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Wu PC, Lin WC, Wang CW, Chung WH, Chen CB. Cutaneous adverse reactions associated with COVID-19 vaccines: Current evidence and potential immune mechanisms. Clin Immunol 2024; 263:110220. [PMID: 38642783 DOI: 10.1016/j.clim.2024.110220] [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: 09/26/2023] [Revised: 03/04/2024] [Accepted: 04/14/2024] [Indexed: 04/22/2024]
Abstract
As the number of vaccinated individuals has increased, there have been increasing reports of cutaneous hypersensitivity reactions. The main COVID-19 vaccines administered include messenger ribonucleic acid vaccines, non-replicating viral vector vaccines, inactivated whole-virus vaccines, and protein-based vaccines. These vaccines contain active components such as polyethylene glycol, polysorbate 80, aluminum, tromethamine, and disodium edetate dihydrate. Recent advances in understanding the coordination of inflammatory responses by specific subsets of lymphocytes have led to a new classification based on immune response patterns. We categorize these responses into four patterns: T helper (Th)1-, Th2-, Th17/22-, and Treg-polarized cutaneous inflammation after stimulation of COVID-19 vaccines. Although the association between COVID-19 vaccination and these cutaneous adverse reactions remains controversial, the occurrence of rare dermatoses and their short intervals suggest a possible relationship. Despite the potential adverse reactions, the administration of COVID-19 vaccines is crucial in the ongoing battle against severe acute respiratory syndrome coronavirus 2.
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Affiliation(s)
- Po-Chien Wu
- Department of Dermatology, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; Research Center of Big Data and Meta-Analysis, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Wan-Chen Lin
- Department of Dermatology, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan
| | - Chuang-Wei Wang
- Department of Dermatology, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; Research Center of Big Data and Meta-Analysis, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; Cancer Vaccine and Immune Cell Therapy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; Chang Gung Immunology Consortium, Chang Gung Memorial Hospital, Linkou, and Chang Gung University, Taoyuan, Taiwan; Department of Dermatology, Xiamen Chang Gung Hospital, Xiamen, China; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Wen-Hung Chung
- Department of Dermatology, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; Cancer Vaccine and Immune Cell Therapy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; Chang Gung Immunology Consortium, Chang Gung Memorial Hospital, Linkou, and Chang Gung University, Taoyuan, Taiwan; Department of Dermatology, Xiamen Chang Gung Hospital, Xiamen, China; College of Medicine, Chang Gung University, Taoyuan, Taiwan; Whole-Genome Research Core Laboratory of Human Diseases, Chang Gung Memorial Hospital, Keelung, Taiwan; Immune-Oncology Center of Excellence, Chang Gung Memorial Hospital, Linkou, Taiwan; Department of Dermatology, Beijing Tsinghua Chang Gung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China; Department of Dermatology, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Genomic Medicine Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Chun-Bing Chen
- Department of Dermatology, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; Cancer Vaccine and Immune Cell Therapy Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taoyuan, Taiwan; Chang Gung Immunology Consortium, Chang Gung Memorial Hospital, Linkou, and Chang Gung University, Taoyuan, Taiwan; Department of Dermatology, Xiamen Chang Gung Hospital, Xiamen, China; College of Medicine, Chang Gung University, Taoyuan, Taiwan; Whole-Genome Research Core Laboratory of Human Diseases, Chang Gung Memorial Hospital, Keelung, Taiwan; Immune-Oncology Center of Excellence, Chang Gung Memorial Hospital, Linkou, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Genomic Medicine Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taiwan; School of Medicine, National Tsing Hua University, Hsinchu, Taiwan.
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Sattler S, Gollomp S, Curry A. A Narrative Literature Review of the Established Safety of Human Serum Albumin Use as a Stabilizer in Aesthetic Botulinum Toxin Formulations Compared to Alternatives. Toxins (Basel) 2023; 15:619. [PMID: 37888650 PMCID: PMC10610632 DOI: 10.3390/toxins15100619] [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: 08/11/2023] [Revised: 10/06/2023] [Accepted: 10/11/2023] [Indexed: 10/28/2023] Open
Abstract
Despite more than 80 years of use in a number of conditions, including in critically ill patients, comments have recently arisen regarding the safety and efficacy of human serum albumin (HSA) as a therapeutic product and stabilizer/excipient in botulinum neurotoxins. This review summarizes the literature on the safety of HSA. Beyond decades of safe use, the largest clinical dataset of HSA safety is a large meta-analysis of HSA supplier data, which found only an extremely remote risk of serious adverse events across millions of doses of therapeutic concentrations of HSA. There is a paucity of literature identifying HSA-specific adverse events when used as a stabilizer/excipient; however, studies of HSA-containing botulinum neurotoxins (BoNTs) suggest that adverse events are not related to HSA. Polysorbates, which are synthetically produced and not physiologically inert, are contained in pending or new-to-market BoNT formulations. In contrast to HSA, evidence exists to suggest that polysorbates (particularly PS20/PS80) can cause serious adverse events (e.g., hypersensitivity, anaphylaxis, and immunogenicity).
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Hong K, Rowhani-Farid A, Doshi P. Definition and rationale for placebo composition: Cross-sectional analysis of randomized trials and protocols published in high-impact medical journals. Clin Trials 2023; 20:564-570. [PMID: 37050893 DOI: 10.1177/17407745231167756] [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] [Indexed: 04/14/2023]
Abstract
BACKGROUND/AIMS Inadequate description of trial interventions in publications has been repeatedly reported, a problem that extends to the description of placebo controls. Without describing placebo contents, it cannot be assumed that a placebo is inert. Pharmacologically active placebos complicate accurate estimation and interpretation of efficacy and safety data. In this study, we sought to assess whether placebo contents are described in study protocols and publications of trials published in high-impact medical journals. METHODS We identified all placebo-controlled randomized clinical trials (RCTs) published in 2016 in Annals of Internal Medicine, The BMJ, the Journal of the American Medical Association (JAMA), The Lancet, and the New England Journal of Medicine (NEJM). We included all trials with publicly available study protocols. From journal publications and associated study protocols, we searched and recorded: description of placebo contents; the amount of each placebo ingredient; and investigators' stated rationale for selection of placebo ingredients. RESULTS We included 113 placebo-controlled RCTs. Of the 113 trials, placebo content was described in 22 (19.5%) journal publications and 51 (45.1%) study protocols. The amount of each placebo ingredient was described in 15 (13.3%) journal publications and 47 (41.6%) study protocols. None of the journal publications explained the rationale for the choice of placebo ingredients, whereas a rationale was provided in 4 (3.5%) study protocols. The stated rationales were to ensure the placebo was visually indistinguishable from the experimental intervention (N = 3) and ensure comparability with a previous study (N = 1). CONCLUSION There is no accessible record of the composition of placebos for approximately half of high-impact RCTs, even with access to study protocols. This impedes reproducibility and raises unanswerable questions about what effects-beneficial or harmful-the placebo may have had on trial participants, potentially confounding an accurate assessment of the experimental intervention's safety and efficacy. Considering that study protocols are unabridged, detailed documents describing the trial design and methodology, the fact that less than half of the study protocols described the placebo contents raises concerns about clinical trial transparency. To improve the reproducibility and potential of placebo-controlled RCTs to provide reliable evidence on the efficacy and safety profile of drugs and other experimental interventions, more detail regarding placebo contents must be included in trial documents.
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Affiliation(s)
- Kyungwan Hong
- Department of Practice, Sciences, and Health Outcomes Research, School of Pharmacy, University of Maryland, Baltimore, MD, USA
| | - Anisa Rowhani-Farid
- Department of Practice, Sciences, and Health Outcomes Research, School of Pharmacy, University of Maryland, Baltimore, MD, USA
| | - Peter Doshi
- Department of Practice, Sciences, and Health Outcomes Research, School of Pharmacy, University of Maryland, Baltimore, MD, USA
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Dodier K, Laverdière I, Roy MJ. Etoposide hypersensitivity reactions associated with in-line filter use: A retrospective cohort study at CHU de Québec-Université Laval. J Oncol Pharm Pract 2023; 29:1687-1694. [PMID: 36544381 PMCID: PMC10612379 DOI: 10.1177/10781552221146801] [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: 11/14/2022] [Revised: 12/04/2022] [Accepted: 12/05/2022] [Indexed: 10/28/2023]
Abstract
INTRODUCTION A case series of hypersensitivity reactions (HSRs) during intravenous administration of etoposide was observed following the introduction of in-line filters (ILFs) at a specialized university-affiliated center. This raised questions about the possible involvement of filters in these reactions. Despite there being very little published evidence to inform clinical decision making in this potentially clinically significant situation, the use of ILFs was discontinued at this center pending further investigation. The aims of this study were to evaluate the cumulative incidence of etoposide-related HSR with and without the use of ILF and to describe the reactions in adult and pediatric patients with cancer. METHODS A retrospective cohort study was performed among all pediatric and adult patients treated with intravenous etoposide at a maximal concentration of 0.4 mg/mL at our center between 30 September 2015 and 16 August 2018. This covered periods of time during which ILFs were used, as well as 6 months before their implementation and after their withdrawal. Data were extracted from medical records and cumulative incidence was calculated for each of the time periods (pre-ILF, ILF, and post-ILF) as the proportion of patients who recorded an HSR (one or more). Confidence intervals were calculated for each proportion using Fisher's Exact 95%. Comparisons of proportions between time periods were performed using Exact Pearson Chi-squared tests. Data were stratified by a number of perfusion cycles (single cycle or multiple cycles) and by patient population (adult and pediatric). RESULTS A total of 284 patients were included in the study. The overall cumulative incidence of etoposide HSR was 9.9%. The cumulative incidence of HSR tended to be higher during ILF use when compared with combined pre- and post-ILF periods (12.2% [95% CI: 7.9-17.8] vs. 5.2% [95% CI: 1.7-11.7], p = 0.09). In patients who received multiple cycles of etoposide, the cumulative incidence of HSRs was higher during ILF use when compared with combined pre- and post-ILF periods (15.0% [95% CI: 9.6-21.8] vs. 3.9% [95% CI: 0.8-11.0], p = 0.01). The majority of HSRs' maximal severity were grade 1 or 2 (85.7%) according to Common Terminology Criteria for Adverse Events (CTCAE) version 4.0. CONCLUSIONS This study suggests a link between the use of ILFs and increased incidence of HSR during etoposide perfusion.
