Updated Anaphylaxis Guidelines: Moving Away From Steroids and Antihistamines

Anaphylaxis management has evolved substantially over the past decade, with recent guideline updates sharpening the focus on early epinephrine administration as the cornerstone of care. Contemporary recommendations, informed by practice parameters issued in 2015 and updated in 2020 and 2024, increasingly question the routine use of systemic corticosteroids and first‑generation antihistamines in the acute setting. For primary care clinicians, these updates are especially relevant because initial recognition and treatment decisions often occur in outpatient offices and urgent care centers, where old habits may persist long after the evidence has changed.

The newer guidance underscores that epinephrine is the only intervention that reliably reverses anaphylaxis by addressing both the hemodynamic and respiratory consequences of mast cell mediator release. In contrast, corticosteroids and antihistamines have delayed onset of action, do not prevent progression of anaphylaxis, and may create diagnostic confusion when sedating agents are used while a reaction is still evolving. Quality‑improvement efforts in many emergency departments have already removed “automatic” orders for corticosteroids in anaphylaxis pathways, a shift that ambulatory practices are encouraged to emulate. The practical message for front‑line clinicians is to treat epinephrine as the first and principal therapy, not as a rescue measure after other medications fail.

These principles are highlighted in a video discussion featuring Brian Schroer, MD (Cleveland Clinic Children’s Hospital), who moderates a conversation with allergists David Golden, MD (Johns Hopkins University School of Medicine), and Jay Lieberman, MD (University of Tennessee). Schroer leads a review of how the 2020 grade‑focused update addressed specific therapeutic questions around epinephrine, antihistamines, and corticosteroids, while the broader 2024 update synthesized a decade of data to inform real‑world management. Golden and Lieberman describe observed practice changes, including reduced routine use of steroids and sedating antihistamines in acute anaphylaxis and increased emphasis on timely intramuscular epinephrine as the evidence‑based standard of care.

Disclosures include Novartis Pharmaceuticals, Regeneron Pharmaceuticals, BioCryst, GlaxoSmithKline, Amgen, GENZYME Corporation, AstraZeneca Pharmaceuticals, and LEO Pharma for Schroer; Novartis Pharmaceuticals, ABBVIE, Genentech, Aquestive Therapeutics for Lieberman; and Phadia US and Genentech USA for Golden.

References:

1. Golden DBK, Wang J, Waserman S, et al. Anaphylaxis: A 2023 practice parameter update. Ann Allergy Asthma Immunol. 2024;132(2):124-176. doi:10.1016/j.anai.2023.09.015

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3. Aquestive Therapeutics. Aquestive Therapeutics Announces FDA Issuance of Complete Response Letter for Anaphylm^TM - Aquestive Therapeutics. Aquestive Therapeutics. Published February 6, 2026. Accessed February 20, 2026. https://investors.aquestive.com/news-releases/news-release-details/aquestive-therapeutics-announces-fda-issuance-complete-response