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Barbaud A, Garvey LH, Torres M, Laguna JJ, Arcolaci A, Bonadonna P, Scherer Hofmeier K, Chiriac AM, Cernadas J, Caubet JC, Brockow K. EAACI/ENDA position paper on drug provocation testing. Allergy 2024; 79:565-579. [PMID: 38155501 DOI: 10.1111/all.15996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 12/12/2023] [Accepted: 12/13/2023] [Indexed: 12/30/2023]
Abstract
In drug hypersensitivity, drug provocation testing (DPT), also called drug challenge, is the gold standard for investigation. In recent years, risk stratification has become an important tool for adjusting the diagnostic strategy to the perceived risk, whilst still maintaining a high level of safety for the patient. Skin tests are recommended before DPT but may be omitted in low-risk patients. The task force suggests a strict definition of such low-risk patients in children and adults. Based on experience and evidence from studies of allergy to beta-lactam antibiotics, an algorithm on how to adjust DPT to the risk, and when to omit skin tests before DPT, is presented. For other antibiotics, non-steroidal anti-inflammatory drugs and other drugs, skin tests are poorly validated and DPT is frequently necessary. We recommend performing DPT with chemotherapeutics and biologicals to avoid unnecessary desensitization procedures and DPT with skin tests negative contrast media. We suggest DPT with anesthetics only in highly specialized centers. Specifics of DPT to proton pump inhibitors, anticonvulsants and corticosteroids are discussed. This position paper provides general recommendations and guidance on optimizing use of DPT, whilst balancing benefits with patient safety and optimizing the use of the limited available resources.
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Affiliation(s)
- Annick Barbaud
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP. Sorbonne Université, Hôpital Tenon, Service de dermatologie et allergologie, Paris, France
| | - Lene Heise Garvey
- Allergy Clinic, Department of Dermatology and Allergy, Herlev and Gentofte Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Maria Torres
- Allergy Unit, Regional University Hospital of Malaga-IBIMA-UMA-ARADyAL, Malaga, Spain
| | - Jose Julio Laguna
- Allergy Unit, Allergo-Anaesthesia Unit, Faculty of Medicine, Hospital Central de la Cruz Roja, Alfonso X El Sabio University, ARADyAL, REI, Madrid, Spain
| | - Alessandra Arcolaci
- Immunology Unit, University Hospital of Verona, Policlinico G.B. Rossi, Verona, Italy
| | - Patrizia Bonadonna
- Allergy Unit, University Hospital of Verona, Policlinico G.B. Rossi, Verona, Italy
| | - Kathrin Scherer Hofmeier
- Allergy and Dermatology, Cantonal Hospital Aarau, Cantonal Hospital Aarau, Aarau, Switzerland
- Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Anca Mirela Chiriac
- Allergy Unit, University Hospital of Montpellier and IDESP, UMR UA11, Univ. Montpellier - INSERM, Montpellier, France
| | - Josefina Cernadas
- Hospital Lusíadas, Porto, Portugal
- Centro Hospitalar Universitário H. S. João, Porto, Portugal
| | - Jean Christoph Caubet
- Department of Women-Children-Teenagers, University Hospital of Geneva, Geneva, Switzerland
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, Technical University of Munich, Faculty of Medicine and Health, Munich, Germany
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Mota D, Miranda J, Carneiro-Leão L, Cernadas J. Fixed drug eruption caused by iodinated contrast media: An unusual hypersensitivity reaction. Contact Dermatitis 2024; 90:199-200. [PMID: 38010162 DOI: 10.1111/cod.14466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 11/11/2023] [Accepted: 11/14/2023] [Indexed: 11/29/2023]
Affiliation(s)
- Diogo Mota
- Serviço de Imunoalergologia, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Joana Miranda
- Serviço de Imunoalergologia, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Leonor Carneiro-Leão
- Serviço de Imunoalergologia, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Josefina Cernadas
- Serviço de Imunoalergologia, Centro Hospitalar Universitário de São João, Porto, Portugal
- Hospital Lusíadas Porto, Porto, Portugal
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Bianchi L, Hansel K, Biondi F, Caroppo ES, Galeotti T, Casciola G, Tramontana M, Marietti R, Napolitano M, Patruno C, Stingeni L. Delayed hypersensitivity reactions to iodinated contrast media: A diagnostic approach by skin tests. Contact Dermatitis 2023; 89:352-358. [PMID: 37394777 DOI: 10.1111/cod.14372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 06/09/2023] [Accepted: 06/18/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND Adverse drug reactions to iodinated contrast media (ICM) have risen due to their increasing use in x-ray-based imaging modalities. Delayed hypersensitivity reactions are mainly caused by nonionic monomeric compounds and represent an issue impacting the diagnostic-therapeutic pathways of cancer, cardiology and surgery patients. OBJECTIVES To prospectively evaluate the usefulness of skin tests in delayed hypersensitivity reactions to ICM and to evaluate the tolerability of iobitridol, a monomeric nonionic low osmolality compound, as a possible safe alternative. METHODS Patients with delayed hypersensitivity reactions to ICM referred to us from 2020 to 2022 were prospectively enrolled in the study. All patients underwent patch test and, if negative, intradermal test with the culprit ICM and iobitridol as alternative. RESULTS A total of 37 patients (females 24, 64.9%) were enrolled in the study. Iodixanol and iomeprol were the most frequently involved ICM (48.5% and 35.2%, respectively); 62.2% of patients presented maculopapular eruption, while 37.8% reported delayed urticaria-like rash. Skin tests resulted positive to the culprit ICM in 19 patients (51.4%), 16 to patch test and 3 to intradermal test. Skin tests with iobitridol, tested as alternative, resulted positive in 3/19 patients (15.8%). All 16 patients with negative results to iobitridol were administered this ICM and tolerated it. CONCLUSIONS In at least half of patients, delayed-type hypersensitivity was demonstrated by skin tests, particularly by patch test. This diagnostic approach resulted simple, cost-effective and safe, not only to confirm the culprit ICM but also to identify iobitridol as feasible alternative.
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Affiliation(s)
- Leonardo Bianchi
- Section of Dermatology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Katharina Hansel
- Section of Dermatology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Filippo Biondi
- Section of Dermatology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Elena Sofia Caroppo
- Section of Dermatology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Tommaso Galeotti
- Section of Dermatology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Gabriele Casciola
- Section of Dermatology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Marta Tramontana
- Section of Dermatology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Rossella Marietti
- Section of Dermatology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
| | - Maddalena Napolitano
- Section of Dermatology, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Cataldo Patruno
- Section of Dermatology, Health Sciences Department, Magna Graecia University, Catanzaro, Italy
| | - Luca Stingeni
- Section of Dermatology, Department of Medicine and Surgery, University of Perugia, Perugia, Italy
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Lee JH, Yoo Y, Kim SR, Lee JH, Kim SY, An J, Park SY, Park HK, Kim S, Song WJ, Yang MS, Kwon HS, Park HK, Lee J, Hur GY, Ko GJ, Kim SH, Kim SH, Ye YM, Koh YI, Lee BJ, Cho YS, Yong HS, Kim TB. Skin Test-Guided Strategy to Select Alternative Iodinated Contrast Media in Patients With Immediate Hypersensitivity Reaction: A Prospective Confirmative Study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:3454-3462.e1. [PMID: 37543085 DOI: 10.1016/j.jaip.2023.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 05/30/2023] [Accepted: 07/05/2023] [Indexed: 08/07/2023]
Abstract
BACKGROUND Iodinated contrast media (ICM) are a common cause of drug-induced immediate hypersensitivity reaction (IHR). Repeated use of ICM is often necessary; therefore, a standardized protocol to prevent recurrence of IHR is required. OBJECTIVE We aimed to propose an intradermal skin test (IDT)-guided strategy for previous reactors to prevent recurrence of IHR. METHODS We conducted a prospective multicenter study from May 2018 to December 2020 and recruited patients who had experienced IHR to ICM. Once enrolled, the participants underwent IDT with a causative ICM. The alternatives for reexposure were selected using the following protocol: (1) if the IDT with the culprit ICM was positive, further skin tests with other available ICM were conducted to choose IDT-negative agents as alternatives, and (2) if the IDT with the culprit ICM was negative, a randomly changed ICM was used without additional skin tests. The recurrence and severity of hypersensitivity were assessed in subsequent computed tomography examinations. Premedication was administered according to the severity of the index event in all cases. RESULTS A total of 496 participants were enrolled, and 299 were reexposed to ICM. Among 269 participants who followed the protocol, 228 (84.8%) completed computed tomography examinations without adverse reactions, and IHR recurred in 16 of 30 participants (53.3%) who did not follow the protocol (P < .001). In addition, application of the protocol reduced the severity of IHR in recurred cases (P = 0.003). CONCLUSIONS Our IDT-guided strategy not only reduced recurrence of IHR to ICM but also mitigated the severity in recurred cases. This provides evidence for recommending an IDT to diagnose ICM allergy and find safe alternatives.
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Affiliation(s)
- Ji-Hyang Lee
- Department of Allergy and Clinical Immunology, Asian Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Youngsang Yoo
- Department of Allergy and Clinical Immunology, Asian Medical Center, University of Ulsan College of Medicine, Seoul, Korea; Division of Pulmonary and Allergy and Critical Care Medicine, Department of Internal Medicine, Gangneung Asan Hospital, Gangneung, Korea
| | - Sung-Ryeol Kim
- Division of Allergy and Immunology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jae-Hyun Lee
- Division of Allergy and Immunology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Seo-Young Kim
- Department of Allergy and Clinical Immunology, Asian Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin An
- Department of Pulmonary, Allergy and Critical Care Medicine, Kyung Hee University Hospital at Gangdong, University of Kyung Hee College of Medicine, Seoul, Korea
| | - So-Young Park
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Han-Ki Park
- Department of Allergy and Clinical Immunology, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, Korea
| | - Sujeong Kim
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Woo-Jung Song
- Department of Allergy and Clinical Immunology, Asian Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Min-Suk Yang
- Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
| | - Hyouk-Soo Kwon
- Department of Allergy and Clinical Immunology, Asian Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hye-Kyung Park
- Department of Internal Medicine, College of Medicine, Pusan National University, Busan, Korea
| | - Jaechun Lee
- Department of Internal Medicine, Jeju National University College of Medicine, Jeju, Korea
| | - Gyu-Young Hur
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Gang-Jee Ko
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Sang-Heon Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Sae-Hoon Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Young-Min Ye
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - Young-Il Koh
- Department of Allergy and Clinical Immunology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Byung-Jae Lee
- Division of Allergy, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - You Sook Cho
- Department of Allergy and Clinical Immunology, Asian Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hwan Seok Yong
- Department of Radiology, Korea University Guro Hospital, Seoul, Korea
| | - Tae-Bum Kim
- Department of Allergy and Clinical Immunology, Asian Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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Jia Y, Szewczyk-Bieda M, Greenhalgh R, Drinkwater K. Preventing post-contrast acute kidney injury and hypersensitivity reactions: UK national audit. Clin Radiol 2023; 78:e898-e907. [PMID: 37612224 DOI: 10.1016/j.crad.2023.07.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 07/06/2023] [Accepted: 07/23/2023] [Indexed: 08/25/2023]
Abstract
AIM To audit UK radiology departmental protocols related to the prevention of Iodine-based contrast media (ICM) adverse drug reactions (ADRs) and to assess their compliance with the Royal College of Radiologists (RCR) endorsed Royal Australian and New Zealand College of Radiologists' 2018 Iodinated Contrast Guidelines. MATERIALS AND METHODS Questionnaires were sent to all UK acute National Health Service (NHS) providers treating adult patients with an audit lead registered with the RCR (162 providers encompassing 211 hospital radiology departments). The questionnaire included three main sections: renal function screening, renal protection regimens, and hypersensitivity reactions prevention and follow-up. Data collection was conducted between April and July 2022. RESULTS Sixty-one per cent (129/211) of departments responded, representing 67% of eligible providers. An independent imaging services provider supplied one additional set of data (n=130 overall). Of the responding departments, for post-contrast acute kidney injury (PC-AKI), 41% and 56% had the recommended risk assessment for inpatients and outpatients, respectively. Renal function testing was often over-utilised, and their results were applied improperly. Sixty-eight per cent of departments used the advised threshold for considering renal protection. For hypersensitivity reactions, 9% of departments had the correct risk assessment. Thirty-six per cent of departments had the correct risk mitigation protocol for identified high-risk patients. The documentation and follow-up for hypersensitivity reactions were similarly inadequate. CONCLUSION Local protocols on preventing ICM ADRs were largely non-compliant with RCR guidelines. Departments need to update their protocols in line with current evidence to avoid iatrogenic morbidity or unnecessary tests and over-precaution.
