Should intramuscular (IM) corticosteroids be administered for allergic reactions?

From the Guidelines

Intramuscular (IM) steroids should not be used as a first-line treatment for allergies, and their use should be reserved for severe cases that do not respond to conventional therapy, due to the potential risks and side effects associated with their use, as supported by the most recent evidence from 1 and 1.

Key Points to Consider

• The primary treatment for anaphylaxis, a severe and life-threatening allergic reaction, is epinephrine administered intramuscularly, as emphasized in the 2020 practice parameter update 1.
• IM steroids, such as triamcinolone acetonide or methylprednisolone, may be considered in severe allergic reactions or acute exacerbations that do not respond to conventional therapy, but their use should be cautious due to potential side effects, including blood sugar elevation, mood changes, and adrenal suppression.
• The use of antihistamines and glucocorticoids, including IM steroids, as adjunctive therapy in anaphylaxis is not recommended before or in place of epinephrine, as they have a slow onset of action and are not reliable in preventing biphasic anaphylaxis, as noted in 1.

Recommendations for Practice

• For routine allergy management, safer options such as daily oral antihistamines (e.g., cetirizine, loratadine), nasal corticosteroids (e.g., fluticasone, mometasone), or short courses of oral prednisone should be preferred.
• Patients with diabetes, osteoporosis, or immunocompromised conditions should be particularly cautious with IM steroid use, as they may be at higher risk for adverse effects.
• Clinicians should educate patients and their caregivers about the signs and symptoms of anaphylaxis and the proper use of epinephrine, as well as the potential risks and benefits of IM steroid use, as recommended in 1 and 1.

From the FDA Drug Label

Allergic States: Control of severe or incapacitating allergic conditions intractable to adequate trials of conventional treatment in asthma, atopic dermatitis, contact dermatitis, drug hypersensitivity reactions, seasonal or perennial allergic rhinitis, serum sickness, transfusion reactions. The answer is yes, IM steroids, such as methylprednisolone, can be given for allergies, specifically for the control of severe or incapacitating allergic conditions that are intractable to conventional treatment 2.

• Key indications include asthma, atopic dermatitis, contact dermatitis, and seasonal or perennial allergic rhinitis.
• The dosage may vary depending on the condition being treated, but a single injection during each 24-hour period of a dose of the suspension equal to the total daily oral dose of MEDROL® Tablets is usually sufficient 2.

From the Research

IM Steroids for Allergies

• The use of intramuscular (IM) steroids for allergies is a topic of discussion, with some studies suggesting their effectiveness in managing allergic reactions 3, 4.
• However, there are also reports of hypersensitivity reactions to corticosteroids, which can range from mild to severe, including anaphylaxis 5, 6, 7.
• The incidence of anaphylactic reactions has increased in recent years, and the treatment of allergic reactions should be guided by the severity of the reaction 3.
• IM steroids, such as corticosteroids, are often used to treat allergic reactions, but patients can also have allergic-type reactions to these agents 5, 6, 7.
• The severity of the reaction can vary from a rash to anaphylaxis or death, and both immediate and delayed reactions can occur 5, 6, 7.

Benefits and Risks

• The use of corticosteroids in emergency management of anaphylaxis may reduce the length of hospital stay, but there is no consensus on whether they reduce biphasic anaphylactic reactions 4.
• Animal studies have demonstrated that corticosteroids act through multiple mechanisms, modulating gene expression and blocking signal activation of glucocorticoid receptors 4.
• However, there is also evidence that patients can develop hypersensitivity reactions to nasal, inhaled, oral, and parenteral corticosteroids, and that atopic dermatitis and stasis dermatitis of the lower extremities are risk factors for the development of allergic contact dermatitis from topical corticosteroids 5, 6, 7.

Clinical Considerations

• Clinicians should be aware that allergic reactions to corticosteroids are possible, and that worsening of symptoms may not always mean treatment failure, but may indicate an allergic reaction 5, 6, 7.
• High doses of corticosteroids should be given over 30-60 minutes, and patients should be observed after administration for at least the same time period 7.
• Asthmatics, renal transplant patients, and hemodynamically unstable patients may be at higher risk for adverse events, and intradermal skin testing may help determine cross-sensitivity and identify another corticosteroid that can be tolerated 5, 6, 7.