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Affiliation(s)
- Kelly Dodier
- Faculty of Pharmacy, Université Laval, Québec, Canada
- Department of Pharmacy, CHU de Québec - Université Laval, Québec, Canada
| | - Isabelle Laverdière
- Faculty of Pharmacy, Université Laval, Québec, Canada
- Department of Pharmacy, CHU de Québec - Université Laval, Québec, Canada
- Oncology Axis, CHU de Québec Research Center - Université Laval, Québec, Canada
| | - Marie-Julie Roy
- Department of Pharmacy, CHU de Québec - Université Laval, Québec, Canada
- Oncology Axis, CHU de Québec Research Center - Université Laval, Québec, Canada
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Gosse L, Hacard F, Crumbach L, Vancappel M, Bérard F, Nicolas J, Vial T, Juillard L, Dussard C, Nosbaum A. [Suspected allergy to COVID-19 vaccines: A retrospective study of 320 patients]. REVUE FRANCAISE D'ALLERGOLOGIE (2009) 2023; 63:103303. [PMID: 36694692 PMCID: PMC9850855 DOI: 10.1016/j.reval.2023.103303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 01/10/2023] [Indexed: 01/21/2023]
Abstract
Introduction The health context with COVID-19 pandemic has led to fast development of many vaccines against the SarS-Cov-2 virus. Four of them are currently available in France and contain polyethylene glycol (PEG) or polysorbate 80 as excipients, already described as causing anaphylaxis. French recommendations have been suggested by allergology authorities and proposed a course of action in the event of a suspected allergy to these vaccines. Thus, allergies to excipients were the only contraindication to COVID-19 vaccination. Our main objective was to determine the impact of these allergology vaccine recommendations on the management of these patients. Our secondary objective was to determine prevalence of true allergies to these vaccines. Materials and methods We conducted a unicentric descriptive retrospective study with all patients over 18 years of age referred for an allergological opinion before or after an injection of one of the anti-COVID-19 vaccines. Nineteen patients were classified into different interest groups, based on french recommendations. Results The vast majority of patients did not require a pre-vaccination allergological assessment. Indeed, only 25 patients received skin tests prior to vaccination. The rest of patients were able to be vaccinated without allergological assessment. Patients not vaccinated due to allergy to excipients represent less than 1% of the population (n = 3/320). Conclusion French recommendations made it possible to vaccinate the vast majority of patients included in our study. Allergy to PEG, polysorbate or their derivatives, the only contraindication to anti-COVID vaccination, according to the recommendations of February 2021, remains rare. Today, several authors propose tolerance inductions allowing the vaccination of patients allergic to PEGs or their derivatives with good tolerance.
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Affiliation(s)
- L. Gosse
- Hospices civils de Lyon, service d’allergologie et immunologie clinique, centre hospitalier Lyon Sud, Pierre-Bénite, France
| | - F. Hacard
- Hospices civils de Lyon, service d’allergologie et immunologie clinique, centre hospitalier Lyon Sud, Pierre-Bénite, France
| | - L. Crumbach
- Hospices civils de Lyon, service d’allergologie et immunologie clinique, centre hospitalier Lyon Sud, Pierre-Bénite, France
| | - M. Vancappel
- Hospices civils de Lyon, service d’allergologie et immunologie clinique, centre hospitalier Lyon Sud, Pierre-Bénite, France
| | - F. Bérard
- Hospices civils de Lyon, service d’allergologie et immunologie clinique, centre hospitalier Lyon Sud, Pierre-Bénite, France
| | - J.F. Nicolas
- Hospices civils de Lyon, service d’allergologie et immunologie clinique, centre hospitalier Lyon Sud, Pierre-Bénite, France,CIRI, centre international de recherche en infectiologie, université de Lyon, Inserm, U1111, université Claude Bernard Lyon 1, CNRS, UMR5308, ENS de Lyon, 69007 Lyon, France
| | - T. Vial
- Centre régional de pharmacovigilance de Lyon, France
| | - L. Juillard
- Hospices civils de Lyon, service de néphrologie, hôpital E. Herriot, Lyon, France
| | - C. Dussard
- EA 4129 P2S parcours santé systémique, université Claude Bernard Lyon 1, université de Lyon 1, Lyon, France
| | - A. Nosbaum
- Hospices civils de Lyon, service d’allergologie et immunologie clinique, centre hospitalier Lyon Sud, Pierre-Bénite, France,CIRI, centre international de recherche en infectiologie, université de Lyon, Inserm, U1111, université Claude Bernard Lyon 1, CNRS, UMR5308, ENS de Lyon, 69007 Lyon, France,Auteur correspondant
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Podevin P, Vanlerberghe J, Templier C, Lannoy D, Azib S, Staumont-Sallé D, Mortier L, Dezoteux F. Anaphylactic reaction to checkpoint inhibitors with confirmed hypersensitivity to polysorbate 80. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:655-657. [PMID: 36572183 DOI: 10.1016/j.jaip.2022.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 12/01/2022] [Accepted: 12/08/2022] [Indexed: 12/25/2022]
Affiliation(s)
| | | | | | - Damien Lannoy
- CHU Lille, Univ. Lille, Institut de Pharmacie, ULR7365 GRITA Groupe de Recherche sur les Formes Injectables et les Technologies Associées, Lille, France
| | - Selma Azib
- CHU Lille, Service de Dermatologie, Lille, France
| | - Delphine Staumont-Sallé
- CHU Lille, Univ. Lille, Service de Dermatologie, U1286 Inserm INFINITE Institute for Translational Research in Inflammation, Lille, France
| | - Laurent Mortier
- CHU Lille, CARADERM and University of Lille, Service de Dermatologie, U1189 Inserm, Lille, France
| | - Frédéric Dezoteux
- CHU Lille, Univ. Lille, Service de Dermatologie, U1286 Inserm INFINITE Institute for Translational Research in Inflammation, Lille, France
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Castañeda Ruiz AJ, Shetab Boushehri MA, Phan T, Carle S, Garidel P, Buske J, Lamprecht A. Alternative Excipients for Protein Stabilization in Protein Therapeutics: Overcoming the Limitations of Polysorbates. Pharmaceutics 2022; 14:pharmaceutics14122575. [PMID: 36559072 PMCID: PMC9781097 DOI: 10.3390/pharmaceutics14122575] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 11/11/2022] [Accepted: 11/15/2022] [Indexed: 11/25/2022] Open
Abstract
Given their safety and efficiency in protecting protein integrity, polysorbates (PSs) have been the most widely used excipients for the stabilization of protein therapeutics for years. In recent decades, however, there have been numerous reports about visible or sub-visible particles in PS-containing biotherapeutic products, which is a major quality concern for parenteral drugs. Alternative excipients that are safe for parenteral administration, efficient in protecting different protein drugs against various stress conditions, effective in protein stabilization in high-concentrated liquid formulations, stable under the storage conditions for the duration of the product's shelf-life, and compatible with other formulation components and the primary packaging are highly sought after. The aim of this paper is to review potential alternative excipients from different families, including surfactants, carbohydrate- and amino acid-based excipients, synthetic amphiphilic polymers, and ionic liquids that enable protein stabilization. For each category, important characteristics such as the ability to stabilize proteins against thermal and mechanical stresses, current knowledge related to the safety profile for parenteral administration, potential interactions with other formulation components, and primary packaging are debated. Based on the provided information and the detailed discussion thereof, this paper may pave the way for the identification or development of efficient excipients for biotherapeutic protein stabilization.
