Desensitization for the prevention of drug hypersensitivity reactions

Desensitization for Vitamin B12 Hypersensitivity and How to Do It

Vitamin B12 is the common name for a group of cobalamins, which are cobalt corrines. Cobalamins are water-soluble B vitamins. Vitamin B12, as a coenzyme of various enzymes, is an essential component of many key metabolic processes in the body. Vitamin B12 deficiency causes dysfunction of various organs and systems in the body, including the central nervous system. Humans, like other animals, are unable to synthesize cobalamin. This vitamin must be supplied with a balanced diet. The only valuable dietary sources of cobalamin are foods of animal origin, especially offal (e.g., liver). Vegan and vegetarian diets are deficient in vitamin B12. People who follow this nutritional model require systematic cobalamin supplementation, usually in oral form. Other causes of cobalamin deficiency are various pathogenetic processes, in the course of which any of the stages of the complicated process of absorption of this vitamin from the gastrointestinal tract are impaired. Disorders of intestinal absorption of vitamin B12 require systematic supplementation of cobalamin parenterally (usually by intramuscular or subcutaneous injections) for the rest of life. Supplementary therapy with vitamin B12 may cause various adverse reactions, among which hypersensitivity reactions of various spectrums and intensity of symptoms are possible. According to available data, hypersensitivity to cobalamin is more likely after intramuscular or subcutaneous administration than in oral form. It also seems that long-term administration of cobalamin predisposes to allergy to vitamin B12, regardless of its chemical form. Although hypersensitivity to cobalamin is rather rare, it can also be of great clinical importance. This is due to the fact that vitamin B12 deficiency affects a significant part of the population, especially the elderly and those with chronic diseases that impair its absorption. In addition, supplementary therapy with cobalamin is long-term (usually lifelong) and there is no alternative form of treatment. For these reasons, solutions are sought that will allow for the safe continuation of treatment supplementing cobalamin deficiency. Various cyanocobalamin desensitization protocols are proposed, differing in duration, the dynamics of gradual dose increase, or the method of injection (intramuscular or subcutaneous). An analysis of available data in this field suggests that desensitization with cyanocobalamin seems to be an effective way to obtain tolerance to vitamin B12, allowing for long-term supplementation of this vitamin regardless of the chemical form, dose size, frequency, or route of administration.

A Case Report on Rabeprazole Desensitization for a Patient With Barrett's Esophagus and Anaphylaxis to Multiple Proton Pump Inhibitors

We report the case of a 58-year-old male patient with Barrett's esophagus who experienced anaphylaxis following the administration of omeprazole and esomeprazole. The patient was successfully desensitized using rabeprazole despite also being sensitized to rabeprazole. Approximately seven years prior, the patient developed generalized urticaria, angioedema, respiratory distress, and loss of consciousness after taking omeprazole, necessitating emergency medical intervention. One year ago, the patient underwent a drug allergy workup with 20 mg of esomeprazole under our supervision at the clinic. As the prick test was negative, oral provocation with 1/64 of the full dose of esomeprazole (0.31 mg) was performed. However, a couple of hours after administration, the patient developed angioedema, urticaria, and shortness of breath, which led to hospitalization. Given the clinical necessity for proton pump inhibitor (PPI) therapy due to Barrett's esophagus, as recommended by a gastroenterologist, desensitization to rabeprazole 20 mg was initiated in a hospital setting, adhering to established international protocols. Prior to the desensitization, the patient's sensitivity to rabeprazole was confirmed through skin tests. The desensitization procedure was successful. In conclusion, while omeprazole and esomeprazole have a high potential for cross-reactivity due to their structural similarity, rabeprazole may be a viable alternative, though hypersensitivity to rabeprazole should not be ruled out. This case highlights the necessity of considering cross-reactivity in PPI hypersensitivity and underscores the utility of skin tests prior to provocation. When no alternative PPI treatment options are available, a PPI desensitization protocol may be successfully implemented.

Rapid drug desensitization to taxanes: a descriptive study from Turkey

AIM

To present the characteristics of drug hypersensitivity reactions (DHRs) among taxane recipients with non-small cell lung carcinoma (NSCLC), and to describe the results of rapid drug desensitization (RDD).

METHODS

A retrospective cross-sectional study included 45 patients who were treated with taxane for NSCLC and were found to be hypersensitive to taxane. All patients were administered the standard 3-bag, 12-step RDD protocol following the development of DHR. RDD success was evaluated separately for each cycle, and successful RDD was defined as the completion of the cycle with application of 12 steps of the desensitization protocol and the absence of early and/or late reactions afterwards.

RESULTS

Among 45 patients hypersensitive to taxane 43 (95.6%) successfully received taxane cycles with desensitization. Failed RDD occurred in only 2 (4.4%) patients. The total number of desensitization cycles was 183, of which 181 (98.9%) were successful. The mean age of patients with successful desensitization was 59.42 ± 10.48 years and 37 (86.0%) of them were male.

