When to prescribe oral corticosteroids (oral steroids) for a suspected allergic reaction in an outpatient setting?

From the Guidelines

Oral corticosteroids should be prescribed for suspected allergic reactions in the outpatient setting when patients present with moderate to severe symptoms that affect quality of life but are not life-threatening, as evidenced by the most recent study from 2020 1. When considering the use of oral corticosteroids, it is essential to weigh the benefits against the potential risks and consider the severity of the allergic reaction.

• The primary indication for oral corticosteroids in this context is for allergic reactions involving significant skin manifestations, such as widespread urticaria or angioedema without airway involvement, moderate to severe allergic rhinitis unresponsive to antihistamines, or non-anaphylactic drug reactions.
• Before prescribing oral corticosteroids, clinicians should rule out contraindications such as systemic infections, uncontrolled diabetes, or peptic ulcer disease, as noted in various guidelines 1.
• Patients should be counseled about potential side effects, including mood changes, increased appetite, insomnia, and elevated blood glucose, and short-term steroid use should be accompanied by H1 antihistamines like cetirizine 10mg daily or diphenhydramine 25-50mg every 4-6 hours as needed.
• The use of oral corticosteroids, such as prednisone, is supported by their anti-inflammatory properties, which can help alleviate symptoms and improve quality of life, although their role in preventing biphasic reactions is less clear 1.
• For severe allergic reactions involving respiratory distress or hypotension, immediate emergency care with epinephrine and hospital admission is necessary rather than outpatient oral corticosteroids, as emphasized in the guidelines 1.

From the Research

Oral Corticosteroids for Suspected Allergic Reactions

• Oral corticosteroids may be considered as adjunct medications for the treatment of anaphylaxis, but only after the administration of intramuscular epinephrine 2.
• The treatment of acute severe reactions like anaphylaxis includes resuscitating the patient, ensuring airway patency, injecting adrenaline i.m., setting up an i.v. infusion of a plasma expander, and injecting an anti-histamine and hydrocortisone 3.
• In the management of drug allergy, additional therapy for drug hypersensitivity reactions is largely supportive and may include topical corticosteroids, oral antihistamines and, in severe cases, systemic corticosteroids 4.
• However, it is essential to note that glucocorticoids themselves can cause allergic reactions, including anaphylaxis, in some individuals 5, 6.
• The incidence of adverse reactions induced by steroids is up to 0.3%, with the most commonly reported steroids causing anaphylaxis being hydrocortisone, prednisone, and methylprednisolone 6.

Key Considerations

• Clinicians should be aware of the potential for allergic reactions to glucocorticoids and carefully evaluate the risk-benefit ratio before prescribing oral corticosteroids for a suspected allergic reaction 5, 6.
• If oral corticosteroids are prescribed, patients should be closely monitored for signs of an allergic reaction, and alternative treatments should be considered if necessary 2, 4.