What oral steroid can be used as an alternative to prednisone (Pred) or methylprednisolone (Medrol) in a patient with a known allergy to fluticasone?

From the Guidelines

Deflazacort would be the most appropriate oral steroid option for you given your constraints. Since you cannot take prednisone or methylprednisolone (Medrol) and have a fluticasone allergy, deflazacort provides an alternative corticosteroid with potentially lesser metabolic side-effects as compared to prednisolone 1. A typical starting dose would be 0.75 mg·kg−1·day−1 for 4 weeks, with subsequent tapering as needed, depending on the condition being treated and your specific medical needs. Before starting deflazacort, inform your healthcare provider about all medications you're taking and any medical conditions you have, particularly diabetes, osteoporosis, hypertension, or immunosuppression, as steroids can affect these conditions. Some key points to consider with deflazacort include:

• It has a different side effect profile compared to prednisolone, with potentially fewer metabolic side effects 1.
• The dosage may need to be adjusted based on your response to the medication and the presence of any side effects.
• Never stop taking oral steroids abruptly as this can cause adrenal crisis; always follow your doctor's tapering schedule when discontinuing treatment. It's also important to note that while deflazacort is an option, an ongoing trial is comparing prednisolone with deflazacort, which may provide more insight into its efficacy and safety in the future 1.

From the FDA Drug Label

DOSAGE REQUIREMENTS ARE VARIABLE AND MUST BE INDIVIDUALIZED ON THE BASIS OF THE DISEASE AND THE RESPONSE OF THE PATIENT. The patient has an allergy to fluticasone and cannot have prednisone or medrol.

• Dexamethasone is an alternative oral steroid option.
• The dosage of dexamethasone varies depending on the disease being treated, and the initial dosage should be maintained or adjusted until the patient's response is satisfactory 2.
• Another option is hydrocortisone, which is available as an oral tablet 3.

From the Research

Alternatives to Prednisone and Medrol

• Considering the patient's allergy to fluticasone, alternative oral steroids need to be explored.
• According to the study 4, a patient with multiple corticosteroid allergies was found to be tolerant to hydrocortisone, suggesting it as a potential option.
• Another study 5 compared the effectiveness of intravenous hydrocortisone, methylprednisolone, and dexamethasone in acute bronchial asthma, finding no significant differences between the three groups.

Cross-Reactivity and Allergies

• The study 4 highlights the issue of cross-reactivity among corticosteroids, where patients allergic to one corticosteroid may exhibit reactions to others.
• This is crucial in considering alternative treatments, as the patient's allergy to fluticasone may indicate a potential reaction to other corticosteroids.
• The study 6 ranked glucocorticoids by their trans-activation potency, which may be useful in selecting alternative treatments.

Clinical Decision-Making

• The study 7 emphasizes the importance of clinical reasoning in making decisions, particularly when evidence is incomplete or contradictory.
• This is relevant in the current scenario, where the patient's specific allergies and needs must be taken into account when selecting an alternative oral steroid.
• The study 8 discusses the challenges of making strong recommendations based on low-certainty evidence, highlighting the need for careful consideration and clinical judgment.