Anaphylaxis in general practice: early adrenaline and the nasal option
Based on a Gold Coast CPD panel with an adult allergist, a paediatric allergist, and an allergy nurse practitioner — covering recognition, delay, real-world barriers, and neffy (adrenaline nasal spray).
- Dr Elizabeth da Silva
- Allergist and clinical immunologist, Gold Coast (adult practice; session chair). Otter labelled her “Liz / Elizabeth”.
- Dr Birgit Marchand
- Paediatric allergist and clinical immunologist, Southport / Gold Coast (Paediatric Allergy Specialist Clinic; also John Flynn). The Otter transcript garbled her name as “Megan Marsham”; “Biggie / Beer” in the recording is Birgit.
- Lena James NP
- Allergy and eczema nurse practitioner, Compass Immunology, Brisbane. Nursing since 2003; nurse practitioner from late 2024; ASCIA member. Former emergency nurse, and parent of a child with allergy.
Dr da Silva disclosed an honorarium for the evening. The session included product education on neffy (CSL Seqirus). This write-up reports the panel’s clinical teaching; it is not an advertisement.
Why the night mattered
Dr da Silva opened with a point GPs already feel: allergic disease is a daily load for patients and carers. People living with significant food or venom allergy need ready access to a reliable adrenaline device they will actually carry and use. Choosing the device is not a trivial brand preference — it changes whether adrenaline is given in time.
Adrenaline is the only medication proven to reverse anaphylaxis. International guidelines agree it is first-line. Antihistamines and steroids may follow; they do not replace it. neffy — an adrenaline nasal spray — is the first new community delivery method in this space in decades (injectable adrenaline has been the Australian default since the 1990s). The panel’s job was practical: when to give it, why people hesitate, and how a needle-free option fits beside EpiPen and other injectors.
What anaphylaxis looks like
Several grading systems exist and can get fiddly. Dr da Silva’s working rule matches ASCIA teaching: any one of the severe signs is enough.
| Severe sign (any one = anaphylaxis) | Clinic notes from the panel |
|---|---|
| Difficult or noisy breathing | Includes stridor |
| Swelling of the tongue | Airway threat — do not wait |
| Swelling or tightness in the throat | Patients may describe “tightness” rather than visible swelling |
| Wheeze or persistent, uncontrollable cough | Often the first sign in children during food challenges |
| Difficulty talking, dysphonia, hoarseness | Voice change is an airway sign |
| Dizziness or collapse | Think hypotension; do not wait for a rash |
| Pale and floppy (young children) | May go blue; cardiovascular compromise in toddlers is easy to miss |
| Abdominal pain and vomiting | Anaphylaxis after hymenoptera venom (bee, wasp, jumping ants; fire ants rising). Also give adrenaline for venom-related nausea/vomiting without waiting for breathing signs. |
That venom caveat is worth repeating in every ASCIA action-plan review: gut symptoms after a sting are not “just a tummy upset.”
Why delayed adrenaline is dangerous
Early adrenaline restores heart rate, blood pressure, and a clear airway. Dr da Silva emphasised a second, less-quoted harm of delay: it substantially raises the chance of needing more adrenaline later (including an infusion), staying in hospital beyond ED, and a biphasic reaction hours later — classically around four hours, but six or even eight — from poorly controlled mast-cell activation.
Australia should not still see anaphylaxis deaths. The panel was frank that we still do, including recent media cases. The international and local data they cited:
- About one third of Australians prescribed adrenaline do not actually carry the device.
- Two in five report delayed or no adrenaline during anaphylaxis — seen in community practice, and historically even in some emergency departments (that last figure is improving, but not gone).
Adrenaline is first-line. Delay is not a “wait and see” strategy — it is a risk factor for more doses, more hospital time, and biphasic reactions.
Why devices sit unused
The barriers are not mysterious. They are human, practical, and they cluster in predictable groups.
Permission culture and needle fear — Dr Marchand
Delayed adrenaline is more common than we admit. Many parents — “anxious mums” in her words — and students at school believe they need someone else’s permission before using an adrenaline device. That idea has to change. Needle phobia cuts both ways: children who do not want the needle, and parents who do not want to give it.
Even experts hesitate — Lena James
Lena spoke from three seats: allergy nurse, former emergency nurse, and parent of a child with allergy. Her child had anaphylaxis a few years ago. Despite years of drawing up adrenaline in hospital and in clinic, she had never actually given an EpiPen until that moment. It was not automatic. The hesitation families describe is real — even when your head knows adrenaline will help your child.
That experience now shapes her counselling. In clinic the previous week she had seen a child who went to ED with an allergic reaction suggestive of anaphylaxis and was not given adrenaline — not even a second antihistamine — just monitored. Her line to families:
“If you’re looking at your child, you’re looking at your partner, or you’re feeling unwell — you’re not feeling good — use it.” Then call an ambulance.
Bulk, handbags, and jackhammers — Dr da Silva
In adult allergy, the biggest carry-barrier group is teenagers and young adults. Young women with a small evening bag. Young men who will not carry a bag at all. Another group: outdoor manual workers — heat, jackhammers, tractors — who cannot cart a bulky pack. Cargo pants and thigh pockets help; large injectors are still awkward.
