Hypersensitivity reactions to systemic glucocorticoids
- Rima Rachid, MD
Rima Rachid, MD
- Assistant Professor of Pediatrics
- Harvard Medical School
- Boston Children's Hospital
Glucocorticoids are prescribed for their immunosuppressive, antiproliferative, antiinflammatory, and antiallergenic effects, and are integral to the management of numerous conditions, including malignancies, transplantation, autoimmune and allergic diseases, and asthma. They are also administered to prevent late phase anaphylactic reactions. However, injected, infused, or orally administered systemic glucocorticoids have been associated with immediate hypersensitivity (allergic) reactions, including life-threatening anaphylaxis.
This topic will review the epidemiology, clinical manifestations, diagnosis, and management of hypersensitivity reactions to systemic glucocorticoids. Topical corticosteroids, usually in the form of skin preparations or inhaled glucocorticoids, can cause contact hypersensitivity, which is discussed elsewhere. (See "General principles of dermatologic therapy and topical corticosteroid use", section on 'Side effects' and "Major side effects of inhaled glucocorticoids", section on 'Contact hypersensitivity'.)
Hypersensitivity reactions to systemic glucocorticoids are rare, although the exact incidence is unknown. These reactions appear to occur in ≥0.1 percent of parenteral administrations, as demonstrated in the following studies:
●An early report in the 1950s described 6700 glucocorticoid injections given to 2256 patients . There were 20 instances of urticaria (including reactions localized to the injection site) or bronchospasm (0.29 percent of injections and 0.89 percent of patients).
●In a prospective study involving 202 children with rheumatologic diseases, approximately 0.1 percent of 10,000 doses of glucocorticoids administered were thought to cause reactions that were possibly of an allergic nature . Symptoms included pruritus, hives, and anaphylactic-like reactions. There was no statistical difference with respect to the ethnicity or underlying rheumatologic condition.
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- Risk factors
- CLINICAL MANIFESTATIONS
- Immediate reactions
- - Delayed recognition
- - Causative drugs
- Delayed reactions
- Skin testing
- - Suggested drug concentrations
- - Interpretation
- Other possible allergens in glucocorticoid preparations
- - Succinate esters
- - Preservatives and excipients
- In vitro testing
- Graded drug challenge
- - Indications
- - Safety issues
- DIFFERENTIAL DIAGNOSIS
- Allergy to antihistamines
- OTHER MANAGEMENT ISSUES
- SUMMARY AND RECOMMENDATIONS