Recent Updates in Understanding NSAID Hypersensitivity

Anaphylactic shock induced by intravenous ketorolac: A case report

Ketorolac trometamol injection is the first injectable nonsteroidal anti-inflammatory drug (NSAID) approved for the short-term management of moderate to severe pain. As a non-opioid alternative, it represents a critical development for acute pain relief, particularly in postoperative and injury-related scenarios. Like other NSAIDs, ketorolac trometamol is associated with common adverse reactions such as dizziness, headache, drowsiness, nausea, and vomiting, which are generally mild to moderate. However, rare but severe reactions like anaphylactic shock have been reported. This case report highlights a specific instance of anaphylactic shock induced by intravenous ketorolac trometamol, emphasizing the rapid onset of symptoms and the importance of vigilant monitoring during administration to prevent severe outcomes. Additionally, recommendations for post-recovery monitoring and allergological evaluation are provided to enhance clinical management in similar cases.

Syk/Src/NF-κB axis is essentially targeted in anti-inflammatory and anti-gastritis effects of Bletilla striata ethanol extract

ETHNOPHARMACOLOGICAL RELEVANCE

Traditional herbal medicine books "Shin Rhong Bon Cho Kyung" and "Hyang Yak Jip Sung Bang" mentioned that Bletilla striata (Thunb.) Rchb.f. (Orchidaceae) was often used as a medicinal plant and is used in oriental medicine to treat wounds, inflammatory symptoms, and ulcers in stomach, lung, and skin. However, systematic studies on its value as a promising anti-inflammatory remedy were not fully elucidated yet.

AIM OF THE STUDY

The eventual goal of this paper was to explore anti-inflammatory and anti-gastritis effects of Bletilla striata and its inhibitory mechanism with an ethanol extract of this plant (Bs-EE).

MATERIALS AND METHODS

In vitro study includes nitric oxide (NO) inhibitory test by was Griess assay, cell viability check by MTT assay, mRNA level analysis of inflammatory genes by PCR and RT-PCR, and protein level analysis by Western blotting and CESTA. In vivo analysis was done with a mouse gastritis model triggered by HCl/EtOH. Phytochemical finger printing result was observed by GC/MS-MS.

RESULTS

Our in vitro trials showed that Bs-EE dose-dependently reduced NO production in lipopolysaccharide-, Poly(I:C)-, and Pam3CSK-treated RAW264.7 cells without causing cytotoxicity, as shown by an MTT assay. The levels of inflammation-related genes (iNOS, IL-6, IL-1β) showed meaningful reductions in RT-PCR and real-time PCR. The NF-κB activity enhanced in MyD88-overexpressing HEK293T cells was strongly reduced by Bs-EE. Western blotting results indicated that the Bs-EE suppressed the phosphorylation of IκBα, IKKα/β, AKT, p65, p50, Syk, and Src, which produced anti-inflammatory effects. Both Syk and Src were found to be direct targets of Bs-EE. This extract attenuated the inflammatory effect in a murine acute gastritis model induced by HCl/EtOH.

CONCLUSIONS

These findings suggest that an ethanol extract of Bletilla striata could be developed as a promising natural anti-inflammatory drug or health functional food with NF-κB pathway inhibitory activity.

A single epidural administration of butorphanol combined with patient-controlled intravenous analgesia relieves postpartum contraction pain after cesarean section: A randomized clinical trial

BACKGROUND

Numerous studies have shown that butorphanol exerts an inhibitory effect on visceral pain. The aim of this study was to observe the effects of a single epidural administration of butorphanol combined with patient-controlled intravenous analgesia on postpartum uterine contraction pain after cesarean section.

METHODS

We randomly allotted 121 women undergoing cesarean section surgery procedure to 3 groups: 31 cases were excluded; and 90 cases were divided into group S (blank control, n = 30), group I (intravenous butorphanol, n = 30), and group E (butorphanol administered into the epidural cavity, n = 30). We then observed changes in the indices of uterine contraction pain and intraoperative stretch pain for the 3 groups.

