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Arikoglu T, Tokmeci N, Demirhan A, Ozhan AK, Yalaki Aİ, Akbey V, Kuyucu S. Diagnostic evaluation of hypersensitivity reactions to arylpropionic acid derivatives: a descriptive observational study focusing on clinical characteristics and potential risk factors in children. Int J Clin Pharm 2024:10.1007/s11096-024-01756-4. [PMID: 38861048 DOI: 10.1007/s11096-024-01756-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 05/16/2024] [Indexed: 06/12/2024]
Abstract
BACKGROUND Arylpropionic acid derivatives (APs) are the main triggers of nonsteroidal anti-inflammatory drug (NSAID) hypersensitivity. Data on clinical patterns and risk factors for AP hypersensitivity in children are quite limited. AIM To assess the clinical characteristics and potential risk factors for proven AP hypersensitivity in children. METHOD Patients with a history of AP hypersensitivity were retrospectively assessed using a standardized diagnostic algorithm. Children with confirmed hypersensitivity were defined as selective responders or cross-intolerants based on the result of drug provocation tests and further categorized according to the EAACI/ENDA classification. A multivariable logistic regression analysis was performed to analyze the potential risk factors for proven AP hypersensitivity. RESULTS A total of 166 patients (51.2% male, median age of six years) with a history of AP hypersensitivity were included. Ibuprofen (89.2%) was the most frequently reported AP in the patients' histories. The reported hypersensitivity of 40 (22.4%) patients was confirmed by diagnostic testing: eight (13.6%) patients with a history of reaction only to APs and 32 (29.9%) patients with a history of reactions to multiple NSAIDs, including chemically unrelated NSAIDs in addition to APs. Five (12.5%) patients were classified as selective responders and 35 (87.5%) were cross-intolerants. Overall, five (12.5%) of the confirmed cases could not be categorized according to the EAACI/ENDA classification. Older age (aOR: 1.11, 95% CI 1.02-1.21, p = 0.015), chronic urticaria as an underlying disease (aOR: 2.87, 95% CI 1.09-7.54, p = 0.033) and a history of anaphylaxis (aOR: 7.84, 95% CI 1.86-33.04, p = 0.005) were related to confirmed AP hypersensitivity. CONCLUSION Almost a quarter of children and adolescents were confirmed to have AP hypersensitivity. Older age, the presence of chronic urticaria and a history of anaphylaxis were potential risk factors for proven AP hypersensitivity.
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Affiliation(s)
- Tugba Arikoglu
- Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Çiftlikköy Kampüsü, Yenişehir, Mersin, Turkey.
| | - Nazan Tokmeci
- Department of Pediatric Allergy and Immunology, Adıyaman University Training and Research Hospital, Adıyaman, Turkey
| | - Ali Demirhan
- Department of Pediatric Allergy and Immunology, Mersin City Training and Research Hospital, Mersin, Turkey
| | - Aylin Kont Ozhan
- Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Çiftlikköy Kampüsü, Yenişehir, Mersin, Turkey
| | - Aysu İlhan Yalaki
- Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Çiftlikköy Kampüsü, Yenişehir, Mersin, Turkey
| | - Veysi Akbey
- Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Çiftlikköy Kampüsü, Yenişehir, Mersin, Turkey
| | - Semanur Kuyucu
- Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Çiftlikköy Kampüsü, Yenişehir, Mersin, Turkey
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Aytekin Güvenir F, Turgay Yağmur İ, Dibek Mısırlıoğlu E. Alternative Drug Safety in Children with Nonsteroidal Anti-Inflammatory Drug Hypersensitivity. Int Arch Allergy Immunol 2024:1-7. [PMID: 38815557 DOI: 10.1159/000538877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 04/08/2024] [Indexed: 06/01/2024] Open
Abstract
INTRODUCTION Nonsteroidal anti-inflammatory drugs (NSAIDs) are frequently used in the pediatric age group as pain relievers, antipyretics and anti-inflammatory drugs. Since NSAIDs are used in many medical conditions, there is a need for alternative NSAIDs to be used safely in people with hypersensitivity reactions. Selective and partially selective COX-2 inhibitors and weak COX-1 inhibitors are generally used as safe alternative drugs. The aim of this study was to evaluate safe NSAIDs determined by oral provocation tests (OPTs) according to phenotypes in children with NSAID hypersensitivity reactions. METHODS The results of the oral provocation test performed with alternative NSAIDs (paracetamol, meloxicam, nimesulide, celecoxib) in patients followed up with the diagnosis of NSAID hypersensitivity reaction in the Pediatric Immunology and Allergy Department between January 2015 and February 2023 were evaluated retrospectively. RESULTS During the study period, 91 patients underwent OPTs with 109 alternative drugs 48 (52.7%) of whom were girls, with a median age of 15 years. 