Corticosteroids Show Little Benefit in Preventing Anaphylaxis Recurrence

A recent study does not support routine use of predischarge corticosteroids after pediatric anaphylaxis in the emergency department, as recurrence is rare and the potential benefit is minimal.1

In the absence of prospective trial evidence, many clinicians use steroids for mild to moderate anaphylaxis, relying primarily on experience and preference. The United States and European guidelines list corticosteroids as an optional therapy for discharged patients admitted for anaphylaxis.

Although corticosteroids have been linked to shorter hospital stays in children admitted with severe anaphylaxis, investigators questioned whether these benefits extend to those discharged from the emergency department. A 2015 study reported that of the 5052 children discharged from the emergency department, 66% received corticosteroids. Within 3 days, 5% of both recipients and non-recipients returned to the emergency department.2

Questioning the benefit of corticosteroids in discharged patients, investigators conducted a blinded, randomized, placebo-controlled pilot trial of children aged 3 months to 14 years who presented with mild to moderate anaphylaxis.

“To our knowledge, this is the first randomized clinical trial to test the effect of steroids in decreasing anaphylactoid reaction in pediatric patients treated for mild-moderate anaphylaxis,” wrote study investigators Rafah Al Sayyed, MD, from Hamad Medical Corporation, and Khalid Alansari, MD, FRCPC, FAAP, from Weill Cornell Medical College and Qatar University Medical College.1

Sayyed, Alansari, and colleagues conducted this study between June 2018 and February 2024 in the short-stay unit of the Pediatric Emergency Center at Hamad General Hospital in Qatar.1 Participants had stays anywhere between 2 to 50 hours. Anaphylaxis causes included medication (1.5% for participants in the dexamethasone arm vs 6.4% in the placebo arm), food (86.7% vs 77.3%), and insect bites (10.3% vs 16%).

Participants received either oral dexamethasone solution (n = 68; 0.3 mg/kg, 1 mg/mL, or 10 mg) or a blinded placebo (n = 75) before discharge. The primary goal was to assess whether treatment reduced recurrence and the need for a revisit within 7 days.1

The projected 1-week placebo return rate of 35% proved to be an overestimate. Only 5 of 75 patients in the placebo group returned within 7 days, corresponding to 6.7% (95% CI, 2.2–14.9%).1

Among patients who received dexamethasone, 3 of 68 returned within 7 days (4.4%; 95% CI, 0.9–12.4%). This represented a relative risk reduction of 33.8%, although the finding was not statistically significant (95% CI, 87.3% reduction to a 208% increased risk). The absolute risk reduction was 2.3%, translating to an estimated number needed to treat of 44 patients to prevent a single revisit within 7 days (95% CI, 12 to infinity; P =.7).1

“The estimated number needed to treat of 44, lower limit of 12, suggests to us that dexamethasone treatment is not routinely warranted,” investigators wrote.1 “There may be some ED-discharge patients with a history of recurrent anaphylactoid reactions in whom dexamethasone is perceived to be warranted to try to avoid this complication.”

Investigators addressed that the unnecessary routine use of corticosteroids for patients who do not need them can lead to harmful adverse events.1 According to the Cleveland Clinic, common adverse events of corticosteroids include an increased appetite, weight gain, skin changes such as bruising easily or increased acne, retaining water (making the skin or face look swollen), stomach irritation, muscle weakness, mood swings (increased anxiety, restlessness, or trouble sleeping), and increased body hair.3 Corticosteroids can also increase patients’ risk for Cushing syndrome, diabetes, hypertension, osteoporosis, and infections.

Investigators noted that this pilot trial was limited by its small sample size, resulting from an overestimation of return visits before the study and a lower-than-expected frequency of return visits after analysis, though the frequency was consistent with findings from other reports.1

“We conclude that dexamethasone treatment of ED-discharged anaphylaxis children aged 3 months to 14 years should not be routine, but rather restricted to those patients for whom there is a sound clinical rationale, because the proportion of patients likely to be spared return within 7 days if all are treated is quite small,” investigators wrote.1

References

1. Al Sayyed R, Alansari K. Randomized blinded pilot trial of corticosteroid after mild-moderate anaphylaxis to prevent recurrence. Medicine (Baltimore). 2025;104(31):e43600. doi:10.1097/MD.0000000000043600

2. Michelson KA, Monuteaux MC, Neuman MI. Glucocorticoids and Hospital Length of Stay for Children with Anaphylaxis: A Retrospective Study. J Pediatr. 2015;167(3):719-24.e243. doi:10.1016/j.jpeds.2015.05.033

3. Cleveland Clinic. Corticosteroids (Glucocorticoids). Cleveland Clinic. Published November 16, 2016. https://my.clevelandclinic.org/health/treatments/corticosteroids-glucocorticoids