Corticosteroids anaphylaxis

It has been stated that adults with mastocytosis as well as children with bullous lesions and with more severe involvement, and especially those with previous reactions, are at increased risk for anaphylaxis [4]. Thus, we recommend that patients at risk carry an emergency kit for self-medication which includes epinephrine and, as warranted, an antihistamine and a corticosteroid [38]. 

In rare cases, initiation of specific immunotherapy with insect venom leads to recurrent anaphylaxis, even with antihistamine premedication. In those cases, comedication with omalizumab (anti-IgE) has been reported to induce tolerance. In a case of recurrent anaphylaxis to induction of specific immunotherapy, the injection of 300 mg of omalizumab between 4 days and 1 h reportedly led to tolerance [42]. This approach also appears worthy of consideration in patients with both idiopathic recurrent anaphylaxis and mastocytosis who do not respond to standard antimediator therapy, as has been described in 2 atopic patients with ISM [43]. Most patients with mastocytosis and idiopathic anaphylaxis, however, are sufficiently controlled by standard antimediator therapy with antihistamines with or without low-dose corticosteroids. 

Common mild local adverse reactions include induration and swelling at the injection site. More severe reactions (generalized urticaria, broncho-spasm, laryngospasm, vascular collapse, and death from anaphylaxis) occur rarely. Severe reactions are treated with epinephrine, antihistamines, and systemic corticosteroids. 

Frick OL, Teuber SS, Buchanan BB, Morigasaki S, Umetsu DT Allergen immunotherapy with heat-killed Listeria monocytogenes alleviates peanut and food-induced anaphylaxis in dogs. Allergy 2005 60 243-250. Stock P, Akbari 0, DeKruyff RH, Umetsu DT Respiratory tolerance is inhibited by the administration of corticosteroids. J Immunol 2005 175 7380-7387. 

Prostatic cancer In clinical trials involving 350 patients with metastatic prostatic cancer, 11 deaths were reported within 2 weeks of starting high-dose ketoconazole (1200 mg/day). It is not known whether death was related to therapy. High ketoconazole doses are known to suppress adrenal corticosteroid secretion. Hypersensitivity reactions Anaphylaxis occurs rarely after the first dose. Hypersensitivity reactions, including urticaria, have been reported. 

Organ rejection prophylaxis Prophylaxis of organ rejection in patients receiving allogeneic liver or kidney transplants. It is recommended that tacrolimus be used concomitantly with adrenal corticosteroids. Because of the risk of anaphylaxis, reserve the injection for patients unable to take the capsules orally. 

Allogeneic transplants For prophylaxis of organ rejection in kidney, liver, and heart allogeneic transplants. Gengraf and A/eora/have been used in combination with azathioprine and corticosteroids. Sanc//n n nne always is to be used with adrenal corticosteroids. Sandimmune a so may be used in the treatment of chronic rejection in patients previously treated with other immunosuppressive agents. Because of the risk of anaphylaxis, reserve Sandimmune injection for patients who are unable to... 

Pneumococcal Vaccine, Polyvalent (Pneumovox-23) [Vaccine/ Inactive Bacteria] Uses Immunization against pneumococcal Infxns in pts at high risk (eg, all = 65 y of age) Action Active immunization Dose 0.5 mL EM. Caution [C, ] Contra Do not vaccinate during immunosuppressive thCTapy Disp Inj SE Fever, inj site Rxn, hemolytic anemia, thromboc5rtopenia, anaphylaxis Interactions Effects W/ corticosteroids, immunosuppressants EMS None OD ... 

It is usual to give a sedating antihistamine, for example chlorphenamine 10 mg by intramuscular or slow intravenous injection, because of the relatively short half-life of epinephrine (adrenaline), and because of the active role of histamine in anaphylaxis. In addition, the inflammatory reaction can be moderated by the administration of a corticosteroid, such as hydrocortisone 200 mg by intramuscular or slow intravenous injection. Corticosteroids may take several hours to act, but can be of some help in so-called biphasic anaphylactic reactions. 

Warnings Hepatotoxicity, primarily of the hepatocellular type, has been reported Anaphylaxis may occur after the first dose Deaths within 2 weeks of treatment initiation have been reported in patients with prostate cancer the role of ketoconazole in these deaths has not been ascertained, but it is known that ketoconazole can suppress adrenal corticosteroid secretion... 

