Epinephrine: Friend or Foe?

Course Author(s):


A patient’s overall health status determines the patient’s ability to undergo and respond to dental care. Consequently, patient-specific problems that may interfere with the clinical process must be identified. In determining perioperative risk, clinicians must consider past and present illnesses, major hospitalizations, functional capacity, history of drug allergies and other adverse drug reactions (ADRs), dietary supplements and special diets, and medications taken by the patient.1

In the United States there are approximately 500 Food and Drug Administration (FDA)-approved active ingredients (chemical entities) in several thousand different therapeutic formulations. ClinCalc DrugStats provides prescription drug utilization data estimates based on the annual Medical Expenditure Panel Survey (MEPS).2 The list of the Top Prescription Drugs of 2017 reflects data collected in 2014 and is based on more than 3.187 billion out-patient prescriptions.2

The DrugStats database is a sanitized, standardized versions of the MEPS database.2 Sanitization measures include identifying prescriptions that are not valid medications and those with incomplete data. Standardization measures predicated on the FDA National Drug Code, the FDA Orange Book, and the NLM RxNorm databases are used to aggregate like-medications based on their active ingredient, i.e., DrugStats entries are standardized against approved chemical entities.

The Top 200 Prescription Drugs of 2017 represent 40% of the available 500 active ingredients and comprise 90% of all prescription drugs taken by ambulatory patients in 2014.2 The Top 300 Prescription Drugs of 2017 represent 60% of the available 500 active ingredients and comprise 97% of all prescription drugs taken by ambulatory patients in 2014.2 These data are invaluable in identifying patient-specific risks factors in ambulatory settings, e.g., oral healthcare settings.

The Top 300 Prescription Drugs of 2017 include epinephrine, ranked # 293.2 The “rank,” based on nearly 1.45 million prescriptions, refers to the frequency that epinephrine formulations were prescribed in 2014 compared to other medications. Drug synonyms used during the sanitization and standardization process included generic- and brand name-formulations that contained epinephrine, epinephrine hydrochloride, and epinephrine bitartrate as active ingredients.2

The rank of 293 indicates that based on the Top 300 Prescription Drugs of 2017, epinephrine formulations are relatively uncommon prescription medications. However, it is of note that the true per annum use of epinephrine is far greater, i.e., epinephrine is underrepresented in the database because local anesthetic (LA) formulations containing epinephrine and epinephrine as an emergency drug administered by healthcare providers are not counted in the database.

Most epinephrine formulations are prescribed primary by physicians. Oral healthcare providers administer epinephrine to patients as an adjuvant in local anesthetic formulations as a matter of standard practice in association with perioperative pain management. Furthermore, in rare instances, oral healthcare providers are called upon to administer epinephrine formulations during the course of managing acute severe Type 1 allergic reactions, i.e., anaphylaxis.

When oral healthcare providers are administering epinephrine-containing drug formulations, minimum competency must reflect knowledge in relation to the pharmacology of epinephrine in the following eight areas: (1) drug name (brand/generic), (2) mechanisms of action, (3) drug kinetics, (4) indications for use, (5) dosing, (6) familiarity with potential ADRs and monitoring parameters, (7) contraindications, and (8) the use of reliable informational resources.

DailyMed, a useful online resource, is the official repository for FDA-approved package inserts, i.e., for individual drug-related, clinically relevant data.3 The posted information is the most recent submitted to the FDA by pharmaceutical companies and includes strengthened warnings undergoing FDA review. The information is accurate; whenever possible it is based on human experience; and does not contain promotional or misleading information such as implied claims.