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Affiliation(s)
- Angel J. Castañeda Ruiz
- Department of Pharmaceutical Technology and Biopharmaceutics, University of Bonn, 53121 Bonn, Germany
| | | | - Tamara Phan
- Boehringer Ingelheim Pharma GmbH & Co. KG, Innovation Unit, PDB, Birkendorfer Straße 65, 88397 Biberach an der Riss, Germany
| | - Stefan Carle
- Boehringer Ingelheim Pharma GmbH & Co. KG, Innovation Unit, PDB, Birkendorfer Straße 65, 88397 Biberach an der Riss, Germany
| | - Patrick Garidel
- Boehringer Ingelheim Pharma GmbH & Co. KG, Innovation Unit, PDB, Birkendorfer Straße 65, 88397 Biberach an der Riss, Germany
| | - Julia Buske
- Boehringer Ingelheim Pharma GmbH & Co. KG, Innovation Unit, PDB, Birkendorfer Straße 65, 88397 Biberach an der Riss, Germany
- Correspondence: (J.B.); (A.L.); Tel.: +49-7351-54-145-398 (J.B.); +49-228-735-243 (A.L.)
| | - Alf Lamprecht
- Department of Pharmaceutical Technology and Biopharmaceutics, University of Bonn, 53121 Bonn, Germany
- Correspondence: (J.B.); (A.L.); Tel.: +49-7351-54-145-398 (J.B.); +49-228-735-243 (A.L.)
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Barbaud A, Garvey LH, Arcolaci A, Brockow K, Mori F, Mayorga C, Bonadonna P, Atanaskovic-Markovic M, Moral L, Zanoni G, Pagani M, Soria A, Jošt M, Caubet JC, Carmo A, Mona AA, Alvarez-Perea A, Bavbek S, Benedetta B, Bilo MB, Blanca-López N, Bogas HG, Buonomo A, Calogiuri G, Carli G, Cernadas J, Cortellini G, Celik G, Demir S, Doña I, Dursun AB, Eberlein B, Faria E, Fernandes B, Garcez T, Garcia-Nunez I, Gawlik R, Gelincik A, Gomes E, Gooi JHC, Grosber M, Gülen T, Hacard F, Hoarau C, Janson C, Johnston SL, Joerg L, Kepil Özdemir S, Klimek L, Košnik M, Kowalski ML, Kuyucu S, Kvedariene V, Laguna JJ, Lombardo C, Marinho S, Merk H, Meucci E, Morisset M, Munoz-Cano R, Murzilli F, Nakonechna A, Popescu FD, Porebski G, Radice A, Regateiro FS, Röckmann H, Romano A, Sargur R, Sastre J, Scherer Hofmeier K, Sedláčková L, Sobotkova M, Terreehorst I, Treudler R, Walusiak-Skorupa J, Wedi B, Wöhrl S, Zidarn M, Zuberbier T, Agache I, Torres MJ. Allergies and COVID-19 vaccines: An ENDA/EAACI Position paper. Allergy 2022; 77:2292-2312. [PMID: 35112371 DOI: 10.1111/all.15241] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 12/17/2021] [Accepted: 01/03/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Anaphylaxis, which is rare, has been reported after COVID-19 vaccination, but its management is not standardized. METHOD Members of the European Network for Drug Allergy and the European Academy of Allergy and Clinical Immunology interested in drug allergy participated in an online questionnaire on pre-vaccination screening and management of allergic reactions to COVID-19 vaccines, and literature was analysed. RESULTS No death due to anaphylaxis to COVID-19 vaccines has been confirmed in scientific literature. Potential allergens, polyethylene glycol (PEG), polysorbate and tromethamine are excipients. The authors propose allergy evaluation of persons with the following histories: 1-anaphylaxis to injectable drug or vaccine containing PEG or derivatives; 2-anaphylaxis to oral/topical PEG containing products; 3-recurrent anaphylaxis of unknown cause; 4-suspected or confirmed allergy to any mRNA vaccine; and 5-confirmed allergy to PEG or derivatives. We recommend a prick-to-prick skin test with the left-over solution in the suspected vaccine vial to avoid waste. Prick test panel should include PEG 4000 or 3500, PEG 2000 and polysorbate 80. The value of in vitro test is arguable. CONCLUSIONS These recommendations will lead to a better knowledge of the management and mechanisms involved in anaphylaxis to COVID-19 vaccines and enable more people with history of allergy to be vaccinated.
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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, Département de dermatologie et allergologie, Paris, France
| | - Lene Heise Garvey
- Allergy Clinic, Copenhagen University Hospital at Gentofte, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Alessandra Arcolaci
- Immunology Unit, University Hospital of Verona, Policlinico G.B. Rossi, Verona, Italy
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein, Faculty of Medicine, Technical University of Munich, Munich, Germany
| | - Francesca Mori
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital
| | - Cristobalina Mayorga
- Allergy Clinical Unit, Hospital Regional Universitario de Málaga-Instituto de Investigación Biomédica de Málaga-IBIMA, ARADyAL, Málaga, Spain
| | | | | | - Luis Moral
- Moral Luis. Pediatric Allergy and Respiratory Unit, Alicante University General Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Giovanna Zanoni
- Giovanna Zanoni, Immunology Unit, Policlinico G.B. Rossi, Azienda Ospedaliera Universitaria Integrata Verona, Italy
| | - Mauro Pagani
- Medicine Department, Medicine Ward Mantova Hospital, ASST di Mantova, Italy
| | - Angèle Soria
- Sorbonne Université, INSERM 1135 Cimi-Paris, Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, Departement de dermatologie et d'allergologie, Paris, France
| | - Maja Jošt
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, Slovenia
| | - Jean-Christoph Caubet
- Department of Women-Children-Teenagers, University Hospital of Geneva, Geneva, Switzerland
| | - Abreu Carmo
- Allergy and Clinical Immunology Unit, Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real and Allergy and Clinical Immunology Unit, Centro Hospitalar do Baixo Vouga, Aveiro, Portugal
| | - Al-Ahmad Mona
- Microbiology Department, Faculty of Medicine, Kuwait University, Kuwait
| | | | - Sevim Bavbek
- School of Medicine, Department of Pulmonary Diseases, Division of Allergy, FAAAI, Ankara University, Ankara, Turkey
| | - Biagioni Benedetta
- Division of Internal Medicine, Hepatobiliary and Immunoallergic Disease, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy
| | - M Beatrice Bilo
- Department of Clinical and Molecular Sciences, Università Politecnica delle Marche, Ancona, Italy
- Allergy Unit - Department of Internal Medicine, University Hospital Ospedali Riuniti di Ancona, Italy
| | | | - Herrera Gádor Bogas
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, and Allergy Unit, Hospital Regional Universitario de Málaga-HRUM, Málaga, Spain
| | - Alessandro Buonomo
- Allergy Unit - Fondazione Policlinico Gemelli IRCCS - Largo Gemelli, Rome, Italy
| | | | - Giulia Carli
- SOS Allergologia e Immunologia, Azienda USL Toscana Centro, Ospedale S. Stefano, Prato, Italy
| | - Josefina Cernadas
- Allergy and Clinical Immunology Department, Centro Hospitalar Universitário de S. João, Porto and Allergy Unit, Hospital Lusíadas, Porto, Portugal
| | - Gabriele Cortellini
- Allergy Unit, Departments of Internal Medicine, Azienda Sanitaria della Romagna, Rimini, Hospital, Rimini, Italy
| | - Gülfem Celik
- Department of Chest Diseases, Division of Immunology and allergy, Ankara University School of Medicine cebeci Hospital, Ankara, Turkey
| | - Semra Demir
- Istanbul University, Istanbul Faculty of Medicine, Internal Medicine, Immunology and Allergic Diseases, Istanbul, Turkey
| | - Inmaculada Doña
- Allergy Research Group, Allergy Unit, Hospital Regional Universitario de Málaga, Instituto de Investigación Biomédica de Málaga-IBIMA, Plaza del Hospital Civil s/n, Málaga, Spain
| | | | - Bernadette Eberlein
- Faculty of Medicine, Department of Dermatology and Allergy Biederstein, Technical University of Munich, Munich, Germany
| | - Emilia Faria
- Allergy and Clinical Immunology Unit, Centro Hospitalar E Universitário de Coimbra, Coimbra, Portugal
| | - Bryan Fernandes
- Barts Health NHS Trust, St Bartholomew's Hospital, London, UK
| | - Tomaz Garcez
- Immunology Department, Manchester University NHS Foundation Trust, Manchester, UK
| | | | - Radoslaw Gawlik
- Department of Internal Diseases, Allergology and Clinical Immunology, Medical University of Silesia, Katowice, Poland
| | - Asli Gelincik
- Istanbul University, Istanbul Faculty of Medicine, Internal Medicine, Immunology and Allergic Diseases, Istanbul, Turkey
| | - Eva Gomes
- Allergy Department, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Jimmy H C Gooi
- Department of Clinical Immunology, King's College Hospital, London, UK
| | - Martine Grosber
- Department of Dermatology, Universitair Ziekenhuis, Vrije Universiteit Brussel, Brussel, Belgium
| | - Theo Gülen
- Department of Respiratory Medicine and Allergy, Department of Medicine, Karolinska University Hospital Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Florence Hacard
- Allergology and Clinical Immunology Department, Centre Hospitalier Lyon-Sud, Pierre-Bénite, France
| | - Cyrille Hoarau
- Service transversal d'allergologie et immunologie clinique, CHR de Tours, Tours, France
| | | | | | - Lukas Joerg
- Division of Allergology and Clinical Immunology, Department of Pneumology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Seçil Kepil Özdemir
