Do I need to discharge a patient with a bee sting allergy who received hydrocortisone (cortisol) 200mg stat with a course of prednisolone?

Management of Bee Sting Allergies After Initial Hydrocortisone Treatment

Yes, you should discharge the patient with a short course of oral prednisolone after administering hydrocortisone 200mg for a bee sting allergy. This approach ensures continued anti-inflammatory coverage and reduces the risk of delayed or biphasic allergic reactions.

Rationale for Oral Prednisolone After Initial Hydrocortisone

• Hydrocortisone 200mg provides immediate anti-inflammatory effect but has a relatively short half-life
• According to guidelines, patients with allergic reactions should receive a short course of oral corticosteroids for 2-3 days after discharge 1
• The British Thoracic Society specifically recommends prednisolone tablets (30mg daily or more) for one to three weeks after discharge for patients with allergic reactions 1

Discharge Medication Protocol

1. Prednisolone prescription:

   • Adult dose: 40-60mg daily for 3-5 days 1
   • Pediatric dose (if applicable): 1-2 mg/kg/day (maximum 60mg/day) for 3-10 days 1
   • No need to taper for short courses under 7 days 1

2. Additional discharge medications to consider:

   • H1 antihistamine (e.g., diphenhydramine every 6 hours for 2-3 days) 1
   • H2 antihistamine (e.g., ranitidine twice daily for 2-3 days) 1

Monitoring and Follow-up

• Educate patient about potential delayed reactions that can occur up to 72 hours after the initial sting
• Instruct patient to return if symptoms worsen or new symptoms develop
• Consider referral to an allergist for patients with systemic reactions to insect stings 2
• For patients with history of severe reactions, consider prescribing an epinephrine auto-injector 1, 2

Important Considerations

• The severity of the initial reaction should guide the aggressiveness of follow-up treatment
• Patients with systemic reactions should be observed for 4-6 hours before discharge 1
• Patients with history of severe reactions may benefit from venom immunotherapy (VIT) 1
• Patients taking β-blockers or ACE inhibitors may be at higher risk for severe reactions and should be monitored more closely 1

Potential Pitfalls

• Failure to prescribe oral corticosteroids after parenteral administration may lead to symptom rebound when the effect of hydrocortisone wears off
• While rare, be aware that some patients may have allergic reactions to corticosteroids themselves 3, 4
• Relying solely on antihistamines without corticosteroids is insufficient for moderate to severe allergic reactions

By providing a short course of oral prednisolone after initial hydrocortisone treatment, you ensure continuous anti-inflammatory coverage during the critical period when delayed or biphasic reactions may occur, significantly reducing morbidity and improving quality of life outcomes.