prednisone allergy

[basementbeast]

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patient states allergy to prednisone (rash, etc) but is now having allergic reaction to something else and would benefit from steroids -> is the allergy likely to a carrier in the pred tab .... what alternative 'roid can you safely use? dex?

thx

 

[Flopotomist]

patient states allergy to prednisone (rash, etc) but is now having allergic reaction to something else and would benefit from steroids -> is the allergy likely to a carrier in the pred tab .... what alternative 'roid can you safely use? dex?

thx

How do you nail down a true prednisone allergy from a patient's misguided attribution of rash to the prednisone that was given for something else that was actually the causal agent?

 

[basementbeast]

perhaps pred for asthma/copd then rash later?

 

[docB]

Patient's stated allergies are usually crap. In this case you can give solumedrol IV or decadron PO or IV. Or, if the patient is just having a minor allergic reaction, give benadryl, pepcid, motrin and tell them that it's too bad they're allergic to steroids.

 

[AmoryBlaine]

Maybe a dumb question but can someone be allergic to something that is used to treat IgE mediated reactions? I have had several patients tell me they are allergic to benadryl, when pressed they say they get "hives and a rash."


...

 

[EM2BE]

Maybe a dumb question but can someone be allergic to something that is used to treat IgE mediated reactions? I have had several patients tell me they are allergic to benadryl, when pressed they say they get "hives and a rash."


...

I recently found out my grandma has an anaphylactic reaction to the antihistamines (including benadryl), so I am assuming it's possible.

 

[Chronic Student]

A lot of times those "Stated Allergies" are BS and are attributable to something else or the patient has convinced themselves of it (i.e., latex allergy or tape allergy).

The thing that sucks is that some of them are real and you don't know which ones.

Its like the freaking patients that are allergic to turkey, strawberries, coumadin, narcan, morphine, dilaudid, demoral, lortab, penicillin, ancef, clindamycin, phenergan, etc. They have painted thenselves into a corner for pain control and are usually the most demanding patients and the most likely to sue you.

In addition, one of those allergies is probably real and not just a result of their axis 2 disorder.

I'm also convinced that a number of the allergies are to dyes, binders, etc.

-Mike

 

[Annette]

A lot of times those "Stated Allergies" are BS and are attributable to something else or the patient has convinced themselves of it (i.e., latex allergy or tape allergy). ****-Mike

Unfortunately, the latex and tape allergies are real.

However, I love the ones who are allergic to tylenol, but take vicodin/norco just fine. Or, even better, the ones who have had anaphylactic rxn's and decide that you don't need to know about them!

And then there is the pharmacy. Pt had eggs added to her allergy list because she doesn't like the taste of them. You duely note it isn't an allergy, but pharmacy won't send you the influenza vaccine because of an "egg allergy."

 

[docB]

Unfortunately, the latex and tape allergies are real.

Most aren't. The tape "allergies" I see daily are for skin irritation and tears. I've seen many latex "allergies" that are due to "I got red where the tourniquet touched me." and some for vaginal irritation after sex with a condom. One lady claimed a latex allergy because paint fumes make her head hurt. I asked what she was talking about and she got mad and said "It was latex paint so I'm allergic!"

When I was in med school some magazine came out with an article that advised everyone to claim a latex allergy when they went in for surgeries because they would get their own, special equipment that was supposed to be cleaner. In actuality they got all this crappy vinyl stuff including gloves that the bovey burned right through. It was a mess.

 

[Chronic Student]

Unfortunately, the latex and tape allergies are real.

However, I love the ones who are allergic to tylenol, but take vicodin/norco just fine. Or, even better, the ones who have had anaphylactic rxn's and decide that you don't need to know about them!

And then there is the pharmacy. Pt had eggs added to her allergy list because she doesn't like the taste of them. You duely note it isn't an allergy, but pharmacy won't send you the influenza vaccine because of an "egg allergy."

We have one anesthesiologist who, while doing his pre-op interview, lays a latex glove against the patients skin. Of the last fifty patients with "Latex allergies", not a single one has had even skin irritation.

