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Zhang C, Ouyang L, Zhang X, Wen W, Xu Y, Li S, Li Y, He F, Liu W, Liu H. Anaphylactoid reactions induced by Shuanghuanglian injection and Shenmai injection and metabolomics analysis. Front Pharmacol 2023; 14:1200199. [PMID: 37484014 PMCID: PMC10358984 DOI: 10.3389/fphar.2023.1200199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/26/2023] [Indexed: 07/25/2023] Open
Abstract
Introduction: Shuanghuanglian injection (lyophilized) (SHLI) is commonly used to treat respiratory tract infection. Shenmai injection (SMI) is mainly used to treat cardiovascular diseases. Despite their widespread clinical use, anaphylactoid reactions (ARs) induced by SHLI and SMI have been reported, which have attracted broad attention. However, the impact of ARs on metabolic changes and the underlying mechanisms are still unclear. Methods: ICR mice were used as model animals and were treated with normal saline, C48/80, SHLI and SMI, respectively. The behavior of mice, auricle blue staining and Evans Blue exudation were used as indexes to evaluate the sensitization of SHLI and SMI and determine the optimal sensitization dose. Anaphylactoid mice model was established based on the optimal dose and enzyme-linked immunosorbent assay (ELISA) was used to model verification. Afterwards, plasma samples of administered mice were profiled by LC-MS metabolomics and analyzed to evaluate the changes in metabolites. Results: High doses of both SHLI and SMI can induce severe anaphylactoid reactions while the reaction induced by SMI was weaker. A Partial Least-Squares Discriminant Analysis (PLS-DA) score plot indicated that following administration, significant metabolic changes occurred in mice. 23 distinct metabolites, including deoxycholic acid, histamine, and 5-hydroxytryptophan, were identified in the SHLI groups. 11 distinct metabolites, including androsterone, 17α-hydroxypregnenolone, and 5-hydroxyindoleacetate, were identified in the SMI groups. Meanwhile, different metabolic pathways of SHLI and SMI were predicted by different metabolites. The associated metabolic pathways include steroid hormone biosynthesis, tryptophan metabolism, histidine metabolism, arachidonic acid metabolism, nicotinate and nicotinamide metabolism, and primary bile acid biosynthesis. Conclusion: Study showed that both SHLI and SMI can induce varying degrees of anaphylactoid reactions, a positive correlation between response intensity and dose was observed. Metabolomics showed that SHLI and SMI may promote the simultaneous release of hormones and inflammatory factors by disturbing relevant metabolic pathways, while SMI may also inhibit the release of inflammatory factors in arachidonic acid metabolic pathway, indicating both pro-inflammatory and anti-inflammatory effects. This study will serve as a reference for developing a new approach to evaluate the safety of SHLI and SMI from perspective of susceptible drug varieties. However, ARs mechanism requires further verification.
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Affiliation(s)
- Chi Zhang
- The First Hospital of Hunan University of Chinese Medicine, Changsha, China
| | - Linqi Ouyang
- The First Hospital of Hunan University of Chinese Medicine, Changsha, China
| | - Xili Zhang
- The First Hospital of Hunan University of Chinese Medicine, Changsha, China
| | - Wen Wen
- The First Hospital of Hunan University of Chinese Medicine, Changsha, China
| | - Yuqin Xu
- The First Hospital of Hunan University of Chinese Medicine, Changsha, China
| | - Shan Li
- The First Hospital of Hunan University of Chinese Medicine, Changsha, China
| | - Yingyu Li
- The First Hospital of Hunan University of Chinese Medicine, Changsha, China
| | - Fuyuan He
- The First Hospital of Hunan University of Chinese Medicine, Changsha, China
| | - Wenlong Liu
- The First Hospital of Hunan University of Chinese Medicine, Changsha, China
| | - Hongyu Liu
- The First Hospital of Hunan University of Chinese Medicine, Changsha, China
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Ghimire A, Olbrecht VA, Tobias JD. Role of sugammadex in the treatment of anaphylaxis due to rocuronium in children: Extrapolation from adult and animal reports. Paediatr Anaesth 2022; 32:706-715. [PMID: 35212434 DOI: 10.1111/pan.14424] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 02/14/2022] [Accepted: 02/18/2022] [Indexed: 12/01/2022]
Abstract
Allergic reactions are generalized hypersensitivity processes triggered by different antigenic stimuli, resulting in the end effect of mast cell degranulation and adverse physiologic effects. During the perioperative period, the most commonly identified agents include antibiotics, neuromuscular blocking agents (rocuronium and succinylcholine), chlorhexidine, and iodinated dyes for radiologic imaging. Sugammadex is a novel agent for the reversal of neuromuscular blockade achieved with rocuronium or vecuronium. Its unique mechanism of action, whereby it encapsulates and forms a one-to-one complex with rocuronium, has led to its anecdotal use as an adjunct in the treatment of anaphylactic and anaphylactoid reactions following rocuronium. The current manuscript discusses the potential use of sugammadex in the treatment of allergic reactions following the administration of rocuronium, reviews previous anecdotal reports of its use in these scenarios, and provides recommendations for future care.