RESULTS

(1) In terms of the uterine contraction pain, the visual analog scale scores of group I were lower than those for group S at 10 minutes (P = .001), 20 minutes (P < .001), 30 minutes (P < .001), 1 hour (P < .001), 2 hours (P < .001), and 4 hours (P < .001) after the epidural administration. The visual analog scale scores of group E were lower than those of group I at 10 minutes (P < .001), 20 minutes (P < .001), 30 minutes (P < .001), 1 hour (P < .001), 2 hours (P < .001), 4 hours (P < .001), and 6 hours (P < .001) after the administration. (2) In terms of intraoperative traction reactions, sedation, and comfort during the operation, group E was superior to groups S and I at any time points (all P < .043).

CONCLUSIONS

Butorphanol single epidural administration combined with intravenous patient-controlled analgesia can effectively reduce the pain of uterine contraction and intraoperative traction reaction and improve perioperative comfort of the parturient.

Diagnostic evaluation of hypersensitivity reactions to arylpropionic acid derivatives: a descriptive observational study focusing on clinical characteristics and potential risk factors in children

BACKGROUND

Arylpropionic acid derivatives (APs) are the main triggers of nonsteroidal anti-inflammatory drug (NSAID) hypersensitivity. Data on clinical patterns and risk factors for AP hypersensitivity in children are quite limited.

AIM

To assess the clinical characteristics and potential risk factors for proven AP hypersensitivity in children.

METHOD

Patients with a history of AP hypersensitivity were retrospectively assessed using a standardized diagnostic algorithm. Children with confirmed hypersensitivity were defined as selective responders or cross-intolerants based on the result of drug provocation tests and further categorized according to the EAACI/ENDA classification. A multivariable logistic regression analysis was performed to analyze the potential risk factors for proven AP hypersensitivity.

RESULTS

A total of 166 patients (51.2% male, median age of six years) with a history of AP hypersensitivity were included. Ibuprofen (89.2%) was the most frequently reported AP in the patients' histories. The reported hypersensitivity of 40 (22.4%) patients was confirmed by diagnostic testing: eight (13.6%) patients with a history of reaction only to APs and 32 (29.9%) patients with a history of reactions to multiple NSAIDs, including chemically unrelated NSAIDs in addition to APs. Five (12.5%) patients were classified as selective responders and 35 (87.5%) were cross-intolerants. Overall, five (12.5%) of the confirmed cases could not be categorized according to the EAACI/ENDA classification. Older age (aOR: 1.11, 95% CI 1.02-1.21, p = 0.015), chronic urticaria as an underlying disease (aOR: 2.87, 95% CI 1.09-7.54, p = 0.033) and a history of anaphylaxis (aOR: 7.84, 95% CI 1.86-33.04, p = 0.005) were related to confirmed AP hypersensitivity.

CONCLUSION

Almost a quarter of children and adolescents were confirmed to have AP hypersensitivity. Older age, the presence of chronic urticaria and a history of anaphylaxis were potential risk factors for proven AP hypersensitivity.

Risk Factors for Intravenous Acetaminophen-Induced Hypotension in Patients with Repeated Acetaminophen Administration

PURPOSE

Intravenous (IV) acetaminophen-induced hypotension is a clinically significant issue that remains difficult to predict. Therefore, this study aimed to identify the factors associated with hypotension in patients with repeated IV acetaminophen administration.

MATERIALS AND METHODS

This observational cohort study included patients who received IV acetaminophen in the critical care unit of the Yongin Severance Hospital in 2020. All IV acetaminophen administration records for each patient were reviewed, and the blood pressure records within 2 h after IV acetaminophen administration were examined. Changes in blood pressure within 2 h of IV acetaminophen administration were monitored to identify hypotension, defined as a systolic blood pressure <90 mm Hg, a decrease in systolic blood pressure by 30 mm Hg, or a decrease in mean arterial pressure by 15%.

