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Cunha F, Cunha I, Gomes E. Safety of direct oral provocation test to delabel reported mild beta-lactam allergy in infants. Allergol Immunopathol (Madr) 2024; 52:10-15. [PMID: 38459885 DOI: 10.15586/aei.v52i2.887] [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: 04/11/2023] [Accepted: 11/30/2023] [Indexed: 03/11/2024]
Abstract
BACKGROUND Around 10% of people report a drug allergy and avoid some medications because of fear of allergic reactions. However, only after a proper diagnostic workup can some of these reactions be confirmed as allergic or nonallergic hypersensitivities. Beta-lactams (BLs) are the most common medication suspected of being involved in drug hypersensivity reactions (DHRs) in children. Recently, direct oral provocation tests (DPT) with BLs gained popularity within pediatric populations as a tool for delabeling children with suspected BL allergies. This study aimed to evaluate the safety of direct provocation tests in infants with mild cutaneous non-immediate reactions to BLs. METHODS The authors retrospectively analyzed the data of 151 infants between 2015 and 2022, referred for evaluating a suspected allergy to BLs that occurred before age 24 months. RESULTS The mean age of the children, including 55% male kids, at the suspected reaction was 15.9 months and the mean age at the time of the DPT was 39.6 months. In most cases, antibiotics were prescribed to treat common upper respiratory infections, such as acute otitis (54.3%) and acute tonsillitis (27.2%). Amoxicillin was considered the culprit drug in 62.9% of the cases, and the combination of amoxicillin-clavulanic acid in the case of 33.8% of children. The most frequent associated cutaneous clinical manifestations were maculopapular exanthema in 74.8% and delayed urticaria/angioedema in 25.2%. Of the 151 infants evaluated, parents of 149 infants agreed for a direct DPT, and only three had a positive test (2%). Symptoms resulting from the DPT were mild and easily treatable. CONCLUSIONS A direct DPT without prior tests is a safe and effective procedure to delabel BL allergy, even in infants. The authors wish to emphasize the importance of properly validating BL allergy suspicions by promoting appropriate diagnostic procedures in infants as, in most cases, DHRs can be excluded and there is no need for further therapeutic restrictions.
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Affiliation(s)
- Francisca Cunha
- Allergy and Clinical Immunology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal;
| | - Inês Cunha
- Allergy and Clinical Immunology Department, Centro Hospitalar e Universitário do Porto, Porto, Portugal
| | - Eva Gomes
- Allergy and Clinical Immunology Department, Centro Hospitalar e Universitário do Porto, Porto, Portugal
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2
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Elzagallaai AA, Rieder MJ. Novel insights into molecular and cellular aspects of delayed drug hypersensitivity reactions. Expert Rev Clin Pharmacol 2023; 16:1187-1199. [PMID: 38018416 DOI: 10.1080/17512433.2023.2289543] [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: 09/18/2023] [Accepted: 11/27/2023] [Indexed: 11/30/2023]
Abstract
INTRODUCTION Delayed drug hypersensitivity reactions (DDHRs) represent a major health problem. They are unpredictable and can cause life-long disability or even death. The pathophysiology of DDHRs is complicated, multifactorial, and not well understood mainly due to the lack of validated animal models or in vitro systems. The role of the immune system is well demonstrated but its exact pathophysiology still a matter of debate. AREA COVERED This review summarizes the current understanding of DDHRs pathophysiology and abridges the available new evidence supporting each hypothesis. A comprehensive literature search for relevant publications was performed using PubMed, Google Scholar, and Medline databases with no date restrictions and focusing on the most recent 10 years. EXPERT OPINION Although multiple milestones have been achieved in our understanding of DDHRs pathophysiology as a result of the development of useful experimental models, many questions are yet to be fully answered. A deeper understanding of the mechanistic basis of DDHRs would not only facilitate the development of robust and reliable diagnostic assays for diagnosis, but would also inform therapy by providing specific target(s) for immunomodulation and potentially permit pre-therapeutic risk assessment to pursue the common goal of safe and effective drug therapy.