I'm not saying the allergies are not real. In fact, in my last ten years in the OR I have seen anaphylaxis twice due to latex allergies. Both were unknown and both were young folks with spina bifida.

Its just that the number of true allergies versus the number who claim them is very small.

-Mike

 

[southerndoc]

There are people who are allergic to epinephrine (they are allergic to horse serum proteins that contaminate it).

I recently had a kid develop hives after ondansetron. Not often you see that.

 

[basementbeast]

Patient's stated allergies are usually crap. In this case you can give solumedrol IV or decadron PO or IV. Or, if the patient is just having a minor allergic reaction, give benadryl, pepcid, motrin and tell them that it's too bad they're allergic to steroids.

docB: is the structure of solumedrol or dex difference enough from pred or is it a carrier/binder/whatever property....? my pharmacist was clueless....

 

[docB]

docB: is the structure of solumedrol or dex difference enough from pred or is it a carrier/binder/whatever property....? my pharmacist was clueless....

I'm pretty sure it's due to an additive. It's hard to be allergic to something so similar to endogenous steroids. Similar to the days before Cerebyx when everyone was allergic to the methylparaben in IV dilantin.

 

[leviathan]

There are people who are allergic to epinephrine (they are allergic to horse serum proteins that contaminate it).

Should we still give epi to a patient who claims they are allergic to it, if they appear to be having a true anaphylactic reaction from something else?

 

[southerndoc]

Should we still give epi to a patient who claims they are allergic to it, if they appear to be having a true anaphylactic reaction from something else?

Not if you have other options available (e.g., glucagon, terbutaline).

Speaking of glucagon, has anyone ever used it for anaphylaxis in patients who are on beta blockers? Supposedly epinephrine is relatively contraindicated. (Most beta blockers are beta-1 selective, and the beta-2 stimulation from epinephrine while beta-1 is blocked will lead to increased hypotension.)

 

[roja]

Should we still give epi to a patient who claims they are allergic to it, if they appear to be having a true anaphylactic reaction from something else?

We have encountered this once, adn give the epi in our crash cart. apparantly its different

 

[WakeMedHeel]

patient states allergy to prednisone (rash, etc) but is now having allergic reaction to something else and would benefit from steroids -> is the allergy likely to a carrier in the pred tab .... what alternative 'roid can you safely use? dex?

thx

I encounter this a lot and usually have a long conversation regarding what they think their allergy is. More than half the time it's, "It makes me puffy." The rest of the time, it's "I don't know, it makes me feel weird."

 

[GeneralVeers]

"I have allergy to morphine......it makes me sleepy!"

I've actually heard that one before.

 

[leviathan]

Not if you have other options available (e.g., glucagon, terbutaline).

Speaking of glucagon, has anyone ever used it for anaphylaxis in patients who are on beta blockers? Supposedly epinephrine is relatively contraindicated. (Most beta blockers are beta-1 selective, and the beta-2 stimulation from epinephrine while beta-1 is blocked will lead to increased hypotension.)

Interesting, I've never heard of that before...is that to do with the effects on cAMP concentration? What dose of glucagon would you give for an anaphylaxis patient with allergy or beta-blocker use?

 

[southerndoc]

Interesting, I've never heard of that before...is that to do with the effects on cAMP concentration? What dose of glucagon would you give for an anaphylaxis patient with allergy or beta-blocker use?

It's not well studied, but 1-2 mg is what has been reported.

 

[ttac]

strange allergies:
http://www.allergycapital.com.au/Pages/shop.html

 

[dlung]

patient states allergy to prednisone (rash, etc) but is now having allergic reaction to something else and would benefit from steroids -> is the allergy likely to a carrier in the pred tab .... what alternative 'roid can you safely use? dex?

thx

Peanuts.😀

 

[NinerNiner999]

My personal Favorite: "i'm allergic to alcohol - it makes me break out in handcuffs."

