What are the benefits of corticosteroids in the treatment of anaphylaxis?

From the Guidelines

Corticosteroids are not recommended as a primary treatment for anaphylaxis, but may be considered as a secondary treatment to help prevent biphasic or protracted reactions, despite the lack of strong evidence supporting their efficacy in this context. The first-line treatment for anaphylaxis is always epinephrine (adrenaline), typically given as 0.3-0.5mg intramuscularly in adults or 0.15mg in children. According to the most recent and highest quality study, 1, glucocorticoids have no proven role in the treatment of acute anaphylaxis due to their slow onset of action, which can take 4 to 6 hours.

Key Points

• The primary treatment for anaphylaxis is epinephrine, which should be administered promptly to address the acute symptoms of anaphylaxis.
• Corticosteroids, such as methylprednisolone (125mg IV), hydrocortisone (200mg IV), or prednisone (40-60mg orally), may be considered as a secondary treatment to help prevent biphasic or protracted reactions.
• The use of corticosteroids in anaphylaxis is based on their anti-inflammatory properties, which may help reduce the risk of symptom recurrence after the initial reaction subsides, as suggested by 1.
• However, the evidence supporting the use of corticosteroids in anaphylaxis is limited, and their efficacy in preventing biphasic or protracted reactions is uncertain, as noted in 1.

Treatment Considerations

• Epinephrine should always be administered first, as it is the most effective treatment for acute anaphylaxis.
• Corticosteroids should not be administered prior to, or in place of, epinephrine, as they have a delayed onset of action and may not address the acute symptoms of anaphylaxis.
• The decision to use corticosteroids in anaphylaxis should be made on a case-by-case basis, taking into account the individual patient's needs and medical history.

From the Research

Benefits of Corticosteroids in Anaphylaxis Treatment

• The use of corticosteroids in anaphylaxis treatment is generally recommended as a third-line treatment, after adrenaline (epinephrine) and other medications such as β2-adrenergic agonists and glucagon 2, 3.
• Corticosteroids, such as glucocorticoids, are used to reduce inflammation and prevent late-phase reactions in anaphylaxis 2, 3.
• However, the administration of corticosteroids should never delay the injection of adrenaline in anaphylaxis, as adrenaline is the first-line treatment and is crucial for preventing hospitalizations, hypoxic sequelae, and fatalities 2, 3.
• A study analyzing data from the Cross-Canada Anaphylaxis REgistry found that patients who received prehospital corticosteroids were more likely to require intravenous fluids in the emergency department and be admitted to the hospital 4.
• The same study suggested that the use of corticosteroids in anaphylaxis should be revisited, implying that their benefits may be limited or that they may even be associated with negative outcomes 4.
• Overall, while corticosteroids may have some benefits in anaphylaxis treatment, their use should be carefully considered and should not take precedence over the administration of adrenaline and other first-line treatments 2, 3, 4.

Comparison with Other Treatments

• Epinephrine is the first-line treatment for anaphylaxis and has been shown to be effective in preventing hospitalizations, hypoxic sequelae, and fatalities 2, 3, 5, 6.
• Antihistamines, such as H1-antihistamines, are often used as second-line treatments for anaphylaxis, but their effectiveness is not as well established as that of epinephrine 3, 6, 4.
• A study found that patients treated with prehospital antihistamines were less likely to have uncontrolled reactions and be admitted to the hospital, suggesting a potential benefit of antihistamines in anaphylaxis treatment 4.

Limitations of Current Evidence

• There is limited research on the effectiveness of corticosteroids in anaphylaxis treatment, and more studies are needed to fully understand their benefits and limitations 6, 4.
• The current evidence suggests that corticosteroids should be used with caution and only as part of a comprehensive treatment plan that prioritizes the administration of adrenaline and other first-line treatments 2, 3, 4.