Use of Rapid Drug Desensitization in Delayed Hypersensitivity Reactions to Chemotherapy and Monoclonal Antibodies

Rapid drug desensitization in seven patients with delayed hypersensitivity reactions to biologics and targeted therapies: Reason, successes, and failures

Backround: Rapid drug desensitization (RDD) is commonly used for immediate drug hypersensitivity reactions (DHR) across various drugs. In delayed DHRs, the conventional approach is slow desensitization; however, limitations may arise due to drug-specific or disease-related factors. With the increasing role of targeted molecular drugs in delayed DHRs, data on the efficacy of RDD in these contexts remain scarce. Objective: This case series aims to explore the rationale and outcomes of RDD in managing delayed DHRs associated with targeted therapies. Methods: We analyzed data from patients referred to a tertiary university hospital's drug allergy outpatient clinic between January 2021 and April 2024. The subjects experienced delayed DHRs during treatment with targeted drugs and, subsequently, underwent RDD. Results: The drugs administered via RDD included bevacizumab, rituximab, daratumumab, lenalidomide, bortezomib, and carfilzomib. The index reactions included maculopapular eruptions (MPE), drug reaction with eosinophilia and systemic symptoms (DRESS), and acute generalized exanthematous pustulosis (AGEP). Delayed breakthrough reactions were observed in four of seven patients. RDD with bortezomib was unsuccessful in all three patients, and delayed reactions were observed in all patients with severe cutaneous adverse reactions (AGEP and DRESS). Conclusion: Suggesting significant success of RDD for delayed DHRs induced by targeted therapies may be overly optimistic. Nevertheless, four of seven patients, including one with AGEP, were able to continue their treatment. Managing patients with advanced diseases and delayed DHR poses notable challenges. The risk to patient survival from withholding life-saving medication must be weighed against the risks of desensitization. The low sensitivity of skin tests and the critical waiting period complicate decision-making. Given the unique contribution of targeted agents in the treatment of severe, life-threatening diseases, further research on desensitization is warranted.

Delayed drug hypersensitivity to anti-tuberculosis drug: a new desensitization scheme

Introduction

Tuberculosis is a communicable illness and one of the leading causes of death, especially in developing countries like Turkey. One of the problems that must be managed well in the treatment of tuberculosis is drug hypersensitivity. The first-line agents are very important for the success of treatment. Alternative drugs are more toxic and less successful in treatment. Therefore, it is very important to be able to include first-line drugs in the post-hypersensitivity regimen. At this point, the success of desensitization comes to the fore. There are fewer studies on rapid drug desensitization in delayed-type drug hypersensitivity to anti-tuberculosis drugs.

Aim

The primary aim of the study was to determine the prevalence of delayed-type hypersensitivity reactions in drug-sensitive cases; the secondary aim was to determine the appropriate treatment management.

Material and methods

This was a retrospective study. Demographic features, tuberculosis diagnostic indicator, clinical signs of developing a hypersensitivity reaction, reaction time, desensitization scheme and treatment were evaluated.

Results

A total of 41 tuberculosis cases were included in the study. Twenty-six of the cases were male; mean age (mean ± SD) 55.44 ±16.93 years; 70.7% of them were diagnosed bacteriologically; 70.7% of them were diagnosed with pulmonary tuberculosis. The most common skin finding was maculopapular drug eruption. The development time (mean ± SD) of the reaction in patients who developed a reaction was 34.93 ±39.62 days. The responsible agent could be identified in 15 reactions. The most common drug responsible for the reaction was rifampicin. Successful desensitization was achieved in 19 (46.3%) cases with the sensitive regimen. The duration of treatment was 8.97 ±3.44 months. When evaluated in terms of treatment results, cure and treatment completion were accepted as treatment success. In this case, 30 (73.2%) patients successfully completed the treatment.

Conclusions

Our study is one of the largest series in which delayed-type hypersensitivity develops under tuberculosis treatment and the desensitization scheme is recommended. A practical, easy desensitization scheme had been shared in this paper.

Infliximab desensitization in patients with inflammatory bowel diseases: a safe therapeutic alternative

BACKGROUND

Hypersensitivity reactions (HSR) to the administration of infliximab (IFX) in Inflammatory Bowel Diseases (IBD) patients are not rare and usually lead to drug discontinuation. We report data on safety and effectiveness of desensitization to IFX in patients with previous HSR.

METHODS

We conducted a retrospective monocentric observational study. Patients for whom a desensitization protocol to IFX was realized after a previous HSR were included. Anti-drug antibodies (ADA) and IFX trough levels at both inclusion and six months after desensitization were collected. Clinical outcomes, including recurrence of HSR were evaluated.

RESULTS

From 2005 to 2020, 27 patients (Crohn's Disease: 26 (96%) were included). Desensitization after HSR was performed after a median time of 10.4 months (2.9-33.1). Nineteen (70%) patients received immunosuppressants at time of desensitization. Eight (30%) patients presented HSR at first (n = 2), second (n = 4) or third (n = 2) IFX perfusion after desensitization. None led to intensive care unit transfer or death. Thirteen (48%) had clinical response at 6 months and 8 (29%) were still under IFX treatment two years after desensitization. IFX trough levels and ADA were available for 14 patients at time of desensitization. Most patients (12 out of 14) had ADA at a high level. At 6 months, among the 7 patients with long term response to IFX, 4 presented a decrease of ADA titers and 2 had a significant trough level of IFX.

CONCLUSION

IFX desensitization in patients with IBD is a safe therapeutic alternative and represents a potential option for patients refractory to multiple biologics.What is already known? Hypersensitivity reactions to the administration of infliximab is frequent. Occurrence of hypersensitivity reaction, either immediate or delayed, usually leads to permanent drug discontinuation.What is new here? Infliximab desensitization is well tolerated with no hypersensitivity reaction recurrence in 70% of patients. Clinical success at 6 months was of 48% and around a third of patients remained under infliximab therapy two years after desensitization. Antidrug antibodies decreased and infliximab trough levels increased in these patients showing the impact of desensitization on immunogenicity.How can this study help patient care? Infliximab desensitization represents a potential option for patients refractory to multiple biologics who presented hypersensitivity reaction to the drug.