RESULTS

There were 1547 instances of IV acetaminophen administration among 398 patients. Of these, 416 instances (26.9%) resulted in hypotension among 204 patients (51.3%). A history of IV acetaminophen-induced hypotension did not predict subsequent hypotensive episodes, and there was no consistent tendency. The use of beta-blocker [odds ratio (OR)=1.50], gastrointestinal (GI) infection (OR=1.42), and septic shock (OR=1.68) were significant risk factors for IV acetaminophen-induced hypotension in multivariate analysis. In subgroup analysis of cases with beta-blocker, heart failure (OR=1.91), urinary tract infection (OR=2.16), GI infection (OR=1.83) were significant risk factors.

CONCLUSION

Severe infections, heart failure, and the use of beta-blockers are associated with IV acetaminophen-induced hypotension. However, IV acetaminophen-induced hypotension is inconsistent and depends on the patient's condition.

Non-IgE-mediated drug-induced hypersensitivity reactions in pediatrics

PURPOSE OF REVIEW

Despite their prevalence and potential severity, non-IgE-mediated drug-induced hypersensitivity reactions (DHRs) are under-researched and poorly defined, particularly in children. Presentations range from mild cutaneous reactions to severe systemic diseases, with pathophysiological mechanisms and reliable diagnostic markers not well established. The lack of validated tests often leads to permanent drug restrictions, reliance on second-line drugs, and increased costs. Focusing on recent advancements and areas needing further research, this review aims to enhance children's recognition, diagnosis, and management of non-IgE-mediated DHRs.

RECENT FINDINGS

Recent studies have enhanced the understanding of immediate and delayed non-IgE-mediated drug reactions. Key findings include the Mas-related G protein-coupled receptor X2 in mast cells and the identification of HLA alleles linked to severe cutaneous adverse reactions, such as Stevens-Johnson syndrome and toxic epidermal necrolysis. Improved diagnostic techniques, including skin testing, show promise in identifying immediate and delayed non-IgE DHRs. Additionally, research highlights the impact of cofactors, drug metabolites, and co-infections on these DHRs and explores potential biomarkers for predicting reaction severity.

SUMMARY

Non-IgE-mediated DHRs are a significant cause of morbidity and treatment changes in pediatric patients. Recent research underscores their clinical presentations and mechanisms, paving the way for more precise diagnostic and therapeutic strategies to improve patient outcomes.

Aspirin Hypersensitivity in Patients with Coronary Artery Disease: An Updated Review and Practical Recommendations

Acetylsalicylic acid (ASA) represents a cornerstone of antiplatelet therapy for the treatment of atherosclerotic coronary artery disease (CAD). ASA is in fact indicated in case of an acute coronary syndrome or after a percutaneous coronary intervention with stent implantation. Aspirin hypersensitivity is frequently reported by patients, and this challenging situation requires a careful evaluation of the true nature of the presumed sensitivity and of its mechanisms, as well as to differentiate it from a more frequent (and more easily manageable) aspirin intolerance. Two main strategies are available to allow ASA administration for patients with CAD and suspected ASA hypersensitivity: a low-dose ASA challenge, aimed at assessing the tolerability of ASA at the antiplatelet dose of 100 mg, and desensitization, a therapeutic procedure which aims to induce tolerance to ASA. For those patients who cannot undergo ASA challenge and desensitization due to previous serious adverse reactions, or for those in whom desensitization was unsuccessful, a number of further alternative strategies are available, even if these have not been validated and approved by guidelines. The aim of this state-of-the-art review is therefore to summarize the established evidence regarding pathophysiology, clinical presentation, diagnosis, and management of aspirin hypersensitivity and to provide a practical guide for cardiologists (and clinicians) who have to face the not uncommon situation of a patient with concomitant coronary artery disease and aspirin hypersensitivity.