- Department of Chest Diseases, Division of Allergy and Immunology, Chest Diseases and Surgery Training and Research Hospital, Izmir, Turkey
| | - Ludger Klimek
- Center for Rhinology and Allergology, Wiesbaden, Germany
| | | | - Marek L Kowalski
- Department of Immunology and Allergy, Medical University of Lodz, Poland
| | - Semanur Kuyucu
- Faculty of Medicine, Dpt of Pediatric Allergy and Immunology, Mersin University, Mersin, Turkey
| | - Violeta Kvedariene
- Institute of Biomedical Sciences, Department of Pathology, Faculty of Medicine, Vilnius University, Institute of Clinical Medicine, Clinic of Chest diseases, Immunology and Allergology, Faculty of Medicine, Vilnius, Lithuania
| | - Jose Julio Laguna
- Allergy Unit, Allergo-Anaesthesia Unit, Faculty of Medicine, Hospital Central de la Cruz Roja, Alfonso X El Sabio University, Madrid, Spain
| | | | - Susana Marinho
- Allergy Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust and University of Manchester, Manchester, UK
| | | | - Elisa Meucci
- SOS Allergologia ed Immunologia clinica, Azienda USL Toscana Centro, Ospedale San Giovanni di Dio, Firenze, Italy
| | | | | | | | - Alla Nakonechna
- Allergy and Clinical Immunology Department, University of Liverpool, Royal Preston Hospital, Lancashire Teaching Hospitals, NHS Foundation Trust, UK
| | - Florin-Dan Popescu
- Department of Allergology, Carol Davila University of Medicine and Pharmacy, Nicolae Malaxa Clinical Hospital, Bucharest, Romania
| | - Grzegorz Porebski
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Krakow, Poland
| | - Anna Radice
- SOS Allergologia ed Immunologia clinica, Azienda USL Toscana Centro, Ospedale San Giovanni di Dio, Firenze, Italy
| | - Frederico S Regateiro
- Allergy and Clinical Immunology Unit, Centro Hospitalar E Universitário de Coimbra, Coimbra, Portugal
- Institute of Immunology, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
- ICBR - Coimbra Institute for Clinical and Biomedical Research, CIBB, Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Heike Röckmann
- Department of Dermatology, University Medical Centre Utrecht-Heidelberglaan 100, Utrecht, The Netherlands
| | | | - Ravishankar Sargur
- Clinical Immunology and Allergy Unit, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Joaquin Sastre
- Allergy Department, Fundación Jiménez Diaz, Universidad Autonoma de Madrid, CIBERES, Instituto de Salud Carlos III, Spain
| | | | | | - Marta Sobotkova
- Department of Immunology, Motol University Hospital and 2nd Faculty of Medicine Charles University, Prague, Czech Republic
| | | | - Regina Treudler
- Department of Dermatology, Venerology and Allergology, Universitätsmedizin Leipzig, Leipzig, Germany
| | - Jolanta Walusiak-Skorupa
- Department of Occupational Diseases and Environmental Health, Walusiak-Skorupa Jolanta, Nofer Institute of Occupational Medicine, Lodz, Poland
| | - Bettina Wedi
- Department of Dermatology & Allergy, OE6600, Comprehensive Allergy Center, Hannover Medical School, Hannover, Germany
| | - Stefan Wöhrl
- Floridsdorf Allergy Center (FAZ), Vienna, Austria
| | - Mihael Zidarn
- University Clinic of Respiratory and Allergic Diseases Golnik, Golnik, and Internal Medicine, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Torsten Zuberbier
- Charité - Universitätsmedizin Berlin, Klinik für Dermatologie, Berlin, Germany
| | - Ioana Agache
- Faculty of Medicine, Transylvania University, Brasov, Romania
| | - Maria J Torres
- Allergy Unit, Regional University Hospital of Malaga, IBIMA-UMA-ARADyAL, Malaga, Spain
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9
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New Challenges in Drug Allergy: the Resurgence of Excipients. CURRENT TREATMENT OPTIONS IN ALLERGY 2022; 9:273-291. [PMID: 35910462 PMCID: PMC9308858 DOI: 10.1007/s40521-022-00313-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/20/2022] [Indexed: 10/28/2022]
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10
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Anaphylaxis to drug excipients. ALLERGO JOURNAL INTERNATIONAL 2022; 31:137-140. [PMID: 35669611 PMCID: PMC9155194 DOI: 10.1007/s40629-022-00214-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 04/05/2022] [Indexed: 11/12/2022]
Abstract
In addition to the therapeutic agent, drugs contain excipients such as stabilizers, preservatives, solubilizers, or dyes, some of which are identical to additives in foods. Anaphylaxis to these excipients is probably an underestimated problem. After the first descriptions of anaphylactic reactions to drug excipients appeared more than 30 years ago, the number of corresponding reports has increased significantly over the years. However, a diagnostic gap exists in the clarification of drug allergic reactions when the index product is not known and/or is not available for testing. In the present work, individual excipients are presented as examples for which publications on anaphylaxis are available. Furthermore, the options of allergological testing both in vivo and in vitro are discussed. The pathogenesis of such reactions is still unresolved in many cases, and current concepts are briefly presented in the conclusion. With increasing knowledge about anaphylaxis to drug excipients, it is assumed that these can then be recognized more often and diagnostically clarified.
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11
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Anaphylaxie auf Hilfsstoffe in Arzneimitteln. ALLERGO JOURNAL 2022; 31:40-43. [PMID: 35911655 PMCID: PMC9309020 DOI: 10.1007/s15007-022-5055-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Neben dem therapeutischen Agens enthalten Arzneimittel Hilfsstoffe als beispielsweise Stabilisatoren, Konservierungsstoffe, Löslichkeitsvermittler oder Farbstoffe, die teilweise identisch mit Zusatzstoffen in Nahrungsmitteln sind. Anaphylaxien auf diese Hilfsstoffe sind ein vermutlich unterschätztes Problem. Nachdem erste Beschreibungen anaphylaktischer Reaktionen auf Arzneimittelhilfsstoffe bereits vor über 30 Jahren auftauchten, hat die Zahl entsprechender Berichte in den letzten Jahren deutlich zugenommen. Eine diagnostische Lücke besteht allerdings in der Abklärung arzneimittelallergischer Reaktionen, wenn das Indexpräparat nicht bekannt ist und/oder nicht als Originalpräparat für Testungen zur Verfügung steht. In der vorliegenden Arbeit werden einzelne Hilfsstoffe exemplarisch vorgestellt, für die Publikationen zu Anaphylaxien vorliegen. Des Weiteren werden die Optionen allergologischer Testungen sowohl in vivo als auch in vitro besprochen. Die Pathogenese derartiger Reaktionen ist vielfach noch unklar, hier werden abschließend aktuelle Konzepte kurz vorgestellt. Mit zunehmendem Wissen über Anaphylaxien auf Arzneimittelhilfsstoffe ist davon auszugehen, dass diese auch vermehrt wahrgenommen und diagnostisch aufgeklärt werden können. Zitierweise: Pfützner W. Anaphylaxis to drug excipients. Allergo J Int 2022;31:137-40 https://doi.org/10.1007/s40629-022-00214-9
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12
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Escudero C, Prieto-Montaño P, Audicana MT. Adverse Reactions to Anti-Infective Vaccines: an Emerging Problem in the COVID-19 Era. CURRENT TREATMENT OPTIONS IN ALLERGY 2022; 9:250-272. [PMID: 35789930 PMCID: PMC9244417 DOI: 10.1007/s40521-022-00311-8] [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] [Accepted: 06/13/2022] [Indexed: 11/23/2022]
Abstract
Purpose of review Vaccines are an essential tool for preventing infectious diseases and reducing associated morbidity and mortality. Vaccination has a significant impact at both individual and community levels, and COVID‐19 vaccination programs are a new example of the great value of this public health strategy. However, adverse reactions, especially severe reactions such as anaphylaxis, prevent these programs from progressing properly, thus limiting vaccination uptake in the population. Recent findings The frequency of reactions and types of vaccine components, with special attention to COVID-19 vaccines studies, provides information on the magnitude and causes of adverse events. The understanding of mechanisms involved has made it possible to adequately guide diagnosis, especially to COVID-19 vaccine components, such as polyethylene glycol, trometamol, and polysorbate-80. Summary This review focuses on adverse reactions to vaccines, with emphasis on allergic reactions. A diagnostic pathway is suggested that, on the one hand, enables to take the necessary precautions in persons with a history of allergy to vaccine components or allergic reactions to vaccines and, on the other, supports administration of subsequent doses. The overall objective is to ensure that people with allergy can be vaccinated in the same way as the rest of the population, and that they are offered alternatives where necessary.