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Affiliation(s)
- Anuranjan Ghimire
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Vanessa A Olbrecht
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio, USA.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
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Holbrook K, Andrews D, Sutherland W, Coppi A, Barry S, Escamilla M, Authier S, Miraucourt L, Xie F, Rock B, Bussiere J. Threshold for Anaphylactoid Reaction to Polysorbate 80 in Canines. Int J Toxicol 2022; 41:89-98. [PMID: 35337210 DOI: 10.1177/10915818211063478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Polysorbate 80 (PS80) functions as a dispersing agent or solubilizer in many pharmaceuticals, and as a stabilizer in biopharmaceuticals. Topical or parenteral administration of low doses of PS80 in biopharmaceuticals has been associated with mild allergic reactions, including local injection site reactions in humans. High doses of PS80, such as levels found in traditional Chinese herbal parenteral medicines, have been linked to systemic effects consistent with anaphylactoid-type reactions, which are characterized by the direct release of histamine from mast cells (degranulation). Nonclinical safety assessments of PS80 in vivo have mainly focused on canine model systems, a species established to be particularly sensitive to PS80. However, there is conflicting data about the dose and route of administration of PS80 required to elicit an anaphylactoid-type reaction in this model system. Therefore, studies using multiple dosing regimens in anesthetized and conscious dogs including a combination of cardiovascular data, clinical signs, and biomarkers of mast cell degranulation were conducted. An intravenous (IV) bolus of 1 mg/kg PS80 (0.25% w/v) elicited a positive anaphylactoid reaction including increased heart rate, hypotension, and clinical signs associated with anaphylactoid reactions (e.g., reddened muzzle). However, a full reaction was not observed with a subcutaneous (SC) injection of PS80 (0.25% w/v) up to 20 mg/kg and IV bolus or IV infusions up to 0.5 mg/kg. These data establish a threshold dose for eliciting an anaphylactoid reaction in canine which varies depending on the route of administration as well as the rate of PS80 infusion.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Fang Xie
- 7129Amgen Research, South San Francisco, CA, USA
| | - Brooke Rock
- 7129Amgen Research, South San Francisco, CA, USA
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Karakaya Z, Duyu M, Koksal Atis S. Anaphylactoid reaction during hemodiafiltration on AN69 membrane in a patient with atypical hemolytic uremic syndrome: A pediatric case report. Hemodial Int 2021; 26:E8-E11. [PMID: 34219382 DOI: 10.1111/hdi.12966] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 06/25/2021] [Indexed: 11/28/2022]
Abstract
Reactions associated with hemodiafiltration can be life threatening if not recognized early in the course of dialysis. AN69 (acrylonitrile and sodium methallyl sulfonate copolymer) membrane-associated reactions during hemodialysis have been documented in adult patients receiving angiotensin converting enzyme inhibitors, which are thought to be triggered by the negative charge of the AN69 membrane. Here, we present a 5-month-old girl requiring continuous renal replacement therapy (CRRT) for acute kidney injury secondary to atypical hemolytic uremic syndrome who experienced acute cyanosis, angioedema, tachycardia, and impaired circulation during CRRT. After switching to a different type of hemofiltration membrane, her clinical findings improved and she was able to tolerate hemodialysis. We concluded that she had experienced an anaphylactoid reaction to the AN69 membrane. To our knowledge, this case is the first pediatric case report of AN69 membrane-associated anaphylactoid reaction.