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Affiliation(s)
- Abdelbaset A Elzagallaai
- Department of Pharmacology, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
| | - Michael J Rieder
- Department of Pharmacology, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
- Department of Paediatrics and Physiology, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Ontario, Canada
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3
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Cernadas J, Vasconcelos MJ, Carneiro-Leão L. Desensitization in children allergic to drugs: Indications, protocols, and limits. Pediatr Allergy Immunol 2023; 34:e13965. [PMID: 37366205 DOI: 10.1111/pai.13965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 04/21/2023] [Accepted: 05/11/2023] [Indexed: 06/28/2023]
Abstract
Any drug can potentially induce a hypersensitivity reaction. If after the allergological work-up the drug hypersensitivity reaction is confirmed, in most cases, the simple avoidance of the culprit drug and a suggestion of an unrelated alternative is enough. However, there are circumstances where the choice to stop the treatment affects the survival, the safety and/or the quality of life of the patient and the global outcome of the disease in question. When this occurs, drug desensitization can be the answer and should not be viewed as an extravagance, nor the pediatric age should be considered a contraindication. Drug desensitization in children can be safely and successfully performed, having a positive impact on the survival and overall prognosis. In general, the indications for DDS are the same in adults as in children. However, in this age group there are specificities that this paper aimed to describe, reviewing the mechanisms behind drug hypersensitivity and rapid drug desensitization, types of protocols, indications, and contraindications, as well as several technical aspects that are specific to the pediatric age.
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Affiliation(s)
- Josefina Cernadas
- Serviço de Imunoalergologia, Centro Hospitalar Universitário de São João, Porto, Portugal
- Unidade de Imunoalergologia, Hospital Lusíadas Porto, Porto, Portugal
| | - Maria João Vasconcelos
- Serviço de Imunoalergologia, Centro Hospitalar Universitário de São João, Porto, Portugal
- Unidade de Imunoalergologia, Hospital Lusíadas Porto, Porto, Portugal
| | - Leonor Carneiro-Leão
- Serviço de Imunoalergologia, Centro Hospitalar Universitário de São João, Porto, Portugal
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Atakul G, Köse SŞ, Atay O, Boyacıoglu OK, Al S, Asilsoy S, Uzuner N, Karaman O. Oral Challenge without Penicillin Skin Tests in Children with Suspected Beta-Lactam Hypersensitivity. JOURNAL OF CHILD SCIENCE 2022. [DOI: 10.1055/s-0042-1757151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Abstract
Objective A misdiagnosed “penicillin allergy” is a common problem in childhood. Recently, skipping skin tests (STs) and performing a direct oral challenge test (OCT) have become an increasingly common approach in children with suspected β-lactam (BL) allergy. In our study, we aimed to evaluate the safety and efficacy of OCT without using ST in children who had a history of hypersensitivity reactions with BL antibiotics.
Materials and Methods We retrospectively evaluated direct OCT outcomes in children with both nonimmediate and immediate-type reaction history with BL antibiotics. STs were not performed before the challenge test. The patients were monitored for 4 hours after the challenge and continued using the drug in two divided doses for 3 days at home.
Results In this study, 72 patients were included, with median age of 7 years (interquartile range: 4; min: 1 year to max: 16 years), and of these, 56% were male. Forty-five subjects (63%) reported immediate-type adverse reactions. The most common clinical manifestation was urticaria/angioedema (51%, n: 37) and maculopapular exanthema in 46% (n: 33) of patients, respectively. The most commonly suspected drug was 71% amoxicillin-clavulanate. A 3-day OCT without preceding ST was performed in all patients. Only three patients (4.2%) showed a positive response to the oral drug challenge test. None of these reactions observed was more severe than index reactions.
Conclusion Performing OCT without STs is a safe and convenient method to exclude BL hypersensitivity in the pediatric age group.
