How often should steroids be repeated in the management of an allergic reaction?

Steroid Administration in Allergic Reactions

Corticosteroids should be administered for 2-3 days following an allergic reaction, with oral prednisone at 1 mg/kg daily (maximum 60-80 mg) being the recommended regimen. 1

Initial Management of Allergic Reactions

First-Line Treatment

• Epinephrine is the first-line treatment for anaphylaxis and severe allergic reactions
  • Administered intramuscularly in the mid-outer thigh
  • Should never be delayed for secondary treatments

Adjunctive Treatments

1. Antihistamines

   • H1 antihistamines: Diphenhydramine 1-2 mg/kg (maximum 50 mg) every 6 hours
   • H2 antihistamines: Ranitidine 1-2 mg/kg (maximum 75-150 mg) twice daily

2. Corticosteroids

   • Duration: 2-3 days 1
   • Dosing options:
     • Oral prednisone: 1 mg/kg daily (maximum 60-80 mg) 1
     • IV methylprednisolone: 1-2 mg/kg/day divided every 6 hours 1

Steroid Administration Protocol

Mild-Moderate Allergic Reactions

• Oral prednisone 0.5-1 mg/kg daily for 2-3 days 1
• Can be given as a single daily dose
• No tapering necessary for short courses

Severe Allergic Reactions/Anaphylaxis

1. Acute phase:

   • IV methylprednisolone 1-2 mg/kg/day 1, 2
   • Administered after epinephrine and antihistamines

2. Discharge regimen:

   • Oral prednisone 1 mg/kg daily for 2-3 days 1
   • No need for tapering with short courses

Special Considerations

Biphasic Reactions

• Corticosteroids are often recommended to prevent biphasic or protracted allergic reactions, though evidence for this is limited 1
• Despite limited evidence, they are still recommended due to their anti-inflammatory properties

Steroid Allergies

• Hypersensitivity reactions to corticosteroids are rare (0.3-0.5%) but should be considered in patients with worsening symptoms after steroid administration 3
• Patients with steroid allergy may tolerate steroids from different chemical groups 4

Pediatric Considerations

• Children should receive the same 2-3 day duration of steroids
• Dosing should be weight-based: 1 mg/kg of prednisone (maximum 60 mg) 1
• Methylprednisolone in pediatric patients ranges from 0.11-1.6 mg/kg/day in divided doses 2

Monitoring and Follow-up

• Patients should be observed for 4-6 hours after initial treatment of anaphylaxis 1
• Longer observation may be needed for patients with:
  • History of biphasic reactions
  • Severe initial reaction
  • Incomplete response to initial treatment

Pitfalls to Avoid

• Don't use steroids as first-line treatment: Epinephrine should never be delayed to administer steroids in anaphylaxis
• Don't extend steroid treatment unnecessarily: Longer courses increase risk of side effects without proven benefit
• Don't forget to provide an epinephrine auto-injector prescription at discharge for patients with anaphylaxis
• Don't rely solely on steroids: They have a delayed onset of action and should be used as adjunctive therapy

Remember that while corticosteroids are important in managing allergic reactions, they should not replace or delay the administration of epinephrine in anaphylaxis, which remains the definitive life-saving intervention.