I refer every patient to an allergist within 24 hours if they have any documented "allergy" to common treatment agents for anyphylaxis. I cc my dictation to the allergist and ask for a return consult note. So far, of the the three that I have done this with two have had minor skin irritation from paraben, and none have demonstrated actual allergies. Anecdotal, I know, but at least I can add the consult note to their computer file and treat them in the future...

 

[bartleby]

The main difference is that code cart meds are single dose vials without preservatives, where as usual floor meds can be mult-dose vials with preservatives.

We have encountered this once, adn give the epi in our crash cart. apparantly its different

 

[WallowaWanderer]

The main difference is that code cart meds are single dose vials without preservatives, where as usual floor meds can be mult-dose vials with preservatives.

Good to know.

 

[roja]

My personal Favorite: "i'm allergic to alcohol - it makes me break out in handcuffs."

😀

 

[anthoncr]

An allergy to steroids can be real, mine had anaphylaxis after solumedrol, and no it wasn't a reaction to the preservative. There are several peer reviewed articles documenting the phenomenon. I might encourage everyone to be very careful before dosing a patient with a medication they claim to be allergic to, even if it doesn't fit within your clean training from medical school.

Those that think they know better may be comforted by knowing that epinephrine can usually still be used after your patient's airway starts to close down.

~T

Patient's stated allergies are usually crap. In this case you can give solumedrol IV or decadron PO or IV. Or, if the patient is just having a minor allergic reaction, give benadryl, pepcid, motrin and tell them that it's too bad they're allergic to steroids.

 

[docB]

I might encourage everyone to be very careful before dosing a patient with a medication they claim to be allergic to, even if it doesn't fit within your clean training from medical school.

😕

Nothing about my training was ever "clean."

The vast majority of reported allergies are false. To patients "allergy" ofetn means everything from "it doesn't work for me" to "I get a side effect such as nausea." And don't forget the ubiquitous "I prefer early goal directed Demerol therapy."

 

[Chronic Student]

An allergy to steroids can be real, mine had anaphylaxis after solumedrol, and no it wasn't a reaction to the preservative. There are several peer reviewed articles documenting the phenomenon. I might encourage everyone to be very careful before dosing a patient with a medication they claim to be allergic to, even if it doesn't fit within your clean training from medical school.

Those that think they know better may be comforted by knowing that epinephrine can usually still be used after your patient's airway starts to close down.

~T

Just a question. How do you know for certain that it wasn't a reaction to the preservative or something else and that it was indeed the steroid?

-Mike

 

[Lola713]

My favorite allergy is to Benadryl! I honestly can't reason with those patients-it's like talking in circles...anyone else ever encounter that? I also had someone once who requested in an FP clinic: I would like all of my prescriptions (about 25) rewritten as trade names only since "I am allergic to all generic medications".
Let me just tell you, that FP physician loved having a medical student around at that time!

 

[NinerNiner999]

An allergy to steroids can be real, mine had anaphylaxis after solumedrol, and no it wasn't a reaction to the preservative. There are several peer reviewed articles documenting the phenomenon. I might encourage everyone to be very careful before dosing a patient with a medication they claim to be allergic to, even if it doesn't fit within your clean training from medical school.

Those that think they know better may be comforted by knowing that epinephrine can usually still be used after your patient's airway starts to close down.

~T

I think I'm allergic to this statement.

 

[anthoncr]

Radioallergosorbent test (RAST) measures specific immunoglobin IgE antibodies against methylprednisolone-21-sodium succinate. (Parmacia Diagnostics, Uppsala Sweden)

You can also check with your pharmacy that made your preparation, often preservatives are not used.

Just a question. How do you know for certain that it wasn't a reaction to the preservative or something else and that it was indeed the steroid?

-Mike

 

[Chronic Student]

Radioallergosorbent test (RAST) measures specific immunoglobin IgE antibodies against methylprednisolone-21-sodium succinate. (Parmacia Diagnostics, Uppsala Sweden)

You can also check with your pharmacy that made your preparation, often preservatives are not used.

I'm familar with RAST having learned about it and performed it, as my undergrad is in the lab. It is a fairly unusual substance to test for and as you well know the reagents are specific to what you are testing for and quite expensive.