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Affiliation(s)
- Gizem Atakul
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey
| | - Seda Şirin Köse
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey
| | - Ozge Atay
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey
| | - Ozge Kangallı Boyacıoglu
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey
| | - Serdar Al
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey
| | - Suna Asilsoy
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey
| | - Nevin Uzuner
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey
| | - Ozkan Karaman
- Division of Pediatric Allergy and Immunology, Faculty of Medicine, Dokuz Eylul University, İzmir, Turkey
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5
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Rhyou HI, Nam YH. The Psychological Relieving Effect of Drug Provocation Test in Drug Hypersensitivity. J Asthma Allergy 2022; 15:1337-1345. [PMID: 36189190 PMCID: PMC9518683 DOI: 10.2147/jaa.s380516] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 09/06/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Hyo-In Rhyou
- Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Young-Hee Nam
- Department of Internal Medicine, College of Medicine, Dong-A University Hospital, Busan, Korea
- Correspondence: Young-Hee Nam, Department of Internal Medicine, College of Medicine, Dong-A University, 26 Daesingongwon-ro, Seo-Gu, Busan, Korea, Tel +8251-240-5860, Fax +82-51-242-5864, Email
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Welponer T, Brandlmaier M, Feuerstein B, Bauer JW. Identifying drug allergies by means of exposure testing - the frequency and nature of hypersensitivity reactions. Postepy Dermatol Alergol 2022; 39:632-634. [PMID: 35950111 PMCID: PMC9326907 DOI: 10.5114/ada.2021.106036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 03/10/2021] [Indexed: 11/17/2022] Open
Affiliation(s)
- Tobias Welponer
- Department of Dermatology and Allergology, University Hospital of the Paracelsus Medical University Salzburg, Austria
| | - Matthias Brandlmaier
- Department of Dermatology and Allergology, University Hospital of the Paracelsus Medical University Salzburg, Austria
| | | | - Johann W. Bauer
- Department of Dermatology and Allergology, University Hospital of the Paracelsus Medical University Salzburg, Austria
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Demirhan A, Yildirim DD, Arikoglu T, Ozhan AK, Tokmeci N, Yuksek BC, Kuyucu S. A combined risk modeling strategy for clinical prediction of beta-lactam allergies in children. Allergy Asthma Proc 2021; 42:e159-e166. [PMID: 34871164 DOI: 10.2500/aap.2021.42.210068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background: Drug provocation test (DPT) without skin tests is increasingly recommended in the evaluation of children with low-risk beta-lactam (BL) allergies. However, risk definitions are unclear. Objective: The aim of this study was to compose a clinical predictive model that could identify the children at low risk who could safely undergo direct DPT. Methods: The clinical data of 204 children who underwent a full diagnostic algorithm for suspected BL allergy were analyzed. Clinical data were used to construct mathematical predictive model for confirmed BL allergies. A prospective new sample was used for external validation of the final model. Results: The presentations during the index reaction were anaphylaxis in 5.9% and cutaneous reactions in the majority. BL allergy was confirmed in 15.7% of suspected cases. A backward multiple logistic regression model showed that a family history of drug allergy (adjusted odds ratio [aOR], 5.52), anaphylaxis (aOR, 5.14), any atopic disease other than asthma (aOR, 4.38), and a reaction interval of 0-6 hours during the index reaction (aOR, 5.32) were significantly associated with a confirmed BL allergy. A mathematical combined model based on these factors showed a sensitivity of 77.8% and a negative predictive value (NPV) of 94.3%. The validation study replicated sensitivity and NPV values of the main cohort. Conclusion: The risk definition in BL allergies should depend on population-specific predictive models, including a combination of significant risk factors rather than empiric risk approaches. This may help to accurately determinate children at low risk who may safely proceed to direct DPT.