Fear of using the device “wrong,” including finger-stick injuries on some injectors, is not entirely unfounded. Needle concern affects the person giving it and the person receiving it, especially children.
Do not wait for a rash — treat the picture in front of you
Lena’s food-challenge clinic rule, after a decade of watching reactions: each episode is a bit different (anxiety, the allergen, how the patient copes). The simple lesson is you do not wait for symptoms to “complete the textbook.”
- About 40% of children do not get a rash. The rash, when it comes, can be late.
- A typical sequence: food challenge underway → a persistent cough in the waiting area → within minutes, anaphylaxis.
- Facial swelling plus cough or wheeze is a reason to give adrenaline.
Dr Marchand: you do not have to start with antihistamines and “step up.” If the presentation is anaphylaxis, start with adrenaline.
Allergen patterns GPs actually see
| Trigger | How it often declares itself (panel) | Action |
|---|---|---|
| Insect venom (bee, wasp, jumping ant, fire ant) | May start with nausea; vomiting is anaphylaxis. Tongue tingling is early — be ready, but not automatically a first dose on tingling alone. | Nausea/vomiting after a sting → adrenaline |
| Food (especially supervised challenges) | Persistent cough; airway signs; rash optional and often late | Adrenaline for any severe sign |
| Alpha-gal (mammalian meat; emerging, including northern NSW rivers) | Often urticaria plus profound GI symptoms (including incontinence), then collapse. Bronchospasm is not required. First responders can miss it until they take a blood pressure. | Think anaphylaxis; check BP; give adrenaline |
| Clinic immunotherapy / drug challenge | Dr da Silva has seen anaphylaxis to penicillin challenges and dust-mite desensitisation — high-risk settings, especially subcutaneous venom immunotherapy | Have adrenaline in the room, ready |
neffy: who it is for, and how nasal adrenaline can work
Dr Marchand presented neffy as an adrenaline nasal device for emergency anaphylaxis in adults and children aged 4 years and over, weighing 15 kg and above. It is a single-dose spray (like an EpiPen, you only get one shot per device). Do not prime it.
| Weight | Device |
|---|---|
| 15 kg to less than 30 kg (and age ≥ 4) | neffy 1 mg, one spray into one nostril |
| 30 kg or greater | neffy 2 mg, one spray into one nostril |
| Under 4 years or under 15 kg | Not on-label for neffy — use an age/weight-appropriate injector |
PBS listing from 1 July 2026 is a pack of two single-dose sprays in a blister. A small blue carry case was on the tables — designed to fit an evening bag or a sleep-short pocket, which is exactly the carry problem Dr da Silva described in young adults. The product has been available overseas since September 2024 (US experience is therefore a year ahead of Australia’s PBS era).
Why a nose spray can work at all — Intravail
Same adrenaline. The extra ingredient is Intravail (trade name for dodecyl maltoside), a GRAS (“generally recognised as safe”) absorption enhancer used in other nasal medicines. GPs already know the idea from naloxone nasal spray; the platform has tens of millions of prescriptions worldwide.
Plain adrenaline up the nose would mostly cause local vasoconstriction and go nowhere. Intravail briefly loosens the tight junctions between nasal mucosal cells so adrenaline can reach the systemic circulation and hit alpha and beta receptors. The panel’s teaching — matching the product story — is that nasal congestion, allergic rhinitis, turbinate hypertrophy, or a cold may facilitate absorption rather than block it (damaged barrier, more leak).
A second dose, if needed, is given in the same nostril, because that side is already primed with Intravail.
What adrenaline is actually doing
Dr Marchand walked through receptor effects — useful when explaining “why we do not wait for the mast-cell cascade to finish.”
| Receptor | Physiology | What you hope to see |
|---|---|---|
| Alpha-1 | Vasoconstriction, higher systolic BP, less airway oedema | Shock eases; upper-airway obstruction starts to lift |
| Beta-1 | Heart rate and contractility | Perfusion improves |
| Beta-2 | Bronchial smooth-muscle relaxation; less mediator release from mast cells and basophils | Airflow returns; the histamine cascade is interrupted — which is why early dosing matters |
PK/PD, the Japanese food-challenge study, and real-world use
You cannot ethically run a classic blinded randomised trial in people who are actively anaphylaxing. Registration therefore used pharmacokinetic (PK) blood levels and pharmacodynamic (PD) body responses as surrogates. The panel’s headline:
- neffy’s PK profile sits within the range of EpiPen and intramuscular adrenaline.
- Clinical reversal does not map neatly onto a blood-level number, and the minimum effective concentration is unknown — so PD matters more in practice.
- PD effects (heart rate, systolic BP) have been seen as early as one minute, comparable to EpiPen and IM adrenaline, in adult and paediatric datasets shown on the night.
A Japanese phase-3 open-label study in 15 children and teenagers (6–17) with food-challenge anaphylaxis (moderate / grade 2 or higher) reported 15/15 symptom resolution after one nasal dose, improvement within five minutes, median resolution 16 minutes. One later biphasic reaction was described (the panel said about two hours; published detail puts recurrence closer to 2 hours 45 minutes, then intramuscular adrenaline). Small numbers — “encouraging, not encyclopaedic.”
