We continue on with the series with Knowledge Bomb #11. The purpose and motivation for this series is outlined in the first entry and extensively in an ALiEM IDEA series blog entry. This knowledge bomb discusses the use of corticosteroids for allergic reaction.
Corticosteroids are routinely given for both allergic reactions and anaphylaxis. In theory, they improve symptoms of allergic reactions and prevent protracted/biphasic reactions in anaphylaxis. However, the literature has not examined the utility of steroids in treating these conditions. In fact, when Cochrane attempted to review the literature they concluded that there were no articles meeting the outlined criteria and were therefore unable to comment.
Corticosteroids are not benign medications. Many of the patients treated in the ED have complex medical histories and steroids carry the risk of glucose intolerance, psychiatric effects, fluid retention and dyspepsia, all of which can exacerbate chronic conditions that are present in many ED patients.
Do these medications improve symptoms and prevent biphasic reactions in these patients?
Grunau BE, Wiens MO, Rowe BH, et al. Emergency Department Corticosteroid Use for Allergy or Anaphylaxis Is Not Associated With Decreased Relapses. Annals of Emergency Medicine. 2015;66(4):381-389. doi:10.1016/j.annemergmed.2015.03.003. PMID: 25820033
This retrospective cohort study attempts to answer this question by examining how many patients discharged home after a visit for an allergy complaint present to the ED with the same complaint within 7 days.
This study concluded that there was no statistically significant difference between the 2 groups. Of the steroid group, 5.6% of the patients re-visited, 6.7% of the non-steroid group revisited with an adjusted odds ratio of 0.91(95% CI 0.64-1.28). They attempted to examine occurrence of biphasic reactions within the anaphylaxis subgroup, but there were only 4 reactions so they were unable to determine statistical significance.
This study is interesting in that it begins to examine whether or not corticosteroids make a difference in treating allergic reactions and anaphylaxis. However, it is difficult to apply these data to specific patient encounters. They have very broad inclusion criteria and are not able to follow up on which symptoms are causing patients to return to the ED. They are also not able to track whether or not patients filled the prescriptions.
This study raises additional questions for me. Since they were unable to find a difference between the steroid vs. no steroid groups in re-visit to ED, how effective are these medications in improving symptoms? They also found 9.94% of the steroid cohort re-visited the ED within 7 days for a different complaint. How many of these people were presenting secondary to side effects of steroids? This study was unable to answer either of those questions which I think relate more directly to my clinical practice.
Moving forward, I plan to continue to give glucocorticoids to patients with anaphylaxis. This study was unable to examine effectiveness of steroids in preventing biphasic reactions secondary to poor power.
For patients with severe reactions I will continue to give steroids in an attempt to alleviate symptoms faster and prevent recurrence.
For patients with a mild reaction I will be less likely to recommend steroids. Especially if the patient has multiple co-morbidities that put them at higher risk for experiencing side effects. I will be more likely to have a discussion with the patient about risks and benefits of steroids and use shared decision making to choose whether or not to use corticosteroids in the treatment plan.
Dr. Kathryn Adams is a current PGY2 at UIC’s EM Program.Click to Read Attending Response - Dr. Melissa Marinelli
This was a great topic since it’s so germane to our practice. Many of us use corticosteroids often for allergic reaction almost reflexively, and this was an interesting look into whether or not there’s data to support that practice.
Taking a look at the study and study design here, I’d say it’s acceptable. The follow-up on the cases after ER visits is good, in large part due to the provincial health system in Canada. However, there are a few caveats. It’s a retrospective review, which is clearly not the gold standard, although the use of steroids for allergic reaction is an intervention that would be amenable to an RCT. On a more nitpicky note, the authors the use vital signs in their calculation of disease severity but note that they randomly generated missing vital signs, decreasing the reliability of their data and conclusions.
In general, doctors in the study gave steroids to sicker patients: those who came by ambulance, who had anaphylaxis, who had mucosal tissue involvement, who had wheeze or stridor and who received epinephrine. The article tries to then calculate a causal risk difference of steroids by taking the predicted probability of an allergy-related subsequent visit factoring in these variables and averaging across all patients. On face, this seems rife with opportunities for confounding and inaccuracy, especially since patients who didn’t receive steroids returned to the ER more frequently, and only when adjusted by the averaged propensity score did the causal risk difference change. Additionally, they don’t quantify the side-effect related return visits to the ER, despite using the side effect profile of steroids as one of the major motivating factors for not using steroids.
The authors’ final conclusion is that we need a large RCT to investigate this. I agree. That would be helpful, and until it happens I will continue my current practice of judiciously using steroids in sick patients with allergic reactions for whom the potential benefit likely outweighs the risks.
Dr. Melissa Marinelli is an Attending physician at Lutheran General Hospital. She is the Author of the Well Aware section on BrownCoatNation – please read!!!
- Grunau BE, Wiens MO, Rowe BH, et al. Emergency Department Corticosteroid Use for Allergy or Anaphylaxis Is Not Associated With Decreased Relapses. Annals of Emergency Medicine. 2015;66(4):381-389. doi:10.1016/j.annemergmed.2015.03.003.