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Affiliation(s)
- Ali Demirhan
- From the Department of Pediatric Allergy and Clinical Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey, and
| | - Didem D. Yildirim
- Department of Biostatistics and Medical Informatics, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Tugba Arikoglu
- From the Department of Pediatric Allergy and Clinical Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey, and
| | - Aylin K. Ozhan
- From the Department of Pediatric Allergy and Clinical Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey, and
| | - Nazan Tokmeci
- From the Department of Pediatric Allergy and Clinical Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey, and
| | - Burcu C. Yuksek
- From the Department of Pediatric Allergy and Clinical Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey, and
| | - Semanur Kuyucu
- From the Department of Pediatric Allergy and Clinical Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey, and
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8
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Blanca-Lopez N, Atanaskovic-Markovic M, Gomes ER, Kidon M, Kuyucu S, Mori F, Soyer O, Caubet JC. An EAACI Task Force report on allergy to beta-lactams in children: Clinical entities and diagnostic procedures. Pediatr Allergy Immunol 2021; 32:1426-1436. [PMID: 33931922 DOI: 10.1111/pai.13529] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 04/24/2021] [Indexed: 12/14/2022]
Abstract
Beta-lactam (BL) allergy suspicion is common in children and constitutes a major public health problem, with an impact on patient's health and on medical costs. However, it has been found that most of these reactions are not confirmed by a complete allergic workup. The diagnostic value of the currently available allergy tests has been investigated intensively recently by different groups throughout the world. This has led to major changes in the management of children with a suspected BL allergy. Particularly, it is now well accepted that skin tests can be skipped before the drug provocation test in children with a benign non-immediate reaction to BL. However, there is still a debate on the optimal allergic workup to perform in children with a benign immediate reaction. In addition, management of children with severe cutaneous adverse drug reactions remains difficult. In this review, based on a selection of the most relevant studies found in the literature, we will review and discuss the diagnosis of different forms of BL allergy in children.
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Affiliation(s)
| | | | - Eva R Gomes
- Allergy Unit, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Mona Kidon
- Safra Children's Hospital and the Clinical Immunology, Angioedema and Allergy Unit, Chaim Sheba Medical Center, Tel Hashomer, Faculty of Pediatric Medicine, Sackler Medical School, Tel Aviv University, Tel Aviv, Israel
| | - Semanur Kuyucu
- Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Francesca Mori
- Allergy Unit, Department of Pediatric, Meyer Children's Hospital, Florence, Italy
| | - Ozge Soyer
- Department of Pediatric Allergy, School of Medicine, Hacettepe University, Ankara, Turkey
| | - Jean-Christoph Caubet
- Pediatric Allergy Unit, Department of Child and Adolescent, Geneva University Hospital, Geneva, Switzerland
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9
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Kalangara J, Potru S, Kuruvilla M. Clinical Manifestations and Diagnostic Evaluation of Opioid Allergy Labels – A Review. J Pain Palliat Care Pharmacother 2019; 33:131-140. [DOI: 10.1080/15360288.2019.1666955] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Jerry Kalangara
- Jerry Kalangara, MD, and Sudheer Potru, MD, are with the Division of Pain Medicine, Emory University School of Medicine, Atlanta, Georgia, USA. Merin Kuruvilla, MD, are with the Division of Pulmonary, Allergy and Critical Care, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Sudheer Potru
- Jerry Kalangara, MD, and Sudheer Potru, MD, are with the Division of Pain Medicine, Emory University School of Medicine, Atlanta, Georgia, USA. Merin Kuruvilla, MD, are with the Division of Pulmonary, Allergy and Critical Care, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Merin Kuruvilla
- Jerry Kalangara, MD, and Sudheer Potru, MD, are with the Division of Pain Medicine, Emory University School of Medicine, Atlanta, Georgia, USA. Merin Kuruvilla, MD, are with the Division of Pulmonary, Allergy and Critical Care, Emory University School of Medicine, Atlanta, Georgia, USA
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11
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Stanulović V, Venegoni M, Edwards B. Impact of causal uncertainty on rechallenge after dress syndrome has occurred. Clin Exp Allergy 2019; 49:1262-1263. [DOI: 10.1111/cea.13451] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Accepted: 06/13/2019] [Indexed: 12/21/2022]