Revitalizing elixir with orange peel amplification of alginate fish oil beads for enhanced anti-aging efficacy

The research introduces a novel method for creating drug-loaded hydrogel beads that target anti-aging, anti-oxidative, and anti-inflammatory effects, addressing the interconnected processes underlying various pathological conditions. The study focuses on the development of hydrogel beads containing anti-aging compounds, antioxidants, and anti-inflammatory drugs to effectively mitigate various processes. The synthesis, characterization and in vitro evaluations, and potential applications of these multifunctional hydrogel beads are discussed. A polymeric alginate-orange peel extract (1:1) hydrogel was synthesized for encapsulating fish oil. Beads prepared with variable fish oil concentrations (0.1, 0.3, and 0.5 ml) were characterized, showing no significant decrease in size i.e., 0.5 mm and a reduction in pore size from 23 to 12 µm. Encapsulation efficiency reached up to 98% within 2 min, with controlled release achieved upto 45 to 120 min with increasing oil concentration, indicating potential for sustained delivery. Fourier-transform infrared spectroscopy confirmed successful encapsulation by revealing peak shifting, interaction between constituents. In vitro degradation studies showed the hydrogel's biodegradability improved from 30 to 120 min, alongside anti-inflammatory, anti-oxidative, anti-collagenase and anti-elastase activities, cell proliferation rate enhanced after entrapping fish oil. In conclusion, the synthesized hydrogel beads are a promising drug delivery vehicle because they provide stable and effective oil encapsulation with controlled release for notable anti-aging and regenerative potential. Targeted delivery for inflammatory and oxidative stress-related illnesses is one set of potential uses. Further research may optimize this system for broader applications in drug delivery and tissue engineering.

How to Define and Manage Low-Risk Drug Allergy Labels

Risk stratification in drug allergy implies that specific risk categories (eg, low, moderate, and high) classify historical drug hypersensitivity reactions. These risk categories can be based on reaction phenotypic characteristics, the timing of the reaction and evaluation, the required reaction management, and individual characteristics. Although a multitude of frameworks have been described in the literature, particularly for penicillin allergy labels, there has yet to be a global consensus, and approaches continue to vary between allergy centers. Immune-mediated drug allergies can sometimes be confirmed using skin testing, but a negative drug challenge is required to demonstrate tolerance and remove the allergy from the electronic health record ("delabel" the allergy). Even for quintessential IgE-mediated drug allergy, penicillin allergy, recent data reveal that a direct oral challenge, without prior skin testing, is an appropriate diagnostic strategy in those who are considered low-risk. Drug allergy pathogenesis and clinical manifestations may vary depending on the culprit drug, and as such, the optimal approach should be based on risk stratification that considers individual patient and reaction characteristics, the likely hypersensitivity reaction phenotype, the drug class, and the patient's clinical needs. This article will describe low-risk drug allergy labels, focusing on β-lactam and sulfonamide antibiotics, nonsteroidal anti-inflammatory drugs, iodinated contrast media, and common chemotherapeutics. This review will also address practical management approaches using currently available risk stratification and clinical decision tools.

Non-IgE-Mediated Immediate Drug-Induced Hypersensitivity Reactions

Immediate drug-induced hypersensitivity reactions (IDHSRs) have conventionally been attributed to an immunoglobulin E (IgE)-mediated mechanism. Nevertheless, it has now been acknowledged that IDHSRs can also occur independently of IgE involvement. Non-IgE-mediated IDHSRs encompass the activation of effector cells, both mast cell-dependent and -independent and the initiation of inflammatory pathways through immunogenic and nonimmunogenic mechanisms. The IDHSRs involve inflammatory mediators beyond histamine, including the platelet-activating factor, which activates multiple cell types, including smooth muscle, endothelium, and MC, and evidence supports its importance in IgE-mediated reactions in humans. Clinically, distinguishing IgE from non-IgE mechanisms is crucial for future treatment strategies, including drug(s) restriction, readministration approaches, and pretreatment considerations. However, this presents significant challenges because certain drugs can trigger both mechanisms, and their presentations can appear similarly, ranging from mild to life-threatening symptoms. Thus, history alone is often inadequate for differentiation, and skin tests lack a standardized approach. Moreover, drug-specific IgE immunoassays have favorable specificity but low sensitivity, and the usefulness of the basophil activation test remains debatable. Lastly, no biomarker reliably differentiates between both mechanisms. Whereas non-IgE-mediated mechanisms likely predominate in IDHSRs, reclassifying most drug-related IDHSRs as non-IgE-mediated, with suggested prevention through dose administration adjustments, is premature and risky. Therefore, continued research and validated diagnostic tests are crucial to improving our capacity to distinguish between these mechanisms, ultimately enhancing patient care.

