Epinephrine treats anaphylaxis by opening the airways and increasing blood pressure.
Current delivery devices include intramuscular autoinjectors and nasal sprays.
States regulate epinephrine delivery devices to ensure rapid treatment in community settings, lowering the chance of hospitalization.
Epinephrine, also known as adrenaline, is a hormone that stimulates heart muscle contractions, increases blood pressure, relaxes airway muscles, and decreases airway spasms (Cleveland Clinic 2022). Epinephrine is the medical treatment for emergencies like cardiac arrest, extreme acute asthma, and severe allergic reaction, known as anaphylaxis (Bernstein et al. 2025). Without treatment, anaphylaxis can progress to respiratory or cardiac arrest within five minutes (Bernstein et al. 2025, Cleveland Clinic 2023).
Anaphylaxis affects approximately 120 million people and causes 225 deaths per year in the U.S. (Allergy and Asthma Network 2025a). Food allergies are the primary driver of severe allergic reaction, but insect venom, medications, latex, and exercise are also triggers (Yu et al. 2021, Barg 2011). Approximately 33 million American adults and children have a diagnosed food allergy, and roughly half of those individuals have experienced a severe reaction (Bottoms-McClain et al. 2026, Ng et al. 2026). One in four severe reactions in school settings occur in children with no prior history of a known allergy (Nieto 2020). Up to 5% of the population (16 million people) experiences a severe reaction to insect venom (American College of Allergy, Asthma, and Immunology (ACAAI) 2023).
Epinephrine cannot survive in the digestive tract and must be administered directly into the bloodstream (Bernstein et al. 2025). Intramuscular (IM) injection into the outer thigh is the recommended first-line treatment for anaphylaxis, although epinephrine can also be administered through the nasal passages (Bernstein et al. 2025, Pistiner et al. 2023).
Healthcare professionals in hospital settings utilize intravenous (IV) administration of epinephrine to treat cardiac arrest or severe respiratory distress, and IM injection to treat anaphylaxis (Allergy and Asthma Network 2025a). IM injectors are prescribed by primary healthcare providers after evaluating a patient’s allergy history and risk factors and providing the necessary device training (ACAAI 2023). Similarly, inhaled epinephrine is used for asthma symptom relief as a prescription or over-the-counter medication (Mayo Clinic 2026).
Stock supply laws allows a prescription to be issued directly to an organization rather than an individual, enabling responders to treat those with no prior allergy history (RSMo 196.990, RSMo 321.621, Allergy and Asthma Network 2025a). While all 50 states allow schools to maintain a stock supply, MO is among the 37 states that have expanded stock epinephrine laws to include other public entities, such as youth camps and restaurants (Allergy and Asthma Network 2025a). States may define specific training requirements for employees of these entities, and specify the use of delivery devices designed to reduce user error (Bernstein et al. 2025, Pistiner et al. 2024). Many states, including MO, hold harmless any trained person who administers epinephrine in good faith (RSMo 167.624, Allergy and Asthma Network 2025a).
IM auto-injectors are the standard rapid, single-dose epinephrine delivery device, but needle-free nasal sprays have expanded options for people who cannot use needles (Allergy and Asthma Network 2025a, Bernstein et al. 2025, , Cleveland Clinic 2025). Some newer IM devices use voice prompts to guide users through administration steps, while others feature needles that remain fully covered before and after injection to reduce the risk of accidental injury (Allergy and Asthma Network 2025b, Figure 1). Other versions incorporate visual indicators, like a needle that remains visible after use to confirm the dose was successfully delivered.
The FDA approved the first needle-free epinephrine nasal spray for adults and children in 2024. Nasal sprays have a longer shelf life and greater stability when exposed extreme temperatures (Allergy and Asthma Network 2025b, Cleveland Clinic 2025, Figure 1). A sublingual film is currently in the FDA approval process as an additional needle-free delivery option. This postage-stamp-sized film dissolves under the tongue, allowing epinephrine to enter the blood vessels directly without the need for water or swallowing (Bernstein et al. 2025, Ebert 2026).
Figure 1. Comparison of brand and generic epinephrine delivery devices. Community-based devices use single-dose auto-injectors and intranasal sprays allow rapid bystander response. Most auto-injectors are designed for IM administration with a shelf life of 12 to 18 months. Features include voice prompts, needle guards, and automated mechanisms to minimize user error. Nasal sprays are needle free, can tolerate up to 122° Fahrenheit, and have a longer shelf life. Adapted from Allergy and Asthma Network 2025b.
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