FAA's Proposal for Epi on Planes: a Letdown for Allergy Safety

The Federal Aviation Administration has released its long-awaited proposed rule to update the emergency medical kits (EMKs) on U.S. commercial flights. Food allergy advocates had hoped this would be a turning point for requiring modern epinephrine devices to be available in airline medical kits.

Instead, the proposed rule provides airlines with greater flexibility on what’s in the EMK and waters down existing language on which specific medicines a kit is required to contain, including epinephrine.

In a statement to Allergic Living, the FAA said the proposal would “modernize requirements” for emergency medical kits. It proposes replacing today’s checklist of required medical items with a “flexible, performance-based standard” that allows airlines to tailor kit contents and crew training as medical science evolves.

Yet, that flexibility immediately raises this question: After Congress directed the FAA to improve emergency preparedness for anaphylaxis, why does the rule appear to increase uncertainty?

The agency said the proposal is intended to ensure crews have “up-to-date resources to handle the most common in-flight emergencies.” But then it appears to leave it up to the airlines to decide what those resources are.

The newly released proposed rule identifies nine life-threatening conditions the kits should be equipped to address, including anaphylaxis. The proposal is now open for public comment for 60 days before the FAA issues a final rule. Allergic Living and No Nut Traveler, my allergy nonprofit, urge readers to speak up for both required epinephrine in EMKs and easy-to-use epinephrine devices.

Under the FAA Reauthorization Act of 2024, Congress had directed the FAA to update the contents of airlines’ emergency medical kits. Congress even singled out anaphylaxis, noting the agency must determine whether EMKs include “appropriate medications and equipment that can practicably be administered” for it.

Advocates Decry Lack of Epi Devices

The FAA tells Allergic Living that the proposed rule “allows airline operators to tailor kit contents and crew training to evolve with modern medical science.” But will that get us past the basic epinephrine vial and syringe that can be tricky to dose with children and requires medical training?

The food allergy nonprofit FARE views this rule as a setback. “For the more than 33 million Americans living with food allergy, this proposal puts lives at risk,” FARE said in a statement. “Rather than requiring modern, FDA-approved epinephrine administration options like auto-injectors and nasal epinephrine, the proposal moves away from clear national standards.”

The Asthma and Allergy Foundation of America (AAFA) welcomes the concept of the FAA proposing a rule that would require airlines to be ready for severe allergic reactions. However, it is very concerned about the proposed wording.

“The best way to treat anaphylaxis is to use a modern epinephrine delivery device and we should accept nothing less,” AAFA said in a statement. “It saves lives, it’s cost effective, and it’s easy to deliver – even for someone who has no medical training.”

Dr. Anna Nowak-Wegrzyn is a New York City allergist who has treated patients experiencing allergic reactions on flights. She too finds the proposal’s language concerning. “It sounds like these provisions are optional and at the discretion of an airline, as opposed to clearly stated guidelines and standards.”

She also notes that drawing up epinephrine from a vial in an emergency is challenging aboard a plane.

Allergic Living has documented many physicians responding to in-flight allergic emergencies. We’ve heard reports of them finding only cardiac, not anaphylaxis concentrations of epinephrine or encountering unfamiliar devices that required improvisation over the ocean. Others have crowd-sourced among passengers for an epinephrine auto-injector when there wasn’t one in the emergency kit.

FAA’s New Rule: Flexible Uncertainty

Together, these accounts paint a picture of a system in which prevention can fail, and emergency preparedness becomes the last line of defense. Those experiences became part of the broader body of evidence that ultimately led Congress to direct the FAA to revisit emergency medical kit requirements.

Whether the proposal fulfills Congress’s goal remains in question. Although the FAA says crews should have “up-to-date resources,” it does not specify whether every airline would be expected to carry modern epinephrine delivery devices, such as easy-to-use auto-injectors or the newer nasal epinephrine. Or would an epinephrine vial and syringe alone still satisfy the new standard?

If the final rule permits that level of flexibility, emergency treatment for anaphylaxis could also differ depending on the airline.

Rather than citing epinephrine as a required medication, the proposed rule states that treatment for anaphylaxis “could include medication such as epinephrine.”

Epinephrine is the only medication proven to stop a progressing anaphylactic reaction. That wording raises a jarring question: will the final rule even ensure that every commercial aircraft continues to carry epinephrine in its emergency medical kit?

In regulatory language, phrases like “could include” and “such as” provide greater discretion than “must” or “shall” be carried. Whether the FAA intends that flexibility to apply to the requirement to carry epinephrine itself, or only to the form in which it is carried and administered, is not clear.

Epi in Medical Kit in Question

The FAA describes flexibility as a way to keep emergency medical kits aligned with advances in medicine. Yet, this has implications for emergency medicine consistency across airlines. If carriers have greater flexibility to determine the contents of their EMKs, what assurances will passengers have that the medications needed for anaphylaxis will be available when minutes matter?

These questions aren’t merely theoretical. In 2022, Allergic Living reported that over many years, airlines had been granted an FAA exemption from stocking required medications, including epinephrine, during shortages. Physician reports of epinephrine missing from EMKs prompted Allergic Living to check with the FDA. Each time, no shortage existed.

The FAA’s proposal would eliminate that exemption process entirely. Instead, it would fold required medications into the same flexible standard. So airlines could substitute drugs “without requesting an FAA exemption”.

Yet in anaphylaxis, there is no substitute for epinephrine. If the proposed rule eliminates both a required medication list and the exemption process, how will anyone know whether this critical medication is missing – or why?

Allergic Living submitted questions to the FAA following release of the proposed rule. However, the spokesperson said the agency “cannot comment on open rulemaking,” but will evaluate all public comments before issuing a final rule.

Why Epi Must be in the Kit

One challenge in evaluating emergency preparedness is that emergency medical kit use may not accurately reflect how often allergic reactions occur in-flight. In the largest published survey of food-allergic travelers, Northwestern University’s CFAAR found that 8.5 percent of more than 4,700 respondents reported allergic reactions while flying. That’s a rate that suggests these reactions happen far more often than other reporting has captured. Ninety-two percent said they treated themselves rather than use the plane’s medical kit.

That gap matters in understanding the rate of anaphylaxis in the skies. EMK suppliers and airlines can track when an EMK is opened and needs restocking. But that system only captures reactions where the kit was actually used. When most passengers self-treat, the kit is never opened – and the reaction never enters the record.

The aircraft’s emergency medical kit is more than a backup. It may be the only source of lifesaving treatment for passengers who have not yet been diagnosed with a food allergy, travelers who accidentally left their epinephrine at home or packed it in checked baggage, those who eat an airline meal without realizing it is not subject to allergen labeling requirements, and passengers whose severe reaction requires additional epinephrine.

Have Your Say to the FAA

Advocacy groups including No Nut Traveler, AAFA, the Allergy & Asthma Network, the Food Allergy & Anaphylaxis Connection Team, and FARE worked together to advance stronger emergency preparedness aboard commercial aircraft. When Congress framed a section of the FAA Reauthorization Act of 2024 to address epinephrine, the organizations viewed it as a turning point.

Perhaps it still can be. For the food allergy community, this is an opportunity to help shape what comes next. If, after reading the proposal, you believe it falls short of what passengers with food allergies need, now is the time to submit your comments.

The comments submitted over the next 60 days may help shape the standards that govern emergency medical care aboard commercial aircraft for years to come.

When anaphylaxis occurs at 35,000 feet, in my view, uncertainty is not a medical plan.

Lianne Mandelbaum is Allergic Living’s airlines correspondent, and the founder of NoNutTraveler.com.