Affiliation(s)
- Vid Stanulović
- Clinical Development and Pharmacovigilance Consultant Novi Sad Serbia
| | - Mauro Venegoni
- Dipartimento di Diagnostica e Sanità Pubblica, Farmacologia University of Verona Verona Italy
| | - Brian Edwards
- NDA Regulatory Science Limited Leatherhead Surrey UK
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12
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Chaabane A, Fadhel NB, Chadli Z, Romdhane HB, Fredj NB, Boughattas NA, Aouam K. Association of non-immediate drug hypersensitivity with drug exposure: A case control analysis of spontaneous reports from a Tunisian pharmacovigilance database. Eur J Intern Med 2018; 53:40-44. [PMID: 29409745 DOI: 10.1016/j.ejim.2018.01.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Revised: 01/16/2018] [Accepted: 01/31/2018] [Indexed: 12/19/2022]
Abstract
PURPOSE To assess delayed-type cutaneous reactions (DTCRs) related to drugs, using a case-control approach to qualify drug risks. METHODS The study used the Tunisian pharmacovigilance database of Monastir. The association between drugs and DTCRs was assessed using a case/non-case method. Drugs were grouped according to the ATC Classification System. Patients were defined as "cases" if they have developed DTCRs regardless of the causality assessment. All other reports were "non-cases". Association between reactions and drugs was calculated using the reporting odds ratio (ROR) with 95% confidence intervals (CIs). A p value < 0.05 was considered significant. RESULTS The analysis was carried out on 1798 reports, of which 867 concerned DTCRs (cases) and 931 concerned non-cases. The calculated risk estimates were significant for cefotaxime (ROR 2.1; 95% CI 1.5 to 3), pristinamycin (ROR 4; 95% CI 2 to 7.9), sulfamethoxazole (ROR 4.4; 95% CI 1.6 to 11.7), oxacillin (ROR 2.2; 95% CI 1.2 to 3.8), doxycycline (ROR 10.8; 95% CI 1.4 to 84.9), carbamazepine (ROR 3.3; 95% CI 1.7 to 6.2), phenobarbital (ROR 2.3; 95% CI 1.03 to 5.1), allopurinol (ROR 3.6; 95% CI 1.8 to 7.2), furosemide (ROR 2.4; 95% CI 1.3 to 6.3), hydrochlorothiazide(ROR 2.9; 95% CI 1.3 to 6.3) and candesartan (ROR 4.7; 95% CI 1.3 to 16.6). CONCLUSION Our findings corroborate risks for a number of drugs, such as antibacterials, antiepileptics and allopurinol in inducing DTCRs. Given the widespread use of these drug classes, awareness should be raised among patients and prescribers about these risks.
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Affiliation(s)
- Amel Chaabane
- Department of Pharmacology, University of Medicine, Monastir, Tunisia.
| | - Najeh Ben Fadhel
- Department of Pharmacology, University of Medicine, Monastir, Tunisia
| | - Zohra Chadli
- Department of Pharmacology, University of Medicine, Monastir, Tunisia
| | | | - Nadia Ben Fredj
- Department of Pharmacology, University of Medicine, Monastir, Tunisia
| | | | - Karim Aouam
- Department of Pharmacology, University of Medicine, Monastir, Tunisia
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13
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How to Manage Antibiotic Allergy in Cystic Fibrosis? Epidemiologic, Diagnostic, and Therapeutic Aspects. CURRENT TREATMENT OPTIONS IN ALLERGY 2018. [DOI: 10.1007/s40521-018-0152-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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14
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Soyer O, Sahiner UM, Sekerel BE. Pro and Contra: Provocation Tests in Drug Hypersensitivity. Int J Mol Sci 2017; 18:ijms18071437. [PMID: 28677662 PMCID: PMC5535928 DOI: 10.3390/ijms18071437] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Revised: 06/24/2017] [Accepted: 06/27/2017] [Indexed: 02/06/2023] Open
Abstract
Drug provocation test (DPT) is the controlled administration of a drug to diagnose immune- or non-immune-mediated drug hypersensitivity and the last step for accurate recognition of drug hypersensitivity reactions when the previous diagnostic evaluations are negative or unavailable. A DPT is performed only if other conventional tests fail to yield conclusive results. In each clinical presentation, "to provoke or not to provoke" a patient should be decided after careful assessment of the risk-benefit ratio. Well-defined benefits of DPT include confirmative exclusion of diagnoses of drug hypersensitivity and provision of safe alternatives. However, disadvantages such as safety, difficulty in interpretations of results, lack of objective biomarkers, risks of resensitization, efficiency in daily practice, and lack of standardized protocols, are poorly debated. This review summarizes the current published research concerning DPT, with particular emphasis on the advantages and disadvantages of DPT in an evidence-based manner.