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Affiliation(s)
- Zeynep Karakaya
- Department of Paediatrics, Altinova District State Hospital, Yalova, Turkey
| | - Muhterem Duyu
- Department of Paediatrics, Pediatric Intensive Care Unit, Istanbul Medeniyet University Goztepe Training and Research Hospital, Istanbul, Turkey
| | - Seyma Koksal Atis
- Department of Paediatrics, Istanbul Medeniyet University Goztepe Training and Research Hospital, Istanbul, Turkey
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Szebeni J, Bawa R. Human Clinical Relevance of the Porcine Model of Pseudoallergic Infusion Reactions. Biomedicines 2020; 8:E82. [PMID: 32276476 DOI: 10.3390/biomedicines8040082] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 04/01/2020] [Accepted: 04/01/2020] [Indexed: 12/28/2022] Open
Abstract
Pigs provide a highly sensitive animal model for pseudoallergic infusion reactions, which are mild-to-severe hypersensitivity reactions (HSRs) that arise following intravenous administration of certain nanoparticulate drugs (nanomedicines) and other macromolecular structures. This model has been used in research for three decades and was also proposed by regulatory bodies for preclinical assessment of the risk of HSRs in the clinical stages of nano-drug development. However, there are views challenging the human relevance of the model and its utility in preclinical safety evaluation of nanomedicines. The argument challenging the model refers to the “global response” of pulmonary intravascular macrophages (PIM cells) in the lung of pigs, preventing the distinction of reactogenic from non-reactogenic particles, therefore overestimating the risk of HSRs relative to its occurrence in the normal human population. The goal of this review is to present the large body of experimental and clinical evidence negating the “global response” claim, while also showing the concordance of symptoms caused by different reactogenic nanoparticles in pigs and hypersensitive man. Contrary to the model’s demotion, we propose that the above features, together with the high reproducibility of quantifiable physiological endpoints, validate the porcine “complement activation-related pseudoallergy” (CARPA) model for safety evaluations. However, it needs to be kept in mind that the model is a disease model in the context of hypersensitivity to certain nanomedicines. Rather than toxicity screening, its main purpose is specific identification of HSR hazard, also enabling studies on the mechanism and mitigation of potentially serious HSRs.
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Lv Y, Fu J, Jia Q, Dong H, Han S, Li L, He L. Liquid Chromatography Tandem Mass Spectrometry Based Label-Free Quantification Method for Assessment of Allergen-Induced Anaphylactoid Reactions. J Am Soc Mass Spectrom 2020; 31:856-863. [PMID: 32125841 DOI: 10.1021/jasms.9b00104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Mast cells are essential in mediating inflammatory processes. When activated, mast cells can rapidly release characteristic granules and various mediators into the interstitium. Tryptase (TPS) and β-hexosaminidase (HEXB) are typical protease mediators stored in granules and released upon activation. They have been recognized as important biomarkers of anaphylaxis, and the released level is associated with the severity of allergic reactions. In this study, a sensitive, accurate, and selective liquid chromatography tandem mass spectrometry (LC-MS/MS) method for simultaneously quantifying the two biomarkers was developed and validated in LAD2 cell culture supernatant, and P14R was used as internal standard. Good linearity was observed in the range of 50-2500 ng/mL for TPS and 10-2000 ng/mL for HEXB both with R2 > 0.99. The matrix effect and recovery were both within acceptable limits. We quantified TPS and HEXB released from Laboratory of Allergic Disease 2 (LAD2) mast cells treated with several potential allergens, and the results demonstrate that the method can be used to investigate TPS and HEXB levels in LAD2 mast cell model during allergy research. We anticipate our approach to be a robust and sensitive assessment method for more biomarkers with similar kinetics characteristics and to be a major tool of allergic drug assessment or antiallergic drug development in research.