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13
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Shi D, Beasock D, Fessler A, Szebeni J, Ljubimova JY, Afonin KA, Dobrovolskaia MA. To PEGylate or not to PEGylate: Immunological properties of nanomedicine's most popular component, polyethylene glycol and its alternatives. Adv Drug Deliv Rev 2022; 180:114079. [PMID: 34902516 PMCID: PMC8899923 DOI: 10.1016/j.addr.2021.114079] [Citation(s) in RCA: 137] [Impact Index Per Article: 68.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 12/01/2021] [Accepted: 12/03/2021] [Indexed: 01/03/2023]
Abstract
Polyethylene glycol or PEG has a long history of use in medicine. Many conventional formulations utilize PEG as either an active ingredient or an excipient. PEG found its use in biotechnology therapeutics as a tool to slow down drug clearance and shield protein therapeutics from undesirable immunogenicity. Nanotechnology field applies PEG to create stealth drug carriers with prolonged circulation time and decreased recognition and clearance by the mononuclear phagocyte system (MPS). Most nanomedicines approved for clinical use and experimental nanotherapeutics contain PEG. Among the most recent successful examples are two mRNA-based COVID-19 vaccines that are delivered by PEGylated lipid nanoparticles. The breadth of PEG use in a wide variety of over the counter (OTC) medications as well as in drug products and vaccines stimulated research which uncovered that PEG is not as immunologically inert as it was initially expected. Herein, we review the current understanding of PEG's immunological properties and discuss them in the context of synthesis, biodistribution, safety, efficacy, and characterization of PEGylated nanomedicines. We also review the current knowledge about immunological compatibility of other polymers that are being actively investigated as PEG alternatives.
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Key Words
- Poly(ethylene)glycol, PEG, immunogenicity, immunology, nanomedicine, toxicity, anti-PEG antibodies, hypersensitivity, synthesis, drug delivery, biotherapeutics
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Affiliation(s)
- Da Shi
- Nanotechnology Characterization Lab, Frederick National Laboratory for Cancer Research sponsored by the National Cancer Institute, Frederick MD, USA
| | - Damian Beasock
- University of North Carolina Charlotte; Charlotte, NC, USA
| | - Adam Fessler
- University of North Carolina Charlotte; Charlotte, NC, USA
| | | | | | | | - Marina A. Dobrovolskaia
- Nanotechnology Characterization Lab, Frederick National Laboratory for Cancer Research sponsored by the National Cancer Institute, Frederick MD, USA;,Corresponding author:
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14
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Laisuan W. COVID-19 Vaccine Anaphylaxis: Current Evidence and Future Approaches. FRONTIERS IN ALLERGY 2021; 2:801322. [PMID: 35387045 PMCID: PMC8974674 DOI: 10.3389/falgy.2021.801322] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 12/02/2021] [Indexed: 12/26/2022] Open
Abstract
Vaccine anaphylaxis is rare; however, severe allergic reactions after administration of a coronavirus disease 2019 (COVID-19) vaccines have been reported. Excipients in the vaccine may play a role in severe allergic reactions post-vaccination. Various mechanisms, including IgE-mediated pathways, direct mass cell stimulation via the Mas-related G protein-coupled receptor-X2, and complement pathway activation, have been proposed to cause the anaphylaxis. Skin testing, using the basophil activation test, has been used to clarify the mechanism of the anaphylaxis and provide safety information for the next injection. Here, we review the current evidence and suggested approaches for patients who experienced an immediate severe allergic reaction to the first dose of a COVID-19 vaccine.
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15
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Marchi F, Sutera D, Carabelli A. Towards the best approach to PEG allergy. Clin Exp Allergy 2021; 52:578-579. [PMID: 34923681 DOI: 10.1111/cea.14083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 12/15/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Francesco Marchi
- SD Allergologia Clinica, Azienda Ospedaliero-Universitaria Pisana, Via Roma 67, 56126, Pisa, Italy
| | - Donatella Sutera
- SD Allergologia Clinica, Azienda Ospedaliero-Universitaria Pisana, Via Roma 67, 56126, Pisa, Italy
| | - Anna Carabelli
- SD Allergologia Clinica, Azienda Ospedaliero-Universitaria Pisana, Via Roma 67, 56126, Pisa, Italy
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16
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Katz JS, Chou DK, Christian TR, Das TK, Patel M, Singh SN, Wen Y. Emerging Challenges and Innovations in Surfactant-mediated Stabilization of Biologic Formulations. J Pharm Sci 2021; 111:919-932. [PMID: 34883096 DOI: 10.1016/j.xphs.2021.12.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 12/03/2021] [Accepted: 12/03/2021] [Indexed: 02/08/2023]
Abstract
Biologics may be subjected to various destabilizing conditions during manufacturing, transportation, storage, and use. Therefore, biologics must be appropriately formulated to meet their desired quality target product profiles. In the formulations of protein-based biologics, one critical component is surfactant. Polysorbate 80 and Polysorbate 20 remain the most commonly used surfactants. Surfactants can stabilize proteins through different mechanisms and help the proteins withstand destabilization stresses. However, the challenges associated with surfactants, for instance, impurities, degradation, and potential triggering of adverse immune responses, have been encountered. Therefore, there are continued efforts to develop novel surfactants to overcome these challenges associated with traditional surfactants. Meanwhile, surfactants have also found their use in formulations of newer and novel modalities, namely, antibody-drug conjugates, bispecific antibodies, and adeno-associated viruses (AAV). This review provides an updated in-depth discussion of surfactants in the above-mentioned areas, namely mechanism of action of surfactants, a critical review of challenges with surfactants and current mitigation approaches, and emerging technologies to develop novel surfactants. In addition, gaps, current mitigations, and future directions have been presented to trigger further discussion and research to facilitate the use and development of novel surfactants.
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Affiliation(s)
- Joshua S Katz
- Pharma Solutions R&D, International Flavors and Fragrances, Wilmington, DE 19803, USA.
| | - Danny K Chou
- Compassion BioSolution, LLC, Lomita, CA 90717, USA
| | | | - Tapan K Das
- Bristol Myers Squibb, Biologics Development, New Brunswick, NJ 08903, USA
| | - Mayank Patel
- Dosage Form Design and Development, BioPharmaceuticals Development, R&D, AstraZeneca, Gaithersburg, USA
| | - Shubhadra N Singh
- GlaxoSmithKline R&D, Biopharmaceutical Product Sciences, Collegeville, PA 19426, USA
| | - Yi Wen
- Lilly Research Laboratory, Eli Lilly and Company, Indianapolis, IN 46285, USA
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17
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Sugino H, Sawada Y, Nakamura M. Macular‐type cutaneous adverse reaction due to atezolizumab and pembrolizumab. JOURNAL OF CUTANEOUS IMMUNOLOGY AND ALLERGY 2021. [DOI: 10.1002/cia2.12206] [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)
- Hitomi Sugino
- Department of Dermatology University of Occupational and Environmental Health Fukuoka Japan
| | - Yu Sawada
- Department of Dermatology University of Occupational and Environmental Health Fukuoka Japan
| | - Motonobu Nakamura
- Department of Dermatology University of Occupational and Environmental Health Fukuoka Japan
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18
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Abstract
Vaccination has played a crucial role in the improvement of global health. Some of the world's deadliest diseases, like smallpox and rinderpest, have been eradicated with the help of vaccines, and many others have been restrained. The appearance of the strain of coronavirus disease 2019 (COVID-19) severe acute respiratory syndrome coronavirus 2 and its impact on global health have made the development of effective and safe vaccines crucial for this new lethal disease. So far, there are three main types of COVID-19 vaccines in use around the world: messenger RNA-based vaccines, adenoviral vector vaccines, and inactivated whole-virus vaccines. Some of them have passed through phase 3 of safety and efficacy trials and are widely used for prophylaxis of COVID-19 infection. A plethora of cutaneous adverse events have been reported, most of them mild or moderate injection-site reactions. Some rare delayed inflammatory reactions such as "COVID arm" have also been reported, posing questions on their pathophysiology and clinical importance. Some rare serious adverse events, such as vaccine-induced prothrombotic immune thrombocytopenia and anaphylaxis, have been described raising great concerns on the safety of some widely spread vaccines. More data need to be collected with further and more detailed analysis. The overall risk of such severe adverse reactions remains extremely low, and the benefits of the existing vaccines in combating the widespread threat of COVID-19 continue to outweigh the risk of their side effects.
