In this episode, I’ll discuss why glucocorticoids have no role in reversing the acute symptoms of anaphylaxis.
Despite epinephrine clearly being recommended as the first line of treatment for an acute episode of anaphylaxis, glucocorticoids continue to be given by many providers.
The mechanism of action for glucocorticoids is to form a complex with receptors on cell membranes, translocate this complex to the nucleus, and inhibit the production of new inflammatory mediators.
This process is slow, taking several hours to occur. It is possible based on inference from animal data that some separate effects may occur within 30 minutes, but in acute anaphylaxis, seconds count as hypotension and airway compromise are major contributors to mortality, and neither of these are improved acutely by the administration of steroids.
The American Academy of Allergy, Asthma & Immunology Guidelines on the treatment of anaphylaxis emphasize:
-Epinephrine is first line
-Glucocorticoids have a slow onset of action and inability to reverse acute symptoms
In the past, it was thought that glucocorticoids also prevent biphasic reactions, which is a recurrence of anaphylaxis after initial treatment. Meta-analysis has demonstrated this is not a consistent effect of steroids, and the AAAAI states:
We suggest against administering glucocorticoids or antihistamines as an intervention to prevent biphasic anaphylaxis
There may be reasons to administer glucocorticoids after a patient has been treated for anaphylaxis, such as patients with asthma, continued bronchospasm, and in children they may reduce length of hospital stay. However it is of critical importance to not delay first line treatment with epinephrine, hoping that steroids will treat acute symptoms of anaphylaxis.
Members of my Hospital Pharmacy Academy have access to practical training on the treatment of anaphylaxis from a pharmacist’s point of view. This is in addition to hundreds of other resources to help in your practice. The Hospital Pharmacy Academy is my online membership site that teaches pharmacists practical critical care and hospital pharmacy skills you can apply at the bedside so that you can become confident in your ability to save lives and improve patient outcomes. To get immediate access, go to pharmacyjoe.com/academy.
If you like this post, check out my book – A Pharmacist’s Guide to Inpatient Medical Emergencies: How to respond to code blue, rapid response calls, and other medical emergencies.
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