Methylprednisolone Succinate and Acetate (Solu-Medrol, Depo-Medrol) [Steroid] Uses Tx inflammation d/t anaphylaxis and asthma suspected SCI Action Adrenal corticosteroid Dose Adults. Anaphylaxis/ status asthmaticus 125-250 mg IV/IM Suspected SCI Load w/ 30 mg/kg then inf... 

Uses Severe, systemic fungal Infxns oral cutaneous candidiasis Action Binds ergosterol in the fungal membrane to alter permeability Dose Adults Peds. Test dose 1 mg IV adults or 0.1 mg/kg to 1 mg IV in children then 0.25—1.5 mg/kg/24 h IV over 2-6 h (range 25—50 mg/d or qod). Total dose varies w/ indication PO 1 mL qid Caution [B, ] Disp Inj SE -l K+/Mg2+ from renal wasting anaphylaxis reported, HA, fever, chills, nephrotox, X BP, anemia, rigors Notes X In renal impair pre-Tx w/ APAP antihistamines (Benadryl) X SE Interactions T Nephrotoxic effects W/ antineoplastics, cyclosporine, furosemide, vancomycin, aminoglycosides, T hypokalemia W/ corticosteroids, skeletal muscle relaxants EMS May cause electrolyte imbalances, monitor ECG OD May effect CV and resp Fxn symptomatic and supportive... 

Montoro J, Valero A, Serra-Baldrich E, Amat P, Lluch M, Malet A. Anaphylaxis to paramethasone with tolerance to other corticosteroids. Allergy 2000 55(2) 197-8. 

BETA-BLOCKERS X-RAY CONTRAST SOLUTIONS Beta-blockers are associated with T risk of anaphylactoid reactions to iodinated X-ray contrast materials Uncertain, but postulated that beta-receptors have a role in suppressing the release of mediators of anaphylaxis Consider using low-osmolality contrast media and pretreating with antihistamines and corticosteroids. Stopping beta-blockers a few days before the X-ray is associated with a risk of withdrawal t BP and tachycardia a risk-benefit assessment must therefore be made... 

Bigliardi PL, Izakovic J, Weber JM, Bircher AJ. Anaphylaxis to the carbohydrate carboxymethylcellulose in parenteral corticosteroid preparations. Dermatology 2003 207(1) 100-103. 

King, S.J., Miller, H.R., Newlands, G.F. and Woodbury, R.G. (1985). Depletion of mucosal mast cell protease by gluco-corticosteroids effect on intestinal anaphylaxis in the rat. Proc. Natl. Acad. Sci. USA 82, 1214-1218. 

Acute overdose probably would not result in toxicity. Should oral overdosage occur, standard emergency and supportive care procedures should be followed. If anaphylaxis should occur, epinephrine may be given as 0.3-0.5 ml of a 1 1000 solution for adults (children should receive 0.01 ml kg ). Mild anaphylaxis may be treated with antihistamines alone. If chronic toxicity should occur, it is important to reduce the dosage of corticosteroid to a minimal maintenance dose at the first sign of toxicity. 

A number of other agents may be required for the treatment of anaphylactic reactions. Corticosteroids (hydrocortisone sodium succinate intravenously) are recommended to reduce the risk of late-phase reactions. Aminophylline may be used as adjunctive therapy for bronchospasm. Histamine (Hi) receptor blockers (such as diphenhydramine) may be administered to reduce some of the symptoms associated with anaphylaxis however, these agents are not effective as primary therapy. 

Equations for calculating the appropriate dose of parenteral iron in patients with IDA or those with anemia secondary to blood loss can be found in Table 99-7. When given by IV administration, the dose should not exceed 50 mg of iron per minute (1 mL/min). It is suggested that all patients considered for an iron dextran injection receive a test dose of 25 mg IM or IV, or a 5- to 10-minute infusion of the diluted solution. Patients should then be observed for more than 1 hour for untoward reactions. If an anaphylaxis-like reaction were to occur, it generally responds to IV epinephrine, diphenhydramine, and corticosteroids. Patients receiving total dose infusions can have the remaining solution infused during the next 2 to 6 hours if the test dose is tolerated. 

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