CONCLUSION

RDD is a reliable procedure that enables effective administration and completion of first-line taxane treatments in taxane-sensitive patients.

Single center experience with more than 600 drug desensitization in Colombia

Background

Drug hypersensitivity reactions (DHRs) have a significant impact on both, patient and their treating physicians; it is considered a public health concern. The history of allergy to drugs, limits therapeutic options and will lead to the use of more expensive and potentially less effective options. Drug desensitization (DD) is considered as a procedure with a positive impact on the prognosis of the patient's disease. The objective of this study is to describe the experience with a substantial number of drugs desensitization in a fourth level center in Cali, Colombia.

Methods

An observational, cross-sectional and descriptive study was conducted. Patients with DHRs who underwent a standardized institutional DD protocol, between March of 2012 and May of 2023, were included.

Results

Two hundred forty-one patients were included. The median age was 47.8 years (4-88). One hundred fifty-six (64.7%) were women, including three who were pregnant. A total of 641 DDs were performed. The most frequent groups of drugs for which the desensitization was performed were monoclonal antibodies in 83 patients (34.4%), chemotherapeutic agents in 53 (21.6%), NSAIDs in 44 (18.2%), and antibiotics in 42 (17.4%). Eighty-seven patients (36.1%) experienced hypersensitivity to the culprit drug on first exposure, while 154 (63.9%) exhibited reactions during subsequent cycles. The main clinical presentation that gave rise to desensitization was anaphylaxis in 125 patients (51.8%), followed by cutaneous symptoms in 106 patients (44%). The predominant observed endophenotype was type 1 in 188 patients (78.3%), followed by mixed type in 46 patients (19.2%). Breakthrough reactions were observed in 50 patients (20.7%). Tolerance to DD was achieved in 636 of the procedures (99.2%), allowing the continuity of treatment of choice for the underlying disease.

Conclusions

Most desensitized patients were women with type I reactions. Monoclonal antibodies were the most frequent culprit drugs. DD in patients with DHRs is a useful, safe and effective procedure. The administration of the implicated drug had a positive impact on the course of the disease in these patients.

Safety and oncological effectiveness after desensitization in patients with previous hypersensitivity reactions to chemotherapy

INTRODUCTION

Taxanes and platinum are first-line treatments in gynecological tumors with high rates of hypersensitivity reactions (HSRs), leading to discontinuation of treatment. Desensitization involves induction of temporary tolerance to previously sensitized medications. The aims of this study are to describe HSRs to paclitaxel and carboplatin and evaluate the safety and effectiveness of desensitization protocols in gynecological cancer patients.

METHODS

Original, retrospective, descriptive, analytical study, approved by Bioethics and Research Committee, included >18-year-old patients with gynecological tumors experiencing HSRs to first-line chemotherapy. Patients underwent 3-bag-12-step desensitization.

RESULTS

174 desensitization (95 paclitaxel, 79 carboplatin) in 33 female patients, mean age 45.5 years (18-71y). Cancer diagnosis: breast 8 (24.2%), ovarian 14 (42.2%), endometrial 2 (6.1%) and cervix 9 (27.2%). HSR occurred in paclitaxel during cycles 1-2 and in carboplatin after 6 cycles. The most frequently seen HSR symptom was cardiovascular with paclitaxel (94.7%), and cutaneous (93.3%) with carboplatin. Three-bags 12-steps desensitization protocol (initial dilution 1:100) in 5.67hrs. All patients reached total dose desensitization: 82% with no reaction, 12% mild, 6% moderate and 0% severe reaction. Mean disease-free interval and progression-free interval in months (m): breast cancer 29 m and 14 m, ovarian 22 m and 9 m, endometrial 40 m and cervical cancer: 67.5 m and 27 m. Twenty-five patients (73.5%) are still alive.

CONCLUSION

HSRs to paclitaxel manifest in the first 1-2 cycles and to carboplatin after 6 cycles. Symptoms include cardiovascular, atypical neuromuscular and urticaria. Changing treatment lines impacts prognosis. Our study revealed that ovarian cancer patients undergoing desensitization protocols achieved longer progression-free intervals. All patients successfully reached total dose desensitization. This study provides evidence of the effectiveness and safety of desensitization and promising perspective for continuing first-line treatment with HSRs.

