Is prednisone recommended for excessive histamine response after a viral Upper Respiratory Infection (URI)?

Prednisone for Excessive Histamine Response After Viral URI

Prednisone is not recommended for excessive histamine response following a viral upper respiratory infection (URI) as it provides no clear clinical benefit and may carry more risks than benefits. 1

Evidence-Based Rationale

The European Position Paper on Rhinosinusitis and Nasal Polyps 2020 (EPOS2020) specifically advises against the use of systemic corticosteroids in patients suffering from acute post-viral rhinosinusitis 1. This recommendation is based on the lack of evidence supporting clinical benefit and the potential for adverse effects from systemic corticosteroids.

Pathophysiology and Management Approach

Viral URIs can trigger excessive histamine responses through:

• Increased sensitivity of afferent sensory nerves in the upper airway
• Enhanced reactivity to mechanical stimulation
• Inflammatory mediator release

The appropriate management strategy should follow this algorithm:

1. First-line treatments:

   • Nasal saline irrigation (safe and provides modest symptom relief) 2
   • Analgesics/antipyretics for pain and fever management 2
   • Adequate hydration (approximately 2 liters per day) 2

2. For specific symptom management:

   • Nasal congestion: Short-term topical decongestants (≤3-5 days) or oral decongestants if no contraindications 2
   • Cough: Consider honey as first-line treatment for distressing cough 2
   • Rhinorrhea: First-generation antihistamine/decongestant combinations may be more effective than newer generation antihistamines 1

Antihistamines vs. Corticosteroids

For excessive histamine response following viral URI:

• First-generation antihistamine/decongestant combinations have shown efficacy in reducing symptoms including cough, throat clearing, and postnasal drip 1
• Newer "non-sedating" antihistamines are relatively ineffective in treating common cold symptoms 1
• The American Academy of Otolaryngology-Head and Neck Surgery suggests that antihistamines may provide symptomatic relief of excessive secretions and sneezing, though clinical studies specifically for acute viral rhinosinusitis are limited 1

Important Considerations and Caveats

1. Duration of symptoms: Most viral URIs are self-limited with symptoms typically lasting 5-7 days and peaking by days 3-6 2

2. Red flags requiring further evaluation:

   • Symptoms persisting beyond 10 days without improvement
   • Severe symptoms (fever >39°C, purulent nasal discharge, facial pain >3 days)
   • Worsening symptoms after initial improvement ("double sickening") 2

3. Bacterial vs. viral differentiation:

   • Nasal purulence alone does not indicate bacterial infection
   • Coloration of nasal discharge reflects inflammation, not necessarily infection 1

4. Avoid antibiotics unless clear signs of bacterial infection are present, as they provide no benefit for viral infections and contribute to antibiotic resistance 2

Conclusion on Prednisone Use

While systemic corticosteroids like prednisone might theoretically reduce inflammation and histamine-mediated symptoms, the EPOS2020 guideline specifically recommends against their use in post-viral rhinosinusitis 1. The risk-benefit ratio does not favor prednisone use in this context, and alternative symptomatic treatments should be prioritized.