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Affiliation(s)
- Y Jia
- Department of Medicine, Imperial College London, London, UK.
| | - M Szewczyk-Bieda
- Department of Clinical Radiology, Ninewells Hospital, NHS Tayside, Dundee, UK
| | - R Greenhalgh
- Department of Radiology, London North West University Healthcare NHS Trust, London, UK
| | - K Drinkwater
- Directorate of Education and Professional Practice, The Royal College of Radiologists, London, UK
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Kim S, Jeon KN, Jung JW, Park HK, Lee W, Lee J, Kang HR. Substitution with Low-Osmolar Iodinated Contrast Agent to Minimize Recurrent Immediate Hypersensitivity Reaction. Radiology 2023; 309:e222467. [PMID: 37906013 DOI: 10.1148/radiol.222467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
Background The recurrence of hypersensitivity reaction (HSR) to low-osmolar iodinated contrast media (LOCM) remains challenging despite premedication and substitution of the LOCM. Purpose To determine the optimal practical preventive strategy for LOCM substitution in patients with a history of prior immediate HSR to LOCM. Materials and Methods In a retrospective study, patients with an immediate HSR to LOCM before February 2020 and who underwent subsequent exposure to LOCM until March 2021 were enrolled in five tertiary referral hospitals in South Korea. The association of recurrence of an HSR after subsequent LOCM exposures was assessed using multivariate general estimating equation analysis according to age, sex, the severity of the index HSR, premedication, and substituting LOCM based on common carbamoyl side chains, including the N-(2,3-dihydroxypropyl)-carbamoyl and N-(2,3-dihydroxypropyl)-N-methyl-carbamoyl moieties. Results The evaluation included 3800 subsequent LOCM exposures in 1066 patients (mean age, 56.2 years ± 13.5 [SD]; 567 [53%] female and 499 [47%] male patients). The general estimating equation analysis, using 1:1 propensity score matched data for age, sex, HSR severity, and LOCM selection, showed that premedication with corticosteroids significantly reduced recurrent HSR (odds ratio [OR], 0.72; 95% CI: 0.52, 1.00; P = .049). The change to another LOCM with a common side chain had a similar recurrence rate as using the same LOCM (OR, 0.98; 95% CI: 0.64, 1.50; P = .93), whereas the use of a different LOCM without a common side chain significantly lowered HSR recurrence (OR, 0.51; 95% CI: 0.37, 0.69; P < .001) in multivariate general estimating equation analysis. Substitution of an LOCM without a common side chain was effective regardless of the index HSR severity but was more pronounced in moderate-to-severe reactions (OR, 0.30; 95% CI: 0.16, 0.55; P < .001). Conclusion For patients with a previous immediate HSR of any severity to LOCM, alternative LOCM without a common carbamoyl side chain reduced recurrent HSR during subsequent exposures. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by McDonald in this issue.
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Affiliation(s)
- Sujeong Kim
- From the Division of Allergy and Clinical Immunology, Department of Internal Medicine (S.K.), and Department of Radiology (J.L.), School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Republic of Korea; Department of Radiology, Gyeongsang National University School of Medicine, Jinju, Republic of Korea (K.N.J.); Department of Radiology, Gyeonsang National University Changwon Hospital, Changwon, Republic of Korea (K.N.J.); Department of Internal Medicine, Chung-Ang University Hospital, Seoul, Republic of Korea (J.W.J.); Division of Allergy and Clinical Immunology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, Republic of Korea (H.K.P.); Departments of Radiology (W.L.) and Internal Medicine (H.R.K.), Seoul National University College of Medicine, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea; and Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul, Republic of Korea (H.R.K.)
| | - Kyung Nyeo Jeon
- From the Division of Allergy and Clinical Immunology, Department of Internal Medicine (S.K.), and Department of Radiology (J.L.), School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Republic of Korea; Department of Radiology, Gyeongsang National University School of Medicine, Jinju, Republic of Korea (K.N.J.); Department of Radiology, Gyeonsang National University Changwon Hospital, Changwon, Republic of Korea (K.N.J.); Department of Internal Medicine, Chung-Ang University Hospital, Seoul, Republic of Korea (J.W.J.); Division of Allergy and Clinical Immunology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, Republic of Korea (H.K.P.); Departments of Radiology (W.L.) and Internal Medicine (H.R.K.), Seoul National University College of Medicine, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea; and Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul, Republic of Korea (H.R.K.)
| | - Jae-Woo Jung
- From the Division of Allergy and Clinical Immunology, Department of Internal Medicine (S.K.), and Department of Radiology (J.L.), School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Republic of Korea; Department of Radiology, Gyeongsang National University School of Medicine, Jinju, Republic of Korea (K.N.J.); Department of Radiology, Gyeonsang National University Changwon Hospital, Changwon, Republic of Korea (K.N.J.); Department of Internal Medicine, Chung-Ang University Hospital, Seoul, Republic of Korea (J.W.J.); Division of Allergy and Clinical Immunology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, Republic of Korea (H.K.P.); Departments of Radiology (W.L.) and Internal Medicine (H.R.K.), Seoul National University College of Medicine, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea; and Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul, Republic of Korea (H.R.K.)
| | - Han-Ki Park
- From the Division of Allergy and Clinical Immunology, Department of Internal Medicine (S.K.), and Department of Radiology (J.L.), School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Republic of Korea; Department of Radiology, Gyeongsang National University School of Medicine, Jinju, Republic of Korea (K.N.J.); Department of Radiology, Gyeonsang National University Changwon Hospital, Changwon, Republic of Korea (K.N.J.); Department of Internal Medicine, Chung-Ang University Hospital, Seoul, Republic of Korea (J.W.J.); Division of Allergy and Clinical Immunology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, Republic of Korea (H.K.P.); Departments of Radiology (W.L.) and Internal Medicine (H.R.K.), Seoul National University College of Medicine, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea; and Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul, Republic of Korea (H.R.K.)
| | - Whal Lee
- From the Division of Allergy and Clinical Immunology, Department of Internal Medicine (S.K.), and Department of Radiology (J.L.), School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Republic of Korea; Department of Radiology, Gyeongsang National University School of Medicine, Jinju, Republic of Korea (K.N.J.); Department of Radiology, Gyeonsang National University Changwon Hospital, Changwon, Republic of Korea (K.N.J.); Department of Internal Medicine, Chung-Ang University Hospital, Seoul, Republic of Korea (J.W.J.); Division of Allergy and Clinical Immunology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, Republic of Korea (H.K.P.); Departments of Radiology (W.L.) and Internal Medicine (H.R.K.), Seoul National University College of Medicine, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea; and Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul, Republic of Korea (H.R.K.)
| | - Jongmin Lee
- From the Division of Allergy and Clinical Immunology, Department of Internal Medicine (S.K.), and Department of Radiology (J.L.), School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Republic of Korea; Department of Radiology, Gyeongsang National University School of Medicine, Jinju, Republic of Korea (K.N.J.); Department of Radiology, Gyeonsang National University Changwon Hospital, Changwon, Republic of Korea (K.N.J.); Department of Internal Medicine, Chung-Ang University Hospital, Seoul, Republic of Korea (J.W.J.); Division of Allergy and Clinical Immunology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, Republic of Korea (H.K.P.); Departments of Radiology (W.L.) and Internal Medicine (H.R.K.), Seoul National University College of Medicine, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea; and Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul, Republic of Korea (H.R.K.)
| | - Hye-Ryun Kang
- From the Division of Allergy and Clinical Immunology, Department of Internal Medicine (S.K.), and Department of Radiology (J.L.), School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Republic of Korea; Department of Radiology, Gyeongsang National University School of Medicine, Jinju, Republic of Korea (K.N.J.); Department of Radiology, Gyeonsang National University Changwon Hospital, Changwon, Republic of Korea (K.N.J.); Department of Internal Medicine, Chung-Ang University Hospital, Seoul, Republic of Korea (J.W.J.); Division of Allergy and Clinical Immunology, Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, Republic of Korea (H.K.P.); Departments of Radiology (W.L.) and Internal Medicine (H.R.K.), Seoul National University College of Medicine, Seoul National University Hospital, 101, Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea; and Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul, Republic of Korea (H.R.K.)
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Rodríguez-Pérez R, de las Vecillas L, Cabañas R, Bellón T. Tools for Etiologic Diagnosis of Drug-Induced Allergic Conditions. Int J Mol Sci 2023; 24:12577. [PMID: 37628756 PMCID: PMC10454098 DOI: 10.3390/ijms241612577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 08/03/2023] [Accepted: 08/06/2023] [Indexed: 08/27/2023] Open
Abstract
Drug hypersensitivity reactions are a serious concern in clinical practice because they can be severe and result in lifelong sequelae. An accurate diagnosis and identification of the culprit drug is essential to prevent future reactions as well as for the identification of safe treatment alternatives. Nonetheless, the diagnosis can be challenging. In vivo and in vitro tests can be helpful, although none are conclusive; therefore, the tests are not usually performed in isolation but as part of a diagnostic algorithm. In addition, some in vitro tests are only available in research laboratories, and standardization has not been fully accomplished. Collaborating research is needed to improve drug hypersensitivity reaction diagnosis. In this review, we update the current available in vivo and in vitro tools with their pros and cons and propose an algorithm to integrate them into clinical practice.
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Affiliation(s)
- Rosa Rodríguez-Pérez
- Institute for Health Research Hospital Universitario La Paz (IdiPAZ), Paseo Castellana 261, 28046 Madrid, Spain; (L.d.l.V.); (R.C.); (T.B.)
| | - Leticia de las Vecillas
- Institute for Health Research Hospital Universitario La Paz (IdiPAZ), Paseo Castellana 261, 28046 Madrid, Spain; (L.d.l.V.); (R.C.); (T.B.)
- Allergy Department, La Paz University Hospital, Paseo Castellana 261, 28046 Madrid, Spain
- PIELenRed Consortium, 28046 Madrid, Spain
| | - Rosario Cabañas
- Institute for Health Research Hospital Universitario La Paz (IdiPAZ), Paseo Castellana 261, 28046 Madrid, Spain; (L.d.l.V.); (R.C.); (T.B.)
- Allergy Department, La Paz University Hospital, Paseo Castellana 261, 28046 Madrid, Spain
- PIELenRed Consortium, 28046 Madrid, Spain
- Center for Biomedical Research Network on Rare Diseases (CIBERER U754), 28046 Madrid, Spain
| | - Teresa Bellón
- Institute for Health Research Hospital Universitario La Paz (IdiPAZ), Paseo Castellana 261, 28046 Madrid, Spain; (L.d.l.V.); (R.C.); (T.B.)
- PIELenRed Consortium, 28046 Madrid, Spain
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Wong PMP, Chiow SM, Lee CH, Tan SC, H’ng MWC. Clinical outcomes and management of contrast hypersensitivity in patients requiring repeated computed tomography imaging. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2023. [DOI: 10.47102/annals-acadmedsg.2022223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/03/2023]
Abstract
Introduction: In collaboration with the Department of Rheumatology, Allergy and Immunology, our study aims to review the outcomes of and propose an improved workflow for the management of patients with prior hypersensitivity reactions to iodinated contrast media (ICM).
Method: Outpatients coming for contrast-enhanced computed tomography (CECT) were stratified into 3 categories (definite, unconfirmed and inaccurate) based on likelihood of their contrast hypersensitivity label. Patients could be offered a different ICM, receive the same ICM, or be referred to an allergist for further evaluation. There were 4 outcomes: (1) alternative ICM tolerated; (2) same ICM tolerated again; (3) patient developed a hypersensitivity reaction to either alternative or original ICM; and (4) CECT was deferred until assessment by an allergist. Comparison was made pre- and post-intervention to see if patient outcomes were improved.