Dr da Silva liked the PK package and pointed to a large US clinic series (she recalled about 545 patients after oral food challenge or allergen immunotherapy, including subcutaneous venom — a high-bar setting). Subsequent public case-series updates have grown further; the direction of travel is the same: most clinic anaphylaxis episodes settled with one nasal dose, a minority needed a second adrenaline dose. Lena’s US nursing colleagues have been using it for years; the consistent comment is that taking the needle out of the moment reduces fear in paediatric patients.
Australian experience (private scripts, then a patient-access programme, then PBS) is still accumulating. Anecdotes from colleagues, including during venom desensitisation, were described as confirmatory rather than merely promising. Dr da Silva’s own nurses prefer having neffy on standby for clinic anaphylaxis rather than drawing up adrenaline. She offers patients a range of devices with side-effect and technique information; preference for the nasal option is already showing, for size and needle-avoidance. She expects it to become a dominant community device in eligible age/weight groups — not a replacement for injectors in under-fours or under 15 kg, and not a reason to be casual about high-risk venom or previously multi-dose anaphylaxis (those are the groups where some overseas guidance still prefers an injector in the kit).
No serious adverse events in the trial programme discussed. No needle injuries, no finger-sticks, no accidental intravascular injection. Common effects: headache and nasal discomfort, more so after a second dose. The panel stated no contraindications to adrenaline in true anaphylaxis.
Second doses, hypotension, and clinic adjuncts
Floor question: when do you give a second dose, and is the rule different for nasal versus intramuscular? Dr da Silva: no. If features of anaphylaxis persist at five minutes, give a second dose of whichever adrenaline you have. Devices are equivalent for that purpose. Repeat every five minutes while you still have anaphylaxis.
The sign most often missed for a second or third dose — especially in ED — is persisting hypotension after the airway and gut have settled. Third dose at five minutes if needed; a fourth while you obtain IV access. After three doses the patient belongs on an adrenaline infusion with cardiac monitoring — ambulance in some regions, otherwise ED / ICU. That is not a GP-rooms improvisation.
Adjuncts — and what not to push
Between adrenaline doses, if you have IV access: fluids, and hydrocortisone 200 mg, were listed as reasonable. Dr da Silva mentioned IV ranitidine as something she stocks in clinic. Ranitidine products were withdrawn in Australia because of NDMA impurity concerns — treat that as historical colour from the talk, not a prompt to hunt residual stock. Current anaphylaxis care does not depend on an H2 blocker.
Dr da Silva does not use IV Phenergan (promethazine) in this setting. It can worsen hypotension, and there are case reports of tissue injury. Heads nodded in the room. If the patient is still anaphylaxing, they should not be swallowing oral antihistamines either.
Dr Marchand’s close: anaphylaxis is nuanced. Watch especially for dangerous hypotension and sudden severe bronchospasm. Have everything ready. Take it seriously, case by case.
PBS, interchangeability, and private cost
Floor question: can you prescribe both an injector and a nasal spray on the PBS? Dr da Silva: not at the same time. PBS is one subsidised adrenaline presentation — injector or nasal. They are interchangeable as continuing therapy: if the patient already has an initial injector authority, a continuing PBS script can be neffy (one-for-one). Patients can buy the other privately. Several of hers do, especially remote travellers (desert, Whitsundays by boat) who want redundancy.
Private-price anecdotes from Gold Coast pharmacies on the night (dispensing fees vary — shop around and price-match):
- Two neffy devices: about $195–215
- One EpiPen: about $110–165
- Two EpiPens: up toward $320
So a two-pack of neffy can be cheaper privately than two injectors, depending on the pharmacy. Published consumer figures change; check the chemist in front of you. Device counselling (“how do I actually use the spray?”) was parked until after dinner on the night — that segment is not in this Otter file, so this article does not invent a technique demo. Use the current ASCIA device instructions and a trainer device.
Take-home messages for clinic
- Adrenaline first, and early. It is the only disease-modifying drug in anaphylaxis. Delay means more doses, more hospital time, and biphasic risk.
- Any one severe sign is enough. Do not wait for hives. Persistent cough, pale-and-floppy toddlers, and venom-related vomiting are anaphylaxis.
- Families hesitate. Permission culture, needle fear, handbags, and worksites all stop devices being used. Counsel: if in doubt, use it, then call 000.
- About one third do not carry the device they were prescribed. Ask, every review. Match the device to the person’s actual life.
- neffy is on-label from age 4 and 15 kg (1 mg below 30 kg; 2 mg at 30 kg+). Single dose; no priming; second dose same nostril at five minutes if still anaphylaxing.
- PBS is either/or with injectors, but continuing scripts are interchangeable. Under-fours and under 15 kg still need an injector.
- In a medical setting, do not miss persisting hypotension; do not use IV promethazine; infusions belong in monitored ED/ICU care after repeated IM/intranasal doses.
Dr Kotha · Gold Coast · anaphylaxis.drkotha.com