91 patients had a history of reactions to 117 drugs. As an alternative NSAID; OPT was performed with paracetamol in 58 patients, meloxicam in 44 patients, nimesulide in 5 patients, and celecoxib in 2 patients. Since 15 patients used paracetamol safely at home, no tests were performed with paracetamol. Reactions were observed in 3 of the 73 patients (4.1%) who underwent OPT with paracetamol and in 2 of the 44 (4.5%) who underwent OPT with meloxicam. Reactions to nimesulide were also observed in the latter 2 patients (2/5, 40%), but they appeared to tolerate celecoxib. No reaction was observed in the 2 patients who were tested with celecoxib. CONCLUSION Paracetamol, meloxicam, and nimesulide can be used as safe alternative drugs in most children with NSAID hypersensitivity. Selective COX-2 inhibitors should be tried as an alternative in patients who cannot tolerate them.
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Affiliation(s)
- Funda Aytekin Güvenir
- Department of Pediatric Allergy/Immunology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey,
| | - İrem Turgay Yağmur
- Department of Pediatric Allergy/Immunology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Emine Dibek Mısırlıoğlu
- Department of Pediatric Allergy/Immunology, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
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Arikoglu T, Tokmeci N, Demirhan A, Kont Ozhan A, Yalaki AI, Akbey V, Kuyucu S. Evaluation of different protocols for classification of pediatric hypersensitivity reactions to nonsteroidal anti-inflammatory drugs: Children with underlying allergic disease should be a separate subgroup. Allergy Asthma Proc 2024; 45:14-23. [PMID: 38151729 DOI: 10.2500/aap.2024.45.230081] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
Background: Different recommendations for the classification of nonsteroidal anti-inflammatory drug hypersensitivity reactions (NSHSR) in children have been reported but a shortage still exists. Objective: The aim of the present study was to evaluate the inclusivity of two European Academy of Allergy and Clinical Immunology (EAACI) position paper classifications and to characterize the factors that underlie classification discordance in children. Methods: Patients with a history of NSHSR were evaluated with a standardized diagnostic protocol according to EAACI/ European Network for Drug Allergy (ENDA) recommendations. Children were classified and compared according to the EAACI 2013 and the pediatric EAACI/ENDA 2018 classifications. Subjects who were unclassified and those who were classified were compared. Results: Of 232 patients (median [interquartile range] age 6 years (4-11 years) with a history of NSHSR, 52 (22.4%) were confirmed with diagnostic tests. Thirty-six (69.2%) were classified as having cross-intolerance, whereas 16 patients (30.8%) were classified as selective responders. Eleven of the confirmed cases (21.2%) could not be categorized according to the 2013 EAACI classification, whereas this number was six adolescents (11.5%) when the 2018 EAACI/ENDA pediatric classification was used. Patients who were unclassified and who were all cross-intolerant were more likely to have atopic sensitization (p = 0.001) and asthma as an underlying disease (p = 0.03), higher serum eosinophil count (p = 0.022), and total immunoglobulin E levels (p = 0.007) compared with those who fit well into the classification. In multivariate regression analysis, the presence of atopic sensitization (adjusted odds ratio 20.36 [95% confidence interval, 2.14-193.48]; p = 0.009) was found to be the only significant underlying factor for an unclassified and/or blended phenotype. Conclusion: The 2013 EAACI classification resulted in a high rate of subjects who were unclassified. Despite better clinical utility, the recent pediatric EAACI/ENDA classification system still has shortcomings in terms of inclusivity for adolescents. Mostly, children with underlying allergic diseases could not be classified by the current guidelines. We propose to classify them as a separate pediatric cross-intolerance subgroup because the underlying mechanism may involve more than cyclooxygenase 1 inhibition.