Results: There were 132 patients who made a total of 154 visits (90.3% had documented contrast hypersensitivity). Post-intervention, the number of visits postponed for premedication decreased (81.0% to 34.7%). There was a reduction in hypersensitivity reactions (from 42.9% to 14.3%). Of the 12 patients assessed by the allergist, 6 could continue using the same or alternative ICM, 4 were advised to abstain from further contrast administration and 2 were pending testing with a third agent.
Conclusion: Active intervention by the radiologist can decrease the number of postponed, converted or cancelled CECT studies as well as reduce the number of adverse allergic-like events. Direct collaboration between radiologist and allergist for specific cases may be helpful in patients who will likely need future/repeated CECTs.
Keywords: Corticosteroid, hypersensitivity, ICM, iodinated contrast media, premedication, skin testing
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Ahn JH, Hong SP, Go TH, Kim H. Contrast Agent Selection to Prevent Recurrent Severe Hypersensitivity Reaction to Iodinated Contrast Media Based on Nationwide Database. J Comput Assist Tomogr 2023:00004728-990000000-00158. [PMID: 36944108 DOI: 10.1097/rct.0000000000001462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
OBJECTIVE To investigate the incidence of severe iodinated contrast media (ICM)-related hypersensitivity reaction (HSR) and to find the optimal alternative ICM to reduce the risk of severe HSR recurrence. METHODS We retrospectively reviewed 23,383,183 cases of ICM administration between January 2015 and December 2019 from the nationwide health insurance database. We classified ICMs based on generic profiles and the presence of N-(2,3-dihydroxypropyl) carbamoyl side chains. The incidence of severe and recurrent severe HSRs was calculated, and χ2 tests were performed to compare the prevalence of severe HSR according to ICM groups. In addition, logistic regression analyses were used to assess differences between ICM groups. RESULTS The incidence of severe HSRs was 1.92% (450,067 of 23,282,183). Among 1,875,245 individuals who received ICM twice on different days, severe HSR occurred in 40,850 individuals, and severe HSR recurred in 3319 individuals (8.12%). The risk of recurrence significantly decreased when the ICM changed (9.24% vs 7.08%, P < 0.001), especially when the ICM changed to one with a different side chain (6.74%, P < 0.001). In addition, compared with the reuse of the culprit agent, using combinations of iobitridol/iohexol (odds ratio [OR], 0.696; P = 0.04), iohexol/iopamidol (OR, 0.757; P = 0.007), iopamidol/iohexol (OR, 0.447; P < 0.001), and ioversol/iohexol (OR, 0.683; P = 0.04) reduced the risk of recurrence of severe HSR. CONCLUSIONS Changing the culprit ICM to that with a different side chain can reduce severe HSR recurrence. The optimal choice of an alternative ICM depends on the causative agent.
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Affiliation(s)
| | | | - Tae-Hwa Go
- Department of Biostatistics, Yonsei University Wonju College of Medicine, Wonju, Korea
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10
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DRESS syndrome due to iodinated contrast media. A case report. ALLERGY, ASTHMA, AND CLINICAL IMMUNOLOGY : OFFICIAL JOURNAL OF THE CANADIAN SOCIETY OF ALLERGY AND CLINICAL IMMUNOLOGY 2023; 19:16. [PMID: 36849962 PMCID: PMC9972718 DOI: 10.1186/s13223-023-00774-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 02/14/2023] [Indexed: 03/01/2023]
Abstract
BACKGROUND The most frequent non-immediate reactions described with iodinated contrast media (ICM) are mild to moderate, however, some cases of patients with severe non-immediate reactions, such as drug eruption with eosinophilia and systemic symptoms (DRESS) have been described. CASE PRESENTATION An 84-year-old patient developed DRESS syndrome after administration of ICM ioversol. The patient fullfilled the RegiSCAR diagnostic criteria for DRESS (definite score = 6). He underwent intradermal skin testing (IDT) with the widest panel of ICM available at our center. IDT was positive with ioversol and iomeprol. A punch biopsy was performed on the positive IDT with the culprit drug (ioversol) and histopathology was compatible with a T-cell mediated mechanism. CONCLUSION In this case, the IDT-positive biopsy was consistent with DRESS syndrome caused by T-lymphocyte activation, supporting the clinical diagnosis.
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11
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Joshi SR, Salinas W, Khan DA. Drug Hypersensitivity. Clin Immunol 2023. [DOI: 10.1016/b978-0-7020-8165-1.00050-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2023]
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12
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Qiu L, Cui Q, Gong X, Zhou H. Anaphylaxis Following Contrast-Enhanced CT with Iodixanol: A Case Report and Literature Review. J Asthma Allergy 2023; 16:195-200. [PMID: 36721740 PMCID: PMC9884438 DOI: 10.2147/jaa.s386811] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 01/10/2023] [Indexed: 01/26/2023] Open
Abstract
Background Iodixanol-induced anaphylactic reaction is a well-known adverse event of contrast agents, which are generally well-tolerated and reversible. Serious and fatal reactions such as anaphylactic shock after computed tomography (CT) enhancement have been described. However, there is no data on these events in the literature. Objective This report describes a case of a serious anaphylactic reaction, possibly related to iodixanol and provides an overview of case reports. Case Summary A 47-year-old women who experienced persistent abdominal pain for more than one month, was proposed of hiatal hernia with CT images taken two weeks previously and was admitted to the gastrointestinal surgery department. The patient underwent contrast-enhanced abdominal CT for the evaluation of multiple intraperitoneal hemodynamic features. A few minutes after abdominal enhanced CT scan, the patient was pale, sweating, had muscle tension and trembling, even coma and profound hypotension with 90/43 mm Hg. Immediately she was supported with oxygen inhalation, was treated with adrenaline subcutaneously, dexamethasone intravenously, and rapid intravenous drip of compound sodium chloride. Ten minutes later, the patient was in respiratory and cardiac arrest and the pupils were dilated. CPR and intermittant static push of 1 mg adrenaline were immediately carried. After endotracheal intubation, the patient's spontaneous heart rate and pupils recovered, and her blood pressure recovered to 105/53 mm Hg. It was suggested that the patient was suffering from iodixanol-induced anaphylactic shock and nephropathy, and she was transferred to the intensive care unit. Despite immediate treatment, the patient died. Conclusion A 47-year-old female patient with no history of allergies developed severe fatal anaphylactic shock after receiving iodixanol. Although contrast agents induced anaphylactoid/anaphylactic reactions do not often occur, clinicians should be conscious of the potentially serious anaphylactic reaction, which could lead to a life-threatening or fatal event.
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Affiliation(s)
- Lin Qiu
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Qihao Cui
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Xuepeng Gong
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
| | - Haiyun Zhou
- Department of Pharmacy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, People's Republic of China
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13
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Caron J, Graf S, Delebarre‐Sauvage C. Immediate hypersensitivity reactions to iodinated contrast media: The diagnosis of allergy by skin testing. Clin Transl Allergy 2022; 12:e12214. [PMID: 36573311 PMCID: PMC9720225 DOI: 10.1002/clt2.12214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Among 74 patients with an immediate hypersensitivity reaction (IHR) to iodinated contrast media (ICM), the rate of allergic patients confirmed by positive prick test or diluted intradermal test (IDT) was 8.1%. 12.5% of re-exposed patients had a recurrent IHR despite negative skin tests. Investigations on pure IDT to ICM and development of drug provocation test may provide additional safety nets to uncover recurrent ICM reactors. Agreements among allergists are needed to unify practices.
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Affiliation(s)
- Juliette Caron
- Service d'allergologie et d’éducation thérapeutiqueHôpital Saint Vincent‐de‐PaulLille CedexFrance
| | - Sahara Graf
- Délégation à la Recherche Clinique et à l’InnovationUnité de BiostatistiquesHôpital Saint PhilibertLomme CedexFrance
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Gamboa P, Sánchez de Vicente J, Galán C, Jáuregui I, Segurola A, García-Lirio E, Seras Y, Martínez-Antón MD, Arrien de Lecea A. Non-immediate hypersensitivity reactions to iomeprol: Diagnostic value of skin tests and cross-reactivity with other iodinated contrast media. Allergy 2022; 77:3641-3647. [PMID: 35815908 DOI: 10.1111/all.15433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 05/28/2022] [Accepted: 06/10/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND Iodinated contrast media produce non-immediate hypersensitivity reactions (NIHR). The goal of this prospective study was to determine the utility of skin tests and the subsequent tolerance to negative skin-tested iodinated contrasts in patients with NIHR caused by iomeprol. METHODS Prick and intradermal tests with iomeprol, iopamidol, iopromide, and iobitridol were performed in all patients. IV challenge with the causative contrast (iomeprol in 90%) was made if skin tests were negative. In case of a positive skin test with the causal contrast, or a positive challenge test with it, IV challenge test with an alternative, negative skin-tested contrast was performed in all patients. RESULTS Skin tests were positive in 47.6% (20/42) of patients with NIHR induced by iomeprol. Of the 66 challenge tests performed with negative skin-tested iodinated contrasts, tolerance was confirmed in 35 (53%): 32 iomeron, 2 iobitridol, 1 iopamidol. Cross-reactivity between iomeprol and iopamidol was 22% (4/20 in patients with positive skin tests and 5/21 in patients with negative skin tests). CONCLUSIONS Sensitivity of the skin tests was less than 50% NIHRs due to iomeprol, while the negative predictive value of skin tests in patients who tolerated challenges with alternative contrasts (mainly iopamidol) was 53% (35 tolerated out of 66 performed). The cross-reactivity between iomeprol and iopamidol is high.
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Affiliation(s)
- Pedro Gamboa
- Servicio de Alergia, Hospital Universitario Cruces, Barakaldo, Spain.,Biocruces Bizkaia Health Research Institute, Immunopathology Group, Barakaldo, Spain
| | - Javier Sánchez de Vicente
- Servicio de Alergia, Hospital Universitario Cruces, Barakaldo, Spain.,Biocruces Bizkaia Health Research Institute, Immunopathology Group, Barakaldo, Spain
| | - Cristina Galán
- Servicio de Alergia, Hospital Universitario Cruces, Barakaldo, Spain
| | - Ignacio Jáuregui
- Servicio de Alergia, Hospital Universitario Cruces, Barakaldo, Spain.,Biocruces Bizkaia Health Research Institute, Immunopathology Group, Barakaldo, Spain
| | - Aritza Segurola
- Servicio de Alergia, Hospital Universitario Cruces, Barakaldo, Spain.,Biocruces Bizkaia Health Research Institute, Immunopathology Group, Barakaldo, Spain
| | - Eduardo García-Lirio
- Servicio de Alergia, Hospital Universitario Cruces, Barakaldo, Spain.,Biocruces Bizkaia Health Research Institute, Immunopathology Group, Barakaldo, Spain
| | - Yolanda Seras
- Servicio de Alergia, Hospital Universitario Cruces, Barakaldo, Spain.,Biocruces Bizkaia Health Research Institute, Immunopathology Group, Barakaldo, Spain
| | - Mª Dolores Martínez-Antón
- Servicio de Alergia, Hospital Universitario Cruces, Barakaldo, Spain.,Biocruces Bizkaia Health Research Institute, Immunopathology Group, Barakaldo, Spain
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Ahn KM, Ahn YH, Cho MK, Kang DY, Lee SY, Kang HR. Validation of Practical Pathway in Patients With Anaphylaxis to Low Osmolar Contrast Media: A Retrospective Cohort Study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:2685-2692.e2. [PMID: 35413472 DOI: 10.1016/j.jaip.2022.03.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/25/2022] [Accepted: 03/28/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND An optimal strategy for choosing safe alternative low osmolar contrast media (LOCM) has not yet been established in patients with a history of LOCM-induced anaphylaxis. OBJECTIVES To validate the practical pathway in patients with anaphylaxis to LOCMs and to compare 2 different doses of challenge testing with skin test-negative LOCM. METHODS A retrospective cohort study was performed in patients with LOCM-induced anaphylaxis. Patients were challenged with intravenous LOCMs showing negativity in the skin test according to 2 different protocols: low-dose and high-dose (maximum dose 10 and 30 mL, respectively). Challenge-negative LOCMs were selected for use during computed tomography scans, and patients received intravenous pretreatment with 4 mg chlorpheniramine and 40 mg methylprednisolone. RESULTS Of the 110 challenge tests, there were 4 (3.6%) positive challenges. Among 106 enhanced computed tomography scans performed using challenge-negative LOCMs, breakthrough reactions occurred in 8 (7.6%). Breakthrough reaction rates were not statistically different between the 2 protocols (8.9% and 6.0% in the low-dose challenge and the high-dose challenge, respectively). Compared with the low-dose protocol, the number needed to test of the high-dose challenge test decreased 2.5-fold. Moreover, none of the patients in the high-dose challenge group incurred severe reactions during computed tomography scans with challenge-negative LOCM, whereas 80% of reactions were severe in the low-dose challenge group. CONCLUSIONS We validated a pathway consisting of a battery of skin testing to LOCMs and challenge with skin test-negative LOCM in patients with LOCM-induced anaphylaxis.
