What you need to know about: Adrenaline Auto-Injectors and Temperature Control

Adrenaline is the medication of choice for use in Anaphylaxis and in Cardiac resuscitation. Despite being so often used in medical emergencies, most people are unaware of how to prevent it from degrading and with this, rendering it either unsafe to use or leading to its loss of effect. Probably the most significant lack of information is related to temperature control.

In reality, most users of adrenaline auto-injectors don’t know that constant or prolonged exposure to a high heat source or to sunlight will lead to the degradation of the adrenaline inside. It is important to note that heat or sunlight does not always change the colour of adrenaline, so there are no warning signs.

In fact, one of the earliest pieces of research happened in 1997 and was focused on GPs carrying adrenaline in their bags in Pert, Western Australia. The evidence they had is that a Doctor’s black bag could reach temperatures as high as 80 oC. They also knew that a previous test made on Adrenaline sent to Sudan, it showed nearly no activity after being stored in temperatures around 45 oC. The conclusions they achieved were that there was a loss of activity between nearly 10% to 20%, and there had been no change in Adrenaline colour.

More extensive research has revealed that adrenaline needs to be kept between 15 oC and 25 oC, although if kept between 15 oC and 30 oC, it is still safe. What is known is that from 37 oC, it starts losing its capacities.

In the past, it was thought that exposure to very low temperatures would lead to the degradation of adrenaline. That has now been shown not to be true, but be aware that both low and high temperatures will affect the mechanism inside the injector itself.

Interestingly, what is considered the “safest” places inside a car, e.g. the glove compartment and the boot, have been found to reach temperatures of nearly 100 oC when exposed to direct sunlight during a hot summer’s day. Due to this, it is even more important to keep the injectors under reasonable temperature control to decrease the chance that the adrenaline inside them is rendered ineffective.

In conclusion, to keep your adrenaline and injectors usable for emergencies, this is what you should do:

Keep your injectors, along with other medication, in a medication bag capable of keeping the temperature stable for a few hours, aiming for a maximum of four hours.
By using this medication bag, you will also prevent exposure to direct sunlight.
At the same time, it is always worth keeping the bag in the shade.
Do not forget the medication bag inside a car, especially the glove compartment or boot, as those are the hottest places.
Do not freeze your injectors, as this may lead to mechanism malfunction.
Do not keep your Adrenaline inside the fridge, next to an ice pack or on ice.
Always check the expiry date of your medication.
Always check the adrenaline’s colour. If no longer transparent, you need to change it urgently.

References:
1) The Effects Of Heating On EpiPen Epinephrine Auto-injector Device Integrity And Function - Samuel Agosti, Pingping Qu, Julie Brown; J Allergy Clin Immunol February 2020.
2) Environmental temperature variations cause degradations in epinephrine concentration and biological activity - Grant TA; Carroll RG; Church WH; Henry A; Prasad NH; Abdel-Rahman AA; Allison EJ Jr; The American journal of emergency medicine May 1994.
3) Adrenaline degradation in general practice - S V Rudland, T Annus, J Dickinson and S Langdon; British Journal of General Practice, 1997.
4) A systematic review of epinephrine degradation with exposure to excessive heat or cold - Hannah G. Parish, Corinna S. Bowser, Jacquelyn R. Morton, Julie C. Brown; Ann Allergy Asthma Immunol, 2016.
5) Adrenaline and Temperature Control - https://allergyfacts.org.au/resources/help-sheets/adrenaline-and-temperature-control

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