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Affiliation(s)
- Tugba Arikoglu
- From the Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Nazan Tokmeci
- Department of Pediatric Allergy and Immunology, Adıyaman University Training and Research Hospital, Adıyaman, Turkey, and
| | - Ali Demirhan
- Department of Pediatric Allergy and Immunology, Mersin City Training and Research Hospital, Mersin, Turkey
| | - Aylin Kont Ozhan
- From the Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Aysu Ilhan Yalaki
- From the Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Veysi Akbey
- From the Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Semanur Kuyucu
- From the Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey
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Hadley A, Slaven JE, Krupp NL, Kloepfer KM. Nonsteroidal anti-inflammatory drug hypersensitivity in a pediatric severe asthmatic population. Pediatr Pulmonol 2023; 58:2983-2986. [PMID: 37503899 PMCID: PMC10538399 DOI: 10.1002/ppul.26618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 07/11/2023] [Accepted: 07/14/2023] [Indexed: 07/29/2023]
Abstract
Introduction: Asthma is a common pediatric disease. Identification of exacerbating factors is important to gain better asthma control. One potential exacerbation trigger is NSAID-hypersensitivity (NSAID-H). Studies regarding pediatric NSAID-H have varied demographics, methodologies, and conclusions. However, most studies find NSAID-H more prevalent in asthmatic patients. Methods: The objective was to determine the prevalence, symptoms, and factors associated with NSAID-H in a pediatric severe asthma population. One hundred children aged 6 to 18 years old from the Severe Asthma Clinic at Riley Hospital for Children in Indianapolis, IN, between 11/2020 and 5/2022 completed a survey about asthma triggers, allergies, co-morbid diagnoses, sinus symptoms, and NSAID reaction history. Results: Nineteen percent of participants reported a reaction to at least one NSAID. Ibuprofen (16%), aspirin (9%), and acetaminophen (9%) were the most implicated NSAIDs. Most common symptoms were dyspnea, wheezing, coughing, lightheadedness, and abdominal pain appearing within 30 minutes. Associated factors included history of a medication other than an NSAID triggering asthma (p = 0.02), nasal polyps (p = 0.01), ageusia (p = 0.01), cold-induced asthma (p = 0.02), and chronic sinusitis in immediate family member (p = 0.04). Conclusions: Prevalence of NSAID-H in a large children’s hospital pediatric severe asthma clinic was 19%. The most common drug was ibuprofen and the most common symptoms were respiratory and gastrointestinal. Associated factors included medication and cold triggered asthma, nasal polyps, ageusia, and family history of chronic sinusitis. This highlights the importance of a thorough history in severe asthma patients who may be at higher risk for NSAID-H. Future studies should focus on looking at the rate of NSAID-H in a larger severe asthma population and if social determinants of health play a role in the increased incidence of reacting.
