
    

2. Audit Prescribing:

• Conduct practice audits to evaluate:

  • Appropriate AAI prescribing aligned with current guidelines

  • Number of devices prescribed and adherence to two-device policy

  • Frequency of patient reviews and training refreshers

RCGP Curriculum Tip:
Auditing AAI prescribing is recommended for Quality Improvement (QI) and CPD.
RCGP Curriculum Link on Anaphylaxis & Adrenaline Device Audits

3. Specialist Referral:
Refer to an allergy specialist for:

• Diagnostic uncertainty: e.g., idiopathic anaphylaxis

• Multiple or complex allergies

• Consideration for immunotherapy (e.g., venom allergy)

• Need for skin prick testing, specific IgE blood testing, or risk stratification

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Always ensure patients have a follow-up plan post-referral and reinforce the importance of carrying AAIs at all times.

Key Resources

• Resuscitation Council UK: Guidelines on anaphylaxis management (www.resus.org.uk).

• NICE: CG134 on anaphylaxis (www.nice.org.uk/guidance/cg134).

• BSACI: Anaphylaxis action plans and patient resources (www.bsaci.org).

• Anaphylaxis Campaign: Patient education materials (www.anaphylaxis.org.uk).

• RCGP eLearning: Modules on allergy and immunology (www.elearning.rcgp.org.uk).

• Allergy UK - Adrenaline Auto-Injector Guides:
  https://www.allergyuk.org/resources/autoinjector-guides/

• Anaphylaxis UK - How to Use Your Adrenaline Auto-Injector:
  https://www.anaphylaxis.org.uk/living-with-anaphylaxis/how-to-use-your-aaid/

• Epipen UK Training Video:
  https://www.epipen.co.uk/en-gb/epipen-instructions

• Jext Trainer Video:
  https://www.jext.co.uk/

• Emerade Training Video:
  https://www.emerade-bausch.co.uk/emerade-video/

Conclusion

GPs play a pivotal role in the prevention and management of anaphylaxis through effective risk assessment, prescribing, and patient education. By following evidence-based guidelines and engaging in reflective practice, GPs can enhance patient safety and confidence in managing this life-threatening condition. This guide supports the RCGP curriculum’s emphasis on allergy and immunology, equipping GPs with the knowledge and tools to deliver high-quality care.

References

1. British Society for Allergy and Clinical Immunology (BSACI). BSACI Guidelines for the Management of Anaphylaxis (2017). Available at: www.bsaci.org

2. BSACI (2023): Guidance for Prescribing Adrenaline Auto-Injectors in the UK. https://www.bsaci.org/wp-content/uploads/2023/06/BSACI-AAI-Guidance-June-2023.pdf

3. General Medical Council (GMC). Good Practice in Prescribing and Managing Medicines and Devices (2021). Available at: www.gmc-uk.org

4. Muraro, A. et al. EAACI Guideline: Anaphylaxis (2014 Update). Allergy, 69(8), 1026–1045.

5. National Institute for Health and Care Excellence (NICE). CG134: Anaphylaxis: Assessment and Referral After Emergency Treatment (2011). Available at: www.nice.org.uk/guidance/cg134

6. NICE NG199: Anaphylaxis: Assessment and Referral after Emergency Treatment (2022). Available at: https://www.nice.org.uk/guidance/ng199

7. Resuscitation Council UK. Emergency Treatment of Anaphylaxis: Guidelines for Healthcare Providers (2021). Available at: www.resus.org.uk

8. Royal College of General Practitioners (RCGP). RCGP Curriculum: Clinical Topic Guide - Allergy and Immunology (2020). Available at: www.rcgp.org.uk

9. RCGP Clinical Topic Guides (2021): https://www.rcgp.org.uk/getmedia/c5151d1a-f895-42d5-aaeb-9afb6d352969/Allergy-and-Immunology-2021-Final.pdf

10. Simons, F. E. R. et al. World Allergy Organization Guidelines for the Assessment and Management of Anaphylaxis. World Allergy Organization Journal, 4(2), 13–37 (2011).

11. Medicine Today (2024): Adrenaline Injector Devices Update. https://medicinetoday.com.au/mt/2024/october/regular-series/adrenaline-injector-devices-2024-update-prescribing

12. Anaphylaxis UK: Adrenaline Factsheet 2025. https://www.anaphylaxis.org.uk/wp-content/uploads/2022/10/Adrenaline-Factsheet-PDF-2025-V14.pdf

13. GP Notebook: Indications for Prescribing an Adrenaline Auto-Injector Device. https://gpnotebook.com/pages/paediatrics/anaphylactic-shock/indications-for-prescribing-an-adrenaline-auto-injector-device

14. ASCIA: Adrenaline Device Prescription Guide. https://www.allergy.org.au/hp/anaphylaxis/adrenaline-device-prescription

15. East Kent Formulary: Prescribing of Adrenaline Auto Injectors. https://www.eastkentformulary.nhs.uk/media/1655/prescribing-of-adrenaline-auto-injectors.pdf

16. MHRA Public Assessment Report: Adrenaline Auto-Injectors Safety and Usage. https://www.gov.uk/government/publications/public-assessment-report-recommendations-to-support-the-effective-and-safe-use-of-adrenaline-auto-injectors