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Affiliation(s)
- Ozge Soyer
- Department of Pediatric Allergy Ankara, School of Medicine, Hacettepe University, Ankara 06100, Turkey.
| | - Umit Murat Sahiner
- Department of Pediatric Allergy Ankara, School of Medicine, Hacettepe University, Ankara 06100, Turkey.
| | - Bulent Enis Sekerel
- Department of Pediatric Allergy Ankara, School of Medicine, Hacettepe University, Ankara 06100, Turkey.
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15
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Yang MS, Ban GY, Kim MH, Lim KH, Kwon HS, Song WJ, Jung JW, Lee J, Suh DI, Kwon JW, Kim SH, Shin YS, Kang HR, Kim TB, Lee BJ, Lee AY, Park HS, Cho SH. KAAACI Standardization Committee Report on the procedures and applications of the diagnostic tests for drug allergy. ALLERGY ASTHMA & RESPIRATORY DISEASE 2017. [DOI: 10.4168/aard.2017.5.5.239] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Min-Suk Yang
- Department of Internal Medicine, Seoul Metropolitan Government - Seoul National University Boramae Medical Center, Seoul, Korea
| | - Ga-Young Ban
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - Min-Hye Kim
- Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea
| | - Kyung-Hwan Lim
- Department of Internal Medicine, Armed Forces Capital Hospital, Seongnam, Korea
| | - Hyouk-Soo Kwon
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Woo-Jung Song
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Jae-Woo Jung
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Jeongmin Lee
- Department of Pediatrics, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Dong In Suh
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Jae-Woo Kwon
- Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Sae-Hoon Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Yoo Seob Shin
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - Hye-Ryun Kang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Tae-Bum Kim
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Byung-Jae Lee
- Division of Allergy, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ai-Young Lee
- Department of Dermatology, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Hae-Sim Park
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - Sang-Heon Cho
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
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16
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Skin testing and drug challenge outcomes in antibiotic-allergic patients with immediate-type hypersensitivity. Ann Allergy Asthma Immunol 2016; 118:73-79. [PMID: 27864093 DOI: 10.1016/j.anai.2016.10.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 09/30/2016] [Accepted: 10/01/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND The evaluation of antibiotic immediate-type hypersensitivity is intricate because of nonstandardized skin testing and challenge method variability. OBJECTIVE To determine the safety outcomes and risk factors for antibiotic challenge reactions in patients reporting a history of antibiotic immediate-type hypersensitivity. METHODS A 5-year retrospective review of patients evaluated for immediate-type antibiotic allergy was conducted. Data analyzed included patient demographics, index reaction details, and outcomes of skin testing and challenges, classified as single-step or multistep. RESULTS Antibiotic hypersensitivity history was identified in 211 patients: 78% to penicillins, 10% to fluoroquinolones, 7.6% to cephalosporins, and 3.8% to carbapenems. In total, 179 patients completed the challenges (median age 67 years, range 50-76 years, 56% women), and compared with nonchallenged patients, they reported nonanaphylactic (P < .001) and remote index (P = .003) reactions. Sixteen patients (8.9%) experienced challenge reactions (5 of 28 for single-step challenge, 11 of 151 for multistep challenge), and 11 of these patients had negative skin testing results before the challenge. Challenge-reactive patients were significantly younger (P = .007), more often women (P = .036), and had additional reported antibiotic allergies (P = .005). No correlation was detected between the reported index and observed challenge reaction severities (κ = -0.05, 95% confidence interval -0.34 to 0.24). Anaphylactic rates were similar during single-step and multistep challenges (3.6% vs 3.3%). CONCLUSION In the present population, younger women with multiple reported antibiotic allergies were at greatest risk for challenge reactions. Negative skin testing results did not exclude reactions, and index severity was not predictive of challenge outcome. The multistep and full-dose methods demonstrated a comparable reaction risk for anaphylaxis.