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Affiliation(s)
- Kyung-Min Ahn
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea; Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul, Korea
| | - Yoon Hae Ahn
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Min Kyoung Cho
- Drug Safety Monitoring Center, Seoul National University Hospital, Seoul, Korea
| | - Dong Yoon Kang
- Drug Safety Monitoring Center, Seoul National University Hospital, Seoul, Korea
| | - Suh Young Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea; Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul, Korea
| | - Hye-Ryun Kang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea; Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul, Korea; Drug Safety Monitoring Center, Seoul National University Hospital, Seoul, Korea.
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16
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Ahn KM, Kim BK, Yang MS. Risk factors of anaphylaxis in Korea: Identifying drug-induced anaphylaxis culprits using big data. Medicine (Baltimore) 2022; 101:e30224. [PMID: 36107532 PMCID: PMC9439811 DOI: 10.1097/md.0000000000030224] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Drug-induced anaphylaxis is a fatal medical condition whose incidence has been increasing continuously. Due to differences between genetic backgrounds and health care systems, different populations may be prone to various causative drugs. Using the Health Insurance Service and Assessment Service database, we investigated culprit drugs for drug-induced anaphylaxis and common medication risk factors in the Korean general population. We collected medical prescription histories within 3 days prior to anaphylaxis between January 2011 and December 2019 from the HIRA database. Designed as a case-crossover study, the attributable visits (case visits) were matched to medical visits (control visits) with the drug sets for each visit. We collected a list of medication risk factors for anaphylaxis and calculated the risk ratio of each agent using the chi-square test and conditional logistic regression analysis. A total of 159,473 individuals were listed in the database with a diagnosis of anaphylaxis in the HIRA from 2011 to 2019. After evaluating the suitability of control visits for matching with a case visit, 8168 subjects and 767 drugs were analyzed. The chi-square analysis identified 31 drugs as potential risk factors for drug-induced anaphylaxis in Korea. After applying a conditional logistic regression analysis for each agent, 5 drugs were found to be the common medication risk factors for drug-induced anaphylaxis: cefaclor, iopromide, iohexol, iomeprol, and tolperisone. We found 5 medication risk factors that showed the highest risk of drug-induced anaphylaxis and their degree of risk using an objective methodology in the Korean general population.
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Affiliation(s)
- Kyung-Min Ahn
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul, Korea
| | - Byung-Keun Kim
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Min-Suk Yang
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul, Korea
- Department of Internal Medicine, SMG-SNU Boramae Medical Center, Seoul, Korea
- *Correspondence: Min-Suk Yang, Division of Allergy and Clinical Immunology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea (e-mail: )
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Srisuwatchari W, Vo T, Gauthier A, Molinari N, Schrijvers R, Demoly P, Chiriac AM. Hypersensitivity reactions to iodinated radiocontrast media: Cluster analysis reveals distinct clinical phenotypes. World Allergy Organ J 2022; 15:100680. [PMID: 36092950 PMCID: PMC9440439 DOI: 10.1016/j.waojou.2022.100680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 07/07/2022] [Accepted: 07/21/2022] [Indexed: 12/02/2022] Open
Abstract
Background Drug hypersensitivity reaction (DHR) to iodinated radiocontrast media (iRCM) is reported in 1%–3% of injections. Risk assessment of patients with suspicion of DHR to iRCM relies solely on clinical phenotyping and drug allergy workup. Using a novel unsupervised TwoStep cluster analysis, we aimed to identify prototypic patterns within a large cohort of patients evaluated for a potential iRCM DHR. Methods A retrospective study was conducted using data from the Drug Allergy and Hypersensitivity Database of the Allergy Unit, University Hospital of Montpellier, Montpellier, France. All referred patients during February 2001 to December 2019 with suspicion of iRCM DHR with either confirmed positive or confirmed negative skin tests were included in the analysis. Results A total of 1439 patients were evaluated. The chronology of the index reaction was immediate and nonimmediate in 77.1% and 22.4%, respectively. Cluster analysis categorized the total study population in 5 clusters. Cluster 1 compiled all nonimmediate and cluster 2–5 almost all immediate reactors. Cluster 1 and 2 had recent reactions (<1 y) with mostly known iRCMs and the highest iRCM allergy prevalence (16–17%). In the other clusters, more remote reactions, unknown iRCMs and a lower allergy prevalence (3–8%) was observed. Chronology and semiology of the index reaction were the factors most strongly differentiated among clusters. History of anaphylactic shock and chronology of immediate hypersensitivity reactions were shown to be independent predictors of allergy with adjusted OR (aOR) of 4.68 (95%CI: 3.01–7.27, p < 0.001) and 2.51 (95%CI: 1.67–3.78, p < 0.001), respectively. Conclusions Unsupervised cluster analysis identified 5 prototypic patterns within patients with a suspected DHR to iRCMs. Well-phenotyped patients cluster together in 2 groups in which the prevalence of allergy is approximately 1 in 6. However, this value decreases for patients with reactions dating back to more than a decade.
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Umakoshi H, Nihashi T, Takada A, Hirasawa N, Ishihara S, Takehara Y, Naganawa S, Davenport MS, Terasawa T. Iodinated Contrast Media Substitution to Prevent Recurrent Hypersensitivity Reactions: A Systematic Review and Meta-Analysis. Radiology 2022; 305:341-349. [DOI: 10.1148/radiol.220370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Chiu TM, Chu SY. Hypersensitivity Reactions to Iodinated Contrast Media. Biomedicines 2022; 10:biomedicines10051036. [PMID: 35625773 PMCID: PMC9138609 DOI: 10.3390/biomedicines10051036] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 04/26/2022] [Accepted: 04/28/2022] [Indexed: 02/04/2023] Open
Abstract
At present, iodinated contrast media (ICM) are mostly non-ionic, have low osmolality, and are safe. Even if adverse drug reactions (ADRs) occur, most are chemo-toxic symptoms and require only observation or H1 antihistamines. However, rare, unpredictable, and even life-threatening hypersensitivity can still occur. The aim of this review is to summarize the issues that all relevant staff need to know about and be able to respond to. The most significant risk factor for ICM hypersensitivity is a history of ICM hypersensitivity. For high-risk populations, we must cautiously weigh the advantages and disadvantages of premedication and be aware that breakthrough reactions may still occur. The best policy for patients with a history of severe ICM hypersensitivity is to avoid the same ICM. If ICM are inevitable, skin tests, in vitro tests, and drug provocation tests may help to find a feasible alternative that is safer. The severity of the hypersensitivity is correlated with the positivity rate of these tests, so there is no need for further investigations for patients with only mild reactions. We should also keep in mind that even excipients in ICM may induce hypersensitivity. Detailed, standardized documentation is essential for correct diagnosis and the prevention of future occurrence.
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Affiliation(s)
- Tsu-Man Chiu
- Department of Dermatology, Changhua Christian Hospital, Changhua City 50073, Taiwan;
- Institute of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan
| | - Sung-Yu Chu
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan 33305, Taiwan
- Correspondence:
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Radiocontrast Media Hypersensitivity Reactions in Children. Medicina (B Aires) 2022; 58:medicina58040517. [PMID: 35454356 PMCID: PMC9028608 DOI: 10.3390/medicina58040517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 03/26/2022] [Accepted: 04/04/2022] [Indexed: 11/23/2022] Open
Abstract
Hypersensitivity reactions to radiocontrast media seem to be rare in children. Furthermore, the use of radiocontrast media in children remains quite safe in terms of the severity of reactions. Since pediatric guidelines are lacking, the diagnostic workup employed in adults could be adapted to children, taking into account that results have not yet been validated in this age group. Specific protocols for risk stratification and management of severe reactions have been proposed so far.
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22
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Kang HR, Jeong J, Brockow K. Diagnosis and Prevention of Hypersensitivity Reactions to Iodinated Contrast Media. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2022; 14:348-360. [PMID: 35837820 PMCID: PMC9293596 DOI: 10.4168/aair.2022.14.4.348] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 06/21/2022] [Accepted: 06/29/2022] [Indexed: 11/22/2022]
Abstract
Iodinated contrast media (ICM) have become one of the major causes of drug hypersensitivity reactions (HSRs) related to increasing numbers of ICM-based radiological imaging procedures. Strategies for diagnosing and preventing ICM-induced HSRs have not been uniformly standardized yet. However, advances have been made based on the results of recent research. A previous history of hypersensitivity to ICM is the most significant risk factor for developing HSR by ICM. Avoidance of culprit agents and premedication is the main strategy to prevent recurrences of HSRs in high-risk patients. In addition, we strongly recommend identifying sensitized ICM using skin tests to determine immunoglobulin E-mediated or delayed-type allergy and to guide the choice of an alternative contrast agent. ICM provocation test procedures have been established and are helpful in selected cases. In this paper, we review how to evaluate patients who have experienced immediate or delayed HSRs caused by ICM to minimize the risk of recurrence and discuss unmet needs that require further research.
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Affiliation(s)
- Hye-Ryun Kang
- Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul National University College of Medicine, Seoul, Korea
- Drug Safety Center, Seoul National University Hospital, Seoul, Korea
| | - Jiung Jeong
- Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul National University College of Medicine, Seoul, Korea
- Drug Safety Center, Seoul National University Hospital, Seoul, Korea
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, School of Medicine, Technical University of Munich, Munich, Germany
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Kang DY, Lee SY, Ahn YH, Yoon SH, Choi YH, Lee W, Kang HR. Incidence and risk factors of late adverse reactions to low-osmolar contrast media: A prospective observational study of 10,540 exposures. Eur J Radiol 2021; 146:110101. [PMID: 34952368 DOI: 10.1016/j.ejrad.2021.110101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 11/22/2021] [Accepted: 12/07/2021] [Indexed: 12/16/2022]
Abstract
PURPOSE To evaluate the incidence and risk factors of late adverse reactions (ARs) to non-ionic low-osmolar contrast media (LOCM). METHODS The occurrence of late AR was monitored on day 1 and from day 7 to day 28 in all patients who received enhanced computed tomography using LOCM during a 5-week study period in a single tertiary hospital. Patients who experienced late AR were followed up for three years. RESULTS Among the total 10,540 LOCM exposures, 315 ARs (3.0%) were reported; acute ARs occurred in 108 LOCM exposures (1.0%) and late ARs occurred in 207 LOCM exposures (2.0%) (90.9% within one week, 9.1% developed afterwards by day 20). Previous history of drug allergy (odds ratio [OR] = 4.59; 95% confidence interval [CI] 2.17-9.71) and allergic diseases (OR = 2.54; 95% CI 1.32-4.91) were risk factors of late ARs to LOCM. Although the recurrence rate was lowered with premedication from 8.5% to 1.7% (8/94 vs. 3/178; p = 0.016), LOCM change did not make difference compared to reuse of the culprit LOCM (2/38 vs. 9/234; p = 0.655). In patients with a history of late AR to LOCM, the risk of recurrent reactions decreased with longer time intervals between exposures (OR = 0.86; 95% CI: 0.77-0.97; p = 0.025) and with the use of antihistamine premedication (OR = 0.27; 95% CI: 0.06-0.99; p = 0.049). CONCLUSIONS Late ARs to LOCM occurred mostly within one week. The use of premedication may be helpful in reducing the recurrence of late ARs.