So, I guess what you're saying that you've been to an allergist and had it worked up.

People with an allergy like yours are incredibly rare. Not as rare as a natural chimera, but not a whole lot more common.

In the end, the point we've been trying to make is the number of allergies claimed versus those that are real and/or documented by an allergist is a very small fraction indeed.

-Mike

 

[anthoncr]

The patient had MS, so losing steroids as a class of medications would most certainly worsen his prognosis, it was worth the workup.

I agree it's unusual, my point was simply think before you dose someone with a medication they claim they are allergic to rather than write them off as being wrong. And just because a medication is used to treat an allergic reaction doesn't mean it won't cause one.

So, I guess what you're saying that you've been to an allergist and had it worked up.

People with an allergy like yours are incredibly rare. Not as rare as a natural chimera, but not a whole lot more common.

In the end, the point we've been trying to make is the number of allergies claimed versus those that are real and/or documented by an allergist is a very small fraction indeed.

-Mike

 

[docB]

The patient had MS, so losing steroids as a class of medications would most certainly worsen his prognosis, it was worth the workup.

I agree it's unusual, my point was simply think before you dose someone with a medication they claim they are allergic to rather than write them off as being wrong. And just because a medication is used to treat an allergic reaction doesn't mean it won't cause one.

No one was saying that we should commonly give people the stuff they claim allergies to. We're saying that every time we hear about some wacky allergy or a reaction to the most allergenic substance on Earth, Toradol, you should just roll your eyes and ask which big D narcotic they want.

 

[NinerNiner999]

Ditto what docB said. I had a patient two days ago who's allergy list read "strawberrys, pine nuts, pineapples, Haldol" They were there for back pain. That should say it all.

 

[leviathan]

The main difference is that code cart meds are single dose vials without preservatives, where as usual floor meds can be mult-dose vials with preservatives.

Nice...so single dose vials being those 1-2 mL things, or do you mean ampules, or both?

 

[EM2BE]

My favorite allergy is to Benadryl! I honestly can't reason with those patients-it's like talking in circles...anyone else ever encounter that? I also had someone once who requested in an FP clinic: I would like all of my prescriptions (about 25) rewritten as trade names only since "I am allergic to all generic medications".
Let me just tell you, that FP physician loved having a medical student around at that time!

I think I wrote this earlier, but it can happen. My grandma goes into anaphylactic shock when given anything with an antihistamine, including Benadryl. Once again, it's worth asking what the reaction is to the med.

 

[la gringa]

how about an allergy to albuterol? anyone heard of this one? had a pretty histrionic fellow claim he had respiratory failure from albuterol....???

 

[docB]

how about an allergy to albuterol? anyone heard of this one? had a pretty histrionic fellow claim he had respiratory failure from albuterol....???

I have seen several patients claim this but none were actually allergic. Most stated that their "allergy" was "racing heart beat" and "jitteriness." One frequent flyer lady who I remember well claimed an anaphylactoid reaction but whenever EMS would get on scene and give her albuterol she had no reactions. She actually wanted ativan so she'd claim allergy to albuterol.

 

[roja]

I think I'm allergic to this statement.

😍

 

[Katydid]

As someone who is a non-med-student, non-doctor, non-pharmacist type, I have a question, and this follows along with the thread.

The last time I was in the ER, I was there for a very nasty migraine. The doctor at urgent care thought I was having a stroke because I was slurring my words, and had right side weakness, so he sent me straight to the ER.

After CT scan, the determination is no stroke, just heinous migraine. Treatment was IV phenergan, followed by IV morphine. Phenergan burns, as usual, I've had IV phenergan before (I hope I at least spelled it right), and it pretty much sucks, but keeps me from losing what's left of the lunch I ate in third grade (yes, it was a long night, and there was much vomiting), twenty years later.

Morphine goes in. Within five minutes, I have HUGE hives going up my arm from the IV site. Hives spread up the left arm, across my torso, down my right arm. I immediately freak out, because in my loopy state, the hives look much bigger than they really are, and I'm already out of it because of the migraine pain. Doctor is called over after the nurse takes a look at me and freaks out, because she's never seen anyone break out in hives after morphine.