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Affiliation(s)
- Abigail Hadley
- Department of Pediatrics, Division of Pulmonary, Allergy and Sleep Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - James E Slaven
- Department of Biostatistics, Indiana University School of Medicine and Indiana Clinical and Translational Sciences Institute, Indianapolis, Indiana, USA
| | - Nadia L Krupp
- Department of Pediatrics, Division of Pulmonary, Allergy and Sleep Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Kirsten M Kloepfer
- Department of Pediatrics, Division of Pulmonary, Allergy and Sleep Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Çerçi P, Kendirlinan R, Büyüköztürk S, Gelincik A, Ünal D, Demir S, Erkekol FÖ, Karakaya G, Dursun AB, Çelikel S, Ediger D, Abadoglu O, Bavbek S. Hypersensitivity reactions to nonsteroidal anti-inflammatory drugs in adults: Beyond current classification. Allergol Immunopathol (Madr) 2023; 51:84-92. [PMID: 37695234 DOI: 10.15586/aei.v51i5.946] [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: 06/28/2023] [Accepted: 08/15/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND Hypersensitivity reactions (HSRs) to nonsteroidal anti-inflammatory drugs (NSAIDs) are a significant clinical issue. Several classifications have been proposed to categorize these reactions, including the current European Academy of Allergy and Clinical Immunology/European Network for Drug Allergy (EAACI/ENDA) classification. This study aimed to evaluate the applicability of this classification in a real-world clinical setting. METHODS We conducted a national multicenter study involving patients from nine hospitals in four major urban centers in Turkey. All patients had a suggestive clinical history of hypersensitivity reactions to NSAIDs. Researchers collected data using a structured form and classified reactions based on the EAACI/ENDA classification. Oral provocation tests with several NSAIDs were performed using a single-blind challenge per EAACI/ENDA guidelines. RESULTS Our retrospective study included 966 adult patients with a history of hypersensitivity to NSAIDs. The most common triggers were Acetylsalicylic Acid (ASA), paracetamol, and metamizole. The most prevalent acute NSAID hypersensitivity group was NSAID-induced urticaria/angioedema (NIUA) (34.3%). However, 17.3% of patients did not fit neatly into the current EAACI/ENDA classification. Notably, patients with underlying asthma or allergic rhinoconjunctivitis exhibited unusual reactions, such as urticaria and/or angioedema induced by multiple chemical groups of NSAIDs, blended mixed reactions, and isolated periorbital angioedema in response to multiple chemical groups of NSAIDs. CONCLUSIONS While the EAACI/ENDA classification system stratifies NSAID-induced hypersensitivity reactions into five distinct endotypes or phenotypes, it may not fully capture the diversity of these reactions. Our findings suggest a need for further research to refine this classification system and better accommodate patients with atypical presentations.
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Affiliation(s)
- Pamir Çerçi
- Department of Chest Diseases, Division of Allergy and Immunology, Faculty of Medicine, Ankara, Ankara University, Türkiye
| | - Reşat Kendirlinan
- Department of Chest Diseases, Division of Allergy and Immunology, Faculty of Medicine, Ankara, Ankara University, Türkiye
| | - Suna Büyüköztürk
- Department of Internal Medicine, Division of Allergy and Immunology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Türkiye
| | - Aslı Gelincik
- Department of Internal Medicine, Division of Allergy and Immunology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Türkiye
| | - Derya Ünal
- Department of Internal Medicine, Division of Allergy and Immunology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Türkiye
| | - Semra Demir
- Department of Internal Medicine, Division of Allergy and Immunology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Türkiye
| | - Ferda Öner Erkekol
- Department of Chest Diseases, Division of Allergy and Immunology, Ataturk Chest Disease and Thoracic Surgery Training and Research Hospital, Ankara, Türkiye
| | - Gül Karakaya
- Department of Chest Diseases, Division of Allergy and Immunology, Hacettepe University School of Medicine, Ankara, Türkiye
| | - Adile Berna Dursun
- Department of Chest Diseases, Division of Allergy and Immunology, School of Medicine, Recep Tayyip Erdoğan University, Rize, Türkiye
- Department of Chest Diseases, Division of Allergy and Immunology, School of Medicine, Lokman Hekim University, Ankara, Türkiye
| | - Serhat Çelikel
- Department of Chest Diseases, Division of Allergy and Immunology, Acibadem Healthcare Group, Maslak Hospital, Istanbul, Türkiye
| | - Dane Ediger
- Department of Chest Diseases, Division of Allergy and Immunology, School of Medicine, Bursa, Bursa Uludag University, Türkiye
| | | | - Sevim Bavbek
- Department of Chest Diseases, Division of Allergy and Immunology, Faculty of Medicine, Ankara, Ankara University, Türkiye;