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Affiliation(s)
- Dong Yoon Kang
- Drug Safety Monitoring Center, Seoul National University Hospital, Seoul, Republic of Korea
| | - Suh-Young Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul, Republic of Korea
| | - Yoon Hae Ahn
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Soon Ho Yoon
- Department of Radiology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Young Hoon Choi
- Department of Radiology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Whal Lee
- Department of Radiology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hye-Ryun Kang
- Drug Safety Monitoring Center, Seoul National University Hospital, Seoul, Republic of Korea; Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea; Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul, Republic of Korea.
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Schmid AA, Morelli JN, Hungerbühler MN, Boehm IB. Cross-reactivity among iodinated contrast agents: should we be concerned? Quant Imaging Med Surg 2021; 11:4028-4041. [PMID: 34476187 DOI: 10.21037/qims-20-1325] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 04/14/2021] [Indexed: 11/06/2022]
Abstract
Background Although several papers deal with "cross-reactivity" in patients with iodinated contrast medium (ICM) hypersensitivity reactions (HSRs), there is no in-depth knowledge of this phenomenon. To define ICM-groups as potential reaction partners and to identify any potential clinical relevance in patients with ICM-HSRs. Methods The literature database PubMed was searched for eligible papers dealing with ICM-allergy and "cross-reactivity". The data presented by the papers was analyzed and individual patient data was extracted for re-evaluation based on a definition for both 'polyvalent reactivity' and 'cross-reactivity' as well as for chemical structure-dependent ICM-groups. Results Twenty-five original papers (with n=340 extracted patients) formed the study population. Incidences of polyvalent reactivity were non-significantly higher than incidences of cross-reactivity (both range from 0% to 100%). Crossover evaluation in reaction pairings (culprit ICM A with ICM B versus culprit ICM B with ICM A) showed concordance of only 30%. Data support rather non-cross-reactivity (individual reaction pattern) than cross-reactivity constellations. Conclusions The obtained results favour an individual reaction pattern, rather than a reactivity driven by chemical structures and so-called cross-reactivity.
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Affiliation(s)
- Adrian A Schmid
- Department of Orthopaedics and Traumatology, Spital Altstaetten, Altstaetten, Switzerland
| | - John N Morelli
- Department of Radiology, St. John's Medical Center Tulsa, OK, USA
| | - Martin N Hungerbühler
- Department of Diagnostic, Interventional, and Pediatric Radiology, Inselspital, University of Bern, Bern, Switzerland
| | - Ingrid B Boehm
- Department of Diagnostic, Interventional, and Pediatric Radiology, Inselspital, University of Bern, Bern, Switzerland
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Brockow K. Diagnosing and Managing Patients with Reactions to Radiocontrast Media. CURRENT TREATMENT OPTIONS IN ALLERGY 2021. [DOI: 10.1007/s40521-021-00287-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Abstract
Purpose of the review
Iodinated radio contrast media (RCM) belong to the most common elicitors of drug hypersensitivity reactions (HR). Urticaria or anaphylaxis may occur ≤ 1(−6) hour(s) (immediate HR) and exanthems (non-immediate HR) develop > 6 h after application of RCM. Evidence for an immunologic mechanism of RCM HR against the different RCM benzene ring molecules and the benefit of allergological testing in patients with previous hypersensitivity reactions is progressively increasing.
Recent findings
Positive skin tests can confirm allergy in patients with previous reactions to RCM and help to select alternative better tolerated RCMs. Severe hypersensitivity reactions are mainly caused by an allergic mechanism, whereas the majority of non-severe reactions appear to be non-allergic. Skin testing is highly recommended to help identify allergic hypersensitivity reactions and to select alternatives. Using structurally different RCM is more effective than premedication for the prevention of future reactions. Drug provocation tests to RCM have been increasingly used, but are not yet standardized among different centers.
Summary
In patients with previous severe hypersensitivity reactions to RCM, skin testing is recommended. For future RCM-enhanced examinations in patients with previous reactions, structurally different, skin test-negative preparations should be applied. Drug provocation tests do confirm or exclude RCM hypersensitivity or may demonstrate tolerability of alternative RCMs.
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Sohn KH, Seo JH, Kang DY, Lee SY, Kang HR. Finding the Optimal Alternative for Immediate Hypersensitivity to Low-Osmolar Iodinated Contrast. Invest Radiol 2021; 56:480-485. [PMID: 33587497 DOI: 10.1097/rli.0000000000000765] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Avoiding culprit agents is recommended for subjects who have had previous hypersensitivity reaction (HSR) to low-osmolar contrast media (LOCM). However, the guidelines for choosing optimal alternatives have not been determined. We investigated the outcomes of reexposure in patients with previous immediate HSRs to provide a safe option. MATERIALS AND METHODS The outcomes of reexposure were assessed in a cohort with previous LOCM-associated HSR based on skin testing results and the presence of a common N-(2,3-dihydroxypropyl) carbamoyl side chain. RESULTS Among 482 skin tests, 38.7% (31/80), 45.8% (99/216), and 64.0% (119/186) of mild, moderate, and severe index HSRs showed positivity to at least 1 LOCM, of which 62.8% showed positivity to at least 2 different LOCM. The overall recurrent HSRs were reduced from 43.8% upon reexposure to the culprit LOCM to 12.3% upon using nonculprit skin test negative LOCM (P = 0.004); those with severe index HSRs exhibited a significant reduction (11.3% vs 100%), but those with non-severe HSRs to LOCM did not. In subjects with severe index HSRs, the skin test cross-reactivity between LOCM was associated with sharing the common side chain (20.7% vs 11.5%, P = 0.003), and the recurrence rate of HSRs was effectively reduced by avoiding the common side chain (24.0% vs 7.8%, P = 0.039). However, these differences were not observed in those with non-severe index HSRs. CONCLUSIONS In patients who experienced a severe index HSR to LOCM, skin test negative LOCM without a common side chain could be suggested as an option for safe reexposure.
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Affiliation(s)
| | | | - Dong-Yoon Kang
- Drug Safety Center, Seoul National University Hospital, Seoul, South Korea
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Thong BYH, Vultaggio A, Rerkpattanapipat T, Schrijvers R. Prevention of Drug Hypersensitivity Reactions: Prescreening and Premedication. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2958-2966. [PMID: 34366094 DOI: 10.1016/j.jaip.2021.04.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 04/03/2021] [Accepted: 04/07/2021] [Indexed: 01/08/2023]
Abstract
Drug hypersensitivity reactions (DHR) are heterogeneous in their pathomechanisms, clinical presentation, severity, and outcomes. Novel DHR mechanisms, phenotypes, and endotypes have been described. The key to prevention from further exposure to the culprit drugs involves correct identification of the putative drug through a combination of in vitro and/or in vivo tests, accurate drug allergy labeling and reporting, and electronic decision support systems within electronic medical records to prevent future accidental prescribing. Prescreening and premedication, the focus of this review, may be a useful adjunct to preventive measures in certain situations. After an index immediate drug hypersensitivity reaction, prescreening may be useful in perioperative anaphylaxis, and iodinated (ICM) and gadolinium-based contrast media (GCM) where the culprit and potential alternative agents are skin tested. In certain nonimmediate DHR, pharmacogenomic prescreening may be used before prescribing high-risk drugs (eg, carbamazepine and allopurinol) where specific human-leukocyte antigen genotypes are associated with severe cutaneous adverse reactions. Premedication with antihistamine and systemic corticosteroids is another therapeutic strategy to prevent infusion reactions for certain biologicals and chemotherapeutic agents, in cases of perioperative anaphylaxis, ICM and GCM DHR, and clonal mast cell disorders. Rapid drug desensitization may also be used to induce temporary tolerance in situations where there are limited alternative drugs.
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Affiliation(s)
- Bernard Yu-Hor Thong
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore.
| | - Alessandra Vultaggio
- Immunoallergology Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Ticha Rerkpattanapipat
- Allergy, Immunology and Rheumatology Division, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Rik Schrijvers
- Department of Microbiology, Immunology and Transplantation, Allergy and Clinical Immunology Research Group, KU Leuven, Leuven, Belgium
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Chen B, Yu F, Chen W, Wang Y, Hao F. Acute Urticaria in Inpatients Undergoing Non-emergent Coronary Angiography With Corticosteroid Prophylaxis: A Retrospective Study. Front Med (Lausanne) 2021; 8:616015. [PMID: 34179031 PMCID: PMC8222595 DOI: 10.3389/fmed.2021.616015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 04/29/2021] [Indexed: 11/13/2022] Open
Abstract
Background and Aims: Acute urticaria (AU) is the most frequently reported immediate hypersensitivity reaction in skin by administration of iodinated contrast media (ICM). We aimed to establish the pattern and identify the risk factors of AU among inpatients undergoing non-emergent coronary angiography (CAG) with prophylactic corticosteroids in China. Methods: Medical records of 19,326 adult inpatients undergoing non-emergent CAG with prophylactic methylprednisolone in 2013–2019 were retrospectively investigated. AU was identified within 1 h post-ICM administration, and diffuse involvement was defined when wheals occur in two or more body parts, including the back, abdomen, chest, and extremities. Age- and sex-matched inpatients (1:4) without AU were randomly selected for assessment of risk factors. Results: Approximately 0.8% of CAG inpatients had AU, including 101 diffuse and 64 limited form. The diffuse AU was more common in settings of non-diagnostic CAG, iohexol used, average ICM injection≥3 ml/min, recurrent CAG, and past history of immediate hypersensitivity to ICM. Inpatients with preexisting allergies, decreased evaluated glomerular filtration rate, and increased high sensitivity C reactive protein or neutrophil-to-lymphocyte ratio prior to CAG had a higher probability of AU (odds ratio >1, P < 0.05 for all variables). All AU inpatients complained of pruritus, and mild itching predominated. AU dissipated in several days under treatment of ebastine or levocetirizine 10 mg/daily, but ebastine showed superiority. Conclusions: ICM-induced AU is not uncommon in non-emergent CAG inpatients with prophylactic methylprednisolone. Preexisting allergies, renal dysfunction, and mild inflammation are high-risk factors, and antihistamine monotherapy is a favorable candidate for ICM-related AU.
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Affiliation(s)
- Bangtao Chen
- Department of Dermatology, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Fubing Yu
- Department of Dermatology, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - WenChieh Chen
- Department of Dermatology and Allergy, Technical University of Munich, Munich, Germany
| | - Yong Wang
- Department of Cardiology, The People's Hospital of China Medical University, The People's Hospital of Liaoning Province, Shenyang, China
| | - Fei Hao
- Department of Dermatology, The Third Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Bansie RD, Karim AF, van Maaren MS, Hermans MA, van Daele PLA, Gerth van Wijk R, Rombach SM. Assessment of immediate and non-immediate hypersensitivity contrast reactions by skin tests and provocation tests: A review. Int J Immunopathol Pharmacol 2021; 35:20587384211015061. [PMID: 34053316 PMCID: PMC8170298 DOI: 10.1177/20587384211015061] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION Allergic and nonallergic hypersensitivity reactions to iodinated contrast media (ICM) and gadolinium-based contrast media are classified as immediate or non-immediate hypersensitivity reactions (IHR and NIHR), respectively. Skin tests and provocation tests are recommended for the evaluation of hypersensitivity reactions to contrast agents; however provocations are not common in clinical practice. METHODS A MEDLINE search was conducted to investigate studies comprising both skin tests and provocation tests that evaluated hypersensitivity reactions to ICM. RESULTS Nineteen studies were identified that reported on skin tests, followed by provocations. In the case of IHR to ICM, 65/69 (94%) patients with a positive skin test for the culprit media tolerated a challenge with a skin-test-negative alternative ICM. In IHR to ICM with a negative skin test for the culprit media, provocations were positive in 3.2%-9.1% patients. In the case of a NIHR to ICM with a positive skin test, provocation with a skin-test-negative agent was tolerated in 75/105 (71%) of cases. In NIHR with a negative skin test for the culprit agent, re-exposure to the culprit or an alternative was positive in 0%-34.6% patients. Provocations with the same ICM in skin test positive patients with IHR or NIHR were positive for a majority of the patients, although such provocation tests were rarely performed. Data on hypersensitivity reactions, skin tests and provocations with gadolinium-based contrast media were limited; however, they exhibited a pattern similar to that observed in ICM. CONCLUSION In both ICM and gadolinium-based contrast media, the risk of an immediate repeat reaction is low when skin tests are negative. In contrast, a provocation with a skin-test-positive contrast medium showed a high risk of an immediate repeat hypersensitivity reaction. Therefore, a thorough medical history is necessary, followed by skin tests. A provocation is recommended, for diagnostic work-up, when the diagnosis is uncertain.