Successful desensitization to atezolizumab-induced near-fatal anaphylaxis in patients with hepatocellular carcinoma: A case report and literature review

Atezolizumab, a humanized antiprogrammed death ligand 1 monoclonal immunoglobulin G1 antibody, is a targeted therapeutic drug known as an immune checkpoint inhibitor. It is currently used to treat various types of cancer, including unresectable hepatocellular carcinoma (HCC), nonsmall cell lung cancer, urothelial cancer, and breast cancer, and is becoming a therapeutic option in the forefront of oncology treatment. However, it may sometimes lead to undesirable adverse reactions owing to the activation of immune responses in various organs. Cutaneous adverse reactions to atezolizumab are well known; however, cases of anaphylaxis are very rare. In this report, we present the first case of HCC who experienced near-fatal anaphylaxis to atezolizumab in South Korea.

Levofloxacin-Induced Arthralgia in Multidrug-Resistant Tuberculosis Patients: A Case Series Spanning Three Age Groups

Multidrug-resistant TB (MDR-TB) is a form of tubercular disease caused by a strain of Mycobacterium tuberculosis complex that is resistant to rifampicin and isoniazid. Microbiologically diagnosed patients are started on an all-oral longer regimen or shorter regimen based on the Guidelines on Programmatic Management of Drug Resistant TB (PMDT) in India. Fluoroquinolones (FQs), being the cornerstone in the treatment of MDR-TB, are categorized as class A drugs. Levofloxacin (Lfx) administered at a dose of 11-14 mg/kg/day holds a strong bactericidal activity against Mycobacterium tuberculosis. FQs are associated with a wide range of adverse drug reactions, such as nausea, bloating, headache, dizziness, and insomnia. Tendon rupture, arthralgia though rare, can also occur due to Lfx. Even though arthralgia is commonly seen in patients on Lfx-associated treatment, only a few cases have been reported in India to date. We present a case series involving three cases of Lfx-induced arthralgia in patients of different age groups who are started on an all-oral longer regimen after they were diagnosed with MDR-TB. Based on the treatment protocol, patients were rechallenged or switched to other drugs in the replacement sequence as per the weight band.

A successful desensitization in an adult patient with ARA-C infusion reaction

INTRODUCTION

Cytarabine (ARA-C) is an antimetabolite agent used especially in the treatment of hematologic malignancies. Infusion reactions have an important place among the side effects that may occur due to treatment. Clinical findings of infusion reactions resemble allergic reactions.

CASE REPORT

47-year-old male patient with a diagnosis of B-cell Acute Lymphoblastic Leukaemia developed infusion reaction during ARA-C treatment.

MANAGEMENT & OUTCOME

There was no alternative treatment option for his existing malignant disease, we decided ARA-C desensitization.

DISCUSSION

We would like to describe a successful desensitization protocol in an adult patient who experienced a reaction during ARA-C infusion.

DRESS syndrome due to anti-TB drugs: A complex case with successful re-desensitization of group A drugs

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a rare, life-threatening adverse reaction caused by certain medications. Clinical findings usually include rash, fever, lymphadenopathy, and eosinophilia, and in some cases, they may affect major organs. This reaction caused by antituberculosis (TB) medication poses a public health risk due to treatment discontinuation, adherence, or success in cure. We present a 23-year-old female patient who developed DRESS syndrome as a result of group A anti-TB drugs (ATDs), an exceedingly rare occurrence. The patient's medication was successfully retrieved using a re-desensitization protocol.

Desensitization in children allergic to drugs: Indications, protocols, and limits

Any drug can potentially induce a hypersensitivity reaction. If after the allergological work-up the drug hypersensitivity reaction is confirmed, in most cases, the simple avoidance of the culprit drug and a suggestion of an unrelated alternative is enough. However, there are circumstances where the choice to stop the treatment affects the survival, the safety and/or the quality of life of the patient and the global outcome of the disease in question. When this occurs, drug desensitization can be the answer and should not be viewed as an extravagance, nor the pediatric age should be considered a contraindication. Drug desensitization in children can be safely and successfully performed, having a positive impact on the survival and overall prognosis. In general, the indications for DDS are the same in adults as in children. However, in this age group there are specificities that this paper aimed to describe, reviewing the mechanisms behind drug hypersensitivity and rapid drug desensitization, types of protocols, indications, and contraindications, as well as several technical aspects that are specific to the pediatric age.

A Narrative Review of Adverse Event Detection, Monitoring, and Prevention in Indian Hospitals

An adverse event is any abnormal clinical finding associated with the use of a therapy. Adverse events are classified by reporting an event's seriousness, expectedness, and relatedness. Monitoring patient safety is of utmost importance as more and more data becomes available. In reality, very low numbers of adverse events are reported via the official path. Chart review, voluntary reporting, computerized surveillance, and direct observation can detect adverse drug events. Medication errors are commonly seen in hospitals and need provider and system-based interventions to prevent them. The need of the hour in India is to develop and implement medication safety best practices to avoid adverse events. The utility of artificial intelligence techniques in adverse event detection remains unexplored, and their accuracy and precision need to be studied in a controlled setting. There is a need to develop predictive models to assess the likelihood of adverse reactions while testing novel pharmaceutical drugs.