Controversies in Allergy: Does Using Epinephrine Always Mean Calling 911?

Abstract

The current standard management of anaphylaxis recommends immediate activation of EMS after epinephrine administration. Recently the AAAAI 2023 anaphylaxis practice parameter has provided a conditional recommendation that patients at low risk may observe initial response to epinephrine at home. This pro-con review explores the evolving debate around whether immediate activation of EMS is always necessary or whether a risk-stratified approach may be appropriate for low-risk patients. We examine the clinical rationale underpinning reflex immediate EMS activation-monitoring for biphasic reactions and providing adjunctive care-against evidence suggesting that most anaphylaxis cases resolve with minimal intervention. Rates of biphasic anaphylaxis and severe outcomes are low, especially with early epinephrine use. Mandatory EMS activation may deter timely epinephrine use and increase healthcare costs, anxiety, and emergency department utilization unnecessarily. However, real-world barriers such as limited access to multiple EAIs, poor EAI usage, and inadequate anaphylaxis education outside specialty care increase risk for adverse outcomes without EMS involvement. We propose a risk-stratified approach that incorporates individual medical history, access to treatment, and capacity for self-management. Shared decision-making, objective assessment tools, and improved anaphylaxis education are essential for safely implementing this shift. Although immediate EMS activation remains critical for high-risk individuals, a tailored strategy may improve outcomes, reduce burden, and increase timely epinephrine use in lower-risk populations. Further research is needed to define clear criteria for safe home management and ensure health equity in access and education.