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Affiliation(s)
- Rakesh D Bansie
- Department of Internal Medicine, Section Allergy and Clinical Immunology, Erasmus Medical Center, Rotterdam, Zuid-Holland, the Netherlands.,Department of Internal Medicine, Academic Hospital Paramaribo, Paramaribo, Suriname
| | - A Faiz Karim
- Department of Internal Medicine, Section Allergy and Clinical Immunology, Erasmus Medical Center, Rotterdam, Zuid-Holland, the Netherlands.,Department of Internal Medicine, Section Allergy and Clinical Immunology, Gouda Groene Hart Ziekenhuis, Zuid-Holland, the Netherlands
| | - Maurits S van Maaren
- Department of Internal Medicine, Section Allergy and Clinical Immunology, Erasmus Medical Center, Rotterdam, Zuid-Holland, the Netherlands
| | - Maud Aw Hermans
- Department of Internal Medicine, Section Allergy and Clinical Immunology, Erasmus Medical Center, Rotterdam, Zuid-Holland, the Netherlands
| | - Paul LA van Daele
- Department of Internal Medicine, Section Allergy and Clinical Immunology, Erasmus Medical Center, Rotterdam, Zuid-Holland, the Netherlands
| | - Roy Gerth van Wijk
- Department of Internal Medicine, Section Allergy and Clinical Immunology, Erasmus Medical Center, Rotterdam, Zuid-Holland, the Netherlands
| | - Saskia M Rombach
- Department of Internal Medicine, Section Allergy and Clinical Immunology, Erasmus Medical Center, Rotterdam, Zuid-Holland, the Netherlands
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Torres MJ, Trautmann A, Böhm I, Scherer K, Barbaud A, Bavbek S, Bonadonna P, Cernadas JR, Chiriac AM, Gaeta F, Gimenez‐Arnau AM, Kang H, Moreno E, Brockow K. Practice parameters for diagnosing and managing iodinated contrast media hypersensitivity. Allergy 2021; 76:1325-1339. [PMID: 33170954 DOI: 10.1111/all.14656] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/30/2020] [Accepted: 10/14/2020] [Indexed: 12/17/2022]
Abstract
Immediate and nonimmediate hypersensitivity reactions to iodinated contrast media (ICM) have been reported to occur in a frequency of about 0.5%-3% of patients receiving nonionic ICM. The diagnosis and management of these patients vary among guidelines published by various national and international scientific societies, with recommendations ranging from avoidance or premedication to drug provocation test. This position paper aims to give recommendations for the management of patients with ICM hypersensitivity reactions and analyze controversies in this area. Skin tests are recommended as the initial step for diagnosing patients with immediate and nonimmediate hypersensitivity reactions; besides, they may also help guide on tolerability of alternatives. Re-exposition or drug provocation test should only be done with skin test-negative ICMs. The decision for performing either re-exposition or drug provocation test needs to be taken based on a risk-benefit analysis. The role of in vitro tests for diagnosis and pretreatment for preventing reactions remains controversial.
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Affiliation(s)
- María José Torres
- Allergy Unit Regional University Hospital of Malaga‐IBIMA‐UMA‐ARADyAL Malaga Spain
| | - Axel Trautmann
- Department of Dermatology and Allergy University Hospital Würzburg Würzburg Germany
| | - Ingrid Böhm
- Department of Diagnostic, Interventional, and Pediatric Radiology Inselspital University of Bern Bern Switzerland
| | | | - Annick Barbaud
- Service de Dermatologie et Allergologie Sorbonne Université INSERM Institut Pierre Louis d’Epidemiologie et de Sante Publique AP‐HP Sorbonne Universite, Hopital Tenon Paris France
| | - Sevim Bavbek
- Department of Chest Disease Division of Immunology and Allergy School of Medicine Ankara University Ankara Turkey
| | | | | | - Anca Mirela Chiriac
- Department of Pulmonology Division of Allergy Hôpital Arnaud de Villeneuve University Hospital of Montpellier Montpellier France
| | - Francesco Gaeta
- Allergy Unit Columbus Hospital Agostino Gemelli IRCCS University Hospital Rome Italy
| | - Ana M. Gimenez‐Arnau
- Department of Dermatology Hospital del Mar IMIM Universitat Autònoma Barcelona Barcelona Spain
| | - Hye‐Ryun Kang
- Department of Internal Medicine Division of Allergy and Clinical Immunology Seoul National University College of Medicine Seoul Korea
| | - Esther Moreno
- Allergy Unit University Hospital of Salamanca‐IBSAL‐UMA‐ARADyAL Salamanca Spain
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein School of Medicine Technical University of Munich Munich Germany
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Soria A, Amsler E, Bernier C, Milpied B, Tétart F, Morice C, Dezoteux F, Ferrier-Le Bouedec MC, Barbaud A, Staumont-Sallé D, Assier H. DRESS and AGEP Reactions to Iodinated Contrast Media: A French Case Series. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2021; 9:3041-3050. [PMID: 33757916 DOI: 10.1016/j.jaip.2021.02.060] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 02/23/2021] [Accepted: 02/28/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Drug reactions with eosinophilia and systemic symptoms (DRESSs) and acute generalized exanthematous pustulosis (AGEP) are potentially severe cutaneous adverse drug reactions. OBJECTIVE To describe the clinical findings and sensitization profiles of DRESS and AGEP patients who had been administered iodinated contrast media (ICM). METHODS All adult patients in the dermatologist's French Investigators for Skin Adverse Reactions to Drugs (FISARD) network diagnosed with a DRESS or AGEP highly suspected to have been caused by an ICM were included retrospectively. RESULTS Thirteen DRESS patients and 19 AGEP patients who had been administered ICM were included, and the median delay in DRESS and AGEP occurrence after ICM administration was short, 4 and 1 days, respectively. Five AGEP patients had systemic involvement. A high cosensitization rate (46%) was observed among the DRESS patients, mainly with beta-lactam antibiotics. Overall, 77% of our patients were sensitized to several ICM. Patch tests identified the suspected ICM for 21 cases (72%). The retrospective nature, the limited number of subjects, the absence of a control group of healthy individuals, and the lack of detailed information on previous exposure to sensitizing drugs are limitations of this study. CONCLUSIONS We report a large series of DRESSs and AGEPs related to ICM administration. Skin tests appear useful for diagnosis and potentially to identify alternative ICM.
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Affiliation(s)
- Angèle Soria
- Sorbonne Universités, Service de Dermatologie et d'Allergologie, Hôpital Tenon, Paris HUEP, APHP, Centre d'Immunologie et des Maladies Infectieuses, INSERM U1135, Paris, France.
| | - Emmanuelle Amsler
- Sorbonne Universités, Service de Dermatologie et d'Allergologie, Hôpital Tenon, Paris HUEP, APHP, Paris, France
| | - Claire Bernier
- Service de Dermatologie, Hôpital Hôtel Dieu, CHU Nantes, France
| | | | - Florence Tétart
- Clinique dermatologique CHU de Rouen et Centre Erik Satie, Allergologie CHU Rouen, France
| | | | | | | | - Annick Barbaud
- Sorbonne Universités, Service de Dermatologie et d'Allergologie, Hôpital Tenon, Paris HUEP, APHP, Paris, France
| | | | - Haudrey Assier
- Service de Dermatologie, Hôpital Henri Mondor, APHP, Créteil, France
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HLA-DRB1*15: 02 Is Associated With Iodinated Contrast Media-Related Anaphylaxis. Invest Radiol 2021; 55:304-309. [PMID: 31985601 DOI: 10.1097/rli.0000000000000644] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The incidence of severe reaction induced by iodinated contrast media (ICM) has increased over the years with an increasing use of imaging modalities. Although ICM anaphylaxis is rare, it can be life-threatening, but currently, there is no biomarker that can identify individuals at risk of ICM anaphylaxis. OBJECTIVE The aim of this study is to investigate the genetic susceptibility of ICM anaphylaxis. METHODS Patients who had ICM anaphylaxis were enrolled in the study, and their blood samples were collected for genotyping of human leukocyte antigen (HLA)-A, -B, -C, and -DR. The results were compared with those of healthy Korean general population. MRGPRX2 gene in ICM anaphylaxis group was also sequenced and compared with the Korean standard database of genetic polymorphism. RESULTS The frequencies of 3 HLA alleles (B*52:01, C*12:02, and DRB1*15:02) were significantly higher in 47 patients with ICM anaphylaxis. In particular, HLA-DRB1*15:02 was 5 times more frequent in the ICM anaphylaxis group than the Korean general population (34.0% vs 6.6%; odds ratio, 7.306; 95% confidence interval, 3.622-14.740), and this difference was most pronounced in subjects with iohexol-induced anaphylaxis (odds ratio, 16.516; 95% CI, 5.241-52.047; P < 0.0001). Eight single nucleotide polymorphisms were identified in MRGPRX2 gene, but their frequencies were not different in those with ICM anaphylaxis compared with the general Korean population. CONCLUSIONS HLA-DRB1*15:02 is associated with ICM anaphylaxis in the Korean population.
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Gamboa P, Sánchez de Vicente J, Galán C, Jáuregui I, Segurola A, García-Lirio E, Seras Y, Martínez-Antón MD, Irazábal B. Tolerance to iopamidol in patients with confirmed allergic immediate hypersensitivity to iomeprol. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2021; 9:2101-2103.e1. [PMID: 33444814 DOI: 10.1016/j.jaip.2020.12.057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 12/19/2020] [Accepted: 12/22/2020] [Indexed: 01/27/2023]
Affiliation(s)
- Pedro Gamboa
- Servicio de Alergia, Hospital Universitario Cruces, Barakaldo, Spain.
| | | | - Cristina Galán
- Servicio de Alergia, Hospital Universitario Cruces, Barakaldo, Spain
| | - Ignacio Jáuregui
- Servicio de Alergia, Hospital Universitario Cruces, Barakaldo, Spain
| | - Aritza Segurola
- Servicio de Alergia, Hospital Universitario Cruces, Barakaldo, Spain
| | | | - Yolanda Seras
- Servicio de Alergia, Hospital Universitario Cruces, Barakaldo, Spain
| | | | - Begoña Irazábal
- Servicio de Alergia, Hospital Universitario Cruces, Barakaldo, Spain
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Jo EJ, Park HK. Effects of an electronic system for the management of adverse reactions to iodinated contrast media. ALLERGY ASTHMA & RESPIRATORY DISEASE 2021. [DOI: 10.4168/aard.2021.9.3.164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Eun-Jung Jo
- Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
- Department of Internal Medicine, Pusan National University College of Medicine, Busan, Korea
| | - Hye-Kyung Park
- Biomedical Research Institute, Pusan National University Hospital, Busan, Korea
- Department of Internal Medicine, Pusan National University College of Medicine, Busan, Korea
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Solé D, Spindola MAC, Aun MV, Araújo Azi LMTD, Bernd LAG, Garcia DB, Capelo AV, Cumino DDO, Lacerda AE, Lima LC, Morato EF, Nunes RR, Rubini NDPM, da Silva J, Tardelli MA, Watanabe AS, Curi EF, Sano F. [Update on perioperative hypersensitivity reactions: joint document from the Brazilian Society of Anesthesiology (SBA) and Brazilian Association of Allergy and Immunology (ASBAI) - Part II: etiology and diagnosis]. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2020; 70:642-661. [PMID: 33308829 PMCID: PMC9373683 DOI: 10.1016/j.bjan.2020.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 07/19/2020] [Accepted: 08/11/2020] [Indexed: 11/30/2022]
Abstract
This second joint document, written by experts from the Brazilian Association of Allergy and Immunology (ASBAI) and Brazilian Society of Anesthesiology (SBA) concerned with perioperative anaphylaxis, aims to review the pathophysiological reaction mechanisms, triggering agents (in adults and children), and the approach for diagnosis during and after an episode of anaphylaxis. As anaphylaxis assessment is extensive, the identification of medications, antiseptics and other substances used at each setting, the comprehensive data documentation, and the use of standardized nomenclature are key points for obtaining more consistent epidemiological information on perioperative anaphylaxis.