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Khan DA, Banerji A, Blumenthal KG, Phillips EJ, Solensky R, White AA, Bernstein JA, Chu DK, Ellis AK, Golden DBK, Greenhawt MJ, Horner CC, Ledford D, Lieberman JA, Oppenheimer J, Rank MA, Shaker MS, Stukus DR, Wallace D, Wang J, Khan DA, Golden DBK, Shaker M, Stukus DR, Khan DA, Banerji A, Blumenthal KG, Phillips EJ, Solensky R, White AA, Bernstein JA, Chu DK, Ellis AK, Golden DBK, Greenhawt MJ, Horner CC, Ledford D, Lieberman JA, Oppenheimer J, Rank MA, Shaker MS, Stukus DR, Wallace D, Wang J. Drug allergy: A 2022 practice parameter update. J Allergy Clin Immunol 2022; 150:1333-1393. [PMID: 36122788 DOI: 10.1016/j.jaci.2022.08.028] [Citation(s) in RCA: 161] [Impact Index Per Article: 80.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 08/18/2022] [Accepted: 08/30/2022] [Indexed: 12/14/2022]
Affiliation(s)
- David A Khan
- Department of Internal Medicine, Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas, Tex
| | - Aleena Banerji
- Department of Internal Medicine, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Kimberly G Blumenthal
- Department of Internal Medicine, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Elizabeth J Phillips
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia; Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Roland Solensky
- Corvallis Clinic, Oregon State University/Oregon Health Science University College of Pharmacy, Corvallis, Ore
| | - Andrew A White
- Department of Allergy, Asthma and Immunology, Scripps Clinic, San Diego, Calif
| | - Jonathan A Bernstein
- Department of Internal Medicine, Division of Immunology, Allergy Section, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Derek K Chu
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; The Research Institute of St Joe's Hamilton, Hamilton, Ontario, Canada
| | - Anne K Ellis
- Division of Allergy and Immunology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - David B K Golden
- Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Matthew J Greenhawt
- Food Challenge and Research Unit Section of Allergy and Immunology, Children's Hospital Colorado University of Colorado School of Medicine, Aurora, Colo
| | - Caroline C Horner
- Department of Pediatrics, Division of Allergy Pulmonary Medicine, Washington University School of Medicine, St Louis, Mo
| | - Dennis Ledford
- Division of Allergy and Immunology, Department of Medicine, University of South Florida Morsani College of Medicine, Tampa, Fla; James A. Haley Veterans Affairs Hospital, Tampa, Fla
| | - Jay A Lieberman
- Division of Allergy and Immunology, The University of Tennessee Health Science Center, Memphis, Tenn
| | - John Oppenheimer
- Division of Allergy, Rutgers New Jersey Medical School, Rutgers, NJ
| | - Matthew A Rank
- Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic in Arizona, Scottsdale, Ariz
| | - Marcus S Shaker
- Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - David R Stukus
- Division of Allergy and Immunology, Nationwide Children's Hospital, Columbus, Ohio; The Ohio State University College of Medicine, Columbus, Ohio
| | - Dana Wallace
- Nova Southeastern Allopathic Medical School, Fort Lauderdale, Fla
| | - Julie Wang
- Division of Allergy and Immunology, Department of Pediatrics, The Elliot and Roslyn Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
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Cavkaytar O, Arga M. NSAID Hypersensitivity in the Pediatric Population: Classification and Diagnostic Strategies. J Asthma Allergy 2022; 15:1383-1399. [PMID: 36199560 PMCID: PMC9527698 DOI: 10.2147/jaa.s267005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 09/11/2022] [Indexed: 11/23/2022] Open
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most frequently administered drugs, mainly for their anti-pyretic, but also for pain-relieving and anti-inflammatory effects in children. NSAIDs are composed of structurally divergent subgroups of drugs with similar pharmacological and adverse effects. Aspirin originates from salicin and was the first synthesized analgesic. As a prototype of NSAIDs; aspirin-induced hypersensitivity reactions were first reported, but subsequently, other phenotypes of hypersensitivity reactions were also described with aspirin and other NSAIDs. There are certain challenging aspects of NSAID-hypersensitivity in the pediatric population that need to be further investigated. These include the effect of age on drug metabolism and the natural history of the various phenotypes of NSAID-hypersensitivity, the effect of certain co-factors (infections, exercise) on NSAID-hypersensitivity, and diagnostic clinical and laboratory biomarkers clarifying the endotypes. In recent years, a non-negligible number of case series, studies and expert panel reports have been published in this field with some novel features and diagnostic modalities in the pediatric population. With the current review; the clinical phenotypes and diagnostic and management modalities of suspected NSAID-induced hypersensitivity reactions in childhood and adolescence were explained and updated by examining past and current publications.