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Calvo Campoverde K, Giner-Muñoz M, Martínez Valdez L, Rojas Volquez M, Lozano Blasco J, Machinena A, Plaza A. Hypersensitivity reactions to non-steroidal anti-inflammatory drugs and tolerance to alternative drugs. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2016. [DOI: 10.1016/j.anpede.2015.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Calvo Campoverde K, Giner-Muñoz MT, Martínez Valdez L, Rojas Volquez M, Lozano Blasco J, Machinena A, Plaza AM. [Hypersensitivity reactions to non-steroidal anti-inflammatory drugs and tolerance to alternative drugs]. An Pediatr (Barc) 2015. [PMID: 26195066 DOI: 10.1016/j.anpedi.2015.05.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
INTRODUCTION Hypersensitivity reactions to non-steroidal anti-inflammatory drugs (NSAIDs) are the most common reactions to drugs. The prevalence varies from 0.6 to 5.7% in general population, but there are no data available in children. The aim of this study is to determine the frequency of patients diagnosed with hypersensitivity to NSAIDs, and describe their clinical characteristics, type of hypersensitivity, and tolerance to alternative drugs. METHODS Retrospective study was conducted on children with suspected hypersensitivity to NSAIDs from January 2012 to December 2013. The diagnosis was confirmed by oral drug provocation test (DPT) to the drug involved in the group with a history of one episode, while in the group with a history of more than one episode with the same drug the diagnosis was based on clinical data. Subsequently, a DPT with acetylsalicylic acid (ASA) was done in order to classify hypersensitivity into selective or multiple. In those cases with a positive result, a DPT was performed with alternative drugs. RESULTS Out of a total of 93 children studied, 26 were diagnosed with hypersensitivity to NSAIDs: 7 confirmed by oral DPT, and 19 based on clinical data. Multiple hypersensitivity was diagnosed in 50% of patients. Ibuprofen was involved in all reactions. The most common clinical manifestation was angioedema (44%). Acetaminophen was the best tolerated alternative drug. CONCLUSIONS More than one quarter (28%) of the population studied was diagnosed with hypersensitivity to NSAIDs, and 50% had multiple hypersensitivity. Acetaminophen is a safe alternative in children with hypersensitivity to NSAIDs. Meloxicam may be an alternative in cases that do not tolerate acetaminophen.
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Affiliation(s)
- K Calvo Campoverde
- Servicio de Alergia e Inmunología Clínica Pediátrica, Hospital Sant Joan de Déu, Universitat de Barcelona, Esplugues de Llobregat, Barcelona, España
| | - M T Giner-Muñoz
- Servicio de Alergia e Inmunología Clínica Pediátrica, Hospital Sant Joan de Déu, Universitat de Barcelona, Esplugues de Llobregat, Barcelona, España
| | - L Martínez Valdez
- Servicio de Alergia e Inmunología Clínica Pediátrica, Hospital Sant Joan de Déu, Universitat de Barcelona, Esplugues de Llobregat, Barcelona, España
| | - M Rojas Volquez
- Servicio de Alergia e Inmunología Clínica Pediátrica, Hospital Sant Joan de Déu, Universitat de Barcelona, Esplugues de Llobregat, Barcelona, España
| | - J Lozano Blasco
- Servicio de Alergia e Inmunología Clínica Pediátrica, Hospital Sant Joan de Déu, Universitat de Barcelona, Esplugues de Llobregat, Barcelona, España
| | - A Machinena
- Servicio de Alergia e Inmunología Clínica Pediátrica, Hospital Sant Joan de Déu, Universitat de Barcelona, Esplugues de Llobregat, Barcelona, España
| | - A M Plaza
- Servicio de Alergia e Inmunología Clínica Pediátrica, Hospital Sant Joan de Déu, Universitat de Barcelona, Esplugues de Llobregat, Barcelona, España.
