Are steroids ever used in the treatment of strongyloidiasis?

From the Guidelines

Steroids should be avoided in the treatment of strongyloidiasis due to the risk of triggering hyperinfection syndrome or disseminated strongyloidiasis, as stated in the British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults 1. The primary concern with using steroids in strongyloidiasis is that they can suppress the immune response, allowing the parasite to multiply and cause severe infection.

• The use of corticosteroids can lead to hyperinfection syndrome, characterized by increased parasite burden, GI bleeding, pneumonia, sepsis, or meningitis, particularly in immunocompromised patients 1.
• The treatment of strongyloidiasis typically involves antiparasitic medications, such as ivermectin or albendazole, rather than steroids.
• However, in cases where patients require steroids for other medical conditions and have strongyloidiasis, preventive treatment with ivermectin should be administered before starting steroid therapy, as suggested by the Infectious Diseases Society of America (IDSA) and the American Society of Tropical Medicine and Hygiene (ASTMH) guidelines 1.
• It is essential to exclude strongyloidiasis prior to steroid use, as recommended by the UK guidelines for the investigation and management of eosinophilia in returning travelers and migrants 1.
• The danger of steroids in strongyloidiasis relates to the parasite's unique autoinfection cycle, where larvae can develop into infectious forms within the host and cause widespread infection when immune function is compromised by steroids.

From the FDA Drug Label

Corticosteroids, including prednisone tablets, should be used with great care in patients with known or suspected Strongyloides (threadworm) infestation In such patients, corticosteroid-induced immunosuppression may lead to Strongyloides hyperinfection and dissemination with widespread larval migration, often accompanied by severe enterocolitis and potentially fatal gramnegative septicemia.

Steroids are not recommended for use in patients with strongyloidiasis due to the risk of corticosteroid-induced immunosuppression leading to hyperinfection and dissemination. 2

From the Research

Treatment of Strongyloidiasis

• The use of steroids in the treatment of strongyloidiasis is generally avoided due to the risk of precipitating or exacerbating hyperinfection syndrome, particularly in immunocompromised individuals 3, 4, 5.
• Steroids can suppress the immune system, allowing the Strongyloides stercoralis parasite to multiply and cause severe disease 3, 5.
• The primary treatment for strongyloidiasis is ivermectin, which has been shown to be effective in curing the infection and preventing hyperinfection syndrome 6, 7.
• Albendazole is an alternative treatment option, but it has a lower efficacy than ivermectin and is typically used when ivermectin is not available or not recommended 6, 7.

Use of Steroids in Specific Situations

• In patients with strongyloidiasis who require corticosteroid therapy for other conditions, such as asthma, the use of steroids should be carefully considered and monitored due to the risk of hyperinfection syndrome 3, 4.
• Empirical prophylaxis with ivermectin may be considered in patients receiving high-dose corticosteroids in areas endemic for strongyloidiasis, although the efficacy and cost-effectiveness of this approach are still being studied 4.
• In immunocompromised individuals, such as those with HIV/AIDS or undergoing immunosuppressive therapy, the use of steroids should be avoided whenever possible due to the high risk of hyperinfection syndrome 5.