What is the recommended steroid treatment for anaphylaxis?

Steroid Treatment for Anaphylaxis

Corticosteroids have no proven role in the acute management of anaphylaxis and should never be administered prior to, or in place of, epinephrine, which is the first-line treatment for anaphylaxis. 1, 2

First-Line Treatment Priorities

1. Epinephrine administration

   • Intramuscular injection in mid-outer thigh at 0.01 mg/kg (maximum 0.5 mg)
   • For autoinjectors: 0.15 mg for patients 10-25 kg, 0.3 mg for patients >25 kg
   • Should NEVER be delayed to administer antihistamines or corticosteroids

2. Supportive measures

   • Place patient in supine position or Trendelenburg if hypotensive
   • Administer oxygen (8-10 L/min) for respiratory distress
   • Rapid fluid resuscitation with normal saline (20 mL/kg bolus) for hypotension

Role of Corticosteroids in Anaphylaxis

Corticosteroids are frequently used as adjunctive therapy but have significant limitations:

• Slow onset of action: Clinical improvement may not occur for 4-6 hours after administration 1, 2
• No proven efficacy: Scarcity of data demonstrating efficacy in acute anaphylaxis 1
• Not for acute symptoms: Ineffective in treating acute cardiovascular or respiratory symptoms 1, 2

When used as adjunctive therapy after epinephrine administration:

Recommended Corticosteroid Options:

• Methylprednisolone: 1-2 mg/kg/day IV every 6 hours 2
• Prednisone: 0.5-1 mg/kg orally 1, 2

Potential Benefits:

• May help prevent protracted or biphasic reactions 1, 2
• May reduce length of hospital stay 1

Important Cautions:

• Treatment should be stopped within 2-3 days, as all reported biphasic reactions occur within 3 days 1
• Methylprednisolone carries warnings about potential neurologic adverse effects with epidural administration and risk of infection 3

Complete Treatment Algorithm

1. Recognize anaphylaxis - rapid onset of multisystem symptoms involving skin, respiratory, cardiovascular, or gastrointestinal systems

2. Administer epinephrine immediately - IM in mid-outer thigh

3. Initiate supportive care:

   • Position patient appropriately
   • Administer oxygen if needed
   • Start IV fluid resuscitation for hypotension

4. Consider adjunctive medications (only after epinephrine):

   • H1 antihistamines (e.g., diphenhydramine 25-50 mg IV/IM/oral) for cutaneous symptoms
   • H2 antihistamines (minimal evidence but often used concurrently with H1)
   • Corticosteroids (methylprednisolone 1-2 mg/kg IV or prednisone 0.5-1 mg/kg orally)
   • Albuterol (2.5-5 mg nebulized) for persistent bronchospasm

5. Monitor for biphasic reactions:

   • Observe for at least 4-6 hours after symptom resolution
   • Consider longer observation (up to 24 hours) for severe reactions

Common Pitfalls to Avoid

1. Delaying epinephrine administration to give antihistamines or corticosteroids first - this is associated with increased mortality 4, 5

2. Using corticosteroids as first-line treatment - they have no role in acute management and delayed onset of action 1, 2

3. Relying on antihistamines alone - they only address cutaneous symptoms, not life-threatening cardiovascular or respiratory symptoms 1, 6

4. Discharging patients too early - risk of biphasic reactions requires extended observation 2

5. Withholding epinephrine due to concerns about side effects - there are no absolute contraindications to epinephrine in anaphylaxis, even with cardiac disease 2

The most recent evidence from the Cross-Canada Anaphylaxis Registry (2023) suggests that while early epinephrine use is beneficial, the role of corticosteroids should be revisited as their use was associated with increased likelihood of requiring IV fluids and hospital admission 5.