We have been asked about the sodium metabisulphite content in EpiPen and Jext adrenaline injectors and the possible risk for people with sulphite sensitivity and for those with sulphite anaphylaxis.
Sodium metabisulphite is used as a preservative in the adrenaline.
According to one of our clinical advisors,
“Reactions to metabisulphite are nearly always relatively mild. The only concerning reactions are asthmatic after inhalation of SO2 which is released from the surface of liquids containing sulphites. The need for adrenaline in anaphylaxis far outweighs the potential for the sulphite content to cause a problem.”
According to another member of our clinical board,“Anaphylaxis due to sulphite allergy is well-described, can be severe, but must be very rare. I know that it has been stated that the presence of sulphite should not deter from the use of adrenaline – and as far as I know all products contain it. This is very unlikely to cause problems for those with coincidental sulphite or SO2 sensitivity who require adrenaline for a separate anaphylaxis risk and this is a reasonable justification for the statement. But should adrenaline be advised in the case of a patient with confirmed sulphite anaphylaxis?”
Correspondence from the Anesthesia and Analgesia journal* suggests the use of adrenaline in patients who have a history of anaphylaxis to adrenaline, in this particular setting, but where full supportive medical treatment is available, is not advised :
“In patients with a definitive history consistent with anaphylactic or anaphylactoid reactions to sulfites,avoidance of medications, including epinephrine, which contain metabisulfites as preservatives might be indicated.”
However, the correspondence suggests that “epinephrine is indicated in patients who continue to have severe and refractory anaphylaxis despite this treatment”.
So in summary, the use of adrenaline would not be contraindicated in patients with sulphite sensitivity. For rare cases of sulphite anaphylaxis, discuss options with an allergy specialist.
* Anesth Analg 2004;98:1499–505