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Misirlioglu ED, Toyran M, Capanoglu M, Kaya A, Civelek E, Kocabas CN. Negative predictive value of drug provocation tests in children. Pediatr Allergy Immunol 2014; 25:685-90. [PMID: 25283219 DOI: 10.1111/pai.12286] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/29/2014] [Indexed: 11/30/2022]
Abstract
BACKGROUND The negative predictive value of the drug provocation test is important for both the patient and the physician. However, in children, this predictive value is unresolved. METHODS The study included patients who had drug provocation test with a suspected drug and was diagnosed as 'not allergic to the drug'. Three months after allergy workup, the patients were contacted and asked for reexposure to the tested drug. Patients who have reported reactions during reexposure were reevaluated with skin tests and drug provocation. RESULTS During the study period, 217 provocations were performed to 203 patients. Of these, 163 patients (80.3%) with 175 negative drug provocation tests could be contacted. Ninety-one (52%) of the 175 cases reported to use the tested drug again, and 11 (12%) of these cases declared that they had a new reaction. Two of the eleven cases refused reevaluation. Nine cases were evaluated by drug allergy workup. Two of the nine cases were classified as allergic after retests. Collectively, the negative predictive value was 95.6% (87 of 91 cases) for all drug challenges. CONCLUSIONS The negative predictive value of the drug provocation test is abundant in children; however, negative drug provocation tests do not necessarily predict tolerance for the drug.
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Affiliation(s)
- Emine D Misirlioglu
- Department of Pediatric Allergy and Immunology, Ankara Children's Hematology Oncology Training and Research Hospital, Ankara, Turkey
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Safety and Outcomes of Test Doses for the Evaluation of Adverse Drug Reactions: A 5-Year Retrospective Review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2014; 2:768-74. [DOI: 10.1016/j.jaip.2014.08.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Revised: 08/04/2014] [Accepted: 08/05/2014] [Indexed: 11/22/2022]
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Dursun AB, Sahin OZ. Allopurinol desensitization with A 2 weeks modified protocol in an elderly patients with multiple comorbidities: a case report. Allergy Asthma Clin Immunol 2014; 10:52. [PMID: 25685161 PMCID: PMC4326512 DOI: 10.1186/1710-1492-10-52] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 10/08/2014] [Indexed: 11/10/2022] Open
Abstract
Background Allopurinol is an effective urate-lowering drug that is well tolerated by the majority of patients. Patients with chronic renal insufficiency have an increased risk of hypersensitivity reactions with allopurinol. Case presentation 75 year old male patient with gout, renal insufficiency, history of metastatic colorectal carcinoma status post-resection was referred to Allergy clinic for a maculopapular eruption that developed 1 week after initiating therapy with allopurinol. The rash resolved with discontinuation of allopurinol. However, his serum urate level rose to 19.9 mg/dl. We initially proposed a slow 4 week oral allopurinol desensitization. The treating nephrologist felt it was critical to lower urate more rapidly. As a result, we modified the dose and standard 4 week protocol down to 2 weeks. A suspension of allopurinol was prepared by the allergy nurse practitioner with a 300 mg allopurinol tablet. The sensitization protocol was modified as a starting dose of 0.3 mg escalating to a final dose of 300 mg/day in 2 weeks. There was no reaction during or after the desensitization. The patient’s urate level normalized (6.3 mg/dl) and has continued on 300 mg allopurinol daily without reaction. Conclusion A 2 week modified allopurinol desensitization protocol is a safe alternative for elderly patients with multiple comorbidities.
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Affiliation(s)
- Adile Berna Dursun
- Department of Internal Medicine, Division of Immunology and Allergic Diseases, Recep Tayyip Erdogan University, School of Medicine, Rize, Turkey
| | - Osman Z Sahin
- Department of Internal Medicine, Division of Nephrology, Recep Tayyip Erdogan University, School of Medicine, Rize, Turkey
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Delayed clavulanic acid-induced anaphylaxis in a patient undergoing bariatric surgery. Ann Allergy Asthma Immunol 2014; 113:324-5. [PMID: 25060818 DOI: 10.1016/j.anai.2014.06.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 06/16/2014] [Accepted: 06/20/2014] [Indexed: 11/20/2022]
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