How to Use an EpiPen (Epinephrine Auto-Injector)

Why carrying and knowing how to use an EpiPen matters

Epinephrine is the only first-line treatment for anaphylaxis -- a severe, potentially life-threatening allergic reaction. During anaphylaxis, epinephrine rapidly reverses airway swelling, low blood pressure, and hives. Antihistamines and corticosteroids work too slowly and are not substitutes. 1Ref 1Golden DBK, Wang J, Waserman S, Akin C, Campbell RL, et al. (Joint Task Force on Practice Parameters, AAAAI/ACAAI) (2024).Anaphylaxis: A 2023 practice parameter update.Epinephrine as the only first-line treatment for anaphylaxis; biphasic reaction risk as basis for 911 call; updated guidance on when immediate EMS activation may be modified; prescribing two auto-injectors

Knowing how to use your auto-injector before an emergency arises -- practicing with the trainer device your clinician provides -- is one of the most important steps anyone with a severe allergy can take. Delay in epinephrine administration is a major contributing factor in fatal anaphylaxis. 2Ref 2Cardona V, Ansotegui IJ, Ebisawa M, El-Gamal Y, Fernandez Rivas M, Fineman S, et al. (2020).World allergy organization anaphylaxis guidance 2020.Outer thigh (vastus lateralis) as preferred injection site for fastest absorption; importance of pre-emergency auto-injector training; prescribing two devices; injection through clothing acceptable

Step-by-step EpiPen technique

Different brands have slightly different designs. The steps below describe the standard EpiPen and generic equivalents. Always read the instructions included with your specific device.

1. Grip the auto-injector in your dominant hand, with your thumb closest to the blue safety cap and fingers wrapped around the device. 2. Remove the blue safety cap by pulling it straight off -- do not bend or twist it. 3. Position the orange tip against the outer middle thigh. You can inject through clothing if needed -- avoid pockets, seams, or thick layers. 2Ref 2Cardona V, Ansotegui IJ, Ebisawa M, El-Gamal Y, Fernandez Rivas M, Fineman S, et al. (2020).World allergy organization anaphylaxis guidance 2020.Outer thigh (vastus lateralis) as preferred injection site for fastest absorption; importance of pre-emergency auto-injector training; prescribing two devices; injection through clothing acceptable 4. Press firmly and hold the injector against the thigh until you hear or feel a click, then continue holding for 10 seconds to ensure the full dose is delivered. 5. Remove the injector and massage the injection site for 10 seconds to aid absorption. 6. Call 911 immediately after every epinephrine injection, even if you feel better. 1Ref 1Golden DBK, Wang J, Waserman S, Akin C, Campbell RL, et al. (Joint Task Force on Practice Parameters, AAAAI/ACAAI) (2024).Anaphylaxis: A 2023 practice parameter update.Epinephrine as the only first-line treatment for anaphylaxis; biphasic reaction risk as basis for 911 call; updated guidance on when immediate EMS activation may be modified; prescribing two auto-injectors

Why do I need to call 911 after using epinephrine?

Epinephrine acts within minutes but wears off in 10-20 minutes. Anaphylaxis can return after the drug's effects fade -- a phenomenon called biphasic anaphylaxis -- sometimes hours after the initial reaction. Emergency medical personnel can monitor you, administer a second dose if needed, and provide additional treatments. 1Ref 1Golden DBK, Wang J, Waserman S, Akin C, Campbell RL, et al. (Joint Task Force on Practice Parameters, AAAAI/ACAAI) (2024).Anaphylaxis: A 2023 practice parameter update.Epinephrine as the only first-line treatment for anaphylaxis; biphasic reaction risk as basis for 911 call; updated guidance on when immediate EMS activation may be modified; prescribing two auto-injectors

The 2023 practice parameter update notes that if epinephrine is used promptly and the patient experiences a complete and durable response, immediate 911 activation may not always be required in every situation. However, professional follow-up is strongly advised in most real-world cases. 1Ref 1Golden DBK, Wang J, Waserman S, Akin C, Campbell RL, et al. (Joint Task Force on Practice Parameters, AAAAI/ACAAI) (2024).Anaphylaxis: A 2023 practice parameter update.Epinephrine as the only first-line treatment for anaphylaxis; biphasic reaction risk as basis for 911 call; updated guidance on when immediate EMS activation may be modified; prescribing two auto-injectors Never drive yourself to the hospital after using an auto-injector.

Should I inject into my arm or my thigh?

The outer thigh is the recommended site. Epinephrine reaches the bloodstream faster from the thigh muscle (vastus lateralis) than from the arm, because the thigh has a richer blood supply and greater muscle mass. 2Ref 2Cardona V, Ansotegui IJ, Ebisawa M, El-Gamal Y, Fernandez Rivas M, Fineman S, et al. (2020).World allergy organization anaphylaxis guidance 2020.Outer thigh (vastus lateralis) as preferred injection site for fastest absorption; importance of pre-emergency auto-injector training; prescribing two devices; injection through clothing acceptable

Avoid the buttocks (slower absorption) and never inject into a vein or inner thigh. The outer middle thigh -- whether the dominant or non-dominant leg -- is safest. Injection through clothing is acceptable in an emergency.

What if a second injection is needed?

If symptoms do not improve or worsen significantly after 5-15 minutes, a second dose can be given in the opposite thigh if a second auto-injector is available. This is why clinicians typically prescribe two devices to be carried together at all times. 2Ref 2Cardona V, Ansotegui IJ, Ebisawa M, El-Gamal Y, Fernandez Rivas M, Fineman S, et al. (2020).World allergy organization anaphylaxis guidance 2020.Outer thigh (vastus lateralis) as preferred injection site for fastest absorption; importance of pre-emergency auto-injector training; prescribing two devices; injection through clothing acceptable Emergency responders can administer additional epinephrine once they arrive.

How to store and carry your EpiPen

• Store at room temperature (59-77 degrees F / 15-25 degrees C) and away from light.
• Do not refrigerate. Freezing can damage the device.
• Do not leave it in a hot car -- high heat degrades the medication.
• Check the expiration date regularly and replace before it expires.
• Carry both devices with you at all times in an accessible location.
• Check the solution through the inspection window: it should be clear and colorless. Do not use a device with discolored or cloudy solution. 2Ref 2Cardona V, Ansotegui IJ, Ebisawa M, El-Gamal Y, Fernandez Rivas M, Fineman S, et al. (2020).World allergy organization anaphylaxis guidance 2020.Outer thigh (vastus lateralis) as preferred injection site for fastest absorption; importance of pre-emergency auto-injector training; prescribing two devices; injection through clothing acceptable

How do I practice without using real epinephrine?

Every EpiPen prescription comes with a free trainer device that contains no needle and no medication. Practice the steps above until they feel automatic -- and teach family members, coworkers, or school staff as well. Practicing regularly helps ensure that anxiety or unfamiliarity does not slow you down in an actual emergency.

A Gale clinician can walk through EpiPen technique with you during a visit and help you create a written anaphylaxis action plan to share with the people around you.