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Affiliation(s)
- Georgi Bogdanov
- Department of Pharmacology and Toxicology, Medical University Sofia, Sofia, Bulgaria.
| | - Ivan Bogdanov
- Acibadem City Clinic Tokuda Hospital, Sofia, Bulgaria
| | - Jana Kazandjieva
- Department of Dermatology and Venerology, Medical University Sofia, Sofia, Bulgaria
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19
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Caballero ML, Krantz MS, Quirce S, Phillips EJ, Stone CA. Hidden Dangers: Recognizing Excipients as Potential Causes of Drug and Vaccine Hypersensitivity Reactions. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2021; 9:2968-2982. [PMID: 33737254 PMCID: PMC8355062 DOI: 10.1016/j.jaip.2021.03.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 02/22/2021] [Accepted: 03/03/2021] [Indexed: 12/18/2022]
Abstract
Excipients are necessary as a support to the active ingredients in drugs, vaccines, and other products, and they contribute to their stability, preservation, pharmacokinetics, bioavailability, appearance, and acceptability. For both drugs and vaccines, these are rare reactions; however, for vaccines, they are the primary cause of immediate hypersensitivity. Suspicion for these "hidden dangers" should be high, in particular, when anaphylaxis has occurred in association with multiple chemically distinct drugs. Common excipients implicated include gelatin, carboxymethylcellulose, polyethylene glycols, and products related to polyethylene glycols in immediate hypersensitivity reactions and propylene glycol in delayed hypersensitivity reactions. Complete evaluation of a suspected excipient reaction requires detailed information from the product monograph and package insert to identify all ingredients that are present and to understand the function and structure for these chemicals. This knowledge helps develop a management plan that may include allergy testing to identify the implicated component and to give patients detailed information for future avoidance of relevant foods, drugs, and vaccines. Excipient reactions should be particularly considered for specific classes of drugs where they have been commonly found to be the culprit (eg, corticosteroids, injectable hormones, immunotherapies, monoclonal antibodies, and vaccines). We provide a review of the evidence-based literature outlining epidemiology and mechanisms of excipient reactions and provide strategies for heightened recognition and allergy testing.
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Affiliation(s)
| | - Matthew S Krantz
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Santiago Quirce
- Department of Allergy, La Paz University Hospital, IdiPAZ, Madrid, Spain; Department of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Elizabeth J Phillips
- Division of Infectious Disease, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn; Department of Pharmacology, Vanderbilt School of Medicine, Nashville, Tenn; Institute of Immunology and Infectious Diseases, Murdoch University, Murdoch, Australia
| | - Cosby A Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn.
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20
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Novak N, Tordesillas L, Cabanillas B. Adverse rare events to vaccines for COVID-19: From hypersensitivity reactions to thrombosis and thrombocytopenia. Int Rev Immunol 2021; 41:438-447. [PMID: 34251972 PMCID: PMC8290371 DOI: 10.1080/08830185.2021.1939696] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 05/14/2021] [Accepted: 05/29/2021] [Indexed: 01/18/2023]
Abstract
Vaccines for the prevention of coronavirus disease 2019 (COVID-19) started to be developed since the initiation of the COVID-19 pandemic. Up to now, four vaccines have been authorized by international agencies such as European Medicines Agency (EMA). Two are DNA vaccines (ChAdOx1 nCov-19 and Ad26.COV2.S) and two mRNA vaccines (BNT162b2 and mRNA-1273). The administration of the vaccines has been associated with a strong decrease in the infections by SARS-CoV-2 and deaths associated with it. However, in parallel to these results, some rare adverse events have also been described. In that sense, events of thrombosis, thrombocytopenia, and hemorrhage have been described in close temporal proximity to the administration of the DNA vaccines ChAdOx1 nCov-19 and Ad26.COV2.S, but also mRNA vaccines. Recent scientific reports have been released with updated information on the possible association of thrombotic thrombocytopenia and COVID-19 vaccines. On the other hand, since the initiation of the vaccination campaigns, adverse hypersensitivity reactions have been described after mRNA and DNA vaccines administration for COVID-19. Although globally these adverse events are rare, a high proportion of the world population will be exposed to these vaccines. For that reason, their safety and tolerance should be carefully considered. In this review, we provide an updated review of the last scientific findings that can explain the rare side effects that the vaccines for COVID-19 can produce.
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Affiliation(s)
- Natalija Novak
- Department of Dermatology and Allergy, University Hospital, Bonn, Germany
| | - Leticia Tordesillas
- Department of Tumor Biology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Beatriz Cabanillas
- Department of Allergy, Research Institute Hospital 12 de Octubre, Madrid, Spain
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21
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Abstract
BACKGROUND Allergic contact dermatitis (ACD) may occur secondary to topical antifungals containing potential allergens in their vehicles. Variation of allergenic ingredients among commonly used antifungal creams (AFCs) has not been well characterized. OBJECTIVE The study goal was to assess the frequency of allergenic ingredients in 4 commonly used topical AFCs. METHODS Topical AFCs (clotrimazole, ketoconazole, miconazole, and terbinafine) were selected, and the ingredient lists for these products were obtained from the US Food and Drug Administration's Online Label Repository via a proprietary name search. A systematic literature review was performed using the ingredient name on MEDLINE (PubMed) database to identify reports of ACD confirmed by patch testing. RESULTS Of the 20 ingredients analyzed, 6 had frequent allergenic potential. Propylene glycol was the most common cause of ACD identified in the literature and is an ingredient in ketoconazole 2% and miconazole nitrate 2%. Ketoconazole 2% and miconazole nitrate 2% creams contained the highest number of potential allergens (n = 3) among the 4 creams analyzed. CONCLUSIONS Of the 4 creams, terbinafine hydrochloride 1% and clotrimazole 1% contained the least number of potential allergenic ingredients. Awareness of the allergenic potential of commonly used AFCs may help health care providers when evaluating patients with ACD.
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22
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Allergy to COVID-19 vaccines: A current update. Allergol Int 2021; 70:313-318. [PMID: 33962863 PMCID: PMC8062405 DOI: 10.1016/j.alit.2021.04.003] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 03/20/2021] [Accepted: 04/06/2021] [Indexed: 01/04/2023] Open
Abstract
Adverse allergic reactions due to the administration of the vaccines developed for the protection of coronavirus disease 2019 (COVID-19) have been reported since the initiation of the vaccination campaigns. Current analyses provided by the Center for Disease Control and Prevention (CDC) and Food and Drug Administration (FDA) in the United States have estimated the rates of anaphylactic reactions in 2.5 and 11.1 per million of mRNA-1273 and BNT162b2 vaccines administered, respectively. Although rather low, such rates could have importance due to the uncommon fact that a large majority of the world population will be subjected to vaccination with the aforementioned vaccines in the following months and vaccination will most likely be necessary every season as for influenza vaccines. Health regulators have advised that any subject with a previous history of allergy to drugs or any component of the vaccines should not be vaccinated, however, certain misunderstanding exists since allergy to specific excipients in drugs and vaccines are in occasions misdiagnosed due to an absence of suspicion to specific excipients as allergenic triggers or due to inaccurate labeling or nomenclature. In this review, we provide an updated revision of the most current data regarding the anaphylactic reactions described for BNT162b2 vaccine, mRNA-1273 vaccine, and AZD1222 vaccine. We extensively describe the different excipients in the vaccines with the potential to elicit systemic allergic reactions such as polyethylene glycol (PEG), polysorbates, tromethamine/trometamol, and others and the possible immunological mechanisms involved.
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23
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Castano-Jaramillo LM, Toledo-Salinas C, Pardo-Diaz E, Contreras-Verduzco FA, Mendoza-Hernandez DA. Anaphylaxis to Subcutaneous Immunoglobulin in a Severe Combined Immunodeficiency Patient. J Clin Pharmacol 2021; 61:1386-1387. [PMID: 33956994 DOI: 10.1002/jcph.1889] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 04/23/2021] [Indexed: 11/10/2022]
Affiliation(s)
- Lina Maria Castano-Jaramillo
- Allergy and Clinical Immunology fellow, Instituto Nacional de Pediatria, Universidad Nacional Autonoma de Mexico, Mexico City, Mexico
| | - Carla Toledo-Salinas
- Allergy and Clinical Immunology fellow, Instituto Nacional de Pediatria, Universidad Nacional Autonoma de Mexico, Mexico City, Mexico
| | - Edwin Pardo-Diaz
- Allergy and Clinical Immunology fellow, Instituto Nacional de Pediatria, Universidad Nacional Autonoma de Mexico, Mexico City, Mexico
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24
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Alpalhão M, Maia-Silva J, Filipe P. Severe Acute Respiratory Syndrome Coronavirus 2 Vaccines and Cutaneous Adverse Reactions: A Review. Dermatitis 2021; 32:133-139. [PMID: 33851937 DOI: 10.1097/der.0000000000000755] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
We are entering a new stage of the severe acute respiratory syndrome coronavirus 2 pandemic with the initiation of large-scale vaccination programs globally. In these circumstances, even rare adverse effects of vaccines may be encountered more often, if millions of people are to be vaccinated in a short period. Vaccination has the potential for causing cutaneous adverse effects. Thus, it is paramount that dermatologists worldwide are acquainted with the possible skin reaction patterns to the coming vaccines. Herein, we conduct a review to discuss the most frequent cutaneous adverse effects of vaccines and their management, with a particular focus on the expected adverse reactions for the coming severe acute respiratory syndrome coronavirus 2 vaccines, such as local reactions, as well as immediate- and delayed-type hypersensitivity reactions, including erythema multiforme, Stevens-Johnson syndrome, toxic epidermal necrosis, serum sickness-like reactions, and vasculitides. We also discuss the yet unanswered questions on vaccines for which we may soon be asked to provide an expert opinion.
