Well done retrospective study. While we are aware of lack of proven efficacy of steroids of allergic rxn and anaphylaxis, it’s important to realize that absence of evidence does not mean evidence of absence.
.
While this paper adds to the previous literature that shows no benefit, I think we really need a large ED-based prospective RCT to put this issue to rest.
1.) Strengths?
– I thought the study did a great job on building on Grunau’s previous paper on the incidence of biphasic reactions (0.18%!) and that none resulted in fatalities. In that paper, he goes on to suggest that prolonged routine monitoring in the ED is likely unnecessary because of the low incidence, very small risk of a biphasic rxn being clinically relevant, and also because we have no idea when the biphasic rxn can occur (10 minutes to 1 week). This paper goes a step forward by suggesting that giving steroids to these patients to avoid a biphasic rxn is unnecessary. I like that the study sought to disprove a common practice. It was large, well powered, and had good interrater reliability when applicable. And it waited the entire 7 day period to check for a biphasic rxn.
2.) Limitations?
– The author does a good job at listing the study’s limitations. First, it’s retrospective. Additionally, the study isn’t very generalizable (2 urban ED’s); dx of allergic rxn has it’s own bias; we don’t know if the research subjects died or simply went to another clinic/ED; can’t confirm that patients prescribed steroids actually took them; can’t confirm if pts w/ repeated visit had a biphasic rxn or just re-exposed to the allergen.
3.) Outcomes?
– In ED patients p/w allergic rxn or anaphylaxis, steroid use not a/w decreased relapse w/in 7 days.
4.) Practice change?
– While just one study – and retrospective at that – I think it adds to the literature downplaying the worry for biphasic rxn. More so than this study, Grunau’s previous paper describing the very low incidence of biphasic rxn and its associated limited morbidity give me more confidence to be less worried for biphasic rx when these patients present to the ED.
1) What are some strengths of the study?
Large patient population with well described exclusion criteria.
Stated their methods and analysis clearly.
Used multiple resources for follow up with patient 7 days out to account for all possible outcomes
2) What are the limitations?
This is a retrospective study so not as strong
Done in 2 urban hospitals so unsure of the applicability of their results into all other settings
Clinically important biphasic reactions needed to meet criteria for anaphylaxis, which is not really applicable to all practices. If patient present with recurrence of symptoms even if they do not meet anaphylaxis criteria then they should be included in a biphasic reaction group
Anaphylactic reaction guidelines are very strict and well defined but in everyday practice patient receive full-blown treatment without needing to meet this strict criteria
The two groups had multiple variables that were different like the group who receive steroids was sicker that the other group (transported by ambulance, more met criteria for anaphylaxis, more treated with epinephrine, more had stridor or wheezing, more had mucosal involvement, more where admitted afterwards). I would this it is this group who will be at a higher risk to have a biphasic reaction when compared to a milder symptom group so it is hard to say that the steroids did not decrease the number of relapses since when the groups were compared they was no significant difference.
3) What are the main outcomes of the study?
Primary outcomes of this study is to determine if the patient who receive steroids for allergic reactions had a decrease rate of relapses (repeat visit for allergic reaction) within 7 days of initial presentation against those who did not get steroids
Secondary outcome was identifying if steroids decrease number of deaths, biphasic reactions, or all-cause repeated ED visit
4) Does reading this article change your practice? If so, how?
Based on this study I will not change my practice of giving steroids to allergic reactions
1. The strength of this study was their clear argument and presentation on the data discounting efficacy of prednisone. Both citation of prior data and their own present a strong case against this common practice.
2. Still not an RCT, also how can i generalize this to my own practice, 2 urban centers in Canada. It would be useful to know more of the demographics of study subjects
3. The primary outcome was that there was not a decrease in repeat visit for ax reaction for people treated with steroids.
4. I don’t think I will change this until stronger evidence comes out (RTC), it will add more worry that I am causing harm to more people than those I am doing any good with prescribing steroids.
For an Original Research Article
What are some strengths of the study?
What are the limitations?
What are the main outcomes of the study?
Does reading this article change your practice? If so, how?
1) Strengths of the study include a large sample size with a well defined outcome and protocol. I also think its great that the number of diagnosis were limited to allergic reaction”” so as not to dilute the number of cases attributed to it.
2) limitations well stated in the article but I think most important ones include inability to determine compliance with outpatient steroid use and the inability to determine if reexposure to same allergen *perhaps unknowingly, and the fact that the steroid cohort might have been sicker objectively speaking.
3)main outcomes are…whether or not there were a decrease in repeat Ed visits following allergic reaction in those who received steroids vs those who haven’t.
4) short course steroid relatively benign intervention. would imagine that most attending suggest continued rx for allergic reactions and the effect this has on patients, while not quantifiable could lead to increased satisfaction ie abx for viral infxns.
