Summer is here. People are going out and eating strange food, getting stung by strange things, and in general, coming into the ED for interesting rashes.
This French, two-center, randomized, double-blinded study look at 5mg of levocetirizine vs 5mg of levocetirizine plus 4 days of 40mg prednisone for acute urticaria of under 24 hours duration. Patients were excluded if they had angioedema or anaphylaxis – among a multitude of other things, such that only 100 of 710 potentially eligible patients were enrolled (exclusion criteria comprised of: a history of diabetes, peptic ulcer disease, pregnancy, and chronic kidney disease, among many others).
The authors note that in Italy (strangely, why not in France?) , 93% of patients presenting to the ED for urticaria received steroids in 2011 – which I imagine is probably slightly higher than what I would expect for US EDs. So they reasonably suggest that, hey, maybe we can lower steroid-related ADR’s if we find a way to decrease the number of times we prescribe them.
Basically, after 1 hour, 2 days, and 5 days, there was no difference in itch control or rash resolution between the two groups, and if anything, a trend towards better outcomes with levocitirizine alone (For instance, 62% with an itch score of zero for steroids + levocitirizine vs 76% in levocitirizine only at 2 days). Relapse rates were 30% vs 24% (steroids+levo vs levo only) during the first 5 days, which was not statistically significant.
Sadly, and oddly, they report that “one patient in the placebo group had vomiting and abdominal pain in the ED 1 hour after initiation of treatment. These symptoms were related to anaphylaxis, and the patient rapidly improved after a steroid injection.” … which as we know, probably was not anaphylaxis if it improved “rapidly” after steroids (and without adrenaline). But I digress…
Previously, there have only been two studies looking at steroid use for urticaria; This one showing earlier resolution with 3 days of prednisolene (unsure if this is prednisolone, prednisone, or something else) against 10mg of loratadine (94% vs 66% resolution at 3 days), and this one showing lower itch scores with 4 days of 40mg prednisone plus 25mg of hydroxyzine every 4-8 hours than hydroxyzine treatment alone.
I think this particular study lends some credibility to those of us that are steroid-averse, and probably lends to a reasonable discussion with patients that are concerned about getting steroids. Likewise, it is probably reasonable to do a single dose dexamethasone treatement and chase it with a short course of levocitirizine.