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Affiliation(s)
- Ozlem Cavkaytar
- Department of Pediatric Allergy and Immunology, Istanbul Medeniyet University Faculty of Medicine, Istanbul, Turkey
- Correspondence: Ozlem Cavkaytar, Department of Pediatric Allergy and Immunology, Istanbul Medeniyet University Faculty of Medicine, Prof. Dr. Suleyman Yalcin City Hospital, Kadıköy, Istanbul, Turkey, Tel +90 216 6065200, Email
| | - Mustafa Arga
- Department of Pediatric Allergy and Immunology, Istanbul Medeniyet University Faculty of Medicine, Istanbul, Turkey
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Prosty C, Copaescu AM, Gabrielli S, Mule P, Ben-Shoshan M. Pediatric Drug Allergy. Immunol Allergy Clin North Am 2022; 42:433-452. [DOI: 10.1016/j.iac.2022.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Ziesenitz VC, Welzel T, van Dyk M, Saur P, Gorenflo M, van den Anker JN. Efficacy and Safety of NSAIDs in Infants: A Comprehensive Review of the Literature of the Past 20 Years. Paediatr Drugs 2022; 24:603-655. [PMID: 36053397 PMCID: PMC9592650 DOI: 10.1007/s40272-022-00514-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2022] [Indexed: 11/29/2022]
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used in infants, children, and adolescents worldwide; however, despite sufficient evidence of the beneficial effects of NSAIDs in children and adolescents, there is a lack of comprehensive data in infants. The present review summarizes the current knowledge on the safety and efficacy of various NSAIDs used in infants for which data are available, and includes ibuprofen, dexibuprofen, ketoprofen, flurbiprofen, naproxen, diclofenac, ketorolac, indomethacin, niflumic acid, meloxicam, celecoxib, parecoxib, rofecoxib, acetylsalicylic acid, and nimesulide. The efficacy of NSAIDs has been documented for a variety of conditions, such as fever and pain. NSAIDs are also the main pillars of anti-inflammatory treatment, such as in pediatric inflammatory rheumatic diseases. Limited data are available on the safety of most NSAIDs in infants. Adverse drug reactions may be renal, gastrointestinal, hematological, or immunologic. Since NSAIDs are among the most frequently used drugs in the pediatric population, safety and efficacy studies can be performed as part of normal clinical routine, even in young infants. Available data sources, such as (electronic) medical records, should be used for safety and efficacy analyses. On a larger scale, existing data sources, e.g. adverse drug reaction programs/networks, spontaneous national reporting systems, and electronic medical records should be assessed with child-specific methods in order to detect safety signals pertinent to certain pediatric age groups or disease entities. To improve the safety of NSAIDs in infants, treatment needs to be initiated with the lowest age-appropriate or weight-based dose. Duration of treatment and amount of drug used should be regularly evaluated and maximum dose limits and other recommendations by the manufacturer or expert committees should be followed. Treatment for non-chronic conditions such as fever and acute (postoperative) pain should be kept as short as possible. Patients with chronic conditions should be regularly monitored for possible adverse effects of NSAIDs.