Changing patterns in the epidemiology of drug allergy

Drug allergy (DA) remains a complex and unaddressed problem worldwide that often deprives patients of optimal medication choices and places them at risk for life-threatening reactions. Underdiagnosis and overdiagnosis are common and due to the lack of standardized definitions and biomarkers. The true burden of DA is unknown, and recent efforts in data gathering through electronic medical records are starting to provide emerging patterns around the world. Ten percent of the general population engaged in health care claim to have a DA, and the most common label is penicillin allergy. Up to 20% of emergency room visits for anaphylaxis are due to DA and 15%-20% of hospitalized patients report DA. It is estimated that DA will increase based on the availability and use of new and targeted antibiotics, vaccines, chemotherapies, biologicals, and small molecules, which are aimed at improving patient's options and quality of life. Global and regional variations in the prevalence of diseases such as human immunodeficiency virus and mycobacterial diseases, and the drugs used to treat these infections have an impact on DA. The aim of this review is to provide an update on the global impact of DA by presenting emerging data on drug epidemiology in adult and pediatric populations.

A case of possible anaphylaxis to ASA and structurally unrelated NSAIDs

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) are one of the most commonly used classes of medications, and are among the leading causes of drug hypersensitivity. NSAIDs hypersensitivity reactions are classified by symptom involvement and NSAIDs subclass cross-reactivity. Reactions varying from cutaneous involvement to respiratory symptoms can be triggered by multiple NSAIDs subclasses. Anaphylaxis, while rare, can be induced by a single NSAID, with tolerability of other structurally unrelated subclasses. Reactions that fall outside of these traditional categories are deemed "blended reactions". We report a unique case of possible anaphylaxis to acetylsalicylic acid (ASA) and ibuprofen, two structurally dissimilar NSAIDs, indicating a severe blended reaction outside of the typical NSAIDs hypersensitivity reaction categories.

CASE PRESENTATION

An otherwise healthy 45 year old woman was referred to the Allergy and Immunology clinic after developing acute onset dyspnea, lip swelling, and generalized urticaria with ibuprofen use requiring treatment with intramuscular epinephrine in the emergency department. She previously tolerated ibuprofen, naproxen, and acetaminophen and had no history of urticaria, angioedema, asthma, or nasal polyps. She underwent an oral challenge to ASA whereby she developed urticaria and throat irritation with rebound symptoms requiring 2 doses of intramuscular epinephrine. On subsequent visits she passed treatment dose acetaminophen and celecoxib challenges. She was counseled to avoid all other NSAIDs and ASA desensitization was offered should this medication be clinically indicated in the future.

CONCLUSIONS

NSAIDs hypersensitivity reactions can be triggered by individual NSAIDs with tolerance of other subclasses or by multiple structurally unrelated NSAIDs due to COX-1 inhibition. Determining the type of reaction (NERD, NECD, NIUA, SNIUAA, or SNIDHR) allows for appropriate oral challenges and safe alternative therapy recommendations. However, not all clinical reactions fit perfectly into these categories. Patients may also develop blended reactions. Our case highlights a severe blended reaction to multiple unrelated NSAIDs, including likely anaphylaxis to ASA. We note the utility of drug provocation tests (DPTs) to identify safe alternative medication options, as well as the importance of performing DPTs in settings properly equipped to assess and manage severe hypersensitivity reactions including anaphylaxis.

Suspected perioperative anaphylaxis: are we making the correct diagnosis?

We provide a commentary on aspects of a prospective study of the epidemiology of perioperative anaphylaxis in Japan (Japanese Epidemiologic Study for Perioperative Anaphylaxis [JESPA]). Accurate diagnosis of perioperative anaphylaxis is important for research but essential for clinical safety. We evaluate the diagnostic approach used in the JESPA study and caution against over-reliance on diagnostic tests that lack sensitivity and specificity when clinical data suggest an immediate perioperative hypersensitivity reaction is likely.