D2.327 - Patient and caregiver perspectives on sublingual adrenaline for anaphylaxis: findings from an international survey

Despite being first-line therapy for anaphylaxis, delayed or missed intramuscular adrenaline administration remains common, driven by low auto-injector carriage, reluctance to self-inject and needle fear. Sublingual adrenaline films are emerging needle-free alternatives requiring stakeholder appraisal.

International, cross-sectional online survey disseminated via EAACI channels in 2025 to patients aged 16+ and caregivers of children with food allergy and prescribed adrenaline autoinjectors. A free-text question on perspectives on sublingual adrenaline for anaphylaxis was included and analysed using reflexive thematic analysis following the Clarke and Braun approach. 

Responses were obtained from 133 patients aged 16+ and 304 caregivers. Five themes were identified in both groups (see table):

(1) Reduced burden and acceptability: Both groups expressed strong interest in a sublingual adrenaline tablet as a needle-free, discreet, portable option that could reduce daily treatment burden, stigma and anxiety linked to injectable adrenaline. Patients emphasised benefits for independent use and reduced visibility in public, while caregivers highlighted reduced distress for children and easier administration by family members or school staff.

(2) Confidence was consistently conditional on robust evidence of comparable speed of onset and effectiveness to autoinjectors. Many questioned whether holding a tablet under the tongue for ~1 minute would be fast enough in anaphylaxis.

(3) Feasibility of sublingual dosing during allergic reactions and safety concerns: A dominant concern was real-world feasibility in severe reactions: vomiting, coughing, airway or tongue swelling, panic and loss of consciousness were commonly cited as situations where sublingual dosing might fail or pose choking/aspiration risk.

(4) Acceptability constraints: Suitability was also seen as age- and cooperation-dependent. Caregivers particularly questioned feasibility in younger children, noting palatability, sensory aversion and the need for cooperation during distress as potential barriers. Additional concerns included tablet excipients, misuse by non-allergic individuals, and tablets being lost or difficult for others to locate in emergencies.

(5) Preference for choice and layered safety: Many respondents advocated “layered safety,” preferring sublingual adrenaline as an added option rather than a replacement, and supporting continued access to injectable adrenaline alongside any new format.

Sublingual adrenaline is viewed as an attractive needle-free option that could reduce treatment burden and improve adherence, although significant knowledge transfer is needed to reduce hesitancy over use as standalone (rather than add-on) medication. Patients and caregivers still prioritise the need for evidence of comparative efficacy to injected adrenaline.