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Annals of the Academy of Medicine,... Nov 2022Drug allergies are often self-reported but of unknown accuracy. We carried out a prospective study to examine the utility and safety of formal allergology evaluation,...
INTRODUCTION
Drug allergies are often self-reported but of unknown accuracy. We carried out a prospective study to examine the utility and safety of formal allergology evaluation, and to identify factors associated with accurate drug allergy labels.
METHOD
All patients who underwent drug allergy evaluation in our clinic during the study period were recruited. Baseline demographics, characteristics of index hypersensitivity reaction and outcomes of evaluation were recorded.
RESULTS
A total of 331 patients from March 2019 to June 2021 completed drug allergy evaluation to index drugs of concern. There were 123 (37%) male patients, and the mean age was 49 years (standard deviation 17). There were 170 beta-lactam antibiotics, 53 peri-operative drugs, 43 others, 38 non steroidal anti-inflammatory drugs, and 27 non-beta-lactam antibiotic evaluations. Index reaction occurred within 5 years in 165 (50%) patients, with latency of less than 4 hours in 125 (38%) patients. The most common index reactions were rash, angioedema and urticaria. There were 57 (17%) evaluations stratified as low risk, 222 (67%) moderate risk, and 52 (16%) high risk based on multidisciplinary consensus. Allergy label was found to be false (negative drug evaluation) in 248 (75%) patients, while 16/237 (7%) skin tests, 44/331 (13%) in-clinic graded challenge, and 23/134 (17%) home prolonged challenges were positive (true drug allergy). The most common evaluation reactions were rash and urticaria. No cases of anaphylaxis were elicited.
CONCLUSION
Seventy-five percent of drug allergy labels are inaccurate. Risk-stratified, protocolised allergy evaluation is safe. Prolonged drug challenge increases the sensitivity of drug allergy evaluation and should therefore be performed when indicated.
Topics: Humans; Male; Middle Aged; Female; Prospective Studies; Drug Hypersensitivity; Exanthema; Urticaria; Monobactams
PubMed: 36453215
DOI: 10.47102/annals-acadmedsg.2022118 -
Current Opinion in Pediatrics Dec 2022The purpose of this review is to identify recent advances in our understanding and management of immunoglobulin E (IgE)-mediated antibiotic allergy. (Review)
Review
PURPOSE OF REVIEW
The purpose of this review is to identify recent advances in our understanding and management of immunoglobulin E (IgE)-mediated antibiotic allergy.
RECENT FINDINGS
Antibiotics remain a leading cause of fatal anaphylaxis reported to the FDA. However, recent advances have defined the features of adult and pediatric patients without true IgE-mediated allergy or any mechanism of anaphylaxis when tested. This has created opportunities to use direct challenges to disprove these allergies at the point-of-care and improves antibiotic stewardship. Additional advances have highlighted cross-reactive structural considerations within classes of drugs, in particular the R1 side-chain of cephalosporins, that appear to drive true immune-mediated cross-reactivity. Further advances in risk-based approaches to skin testing, phenotyping, and re-exposure challenges are needed to standardize antibiotic allergy evaluation.
SUMMARY
Recent advances in defining true IgE-mediated drug allergy have helped to identify patients unlikely to be skin-test positive. In turn, this has identified patients who can skip skin testing and proceed to direct ingestion challenge using history risk-based approaches. The ability to identify the small number of patients with true IgE-mediated allergy and study their natural history over time, as well as the vast majority without true allergy will facilitate important and novel mechanistic discoveries.
Topics: Adult; Humans; Child; Immunoglobulin E; Anaphylaxis; Drug Hypersensitivity; Skin Tests; Anti-Bacterial Agents
PubMed: 36036421
DOI: 10.1097/MOP.0000000000001171 -
Allergy Dec 2019Drug hypersensitivity reactions (DHRs) are nowadays the third cause of allergy after rhinitis and asthma with a significant increase in prevalence in both adults and... (Review)
Review
Drug hypersensitivity reactions (DHRs) are nowadays the third cause of allergy after rhinitis and asthma with a significant increase in prevalence in both adults and paediatric population with new drugs included as culprit. For this, DHRs represent not only a health problem but also a significant financial burden for affected individuals and health systems. Mislabelling DHRs is showing to be a relevant problem for both, false label of drug allergic and false label of nonallergic. All this reinforces the need to improve accurate diagnostic approaches that allow an appropriate management. Moreover, there is a need for training both, nonallergist stakeholders and patients to improve the reaction identification and therefore decrease the mislabelling. The use of allergy cards has shown to be relevant to avoid the induction of DHRs due to the prescription of wrong medication. Recent developments over the last 2 years and highlights about risk factors, diagnostic approaches, mechanisms involved as well as prevention actions, and management have been reviewed. In these papers, it has been outlined the need for correct diagnosis and de-labelling of patients previously false-reported as allergic, which will improve the management and treatment of patients with DHRs.