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Banerji A, Wickner PG, Saff R, Stone CA, Robinson LB, Long AA, Wolfson AR, Williams P, Khan DA, Phillips E, Blumenthal KG. mRNA Vaccines to Prevent COVID-19 Disease and Reported Allergic Reactions: Current Evidence and Suggested Approach. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2021; 9:1423-1437. [PMID: 33388478 PMCID: PMC7948517 DOI: 10.1016/j.jaip.2020.12.047] [Citation(s) in RCA: 294] [Impact Index Per Article: 98.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 12/28/2020] [Indexed: 12/31/2022]
Abstract
The U.S. Food and Drug Administration (FDA) has recently issued an Emergency Use Authorization (EUA) for 2 highly effective coronavirus disease 2019 (COVID-19) vaccines from Pfizer-BioNTech and Moderna. This has brought hope to millions of Americans in the midst of an ongoing global pandemic. The FDA EUA guidance for both vaccines is to not administer the vaccine to individuals with a known history of a severe allergic reaction (eg, anaphylaxis) to any component of the COVID-19 vaccine. The Centers for Disease Control and Prevention (CDC) additionally advises individuals with a history of an immediate allergic reaction to a vaccine or injectable or any history of anaphylaxis be observed for 30 minutes after COVID-19 vaccination. All other individuals should be observed for 15 minutes after COVID-19 vaccination. Staff at vaccine clinics must be able to identify and manage anaphylaxis. Post-FDA EUA, despite very strong safety signals in both phase 3 trials, reports of possible allergic reactions have raised public concern. To provide reassurance and support during widespread global vaccination, allergists must offer clear guidance to individuals based on the best information available, but also in accordance with the broader recommendations of regulatory agencies. This review summarizes vaccine allergy epidemiology and proposes drug and vaccine allergy expert opinion informed risk stratification for Allergy specialist use in conjunction with guidance of public health and regulatory authorities. The risk stratification schema guide care for (1) individuals with different allergy histories to safely receive their first mRNA COVID-19 vaccine and (2) individuals who develop a reaction to their first dose of mRNA COVID-19 vaccine.
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Affiliation(s)
- Aleena Banerji
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass.
| | - Paige G Wickner
- Harvard Medical School, Boston, Mass; Division of Allergy and Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Rebecca Saff
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Cosby A Stone
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Lacey B Robinson
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Aidan A Long
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Anna R Wolfson
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Paul Williams
- Allergy Division, University of Washington School of Medicine, Seattle, Wash
| | - David A Khan
- Division of Allergy & Immunology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Elizabeth Phillips
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Harvard Medical School, Boston, Mass; Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital, Boston, Mass
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Shi Y, Tang R, Luo F, Li H, Pan Z, Xu G, Yang Y, Zhao Z, Liang A, Wei JF, Piao Y, Chang C, Sun JL, Platts-Mills TAE. The Diagnosis and Management of Allergic Reactions Caused by Chinese Materia Medica. Clin Rev Allergy Immunol 2021; 62:103-122. [PMID: 33606192 DOI: 10.1007/s12016-020-08812-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2020] [Indexed: 01/21/2023]
Abstract
Traditional Chinese medicines (TCM) have been used in China for thousands of years. Although TCM has been generally perceived to be safe, adverse reactions to Chinese materia medica (CMM) have been reported. Most of the adverse reactions are allergic in nature, but other mechanisms may play a role. This review focuses on the mechanism and clinical presentation of these allergic reactions. Allergic reactions can occur as a result of the active and inactive ingredients of CMM. Impurities and chemicals generated during the production process can also lead to allergic or adverse reactions. Environmental factors such as temperature, humidity, and light can cause changes in the allergenicity of drugs. Human error in formulating CMM drugs also contributes to adverse drug reactions. The management of allergic reactions to CMM includes taking a good history, avoidance of medications in the same class as those which caused prior reactions, the proper training of staff, adherence to manufacturer guidelines and expiration dates, evaluation of benefit and risk balance, and the formulation of a risk management strategy for the use of CMM. A small test dose of a considered drug before using, improvements in drug purification technology, and proper storage and clinical administration help reduce allergic reactions due to CMM.
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Affiliation(s)
- Yue Shi
- Department of Traditional Chinese Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 100730, Beijing, China
| | - Rui Tang
- Department of Allergy, Peking Union Medical College Hospital, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing Key Laboratory of Precision Medicine for Diagnosis and Treatment on Allergic Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, 100730, Beijing, China
| | - Fangmei Luo
- Department of Ophthalmology and Otorhinolaryngology, Qujing Chinese Traditional Medicine Hospital, Yunnan, 655000, Qujing, China
| | - Hong Li
- Department of Allergy, Peking Union Medical College Hospital, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing Key Laboratory of Precision Medicine for Diagnosis and Treatment on Allergic Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, 100730, Beijing, China
| | - Zouxian Pan
- Department of Allergy, Peking Union Medical College Hospital, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing Key Laboratory of Precision Medicine for Diagnosis and Treatment on Allergic Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, 100730, Beijing, China
| | - Guogang Xu
- Department of Respiratory Medicine, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Medical College of PLA, Chinese PLA General Hospital, 100853, Beijing, China
| | - Yongshi Yang
- Department of Allergy, Peking Union Medical College Hospital, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing Key Laboratory of Precision Medicine for Diagnosis and Treatment on Allergic Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, 100730, Beijing, China
| | - Zuotao Zhao
- Department of Dermatology, Peking University First Hospital, Beijing Key Laboratory of Molecular Diagnosis on Dermatoses, National Clinical Research Center for Skin and Immune Diseases, 100034, Beijing, China
| | - Aihua Liang
- Key Laboratory of Beijing for Identification and Safety Evaluation of Chinese Medicine, Institute of Chinese Materia medical, China Academy of Medical Sciences, 10070, Beijing, China
| | - Ji-Fu Wei
- Research Division of Clinical Pharmacology, The First Affiliated Hospital of Nanjing Medical University, No. 300, Guangzhou Road, 210029, Nanjing, Jiangsu, China
| | - Yuanlin Piao
- Department of Traditional Chinese Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 100730, Beijing, China.
| | - Christopher Chang
- Division of Rheumatology, Allergy and Clinical Immunology, University of California, Davis, CA, USA. .,Division of Pediatric Immunology, Allergy and Rheumatology, Joe DiMaggio Children's Hospital, FL, Hollywood, USA.
| | - Jin-Lyu Sun
- Department of Allergy, Peking Union Medical College Hospital, National Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing Key Laboratory of Precision Medicine for Diagnosis and Treatment on Allergic Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, 100730, Beijing, China.
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Huang Z, Tu C, Liu H, Wang L, Zhu Z, Watanabe I. The composition analysis of free and bonded fatty acids in Polysorbate 80 by on-line two-step pyrolytic methylation-gas chromatography. Microchem J 2020. [DOI: 10.1016/j.microc.2020.105342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Gülsen A, Wedi B, Jappe U. Hypersensitivity reactions to biologics (part II): classifications and current diagnostic and treatment approaches*. ALLERGO JOURNAL 2020. [DOI: 10.1007/s15007-020-2567-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Hypersensitivity reactions to biologics (part II): classifications and current diagnostic and treatment approaches. ACTA ACUST UNITED AC 2020. [DOI: 10.1007/s40629-020-00127-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Abstract
Purpose
Biotechnological substances (BS) have rapidly expanded their clinical use. In parallel, there is an increase in expected or unexpected immunological or non-immunological adverse effects. In this part of the review, the current nomenclature of BSs, the classification of hypersensitivity reactions (HSR), as well as diagnostic and treatment approaches are documented to provide the tools to understand the nomenclature used throughout the databases and the need to harmonize it where applicable.
Methods
Detailed searches were performed on Pubmed, Web of Science, and Google Scholar to include all available publications. The search terms, such as specific BS, allergy, anaphylaxis, hypersensitivity, reactions, classification, diagnosis, grading, management, and desensitization, were determined for the search. Case reports, articles, and reviews on this subject were included.
Results
Today, a variety of non-standardized methods are used to support the clinical diagnosis. These include prick-to-prick tests and intradermal tests with the drug itself and its potentially allergenic ingredients. More rarely, anti-drug antibodies are detected and basophil activation tests are used by centers with research facilities. Although the treatment protocols for acute conditions vary, the overall approach is the same.
Conclusion
HSRs to BS are gradually increasing with the widening of their clinical use and indications. It is very important to prevent HSRs and to know the degree of severity as well as the emergency treatment algorithm. This review summarizes the diagnostic tests that should be applied: (a) immediately during/after a reaction, and (b) subsequently, and in the case that a switch of BS is not possible, desensitization is an option.
