Summary: published economic evidence for epinephrine delivery in anaphylaxis

No published economic model, cost-effectiveness analysis, or health technology assessment of dibutepinephrine sublingual film has been identified, and no price for the product has been announced. Aquestive Therapeutics describes payer and pricing research as under way ahead of a possible launch.

The published economic evidence for epinephrine delivery in anaphylaxis consists of decision-analytic models of auto-injector prescribing, of undesignated stock epinephrine in schools, camps and aircraft, and of non-injectable epinephrine. In a birth-cohort Markov model of children with peanut allergy, the value-based price of a personal auto-injector at a threshold of $100,000 per quality-adjusted life-year was $24 under a 10-fold fatality risk difference and $264 under a 100-fold difference; at the 2016 market cost of $715 per twin pack the incremental cost-effectiveness ratio was $2,742,697 per quality-adjusted life-year. A companion model of the Chicago Public Schools system found that a supplemental undesignated stock epinephrine strategy fell below $100,000 per quality-adjusted life-year only when annual acquisition cost did not exceed $338 per school, while a universal supply model dominated the alternatives. A model of US summer camps found stock epinephrine to be the least expensive and most effective strategy. A model of commercial aircraft reported an incremental cost-effectiveness ratio of $10,766 per quality-adjusted life-year for supplemental stock auto-injectors. A risk-stratification model found that prescribing two auto-injectors to every patient with peanut allergy was not cost-effective in the United States unless the cost of a single device fell below $80.

Two analyses address non-injectable delivery. A 2025 Markov analysis that modelled an approved intranasal form and a sublingual form under development reported that intranasal or sublingual epinephrine was the most cost-effective option, with an incremental cost-effectiveness ratio of $83,748 per quality-adjusted life-year, but only at a marginal annual cost of $4, and that adding a non-injectable device to an existing pair of auto-injectors was not cost-effective at an incremental cost-effectiveness ratio of $858,462. A 2026 United Kingdom analysis of nasal adrenaline spray reported dominance over adrenaline auto-injectors, with 0.26 additional quality-adjusted life-years at a cost 681 pounds lower, driven by assumed higher carriage and greater likelihood of use. A 2013 United Kingdom health technology assessment of specialist services and adrenaline injectors found specialist services with injectors cost-effective at a threshold of 20,000 pounds per quality-adjusted life-year.

Across these analyses the results are governed by device acquisition cost and by assumptions about carriage and use rather than by pharmacological differences, so a non-injectable product priced at parity with current devices would be cost-effective only if it increases carriage or timely administration. None of these analyses evaluates dibutepinephrine.

Cost-effectiveness of non-injectable epinephrine, including a sublingual form in development

“Noninjectable epinephrine to treat allergic reactions addresses an unmet need. Intranasal epinephrine is approved and a sublingual form is under development.” (opens the source at this quote in a new tab)
“In the base-case scenario, assuming a 10-fold decreased risk in peanut allergy fatality associated with intranasal or sublingual epinephrine treatment for a severe allergic reaction (net monetary benefit [NMB], $2,189,134) vs intramuscular epinephrine use (NMB, $2,189,114), intranasal or sublingual epinephrine was the most cost-effective option (incremental cost-effectiveness ratio [ICER], $83,748/quality-adjusted life-year [QALY]), but only at a marginal annual cost of $4.” (opens the source at this quote in a new tab)
“Noninjectable routes of epinephrine can be cost-effective options provided fatality risk is not significantly elevated.” (opens the source at this quote in a new tab)

Cost-effectiveness of nasal adrenaline spray compared with adrenaline auto-injectors in the United Kingdom

“In the base case, the nasal adrenaline spray was dominant versus the AAI, yielding 0.26 additional QALYs at a lower cost (-£681).” (opens the source at this quote in a new tab)
“In the UK, the nasal adrenaline spray may be a cost-effective alternative to AAIs, largely due to assumed higher carriage and greater likelihood of use during anaphylactic episodes.” (opens the source at this quote in a new tab)

Value-based price of a personal epinephrine auto-injector

“The high cost of self-injectable epinephrine autoinjectors may represent a barrier to community anaphylaxis management. Value-based pricing can provide a benchmark for rational epinephrine autoinjector costs.” (opens the source at this quote in a new tab)
“The value-based price (incremental cost-effectiveness ratio, $100 000 per quality-adjusted life-year) for personal epinephrine based on 10-fold fatality risk difference was $24.” (opens the source at this quote in a new tab)
“If a hypothetical fatality risk protection from personal epinephrine was modeled at 100-fold, the value-based price ceiling for a personal autoinjector was $264.” (opens the source at this quote in a new tab)

Cost-effectiveness of undesignated stock epinephrine in schools

“However, epinephrine device costs vary, and the cost-effectiveness of undesignated school stock epinephrine is uncharacterized to date.” (opens the source at this quote in a new tab)
“When comparing supplemental model stock epinephrine to the strategy without undesignated devices, the incremental cost-effectiveness ratio was high at $268 811 per QALY in the base-case simulation.” (opens the source at this quote in a new tab)
“However, the cost of the supplemental model fell below $100 000 per QALY when the annual undesignated epinephrine acquisition costs did not exceed $338 per school (compared with stock epinephrine unavailability).” (opens the source at this quote in a new tab)

Cost-effectiveness of undesignated stock epinephrine in United States summer camps

“Stock epinephrine was the least expensive and most effective ($4.33, 69.9 quality-adjusted life-days [QALDs]) strategy.” (opens the source at this quote in a new tab)
“Secondary analyses demonstrated that the individual-provided epinephrine strategy resulted in the most hospitalizations; stock epinephrine plus individual epinephrine cost $9476 per hospitalization avoided.” (opens the source at this quote in a new tab)

Cost-effectiveness of stock epinephrine auto-injectors on commercial aircraft

“The incremental cost-effectiveness ratio of supplemental airline epinephrine autoinjectors was $10,766/QALY in the base-case analysis.” (opens the source at this quote in a new tab)

Cost-effectiveness of prescribing one compared with two epinephrine auto-injectors

“Universal prescription of 2 EAIs was associated with an incremental cost of $10,696,036/QALY versus the PMH-ana strategy, and $17,514,558/QALY versus the multi-epi strategy.” (opens the source at this quote in a new tab)
“However, the universal strategy became cost-effective versus a multi-epi strategy when single EAI costs were less than $80, second epinephrine dose requirements more than 25.5%, anaphylaxis hospitalization costs more than $18,453, annual anaphylaxis risk more than 76.5%, or anaphylaxis hospitalization rate more than 74.9%.” (opens the source at this quote in a new tab)

Health technology assessment of specialist services and adrenaline auto-injectors

“From the cost-effectiveness analysis (CEA), SC with injectors was dominated by SS with or without injectors.” (opens the source at this quote in a new tab)
“The results of the CEA showed that SS with AIs was cost-effective at a threshold of £ 20,000 per QALY.” (opens the source at this quote in a new tab)

Cost-effectiveness of delayed compared with immediate emergency department transfer after auto-injector use

“Watchful waiting for symptom re-occurrence following EAI administration in non-medical settings is cost-effective.” (opens the source at this quote in a new tab)
“Watchful waiting remained cost-effective in all sensitivity and scenario analyses, except under extreme increases in fatality risk of 500-fold and 1,000-fold.” (opens the source at this quote in a new tab)

Anaphylm (dibutepinephrine)

Modeling overview