ASCIA updates anaphylaxis guidelines — adrenaline first, no exceptions

If you or someone in your household carries an adrenaline auto-injector, or if you care for a patient with known severe allergies, the Australasian Society of Clinical Immunology and Allergy (ASCIA) has just updated its guidelines for the acute management of anaphylaxis for the first time since 2011.

The core message has not changed. What has changed is how clearly it is stated — and what the guidelines now say to do when initial treatment is not enough.

What changed in the 2026 update

ASCIA’s revised guidelines make the following explicit across several areas where ambiguity had previously caused hesitation.

Adrenaline is first-line, without delay. When anaphylaxis is suspected, give adrenaline. Do not give antihistamines first, do not give corticosteroids first, do not wait to see if symptoms settle. Antihistamines have no role in treating the respiratory or cardiovascular effects of anaphylaxis; corticosteroids have unproven benefit in the acute setting and must not substitute for adrenaline.

Second dose at five minutes if inadequate response. If there is no adequate response to the first adrenaline dose within five minutes, a second dose is indicated alongside supportive care — oxygen, monitoring, IV or IO access and fluids where clinically indicated.

Refractory anaphylaxis pathway. This is new. Refractory anaphylaxis is formally defined as persistent respiratory or cardiovascular symptoms despite two adrenaline doses. The guidelines now specify the response: early expert involvement, IV or IO access, an adrenaline infusion, optimised fluid resuscitation, and critical care support. Having a named pathway for refractory cases closes an important gap in the previous guidance.

Asthma plus allergy. For patients with both known asthma and known allergy, if they develop sudden wheeze after a possible allergen exposure, this should be managed as anaphylaxis. Adrenaline goes first. Bronchodilators can be added for persistent wheeze, but they do not replace adrenaline — they supplement it.

Positional guidance. Patients must not stand or sit up during anaphylaxis, even if they appear recovered. Positional hypotension — a sudden, severe drop in blood pressure on standing — can occur even in patients who seem stable. The recommendation is to lie flat; those with predominantly respiratory symptoms may sit with legs outstretched.

Skin features are not required. Acute hypotension or respiratory impairment can constitute anaphylaxis without urticaria (hives) or angioedema. This matters: a proportion of anaphylactic reactions present without obvious skin signs, and waiting for a rash before acting costs time.

New devices. The guidelines now cover all adrenaline devices currently TGA-registered in Australia and New Zealand, including neffy — a nasal adrenaline spray available in 1mg and 2mg doses, registered from July 2026. Existing auto-injector options (EpiPen, Anapen, Jext) remain listed. Neffy is an option for people who find auto-injectors difficult to use, but injectable adrenaline remains the standard form.

Observation and discharge. Observe patients for at least four hours after the last adrenaline dose. Overnight observation is strongly recommended for higher-risk cases — severe or refractory reactions, severe asthma, or previous biphasic reactions. Before discharge, patients should receive an adrenaline device where possible, training in its use, and an ASCIA Action Plan for Anaphylaxis. GP referral to a clinical immunology or allergy specialist should follow all presentations with anaphylaxis.

Both-and: clear guidance in a field where hesitation costs lives

Adrenaline hesitation is documented. Studies consistently show that adrenaline auto-injectors are underused in community settings — by patients, by parents, and sometimes by clinicians — often because of uncertainty about whether a reaction is severe enough to warrant injection, concern about side effects, or waiting to see if less invasive measures work first.

The 2026 ASCIA guidelines are partly a response to that hesitation. The language is clearer. The threshold is lower. The addition of a formal refractory pathway acknowledges that severe presentations exist and that a structured response — rather than improvised escalation — is what the evidence supports.

The concern that sometimes sits alongside clearer guidance is overuse or underuse in ambiguous presentations. Adrenaline is a powerful medication with its own adverse effect profile, and practitioners in community settings may still face genuine diagnostic uncertainty. The guidelines address this by lowering the threshold for suspected presentations — act on suspicion, not certainty. For patients and families: the risk of administering adrenaline for what turns out not to be anaphylaxis is generally far lower than the risk of delayed treatment in a genuine reaction.

The addition of nasal adrenaline is worth noting because it changes the access landscape. Patients who have difficulty with auto-injectors — particularly children, older adults, or people with dexterity issues — now have a registered, guideline-endorsed alternative. Whether PBS listing follows the TGA registration is a separate question the guidelines do not address.

2 cents

For patients and carers managing known severe allergy: the message from the update is act earlier, not later. If you have an ASCIA Action Plan and an adrenaline device, use it when the plan says to use it. Do not wait for antihistamines to fail first.

For GPs: the refractory pathway and the positional guidance are the two areas most likely to change practice in community emergency presentations. Review these with the specialist letter template the guidelines recommend for discharge planning.

For anyone with a family member awaiting a specialist review after anaphylaxis: that referral is now explicitly recommended by ASCIA guidelines for all anaphylaxis presentations. If it has not happened, it is worth raising with the treating GP.

Verdict: yes — clear, evidence-aligned update to guidelines every clinician and patient with allergy history should know about.

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Sources cited

1. Updated anaphylaxis guidance puts adrenaline first — The Medical Republic
2. ASCIA — Australasian Society of Clinical Immunology and Allergy