5 Minute Journal Club: Emergency Department Corticosteroid Use for Allergy or Anaphylaxis Is Not Associated With Decreased Relapses

Author: Dr. Earl C. Williams, Jr.

Article: Grunau BE, Wiens MO, Rowe BH, McKay R, Li J, Yi TW, Stenstrom R, Schellenberg RR, Grafstein E, Scheuermeyer FX. Emergency Department Corticosteroid Use for Allergy or Anaphylaxis Is Not Associated With Decreased Relapses. Ann Emerg Med. 2015 Oct;66(4):381-9. doi: 10.1016/j.annemergmed.2015.03.003. Epub 2015 Mar 25. PMID: 25820033.

Background

National studies of EDs in the US report steroids as the 2nd most prescribed medication for allergic reactions (anti-histamines 1st line). We believe that steroid use leads to reduced biphasic reactions, decreased severity of reactions, and decreased ED return visits. Unfortunately, none of these benefits have been studied. Presumed benefits are the result of verified steroid benefits in asthma relapse reduction.

Study Question:

The primary aim of this study was to determine the association of steroid administration in ED allergy patients with decreased relapses to additional care within a 7-day follow-up period. Secondary aims included identifying potential benefits of steroids in decreasing death, clinically important biphasic reactions, or all-cause repeated ED visits

Design:

Ok. Let’s make this quick and painless.

Study Design:

Inclusion Criterion:

• Age ≥ 18 with ED discharge diagnosis of “allergic reaction.”

Exclusion Criterion:

• Asthma as primary diagnosis
• Hereditary angioedema
• Ace inhibiter etiology
• Already taking steroids
• Total hospital duration > 48hrs

Methods:

• Standardized chart review
• Three reviewers
• 5% dual extracted
• Primary outcome: repeat ED visits for allergic reaction
• Secondary outcome: all-cause mortality, biphasic reactions, all-cause repeat ED visits

Outcomes:

• 428,634 ED visits
• 2,995 patient encounters
• 2701 eligible patient encounters
• Steroid group included greater amount of pts that:
  • Were transported by ambulance
  • Had mucosal involvement
  • Had wheezing or stridor
  • Used Epi as therapy
  • Are classified as anaphylaxis

Results:

Limitations:

• External validity comes into question throughout the study. Being studied in an urban, Canadian, ED may provide different outcomes than what may be found in the general population.

• Retrospective analysis of the study provides clinical impression as a potential source of error. Diagnosis of allergic reaction wasn’t standardized across physicians leaving room for differences in clinical interpretation and diagnosis.

• Confounders may be present. For example, it seems that physicians were more likely to give steroid to sicker patients. Administering medications to a more ailed group may confound both primary and secondary outcomes.

• It’s also unclear if patient completed therapy. We are unsure if patient retrieved prescription, attempted therapy, or tolerated full therapy. Return rates my be skewed based on unknown factors.

• We are unsure if return visit were incorrectly categorized. Patients returning to the hospital may have appear unrelated but may have been allergic reaction sequelae.

• Another limitation may feature re-exposure events. We can’t ascertain that patient didn’t re expose themselves to original trigger after discharge.  Arguments can be made that this is a moot point secondary to steroid therapy (theoretically) prevent re-exposure events.

• Lastly, and most importantly, we may have lost patients based on regional limitations. Patients may have present to a non-studied ED.

Discussion:

Steroids have not been shown to be beneficial in reducing return ED visits. Administration include adverse side effects that should give pause before use, especially considering the high doses required for allergic reactions. Specifically, a patients comorbidities (diabetes, infection, etc) may not benefit from steroid therapy

Take Away:

The benefits of steroids aren’t as well studied in allergic reactions as they are in asthma exacerbations. Coupled with the risk of negative side effects, steroids provide a tenuous risk/benefit profile. We tend to focus on assumed benefits much more than verified risks. With that said, limitations to this study, perceived benefit in the field, anecdotal experiences of benefit, and lack of widespread adverse reactions leave plenty of room to make a case for steroids use. More research is necessary to fully unveil the risk and perceived benefits of steroids use in allergic reactions.