Topics: Cost of Illness; Disease Management; Disease Susceptibility; Drug Hypersensitivity; Drug Labeling; Humans; Incidence; Risk Assessment; Risk Factors
PubMed: 31557314
DOI: 10.1111/all.14061 -
American Journal of Reproductive... Jan 2021Drug allergy is associated with adverse short-term perinatal outcomes such as caesarian delivery and preterm delivery. The aim of the present study was to determine...
Drug allergy is associated with adverse short-term perinatal outcomes such as caesarian delivery and preterm delivery. The aim of the present study was to determine whether being born to a mother with known drug allergy increases the risk for long-term dermatological morbidity of the offspring. A population-based cohort study, comparing long-term dermatological morbidity of offspring to mothers with and without known drug allergy, was conducted. Dermatological morbidity was assessed up to the age of 18 years according to a predefined set of ICD-9 codes associated with hospitalization of the offspring. A Kaplan-Meier survival curve was used to compare cumulative incidence of long-term dermatological morbidity, and a Cox proportional hazards model was constructed to control of confounders. During the study period, 243,682 deliveries met the inclusion criteria, of them 4% (n = 9756) were of mothers with known drug allergy. Offspring born to mothers with known drug allergy had higher rates of long-term dermatological morbidity Likewise, the cumulative incidence of long-term dermatological morbidity was higher as compared with those without known drug allergy (Kaplan-Meier log-rank P = .021). Using a Cox proportional hazards model, controlling for confounders, being born to a mother with known drug allergy was found to be an independent risk factor for long-term dermatological morbidity of the offspring (adjusted HR 1.2, 95% CI 1.03-1.33, P = .016). Being born to a mother with known drug allergy is independently associated with higher risk for long-term dermatological morbidity of the offspring.
Topics: Adolescent; Adult; Child; Child, Preschool; Drug Hypersensitivity; Female; Humans; Infant; Infant, Newborn; Israel; Kaplan-Meier Estimate; Morbidity; Pregnancy; Prenatal Exposure Delayed Effects; Proportional Hazards Models; Retrospective Studies; Risk Factors; Skin Diseases; Young Adult
PubMed: 33025676
DOI: 10.1111/aji.13356 -
Medicina (Kaunas, Lithuania) May 2020Biologic drugs are widely used in pediatric medicine. Monoclonal antibodies (mAbs) in particular are a therapeutic option for rheumatic, autoinflammatory and oncologic... (Review)
Review
Biologic drugs are widely used in pediatric medicine. Monoclonal antibodies (mAbs) in particular are a therapeutic option for rheumatic, autoinflammatory and oncologic diseases. Adverse drug reactions and hypersensitivity reactions (HSR) to mAbs may occur in children. Clinical presentation of HSRs to mAbs can be classified according to phenotypes in infusion-related reactions, cytokine release syndrome, both alpha type reactions and type I (IgE/non-IgE), type III, and type IV reactions, all beta-type reactions. The aim of this review is to focus on HSRs associated with the most frequent mAbs in childhood, with particular attention to beta-type reactions. When a reaction to mAbs is suspected a diagnostic work-up including in-vivo and in-vitro testing should be performed. A drug provocation test is recommended only when no alternative drugs are available. In selected patients with immediate IgE-mediated drug allergy a desensitization protocol is indicated. Despite the heavy use of mAbs in childhood, studies evaluating the reliability of diagnostic test are lacking. Although desensitization may be effective in reducing the risk of reactions in children, standardized pediatric protocols are still not available.
Topics: Adolescent; Antibodies, Monoclonal; Biological Products; Child; Cytokine Release Syndrome; Drug Hypersensitivity; Female; Humans; Immunologic Factors; Male
PubMed: 32408641
DOI: 10.3390/medicina56050232 -
Pediatric Allergy and Immunology :... Apr 2021Antiepileptic drugs (AEDs) are widely used for the treatment of epilepsy, but they can be associated with the development of mainly delayed/non-immediate... (Review)
Review
BACKGROUND
Antiepileptic drugs (AEDs) are widely used for the treatment of epilepsy, but they can be associated with the development of mainly delayed/non-immediate hypersensitivity reactions (HRs). Although these reactions are usually cutaneous, self-limited, and spontaneously resolve within days after drug discontinuation, sometime HR reactions to AEDs can be severe and life-threatening.
AIM
This paper seeks to show examples on practical management of AED HRs in children starting from a review of what it is already known in literature.
RESULTS
Risk factors include age, history of previous AEDs reactions, viral infections, concomitant medications, and genetic factors. The diagnostic workup consists of in vivo (intradermal testing and patch testing) and in vitro tests [serological investigation to exclude the role of viral infection, lymphocyte transformation test (LTT), cytokine detection in ELISpot assays, and granulysin (Grl) in flow cytometry. Treatment is based on a prompt drug discontinuation and mainly on the use of glucocorticoids.
CONCLUSION
Dealing with AED HRs is challenging. The primary goal in the diagnosis and management of HRs to AEDs should be trying to accurately identify the causal trigger and simultaneously identify a safe and effective alternative anticonvulsant. There is therefore an ongoing need to improve our knowledge of HS reactions due to AED medications and in particular to improve our diagnostic capabilities.