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Affiliation(s)
- Yanni Lv
- School of Pharmacy, Xi'an Jiaotong University, 76# Yanta West Road, Xi'an 710061, China
- School of Pharmacy, University of Wisconsin-Madison, 777 Highland Avenue, Madison, Wisconsin 53705, United States
| | - Jia Fu
- School of Pharmacy, Xi'an Jiaotong University, 76# Yanta West Road, Xi'an 710061, China
| | - Qianqian Jia
- School of Pharmacy, Xi'an Jiaotong University, 76# Yanta West Road, Xi'an 710061, China
| | - Hengtao Dong
- Shimadzu (China) Co., Ltd., 56# Jinye First Road, Xi'an 710000, China
| | - Shengli Han
- School of Pharmacy, Xi'an Jiaotong University, 76# Yanta West Road, Xi'an 710061, China
| | - Lingjun Li
- School of Pharmacy, University of Wisconsin-Madison, 777 Highland Avenue, Madison, Wisconsin 53705, United States
| | - Langchong He
- School of Pharmacy, Xi'an Jiaotong University, 76# Yanta West Road, Xi'an 710061, China
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Abstract
OBJECTIVE Acetylcysteine (NAC), an effective antidote for paracetamol poisoning, is commonly associated with adverse reactions. This has been postulated to be related to the rapid initial infusion rate (150 mg/kg over 1 h) of the traditional three-bag protocol. We hypothesized that a slower rate would result in fewer adverse reactions. Our institution in Western Sydney moved to a modified two-bag protocol in February 2015 - first bag: 200 mg/kg over 4 h (50 mg/kg/h) and second bag: (100 mg/kg over 16 h). METHODS Data was extracted from our database on paracetamol overdoses treated with NAC from August 2010 to September 2016. We compared adverse reactions in patients receiving the modified two-bag protocol with a historical control (traditional three-bag regimen with initial bolus of 150 mg/kg/h). RESULTS Over the study period 1011 paracetamol poisonings presented to our toxicology service, of which 476 required NAC (three-bag = 313, two-bag = 163). Demographic characteristics of the two groups were similar. Fewer anaphylactoid reactions (itch, rash, and swelling) occurred using the two-bag regimen (14% versus 5%, p = .002), a relative reduction of 66%. Similarly, there were fewer prescriptions of anti-allergy medications in the two-bag group (11% versus 4%, p = .01). There was no difference in incidence of hepatotoxicity. CONCLUSIONS Adverse reactions to NAC were less common with the two-bag regimen. These results add to the accumulating evidence that reducing the initial NAC infusion rate reduces the risk of adverse reactions.
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Affiliation(s)
- Richard McNulty
- a Western Sydney Toxicology Service , Westmead , Australia.,b School of Medicine , Western Sydney University , Sydney , Australia
| | | | - Pramod Chandru
- a Western Sydney Toxicology Service , Westmead , Australia
| | - Naren Gunja
- a Western Sydney Toxicology Service , Westmead , Australia.,c Sydney Medical School , University of Sydney , Sydney , Australia
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Swender DA, Chernin LR, Mitchell C, Sher T, Hostoffer R, Tcheurekdjian H. The rate of epinephrine administration associated with allergy skin testing in a suburban allergy practice from 1997 to 2010. Allergy Rhinol (Providence) 2012; 3:e55-60. [PMID: 23342290 PMCID: PMC3548609 DOI: 10.2500/ar.2012.3.0034] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Allergy skin testing is considered a safe method for testing for IgE-mediated allergic responses although anaphylactic events can occur. Reported rates of anaphylaxis per patient are not consistent and range from 0.008 to 4%. The aim of this study was to determine the rate of epinephrine use associated with allergy skin-prick testing (SPT) and intradermal testing (IDT) in a suburban practice over 13 years. This retrospective chart review used billing and procedure coding records during the time period from January 1997 to June 2010 to identify encounters where epinephrine was administered after SPT or IDT. Patient encounters with procedure codes for skin testing plus either parenteral epinephrine, corticosteroid, antihistamine, or i.v. fluid administration were identified. These patient charts were reviewed to determine if epinephrine was administered, whether systemic reactions developed, and rates of epinephrine administration were calculated. There were 28,907 patient encounters for SPT and 18,212 for IDT. Epinephrine was administered in six patient encounters (0.02%) where SPT was performed; no IDT encounters led to epinephrine administration. There were no fatalities. Allergy skin testing to a variety of allergens, when administered by well-trained personnel, is a safe procedure. This study, involving the largest population to date, showed a rate of systemic reactions requiring epinephrine of 20 per 100,000 SPT visits. No epinephrine was given after IDT.
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Affiliation(s)
- David A Swender
- University Hospitals, Cleveland, Ohio, ; Richmond Medical Center, Richmond Heights, Ohio
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Lagopoulos V, Gigi E. Anaphylactic and anaphylactoid reactions during the perioperative period. Hippokratia 2011; 15:138-40. [PMID: 22110295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/28/2022]
Abstract
Anaphylactic reactions in the peri-operative period are often serious and potentially life-threatening conditions, involving multiple organ systems in which the clinical manifestations are the consequence of the release of preformed mediators from mast cells and basophils. Anaphylaxis is an immune mediated type I allergic reaction following the massive release of mediators from mast cells and basophils as a response to an allergen. Anaphylactoid reactions are defined as those reactions that produce the same clinical picture with anaphylaxis but are not IgE mediated, occur through a direct nonimmune-mediated release of mediators from mast cells and/or basophils or result from direct complement activation. The occurrence of these reactions during anesthesia, although quite rare, remains a major concern for the anesthesiologists. Thus, the need for systematic screening before surgery and the awareness and expert advice to anaesthesiologists seems to be very critical.
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