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Affiliation(s)
- Dirceu Solé
- Associação Brasileira de Alergia e Imunologia, São Paulo, SP, Brazil; Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, SP, Brazil
| | - Maria Anita Costa Spindola
- Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brazil; Universidade Federal de Santa Catarina, Hospital Universitário Professor Polydoro Ernani de São Thiago, Florianópolis, SC, Brazil
| | - Marcelo Vivolo Aun
- Associação Brasileira de Alergia e Imunologia, São Paulo, SP, Brazil; Faculdade Israelita de Ciências da Saúde Albert Einstein, São Paulo, SP, Brazil; Universidade de São Paulo, Faculdade de Medicina, Hospital Universitário, São Paulo, SP, Brazil
| | - Liana Maria Tôrres de Araújo Azi
- Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brazil; Universidade Federal da Bahia, Hospital Universitário Professor Edgard Santos, Salvador, BA, Brasil.
| | - Luiz Antonio Guerra Bernd
- Associação Brasileira de Alergia e Imunologia, São Paulo, SP, Brazil; Fundação Faculdade Federal de Ciências Médicas de Porto Alegre, Porto Alegre, RS, Brazil
| | - Daniela Bianchi Garcia
- Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brazil; Hospital Infantil Pequeno Príncipe, Curitiba, PR, Brasil
| | - Albertina Varandas Capelo
- Associação Brasileira de Alergia e Imunologia, São Paulo, SP, Brazil; Universidade Federal do Rio de Janeiro, Hospital Universitário Gaffrée e Guinle, Rio de Janeiro, RJ, Brazil
| | - Débora de Oliveira Cumino
- Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brazil; Hospital Infantil Sabará, São Paulo, SP, Brazil
| | - Alex Eustáquio Lacerda
- Associação Brasileira de Alergia e Imunologia, São Paulo, SP, Brazil; Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, SP, Brazil
| | - Luciana Cavalcanti Lima
- Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brazil; Instituto Medicina Integral Prrofessor Fernando Figueira, Recife, PE, Brazil
| | - Edelton Flávio Morato
- Universidade Federal de Santa Catarina, Hospital Universitário Professor Polydoro Ernani de São Thiago, Florianópolis, SC, Brazil
| | - Rogean Rodrigues Nunes
- Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brazil; Hospital Geral de Fortaleza (HGF), Departamento de Anestesia, Fortaleza, CE, Brazil
| | - Norma de Paula Motta Rubini
- Associação Brasileira de Alergia e Imunologia, São Paulo, SP, Brazil; Universidade Federal do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
| | - Jane da Silva
- Associação Brasileira de Alergia e Imunologia, São Paulo, SP, Brazil; Universidade Federal de Santa Catarina, Hospital Universitário Professor Polydoro Ernani de São Thiago, Florianópolis, SC, Brazil
| | - Maria Angela Tardelli
- Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, SP, Brazil; Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brazil
| | - Alexandra Sayuri Watanabe
- Associação Brasileira de Alergia e Imunologia, São Paulo, SP, Brazil; Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, São Paulo, SP, Brazil
| | - Erick Freitas Curi
- Sociedade Brasileira de Anestesiologia, Rio de Janeiro, RJ, Brazil; Universidade Federal do Espírito Santo, Vitória, ES, Brasil
| | - Flavio Sano
- Associação Brasileira de Alergia e Imunologia, São Paulo, SP, Brazil; Hospital Nipo Brasileiro, São Paulo, SP, Brasil
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Update on perioperative hypersensitivity reactions: joint document from the Brazilian Society of Anesthesiology (SBA) and Brazilian Association of Allergy and Immunology (ASBAI) - Part II: etiology and diagnosis. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2020. [PMID: 33308829 PMCID: PMC9373683 DOI: 10.1016/j.bjane.2020.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
This second joint document, written by experts from the Brazilian Association of Allergy and Immunology (ASBAI) and Brazilian Society of Anesthesiology (SBA) concerned with perioperative anaphylaxis, aims to review the pathophysiological reaction mechanisms, triggering agents (in adults and children), and the approach for diagnosis during and after an episode of anaphylaxis. As anaphylaxis assessment is extensive, the identification of medications, antiseptics and other substances used at each setting, the comprehensive data documentation, and the use of standardized nomenclature are key points for obtaining more consistent epidemiological information on perioperative anaphylaxis.
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Doña I, Bogas G, Salas M, Testera A, Moreno E, Laguna JJ, Torres MJ. Hypersensitivity Reactions to Multiple Iodinated Contrast Media. Front Pharmacol 2020; 11:575437. [PMID: 33071787 PMCID: PMC7538657 DOI: 10.3389/fphar.2020.575437] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 09/04/2020] [Indexed: 01/07/2023] Open
Abstract
The incidence of hypersensitivity reactions (HSRs) to iodinated contrast media (ICM) has risen over last years, representing an important health problem. HSRs to ICMs are classified into immediate reactions (IRs) and non-immediate reactions (NIRs) according to if they occur within 1 h or longer after ICM administration. The diagnosis of HSRs to ICM is complex as skin test (ST) sensitivity ranges widely, and drug provocation test (DPT) protocols are heterogeneous. In this manuscript, we describe the clinical characteristics of a series of patients confirmed as HSR to ICM and the diagnosis procedure carried out, looking into those cases confirmed as HSRs to multiple ICMs. For this purpose, we prospectively evaluated patients suggestive of HSRs to ICMs and classified them as IRs or NIRs. STs were carried out using a wide panel of ICMs, and in those with a negative ST, a single-blind placebo controlled DPT was performed with the culprit. If ST or DPT were positive, then tolerance was assessed with an alternative negative ST ICM. We included 101 cases (12 IRs and 89 NIRs) confirmed as allergic. Among them, 36 (35.64%) cases were allergic to more than one ICM (8 IRs and 28 NIRs). The most common ICM involved were iomeprol and iodixanol. Although not statistically significant, the percentage of patients reporting anaphylaxis was higher in patients allergic to multiple ICMs compared with patients allergic to a single ICM (50 vs. 25%). Likewise, the percentage of positive results in STs was higher in patients allergic to multiple ICMs compared with those allergic to a single ICM (for IR 62.5 vs. 25%, p > 0.05; and for NIR, 85.71 vs. 24.59%, p < 0.000). In cases allergic to more than one ICM, DPT with negative-ST ICM was positive in more than 60% (24/36) of cases. Therefore, allergy to multiple ICMs is common, associated to severe reactions in IRs, and confirmed frequently by positive STs. The allergological work-up should include DPT not only to establish the diagnosis but also to identify safe alternative ICM, even if ICM is structurally unrelated and ST is negative. More studies are needed to clarify mechanisms underlying cross-reactivity among ICMs.
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Affiliation(s)
- Inmaculada Doña
- Allergy Unit, Hospital Regional Universitario de Málaga, Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, ARADyAL, Málaga, Spain
| | - Gádor Bogas
- Allergy Unit, Hospital Regional Universitario de Málaga, Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, ARADyAL, Málaga, Spain
| | - María Salas
- Allergy Unit, Hospital Regional Universitario de Málaga, Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, ARADyAL, Málaga, Spain
| | - Almudena Testera
- Allergy Unit, Hospital Regional Universitario de Málaga, Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, ARADyAL, Málaga, Spain
| | - Esther Moreno
- Allergy Unit, University Hospital of Salamanca, Instituto de Investigación Biomédica de Salamanca-IBSAL, ARADyAL, Salamanca, Spain
| | - Jose Julio Laguna
- Allergy Unit, Allergo-Anaesthesia Unit, Hospital Central de la Cruz Roja, Faculty of Medicine, Alfonso X El Sabio University. ARADyAL, Madrid, Spain
| | - María José Torres
- Allergy Unit, Hospital Regional Universitario de Málaga, Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, ARADyAL, Málaga, Spain.,Nanostructures for Diagnosing and Treatment of Allergic Diseases Laboratory, Andalusian Center for Nanomedicine and Biotechnology-BIONAND, Málaga, Spain.,Departamento de Medicina, Facultad de Medicina, Universidad de Málaga, Málaga, Spain
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38
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Costantino MT, Romanini L, Gaeta F, Stacul F, Valluzzi RL, Passamonti M, Bonadonna P, Cerri G, Pucci S, Ricci P, Savi E, Galluzzo M, Mauro M, Grassedonio E, Yacoub MR, Reginelli A, Testi S, Ridolo E, Nettis E, Di Leo E, Rossi O, Montuschi P, Incorvaia C, Romano A. SIRM-SIAAIC consensus, an Italian document on management of patients at risk of hypersensitivity reactions to contrast media. Clin Mol Allergy 2020; 18:13. [PMID: 32765190 DOI: 10.1186/s12948-020-00128-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Accepted: 07/02/2020] [Indexed: 12/20/2022] Open
Abstract
Hypersensitivity reactions (HRs) to contrast media (CM) can be distinguished in immune-mediated (including allergic reactions) and non-immune-mediated reactions, even if clinical manifestations could be similar. Such manifestations range from mild skin eruptions to severe anaphylaxis, making it important for radiologists to know how to identify and manage them. A panel of experts from the Società Italiana di Radiologia Medica e Interventistica (SIRM) and the Società Italiana di Allergologia, Asma e Immunologia Clinica (SIAAIC) provided a consensus document on the management of patients who must undergo radiological investigations with CM. Consensus topics included: the risk stratification of patients, the identification of the culprit CM and of a safe alternative by an allergy workup, as well as the use of premedication and the correct procedure to safely perform an elective (i.e., scheduled) or urgent examination. The most important recommendations are: (1) in all patients, a thorough medical history must be taken by the prescribing physician and/or the radiologist to identify at-risk patients; (2) in patients with hypersensitivity reactions to CM, the radiologist must consider an alternative, non-contrast imaging study with a comparable diagnostic value, or prescribe a different investigation with another class of CM; (3) if such options are not feasible, the radiologist must address at-risk patients to a reference centre for an allergy evaluation; (4) if timely referral to an allergist is not viable, it is recommended to use a CM other than the responsible one, taking into account cross-reactivity patterns; in the case of patients with histories of severe reactions, the presence of an anesthesiologist is also recommended and a premedication is suggested.