5 comments
Well done retrospective study. While we are aware of lack of proven efficacy of steroids of allergic rxn and anaphylaxis, it’s important to realize that absence of evidence does not mean evidence of absence.
.
While this paper adds to the previous literature that shows no benefit, I think we really need a large ED-based prospective RCT to put this issue to rest.
1.) Strengths?
– I thought the study did a great job on building on Grunau’s previous paper on the incidence of biphasic reactions (0.18%!) and that none resulted in fatalities. In that paper, he goes on to suggest that prolonged routine monitoring in the ED is likely unnecessary because of the low incidence, very small risk of a biphasic rxn being clinically relevant, and also because we have no idea when the biphasic rxn can occur (10 minutes to 1 week). This paper goes a step forward by suggesting that giving steroids to these patients to avoid a biphasic rxn is unnecessary. I like that the study sought to disprove a common practice. It was large, well powered, and had good interrater reliability when applicable. And it waited the entire 7 day period to check for a biphasic rxn.
2.) Limitations?
– The author does a good job at listing the study’s limitations. First, it’s retrospective. Additionally, the study isn’t very generalizable (2 urban ED’s); dx of allergic rxn has it’s own bias; we don’t know if the research subjects died or simply went to another clinic/ED; can’t confirm that patients prescribed steroids actually took them; can’t confirm if pts w/ repeated visit had a biphasic rxn or just re-exposed to the allergen.
3.) Outcomes?
– In ED patients p/w allergic rxn or anaphylaxis, steroid use not a/w decreased relapse w/in 7 days.
4.) Practice change?
– While just one study – and retrospective at that – I think it adds to the literature downplaying the worry for biphasic rxn. More so than this study, Grunau’s previous paper describing the very low incidence of biphasic rxn and its associated limited morbidity give me more confidence to be less worried for biphasic rx when these patients present to the ED.
1) What are some strengths of the study?
Large patient population with well described exclusion criteria.
Stated their methods and analysis clearly.
Used multiple resources for follow up with patient 7 days out to account for all possible outcomes
2) What are the limitations?
This is a retrospective study so not as strong
Done in 2 urban hospitals so unsure of the applicability of their results into all other settings
Clinically important biphasic reactions needed to meet criteria for anaphylaxis, which is not really applicable to all practices. If patient present with recurrence of symptoms even if they do not meet anaphylaxis criteria then they should be included in a biphasic reaction group
Anaphylactic reaction guidelines are very strict and well defined but in everyday practice patient receive full-blown treatment without needing to meet this strict criteria
The two groups had multiple variables that were different like the group who receive steroids was sicker that the other group (transported by ambulance, more met criteria for anaphylaxis, more treated with epinephrine, more had stridor or wheezing, more had mucosal involvement, more where admitted afterwards). I would this it is this group who will be at a higher risk to have a biphasic reaction when compared to a milder symptom group so it is hard to say that the steroids did not decrease the number of relapses since when the groups were compared they was no significant difference.
3) What are the main outcomes of the study?
Primary outcomes of this study is to determine if the patient who receive steroids for allergic reactions had a decrease rate of relapses (repeat visit for allergic reaction) within 7 days of initial presentation against those who did not get steroids
Secondary outcome was identifying if steroids decrease number of deaths, biphasic reactions, or all-cause repeated ED visit
4) Does reading this article change your practice? If so, how?
Based on this study I will not change my practice of giving steroids to allergic reactions
1. The strength of this study was their clear argument and presentation on the data discounting efficacy of prednisone. Both citation of prior data and their own present a strong case against this common practice.
2. Still not an RCT, also how can i generalize this to my own practice, 2 urban centers in Canada. It would be useful to know more of the demographics of study subjects
3. The primary outcome was that there was not a decrease in repeat visit for ax reaction for people treated with steroids.
4. I don’t think I will change this until stronger evidence comes out (RTC), it will add more worry that I am causing harm to more people than those I am doing any good with prescribing steroids.
For an Original Research Article
What are some strengths of the study?
What are the limitations?
What are the main outcomes of the study?
Does reading this article change your practice? If so, how?
1) Strengths of the study include a large sample size with a well defined outcome and protocol. I also think its great that the number of diagnosis were limited to allergic reaction”” so as not to dilute the number of cases attributed to it.
2) limitations well stated in the article but I think most important ones include inability to determine compliance with outpatient steroid use and the inability to determine if reexposure to same allergen *perhaps unknowingly, and the fact that the steroid cohort might have been sicker objectively speaking.
3)main outcomes are…whether or not there were a decrease in repeat Ed visits following allergic reaction in those who received steroids vs those who haven’t.
4) short course steroid relatively benign intervention. would imagine that most attending suggest continued rx for allergic reactions and the effect this has on patients, while not quantifiable could lead to increased satisfaction ie abx for viral infxns.