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Affiliation(s)
- Victoria C. Ziesenitz
- grid.5253.10000 0001 0328 4908Pediatric Cardiology and Congenital Heart Diseases, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany ,grid.6612.30000 0004 1937 0642Pediatric Pharmacology and Pharmacometrics, University Children’s Hospital Basel, University of Basel, Basel, Switzerland
| | - Tatjana Welzel
- grid.6612.30000 0004 1937 0642Pediatric Pharmacology and Pharmacometrics, University Children’s Hospital Basel, University of Basel, Basel, Switzerland ,grid.411544.10000 0001 0196 8249Pediatric Rheumatology and Autoinflammatory Reference Center, University Hospital Tuebingen, Tuebingen, Germany
| | - Madelé van Dyk
- grid.1014.40000 0004 0367 2697Flinders Centre for Innovation in Cancer, College of Medicine and Public Health, Flinders University, Adelaide, SA Australia
| | - Patrick Saur
- grid.5253.10000 0001 0328 4908Pediatric Cardiology and Congenital Heart Diseases, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Matthias Gorenflo
- grid.5253.10000 0001 0328 4908Pediatric Cardiology and Congenital Heart Diseases, Centre for Child and Adolescent Medicine, University Hospital Heidelberg, Im Neuenheimer Feld 430, 69120 Heidelberg, Germany
| | - Johannes N. van den Anker
- grid.6612.30000 0004 1937 0642Pediatric Pharmacology and Pharmacometrics, University Children’s Hospital Basel, University of Basel, Basel, Switzerland ,grid.239560.b0000 0004 0482 1586Division of Clinical Pharmacology, Children’s National Hospital, Washington DC, USA ,grid.416135.40000 0004 0649 0805Intensive Care and Department of Pediatric Surgery, Sophia Children’s Hospital, Rotterdam, The Netherlands
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Sánchez‐López J, Araujo G, Cardona V, García‐Moral A, Casas‐Saucedo R, Guilarte M, Torres MJ, Doña I, Picado C, Pascal M, Muñoz‐Cano R, Bartra J. Food-dependent NSAID-induced hypersensitivity (FDNIH) reactions: Unraveling the clinical features and risk factors. Allergy 2021; 76:1480-1492. [PMID: 33289951 DOI: 10.1111/all.14689] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Revised: 10/10/2020] [Accepted: 10/19/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND In up to 70%-80% of patients with a suspected non-steroidal anti-inflammatory drug hypersensitivity (NSAIDH), challenge tests with the culprit drug yield negative results. On the other hand, there could be a NSAIDH overdiagnosis when anaphylaxis is the clinical manifestation. We hypothesize that some negative NSAID challenge tests and an overdiagnosis of NSAIDH occur in patients with food-dependent NSAID-induced hypersensitivity (FDNIH). METHODS We studied 328 patients with a suspected acute NSAIDH. FDNIH was diagnosed in patients meeting all the following: (1) tolerance to the food ingested more temporally closed before the reaction, later the episode, (2) respiratory or cutaneous symptoms or anaphylaxis related to NSAID, (3) positive skin prick test to foods and/or specific IgE to food allergens (Pru p 3, Tri a 19, Pen a 1) involved in the reaction, and (4) negative oral provocation test to the culprit NSAID. RESULTS 199 patients (60%) were diagnosed with NSAIDH and 52 (16%) with FDNIH. Pru p 3 was involved in 44 cases (84.6%) and Tri a 19 in 6 cases (11%). FDNIH subjects were younger (p < .001), with a higher prevalence of rhinitis (p < .001) and previous food allergy (p < .001), together with a higher proportion of subjects sensitized to pollens (p < .001) and foods (p < .001). Using just four variables (Pru p 3 sensitization, Tri a 19 sensitization, anaphylaxis, and any NSAID different from pyrazolones), 95.3% of cases were correctly classified, with a sensitivity of 92% and specificity of 96%. CONCLUSION Evaluation of FDNIH should be included in the diagnostic workup of NSAIDH.