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Affiliation(s)
| | - Laura Romanini
- Radiology, Istituti Ospitalieri di Cremona, ASST Cremona, Cremona, Italy
| | - Francesco Gaeta
- Allergy Unit, Columbus Hospital, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Via Moscati n.30, Rome, Italy
| | - Fulvio Stacul
- Department of Radiology, Ospedale Maggiore, Azienda Sanitaria Universitaria Integrata di Trieste, Trieste, Italy
| | - Rocco Luigi Valluzzi
- Allergy Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Vatican City, Italy
| | | | - Patrizia Bonadonna
- Allergy Unit, Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Giovanni Cerri
- Department of Radiology, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Stefano Pucci
- Allergy Unit. General Hospital, Civitanova Marche, Milan, Italy
| | - Paolo Ricci
- Department of Radiology, Oncologiche ad Anatomopatologiche, Azienda Policlinico Umberto I, Sapienza Università di Roma, Rome, Italy
| | - Eleonora Savi
- Departmental Unit of Allergology, Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - Michele Galluzzo
- Department of Radiology, Azienda Ospedaliera San Camillo Forlanini, Ospedale San Camillo, Rome, Italy
| | | | - Emanuele Grassedonio
- Department of Radiology, Dipartimento di Biopatologia e Biotecnologie Mediche, Policlinico Paolo Giaccone, Università degli Studi di Palermo, Palermo, Italy
| | - Mona Rita Yacoub
- Allergy and Immunology Department, IRCCS San Raffaele Hospital, Milan, Italy
| | - Alfonso Reginelli
- Department of Radiology & Radiotherapy, University of Campania 'Luigi Vanvitelli', Naples, Italy
| | - Sergio Testi
- Allergy and Clinical Immunology Unit, San Giovanni di Dio's Hospital, Florence, Italy
| | - Erminia Ridolo
- Department of Medicine and Surgery Clinical, University of Parma, Via Gramsci 14, 43126 Parma, Italy
| | - Eustacchio Nettis
- Department of Emergency and Organ Transplantation, School of Allergology and Clinical Immunology, University of Bari Aldo Moro, Bari, Italy
| | - Elisabetta Di Leo
- Section of Allergy and Clinical Immunology, Unit of Internal Medicine, "F. Miulli" Hospital, Acquaviva delle Fonti, Bari, Italy
| | - Oliviero Rossi
- Allergy Unit, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - Paolo Montuschi
- Pharmacology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Department of Pharmacology, Faculty of Medicine, Catholic University of the Sacred Heart, Rome, Italy
| | | | - Antonino Romano
- IRCCS Oasi Maria S.S., Troina & Fondazione Mediterranea G.B. Morgagni, Catania, Italy
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Hojreh A, Peyrl A, Bundalo A, Szepfalusi Z. Subsequent MRI of pediatric patients after an adverse reaction to Gadolinium-based contrast agents. PLoS One 2020; 15:e0230781. [PMID: 32243440 PMCID: PMC7122741 DOI: 10.1371/journal.pone.0230781] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 03/09/2020] [Indexed: 11/19/2022] Open
Abstract
Background Gadolinium-based contrast agent (GBCA)-enhanced magnetic resonance imaging (MRI) scans often must be used repeatedly in pediatric oncologic patients. Although GBCAs are usually well tolerated, severe and life-threatening allergic reactions might occur, which can result in overly cautions adherence to special precautions in patients. Purpose To evaluate the management of the reported GBCA-associated adverse reactions in subsequent contrast-enhanced MRIs in pediatric patients, distinguishing non-allergic and allergic reactions. Materials and methods In this retrospective, cross-sectional study, consecutive pediatric neurooncological patients who underwent GBCA-enhanced MRI at our university hospital, between 2007 and 2016, were eligible. The patients’ history was evaluated with regard to any adverse events after GBCA administration. In a subset of patients with reported adverse reactions, the institutional premedication regime or an allergy work-up in clinical practice were performed, using either skin-prick tests or intravenous provocation tests in a double-blind procedure. Results Included were 8156 contrast-enhanced MRI scans in 2109 patients. Nineteen acute adverse events (19/8156; 0.23%) in 17 patients (17/2109; 0.81%) were reported. Despite a premedication regime in 14 patients, three patients (3/14; 21.4%) reported a breakthrough reaction. None of the 12 patients who underwent skin-prick tests or intravenous provocation tests showed allergic reactions. At least one well-tolerated GBCA was identified in almost every tested patient. Conclusion A fast-track allergy work-up can help to distinguish non-allergic and allergic reactions and to identify a well-tolerated GBCA, thus avoiding unnecessary premedication for subsequent GBCA administrations.
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Affiliation(s)
- Azadeh Hojreh
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
- * E-mail:
| | - Andreas Peyrl
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Aleksandra Bundalo
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Zsolt Szepfalusi
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
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40
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Hsu Blatman KS, Sánchez-Borges M, Greenberger PA. Anaphylaxis in the Radiology Suite. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:1203-1209. [DOI: 10.1016/j.jaip.2020.01.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Revised: 01/13/2020] [Accepted: 01/13/2020] [Indexed: 11/24/2022]
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41
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Benzon H, Katz JA, Nagpal G, Liu BP. Reply to Kalangara and Kuruvilla and Boehm. Reg Anesth Pain Med 2020; 45:246-247. [DOI: 10.1136/rapm-2019-100911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 08/09/2019] [Indexed: 11/04/2022]
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42
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Recurrent immediate hypersensitivity reaction to radiocontrast media despite premedication found to be IgE-mediated. Ann Allergy Asthma Immunol 2020; 124:296-298. [PMID: 31945478 DOI: 10.1016/j.anai.2019.12.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 11/27/2019] [Accepted: 12/31/2019] [Indexed: 12/20/2022]
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43
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Kim TB. Prescreening skin test effectiveness in predicting hypersensitivity to iodinated contrast media. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2020. [DOI: 10.5124/jkma.2020.63.3.155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Tae-Bum Kim
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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44
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Cho MK, Lee SY, Kang HR. Recent updates of iodinated contrast media hypersensitivity. ALLERGY ASTHMA & RESPIRATORY DISEASE 2020. [DOI: 10.4168/aard.2020.8.3.107] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Min-Kyoung Cho
- Drug Safety Monitoring Center, Seoul National University Hospital, Seoul, Korea
| | - Suh-Young Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hye-Ryun Kang
- Drug Safety Monitoring Center, Seoul National University Hospital, Seoul, Korea
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul National University College of Medicine, Seoul, Korea
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45
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Gaudin O, Deschamps O, Duong TA, Gener G, Paul M, Luciani A, Chosidow O, Wolkenstein P, Ingen-Housz-Oro S, Assier H. Cutaneous tests and interest of iobitridol in non-immediate hypersensitivity to contrast media: a case series of 43 patients. J Eur Acad Dermatol Venereol 2019; 34:e178-e180. [PMID: 31814161 DOI: 10.1111/jdv.16139] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- O Gaudin
- Dermatology department, AP-HP, Henri Mondor Hospital, Créteil, France.,Reference Center for Toxic Bullous Diseases and Severe Drug Reactions, Créteil, France
| | - O Deschamps
- Dermatology department, AP-HP, Henri Mondor Hospital, Créteil, France
| | - T A Duong
- Dermatology department, AP-HP, Henri Mondor Hospital, Créteil, France.,Reference Center for Toxic Bullous Diseases and Severe Drug Reactions, Créteil, France
| | - G Gener
- Dermatology department, AP-HP, Henri Mondor Hospital, Créteil, France.,Reference Center for Toxic Bullous Diseases and Severe Drug Reactions, Créteil, France
| | - M Paul
- Pharmacology Department, AP-HP, Henri Mondor Hospital, Créteil, France.,EpidermE, Univ Paris Est Creteil, Créteil, France
| | - A Luciani
- Radiology Department, AP-HP, Henri Mondor hospital, Créteil, France
| | - O Chosidow
- Dermatology department, AP-HP, Henri Mondor Hospital, Créteil, France.,Reference Center for Toxic Bullous Diseases and Severe Drug Reactions, Créteil, France
| | - P Wolkenstein
- Dermatology department, AP-HP, Henri Mondor Hospital, Créteil, France.,Reference Center for Toxic Bullous Diseases and Severe Drug Reactions, Créteil, France
| | - S Ingen-Housz-Oro
- Dermatology department, AP-HP, Henri Mondor Hospital, Créteil, France.,Reference Center for Toxic Bullous Diseases and Severe Drug Reactions, Créteil, France.,EpidermE, Univ Paris Est Creteil, Créteil, France
| | - H Assier
- Dermatology department, AP-HP, Henri Mondor Hospital, Créteil, France.,Reference Center for Toxic Bullous Diseases and Severe Drug Reactions, Créteil, France
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46
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Mayorga C, Fernandez TD, Montañez MI, Moreno E, Torres MJ. Recent developments and highlights in drug hypersensitivity. Allergy 2019; 74:2368-2381. [PMID: 31557314 DOI: 10.1111/all.14061] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 09/18/2019] [Accepted: 09/19/2019] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Cristobalina Mayorga
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyAL Málaga Spain
- Allergy Unit Hospital Regional Universitario de Málaga‐ARADyAL Málaga Spain
- Andalusian Center for Nanomedicine and Biotechnology‐BIONAND Málaga Spain
| | - Tahia D. Fernandez
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyAL Málaga Spain
| | - Maria Isabel Montañez
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyAL Málaga Spain
- Andalusian Center for Nanomedicine and Biotechnology‐BIONAND Málaga Spain
| | - Esther Moreno
- Allergy Unit Hospital Universitario de Salamanca‐ARADyAL IBSAL Salamanca Spain
| | - María José Torres
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyAL Málaga Spain
- Allergy Unit Hospital Regional Universitario de Málaga‐ARADyAL Málaga Spain
- Andalusian Center for Nanomedicine and Biotechnology‐BIONAND Málaga Spain
- Universidad de Málaga Málaga Spain
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47
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Management of Patients During Acute Reaction Induced by Drugs. CURRENT TREATMENT OPTIONS IN ALLERGY 2019. [DOI: 10.1007/s40521-019-00226-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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48
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Schönmann C, Brockow K. Adverse reactions during procedures: Hypersensitivity to contrast agents and dyes. Ann Allergy Asthma Immunol 2019; 124:156-164. [PMID: 31765812 DOI: 10.1016/j.anai.2019.11.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 11/06/2019] [Accepted: 11/18/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE This review provides an overview of the literature on hypersensitivity reactions during procedures to commonly used contrast agents and dyes. A synthesis of current knowledge on clinical symptoms, epidemiology and risk factors, pathomechanism, and management of hypersensitivity reactions to these substances is presented. DATA SOURCES A literature search was conducted through Medline. Included were peer-reviewed articles written in English between 2000 and 2019. STUDY SELECTIONS Relevant clinical studies, experimental studies, and review articles have been selected. Additionally, case reports have been included if they carried significant information about rare clinical forms of hypersensitivity reactions, disease mechanisms, or therapy. RESULTS An allergological workup is only indicated for patients with a history of immediate (IHR) and nonimmediate hypersensitivity reactions (NIHR) but not for toxic or unrelated adverse events. Skin tests with or without experimental cellular laboratory tests in patients with previous reactions can provide evidence for an allergic mechanism. Positive skin tests indicating allergy are more common in severe reactions. If the adverse event was allergic, skin testing of alternatives is helpful for the selection of other contrast agents for future procedures. Premedication alone may be insufficient in these cases, and breakthrough reactions occur. For nonallergic reactions, change of contrast agent and premedication is often but not always sufficient to suppress reactions. CONCLUSION Patients with previous NIHR or IHR, especially moderate and severe IHR, needing potential re-administration of contrast agents should be skin tested to identify an allergic mechanism as well as alternative agents to be used for future procedures.
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Affiliation(s)
- Christine Schönmann
- Department of Dermatology and Allergy Biederstein, School of Medicine, Technical University of Munich, Munich, Germany
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, School of Medicine, Technical University of Munich, Munich, Germany.
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Novel Strategy for the Prevention of Recurrent Hypersensitivity Reactions to Radiocontrast Media Based on Skin Testing. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:2707-2713. [DOI: 10.1016/j.jaip.2019.04.036] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 04/21/2019] [Accepted: 04/23/2019] [Indexed: 11/18/2022]
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50
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Premedication for Iodinated Contrast Media Induced Immediate Hypersensitivity Reactions. CURRENT TREATMENT OPTIONS IN ALLERGY 2019. [DOI: 10.1007/s40521-019-00224-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Abstract
Purpose of the review
Premedication using antihistamines and/or corticosteroids has been widely used to prevent reoccurrence of immediate hypersensitivity reactions (iHR) after iodinated contrast media (ICM). However, efficacy has been debated, especially in high-risk patients. Novel findings on the role and risks of premedication and preventive strategies are summarized.
Recent findings
The rate and severity of iHR occurring despite premedication indicate that premedication is not a panacea and the intensity usually reflects that of the initial reaction. Next, the number needed to treat (NNT) to prevent one serious ICM-mediated event using corticosteroid-based premedication is high and associated with a diagnostic delay. Randomly changing the ICM has been suggested as an additional preventive measure, whilst others used a skin test–based approach to identify a subgroup of ICM allergic patients and negative skin test–based alternatives with a high negative predictive value.
Summary
Growing evidence indicates the need to discriminate between non-allergic iHR that are most likely non-obligatory and susceptible to premedication, and rare type I allergic iHR that can be identified using skin testing, especially in those with a severe iHR. Although premedication reduces reoccurrence of mild iHR, it is not always efficacious and should be balanced against side effects, a high NNT and an uncertain efficacy physicians should not blindly rely on. Future work should evaluate combined approaches of an allergy-driven ICM selection and endotype-driven premedication regimens in patients with non-allergic iHR.
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