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Pediatric Safety of Polysorbates in Drug Formulations. CHILDREN-BASEL 2019; 7:children7010001. [PMID: 31877624 PMCID: PMC7022221 DOI: 10.3390/children7010001] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Revised: 12/17/2019] [Accepted: 12/18/2019] [Indexed: 12/02/2022]
Abstract
Polysorbates 20 and 80 are the most frequently used excipients in biotherapeutics, the safety data for which have been well documented in adults. The polysorbate content in therapeutic formulations that are administered to children, however, has been less clearly regulated or defined with regard to safety. In pediatric patients, excessive amounts of polysorbate in biotherapeutics have been linked to hypersensitivity and other toxicity-related effects. To determine safe levels of polysorbates for young patients, we have developed the progressive pediatric safety factor (PPSF), an age- and weight-based tool that estimates the amount of parenterally administered polysorbates 20 and 80 in formulations that will avoid excipient-related adverse events. Compared with existing modalities for calculating maximum acceptable doses of excipients for initial clinical trials in pediatrics, the PPSF is far more conservative, thus constituting an added margin of safety for excipient exposure in the most sensitive subpopulations—i.e., neonates and infants. Further, the PPSF may be applied to any relevant excipient, aiding pharmaceutical developers and regulatory authorities in conservatively estimating the safety assessment of a biotherapeutic’s formulation, based on excipient levels.
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PANICO A, SERIO F, BAGORDO F, GRASSI T, IDOLO A, DE GIORGI M, GUIDO M, CONGEDO M, DE DONNO A. Skin safety and health prevention: an overview of chemicals in cosmetic products. JOURNAL OF PREVENTIVE MEDICINE AND HYGIENE 2019; 60:E50-E57. [PMID: 31041411 PMCID: PMC6477564 DOI: 10.15167/2421-4248/jpmh2019.60.1.1080] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 01/14/2019] [Indexed: 11/16/2022]
Abstract
Introduction Cosmetic products contain a wide range of chemicals to which we are exposed every day. The aim of the study was to determine the presence of potential dangerous substances which can cause adverse health effects by examining product labels. Materials and methods A total of 283 products were collected from various shops in Lecce (Italy) and divided into 3 categories: rinse-off, leave-on and make-up. The label of every product was examined and a list including fragrances, preservatives and other chemicals of concern was created. Results Fragrances were present in 52.3% of the examined products, mostly limonene (76.9%) and linalool (64.6%) but also citronellol (34.1%), geraniol (31.5%), coumarin (30%) and hexyl cinnamal (29.2%). Preservatives showed a rate of 60% and the most frequently identified were phenoxyethanol (48.7%), sodium benzoate (35.6%), potassium sorbate (22%), methylparaben (15.2%) and MI/MCI (9.9%). The other chemicals of concern were detected in 58% of products; included PEGs (62.3%), acrylate copolymer (34%), petrolatum (17.2%), polysorbates (14,8%), BHT (14.7%), ethylhextyl methoxycinnamate (13.6%), benzophenone-1 (3.7%), benzophenone-3 (4.9%), BHA (1.6%), cocamide DEA and toluene (1.2%). Conclusions The use of many of these substances is allowed within certain limits, due to their toxicity at higher concentrations. Other important aspects should be considered as, for instance, the possibility of long-term effects. On the other hand, other substances may induce several acute adverse side-effects, i.e. contact dermatitis and allergic reactions. For these reasons, an enhancement of the criteria used for cosmetics formulation is required since many chemicals used singularly or combined are potentially unsafe.
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Affiliation(s)
- A. PANICO
- Department of Biological and Environmental Science and Technology, University of Salento, Lecce, Italy
| | - F. SERIO
- Department of Biological and Environmental Science and Technology, University of Salento, Lecce, Italy
| | - F. BAGORDO
- Department of Biological and Environmental Science and Technology, University of Salento, Lecce, Italy
| | - T. GRASSI
- Department of Biological and Environmental Science and Technology, University of Salento, Lecce, Italy
- Tiziana Grassi, Department of Biological and Environmental Science and Technology, University of Salento, via Prov.le Lecce-Monteroni, 73100 Lecce, Italy - Tel. +39 0832 298863 - E-mail:
| | - A. IDOLO
- Department of Biological and Environmental Science and Technology, University of Salento, Lecce, Italy
| | - M. DE GIORGI
- Department of Biological and Environmental Science and Technology, University of Salento, Lecce, Italy
| | - M. GUIDO
- Department of Biological and Environmental Science and Technology, University of Salento, Lecce, Italy
- Interuniversity Research Centre on Influenza and other transmitted infections (CIRI-IT), Genoa, Italy
| | - M. CONGEDO
- Operating Unit of Dermatology, Vito Fazzi Hospital, Lecce, Italy
| | - A. DE DONNO
- Department of Biological and Environmental Science and Technology, University of Salento, Lecce, Italy
- Interuniversity Research Centre on Influenza and other transmitted infections (CIRI-IT), Genoa, Italy
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Immediate Hypersensitivity to Polyethylene Glycols and Polysorbates: More Common Than We Have Recognized. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 7:1533-1540.e8. [PMID: 30557713 DOI: 10.1016/j.jaip.2018.12.003] [Citation(s) in RCA: 228] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 11/14/2018] [Accepted: 12/02/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND The most common immediate hypersensitivity to macrogols is associated with polyethylene glycol (PEG) 3350; however, the epidemiology, mechanisms, and cross-reactivity are poorly understood. Thousands of medications contain either PEGs or structurally similar polysorbates. OBJECTIVE Our objective was to better understand the mechanism, cross-reactivity, and scope of PEG hypersensitivity. METHODS Two cases with a past history of immediate hypersensitivity to PEG-containing medications were used to study potential mechanisms and cross-reactivity of immediate reactions to PEG 3350. Skin testing and oral challenges with PEG and polysorbate-containing agents were employed to determine clinical reactivity and cross-reactivity between the 2 allergens. Enzyme-linked immunosorbent assay and electrochemiluminescent immunoassay were used to detect anti-PEG specific IgG and IgE, respectively, using PEGylated protein or PEG alone as antigens in 2 cases and 6 PEG 3350 tolerant controls. We searched US Food and Drug Administration (FDA) adverse event reports for immediate reactions to PEG 3350 to determine the potential scope of this problem in the United States. RESULTS Skin and provocation testing demonstrated symptomatic reactivity in both cases to PEG 3350 and polysorbate 80. Plasma samples were positive for anti-PEG specific IgE and IgG antibodies only in cases and binding increased directly proportional to the molecular weight of PEG tested. FDA adverse event reports revealed 53 additional cases of possible PEG 3350 anaphylaxis. CONCLUSIONS Immediate hypersensitivity to PEG 3350 with cross-reactive polysorbate 80 hypersensitivity may be underrecognized in clinical practice and can be detected with clinical skin testing. Our studies raise the possibility of an IgE-mediated type I hypersensitivity mechanism in some cases.
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Perino E, Freymond N, Devouassoux G, Nicolas JF, Berard F. Xolair-induced recurrent anaphylaxis through sensitization to the excipient polysorbate. Ann Allergy Asthma Immunol 2018; 120:664-666. [PMID: 29481891 DOI: 10.1016/j.anai.2018.02.018] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Revised: 02/15/2018] [Accepted: 02/20/2018] [Indexed: 10/18/2022]
Affiliation(s)
- Emilie Perino
- Allergologie et immunologie clinique, CH-Lyon Sud, Hospices Civils de Lyon, Lyon, France.
| | | | - Gilles Devouassoux
- Pneumologie, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France; Université Lyon 1, Lyon, France
| | - Jean-François Nicolas
- Allergologie et immunologie clinique, CH-Lyon Sud, Hospices Civils de Lyon, Lyon, France; Université Lyon 1, Lyon, France; INSERM U 1111-CIRI, Lyon, France
| | - Frédéric Berard
- Allergologie et immunologie clinique, CH-Lyon Sud, Hospices Civils de Lyon, Lyon, France; Université Lyon 1, Lyon, France; INSERM U 1111-CIRI, Lyon, France
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Sun H, Yang R, Wang J, Yang X, Tu J, Xie L, Li C, Lao Q, Sun C. Component-based biocompatibility and safety evaluation of polysorbate 80. RSC Adv 2017. [DOI: 10.1039/c6ra27242h] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Components in polysorbate 80 are separated and classified into nine groups, which are investigated on their purity, safety and biocompatibility.
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Affiliation(s)
- Huimin Sun
- State Key Laboratory of Nature Medicines
- Department of Pharmaceutics
- China Pharmaceutical University
- Nanjing 210009
- China
| | - Rui Yang
- National Institutes for Food and Drug Control
- Beijing 100050
- China
| | - Jue Wang
- National Institutes for Food and Drug Control
- Beijing 100050
- China
| | - Xia Yang
- Yuncheng University
- Yuncheng 044000
- China
| | - Jiasheng Tu
- State Key Laboratory of Nature Medicines
- Department of Pharmaceutics
- China Pharmaceutical University
- Nanjing 210009
- China
| | - Langui Xie
- National Institutes for Food and Drug Control
- Beijing 100050
- China
| | - Chunqi Li
- Hunter Biotechnology, Inc
- Transfarland
- Xiaoshan Economic & Technology
- Hangzhou 311231
- China
| | - Qiaocong Lao
- Hunter Biotechnology, Inc
- Transfarland
- Xiaoshan Economic & Technology
- Hangzhou 311231
- China
| | - Chunmeng Sun
- State Key Laboratory of Nature Medicines
- Department of Pharmaceutics
- China Pharmaceutical University
- Nanjing 210009
- China
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