Intranasal Epinephrine for Treatment of Anaphylaxis

Lilian White, MD
November 24, 2025

Epinephrine remains the cornerstone of the treatment of anaphylaxis. Traditionally, it has been delivered via intramuscular injection. Barriers to use are generally few, but needle phobia presents a challenge for some patients. In 2023, the US Food and Drug Administration approved an intranasal epinephrine formulation as another option.

Intranasal epinephrine is approved for type 1 hypersensitivity reactions (eg, anaphylaxis) in adults and children weighing more than 30 kg (approximately 66 lbs). At the onset of symptoms, a 2 mg dose given intranasally is recommended. Similar to intramuscular epinephrine, a repeat dose may be given after 5 minutes if indicated; however, in clinical studies, most patients did not require an additional dose. Each bottle is intended for single use and delivers the full 2 mg dose in 0.1 mL as a blister package (two blister packages are included in each prescription). The time to peak plasma concentration and effects on blood pressure and heart rate are similar to those from epinephrine delivered intramuscularly.

Benefits of intranasal epinephrine compared with intramuscular epinephrine include use regardless of body habitus, temperature stability, and needleless delivery. Body habitus may negatively affect the use of intramuscular epinephrine. For example, in overweight patients, a short needle length may lead to subcutaneous rather than intramuscular injection, delaying delivery of the medication. In underweight or younger patients, a needle length that is too long may result in interosseous injection. Intranasal epinephrine is stable for periods at higher temperatures (122ºF) vs lower temperatures required for intramuscular epinephrine storage. The intranasal, needleless delivery may prevent delays in treatment for patients with needle phobia.

Although no absolute contraindications (similar to intramuscular epinephrine) have been found in patients with anaphylaxis, caution is recommended in patients with nasal structural abnormalities (eg, polyps, prior nasal surgery) because of the potential for impaired absorption. Clinical trials of the spray included patients with allergic rhinitis, demonstrating its effectiveness in this population. Additionally, the spray includes sodium metabisulfite, which some patients may have an allergic reaction to; however, this is not a contraindication to using the medication in cases of life-threatening anaphylaxis. Other inactive ingredients may be found on the drug label.

Acute adverse effects are similar to those who are treated with intramuscular epinephrine. Following use, the nasal mucosa may demonstrate increased absorption of other medications for up to 2 weeks and increase the risk of adverse effects from other intranasally administered medications.