Topics: Anticonvulsants; Child; Drug Hypersensitivity; Humans; Hypersensitivity, Delayed; Intradermal Tests; Risk Factors; Skin
PubMed: 33205474
DOI: 10.1111/pai.13409 -
The Journal of Allergy and Clinical... 2019This review focuses on advances in health information technology in the detection, diagnosis, and management of drug allergy. The data regarding the use of electronic... (Review)
Review
This review focuses on advances in health information technology in the detection, diagnosis, and management of drug allergy. The data regarding the use of electronic health records and social media for the detection of drug allergy are reviewed, along with predictive algorithms and clinical decision support systems for drug allergy diagnosis. Drug allergy pathways, algorithms, computerized decision support systems, and computerized physician order entry for patient management are discussed. The use of electronic consults (e-consults) and telehealth in this field is described, as are efforts to improve communication among patients and providers. Future directions for research are suggested.
Topics: Allergy and Immunology; Decision Support Systems, Clinical; Delivery of Health Care; Documentation; Drug Hypersensitivity; Electronic Health Records; Humans; Medical Informatics; Medical Order Entry Systems; Remote Consultation; Skin Tests
PubMed: 31108217
DOI: 10.1016/j.jaip.2019.04.050 -
The Medical Journal of Australia Jun 2022
Topics: Anaphylaxis; Australia; Drug Hypersensitivity; Food Hypersensitivity; Humans; Registries
PubMed: 35568381
DOI: 10.5694/mja2.51527 -
The Journal of Allergy and Clinical... Aug 2021The current method of defining, reporting, assessment, labeling, delabeling, and reconciliation of adverse drug reactions (ADRs), and specifically immunologically...
The current method of defining, reporting, assessment, labeling, delabeling, and reconciliation of adverse drug reactions (ADRs), and specifically immunologically mediated drug hypersensitivity reactions (HSRs), in electronic health records (EHRs) is inadequate and compromises care quality and safety. It is critical to accurately and succinctly report the signs and symptoms associated with ADRs and suspected HSRs to enable clinicians to determine the plausible reaction type and help guide appropriate future management plans. Despite the current limitations of the EHR allergy module, we must encourage improved clinical documentation and demand technological improvements. Telehealth methods have been shown to be valuable in the assessment of ADRs and HSRs, particularly in the case of penicillin allergy evaluation and delabeling. The implementation, assessment, and refinement of advanced technologies, including clinical informatics and artificial intelligence, along with continued education of health care providers have potential to improve EHR documentation and communication, thereby advancing patient safety efforts.
Topics: Artificial Intelligence; Drug Hypersensitivity; Drug-Related Side Effects and Adverse Reactions; Electronic Health Records; Humans; Penicillins
PubMed: 33607342
DOI: 10.1016/j.jaip.2021.02.005 -
The Journal of Allergy and Clinical... Jun 2023Drug reaction with eosinophilia and systemic symptoms (DRESS) is a potentially life-threatening drug reaction; recognizing the diversity of its clinical presentations,...
BACKGROUND
Drug reaction with eosinophilia and systemic symptoms (DRESS) is a potentially life-threatening drug reaction; recognizing the diversity of its clinical presentations, implicated drugs, and management modalities can aid in diagnosis and reduce morbidity and mortality.
OBJECTIVE
To review the clinical features, drug causes, and treatments deployed in DRESS.
METHODS
This review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to review publications relating to DRESS published between 1979 and 2021. Only publications with a RegiSCAR score of 4 or greater were included (indicating "probable" or "definite" DRESS). The PRISMA guidelines were used for data extraction and the Newcastle-Ottawa scale for quality assessment (Pierson DJ. Respir Care 2009;54:1372-8). The main outcomes included implicated drugs, patient demographics, clinical manifestations, treatment, and sequelae for each included publication.
RESULTS
A total of 1124 publications were reviewed, and 131 met the inclusion criteria, amounting to 151 cases of DRESS. The most implicated drug classes were antibiotics, anticonvulsants, and anti-inflammatories, although up to 55 drugs were implicated. Cutaneous manifestations were present in 99% of cases, with a median onset of 24 days and maculopapular rash the most common morphology. Common systemic features were fever, eosinophilia, lymphadenopathy, and liver involvement. Facial edema was present in 67 cases (44%). Systemic corticosteroids were the mainstay of DRESS-specific treatment. A total of 13 cases (9%) resulted in mortality.
CONCLUSION
DRESS diagnosis should be considered in the presence of a cutaneous eruption, fever, eosinophilia, liver involvement, and lymphadenopathy. The class of implicated drug may influence outcome, as allopurinol was associated with 23% of cases that resulted in death (3 cases). Given potential DRESS complications and mortality, it is important that DRESS is recognized early so that any suspect drugs are ceased promptly.
Topics: Drug Hypersensitivity; Humans; Eosinophilia; Anti-Bacterial Agents
PubMed: 36893848
DOI: 10.1016/j.jaip.2023.02.035