ER doc says to me, "Looks like you have a morphine allergy." And sends me home with a scrip for vicodin. Dummy me, I didn't realize that vicodin is part of the morphine family....and filled the scrip. LUCKY me, I didn't have one single problem with vicodin.

However, while I can take vicodin, my charts are clearly labeled with "morphine allergy", along with "iodine allergy" (found THAT one out the hard way, anaphylactic reaction during a CT scan when I was 14, with IV iodine dye....that was a fun trip, and oddly enough, that was when I was diagnosed as being prone to migraines in the first place). And my PCP told me that would make pain care very difficult for me.

So....should I insist on being thoroughly screened to make sure it's really morphine I'm allergic to, rather than something else, or just get used to explaining to the pharmacist who is asking me, with fear in his eyes, that no, I can take vicodin, even though I hate pain killers, and even though I am allergic to morphine, according to the ER doc?

 

[DrMom]

katydid, this is not a site for medical advice. you need to have that conversation with your personal physician.

 

[southerndoc]

katydid, this is not a site for medical advice. you need to have that conversation with your personal physician.

I'm surprised someone would use morphine as a first-line treatment for migraine. I rarely, if ever, give narcotics for headache patients.

 

[DrMom]

I'm surprised someone would use morphine as a first-line treatment for migraine. I rarely, if ever, give narcotics for headache patients.

same here

 

[Katydid]

I'm surprised someone would use morphine as a first-line treatment for migraine. I rarely, if ever, give narcotics for headache patients.

I was certainly not expecting that....I'd NEVER had morphine for a migraine before. Not like I wanted narcotics in the first place, I just wanted to not be throwing up and feeling like my head would explode. I have yet to have a good experience with narcotic painkillers.

I honestly, after that experience, don't know how people can get addicted to morphine. It's HORRIBLE.

 

[Katydid]

katydid, this is not a site for medical advice. you need to have that conversation with your personal physician.

I'm sorry....I shouldn't have done that.

I still have to wonder, how common is that reaction to morphine?

 

[Chronic Student]

Ditto on the morphine for migraines, it just is not the best thing and does not last.

I'm really not a big fan of morphine for pain control unless its in a PCA or the patient is in the unit where they can get it frequently. Say 2-5 mg q1h PRN.

-Mike

 

[Katydid]

Ditto on the morphine for migraines, it just is not the best thing and does not last.

I'm really not a big fan of morphine for pain control unless its in a PCA or the patient is in the unit where they can get it frequently. Say 2-5 mg q1h PRN.

-Mike

Ecch. I have to wonder what the hell the doctor was thinking when he ordered morphine. I'd never had it before, and can only describe my experience as a good way to torture someone. Yeah, constant itch and feeling like your skin is on fire, that's torture!

 

[p8nzmom]

As one of the very few persons with a documented steroid allergy, I must let you ER docs know that I do, in fact, exist. I was given a Medrol dose pack after sinus surgery and took the 6 tabs the next am. Hives within 1 hour. Took 50 benedryl, but had to go to ER later w/ throat closing. It was attributed to antibiotic allergy. One year later, ear infection drained by same doc. Medrol dose pack. 6 tabs. Hives within 1 hour. ER. Change Rx to prednisone, took meds next day. More hives. Back to ER. I told the ER doctor that I suspected that I was allergic to steroids and he told me that it was impossible He treated me with IV steroids. After 2 hours my symptoms worsened and he gave me a second dose of IV steroids. After 30 minutes my chest began to tighten and my heart felt as if it were being squeezed. My son called the nurse and they brought in the crash cart and the doc. I was given Epi and immediately felt relief. The doctor then told me that he thought that I might be allegic to steroids and that I should see an allergist. So it must not be "impossible"? However, I did see an allergist and I am allergic to all steroids, topical, inhaled, IV and oral. So, to you medical professionals out there, I do exist. Please don't patronize me when I tell you that I have a steroid allergy.