Should steroids be prescribed for a patient with anaphylaxis upon discharge?

From the Guidelines

Yes, you should prescribe steroids for someone with anaphylaxis upon discharge, as they may help reduce the risk of biphasic anaphylactic reactions, which can occur up to 72 hours after the initial reaction in approximately 5-20% of cases. A typical regimen includes prednisone 40-60 mg daily for 3-5 days, with no taper needed for this short course 1. In addition to steroids, patients should be discharged with an epinephrine auto-injector (such as EpiPen or Auvi-Q), and instructed on proper use. Patients should also receive a prescription for H1 antihistamines like cetirizine 10 mg daily or diphenhydramine 25-50 mg every 6 hours as needed.

Key Considerations

• The use of steroids in anaphylaxis is supported by many health care professionals, despite limited evidence, due to their potential to prevent biphasic or protracted reactions 1.
• Epinephrine remains the first-line emergency treatment for anaphylaxis, and steroids should not be administered prior to, or in place of, epinephrine 2, 3.
• The risk of biphasic anaphylaxis is associated with a more severe initial presentation of anaphylaxis or repeated epinephrine doses required with the initial presentation 4.
• Patients should be advised to follow up with an allergist to identify triggers and develop a comprehensive anaphylaxis action plan.

Management Approach

• Administer epinephrine as the first-line pharmacotherapy for uniphasic and/or biphasic anaphylaxis 2.
• Provide education on anaphylaxis, including avoidance of identified triggers, presenting signs and symptoms, biphasic anaphylaxis, treatment with epinephrine, and the use of epinephrine auto-injectors 2.
• Consider extended clinical observation in a setting capable of managing anaphylaxis for patients with resolved severe anaphylaxis and/or those who need >1 dose of epinephrine 4.

From the Research

Anaphylaxis Treatment

• Anaphylaxis is a life-threatening systemic reaction that requires immediate treatment, typically with epinephrine 5.
• The use of corticosteroids in anaphylaxis treatment is a topic of debate, with some studies suggesting they may not be effective in preventing biphasic anaphylaxis 6.
• A review of 31 studies found no compelling evidence to support the routine use of corticosteroids in anaphylaxis treatment, citing potential detrimental adverse effects and lack of evidence demonstrating their effectiveness 6.

Corticosteroid Use in Anaphylaxis

• A study of 5364 anaphylactic reactions found that patients who received prehospital corticosteroids were more likely to require intravenous fluids and be admitted to the hospital 7.
• Another study found that corticosteroids may reduce the length of hospital stay, but did not reduce revisits to the emergency department 8.
• The evidence on the use of corticosteroids in anaphylaxis treatment is largely based on observational studies and animal or laboratory studies, with no randomized controlled clinical trials available 8.

Guidelines and Recommendations

• The American Family Physician recommends the use of epinephrine as the first-line treatment for anaphylaxis, with adjunct medications such as histamine H1 and H2 antagonists, corticosteroids, beta2 agonists, and glucagon considered only after epinephrine administration 5.
• A systematic review of evidence on the use of corticosteroids in anaphylaxis management found no compelling evidence to support or oppose their use, but suggested that they may be beneficial based on available data 8.
• The optimal treatment of anaphylaxis is a topic of ongoing debate, with some studies suggesting that antihistamines may not be as effective as epinephrine in relieving symptoms 9.