Intranasal epinephrine (neffy) is now approved on several continents, but how should it fit into anaphylaxis care — especially when a reaction doesn't respond? A 30-expert international panel addresses this in JACI: In Practice.
Their pathway is simple: remove the allergen, position the patient correctly, give epinephrine intramuscularly or intranasally every 5-15 minutes, and support airway, breathing and circulation. The key change: the two routes are treated as equally effective and interchangeable — every dose counts, whichever route it came by.
If there is no response after two doses, prepare an IV epinephrine infusion and start it after the third. Without infusion capability, keep redosing every 5 minutes, give fluids, and transfer to ICU fast.
Dribin TE, et al. J Allergy Clin Immunol Pract. 2026;14(10):2254-2261.
https://www.jaci-inpractice.org/article/S2213-2198(26)00583-0/fulltext