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Affiliation(s)
- Jaime Sánchez‐López
- Department of Pulmonology and Respiratory Allergy Allergy Section Hospital Clinic Barcelona Barcelona Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) Universitat de Barcelona Barcelona Spain
| | - Giovanna Araujo
- Department of Pulmonology and Respiratory Allergy Allergy Section Hospital Clinic Barcelona Barcelona Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) Universitat de Barcelona Barcelona Spain
| | - Victoria Cardona
- Department of Internal medicine, Allergy Section Hospital Universitari Vall d'Hebron Universitat Autònoma de Barcelona Barcelona Spain
- Vall d'Hebron Research Institute Allergy Research Unit Barcelona Spain
- Spanish Network for Allergy—RETIC de Asma, Reacciones adversas y Alérgicas (ARADyAL) Madrid Spain
| | - Alba García‐Moral
- Department of Pulmonology and Respiratory Allergy Allergy Section Hospital Clinic Barcelona Barcelona Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) Universitat de Barcelona Barcelona Spain
| | - Rocío Casas‐Saucedo
- Department of Pulmonology and Respiratory Allergy Allergy Section Hospital Clinic Barcelona Barcelona Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) Universitat de Barcelona Barcelona Spain
- Spanish Network for Allergy—RETIC de Asma, Reacciones adversas y Alérgicas (ARADyAL) Madrid Spain
| | - Mar Guilarte
- Department of Internal medicine, Allergy Section Hospital Universitari Vall d'Hebron Universitat Autònoma de Barcelona Barcelona Spain
- Vall d'Hebron Research Institute Allergy Research Unit Barcelona Spain
- Spanish Network for Allergy—RETIC de Asma, Reacciones adversas y Alérgicas (ARADyAL) Madrid Spain
| | - María José Torres
- Spanish Network for Allergy—RETIC de Asma, Reacciones adversas y Alérgicas (ARADyAL) Madrid Spain
- Allergy Unit Hospital Regional Universitario de Málaga Malaga Spain
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA Malaga Spain
| | - Inmaculada Doña
- Spanish Network for Allergy—RETIC de Asma, Reacciones adversas y Alérgicas (ARADyAL) Madrid Spain
- Allergy Unit Hospital Regional Universitario de Málaga Malaga Spain
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA Malaga Spain
| | - Cesar Picado
- Department of Pulmonology and Respiratory Allergy Allergy Section Hospital Clinic Barcelona Barcelona Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) Universitat de Barcelona Barcelona Spain
- CIBERES CIBER of Respiratory Diseases Madrid Spain
| | - Mariona Pascal
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) Universitat de Barcelona Barcelona Spain
- Spanish Network for Allergy—RETIC de Asma, Reacciones adversas y Alérgicas (ARADyAL) Madrid Spain
- Immunology Department Centre de Diagnòstic Biomèdic (CDB) Hospital Clínic de Barcelona Barcelona Spain
| | - Rosa Muñoz‐Cano
- Department of Pulmonology and Respiratory Allergy Allergy Section Hospital Clinic Barcelona Barcelona Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) Universitat de Barcelona Barcelona Spain
- Spanish Network for Allergy—RETIC de Asma, Reacciones adversas y Alérgicas (ARADyAL) Madrid Spain
| | - Joan Bartra
- Department of Pulmonology and Respiratory Allergy Allergy Section Hospital Clinic Barcelona Barcelona Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS) Universitat de Barcelona Barcelona Spain
- Spanish Network for Allergy—RETIC de Asma, Reacciones adversas y Alérgicas (ARADyAL) Madrid Spain
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Yuenyongviwat A, Chantaravisarut N, Phattarapongdilok W, Koosakulchai V, Jessadapakorn W, Sangsupawanich P. Characteristics and Contributing Factors Related to Nonsteroidal Anti-Inflammatory Drugs Hypersensitivity. Int Arch Allergy Immunol 2020; 182:139-145. [PMID: 32950992 DOI: 10.1159/000510364] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 07/22/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Hypersensitivity to nonsteroidal anti-inflammatory drugs (NSAIDs) is reported to be the most common drug hypersensitivity. The aim of this study was to evaluate the characteristics of self-reported NSAID hypersensitivity and identify patients at high risk of NSAID hypersensitivity. METHODS Patients who presented at a single tertiary care hospital between January-December 2017 with reported NSAID hypersensitivity were evaluated. Clinical information obtained from a review of medical records was further supplemented with data gained from a telephone-administered questionnaire. RESULTS From a total of 535 patients with reported NSAID hypersensitivity, 301 were included in the study. The mean age of onset of NSAID hypersensitivity reaction was 30.3 ± 14.9 years old. A total of 84 patients (27.9%) were hypersensitive to 2 or more chemically unrelated NSAIDs. The leading NSAID hypersensitivity was to propionic acid derivatives (73%) followed by acetic acid derivatives (28.9%). Immediate reaction (≤1 h) was identified in 171 patients (57.8%), and angioedema was the most frequently reported symptom (179 patients, 59.5%), followed by urticaria and anaphylaxis in 85 (28.2%) and 62 (20.6%) patients, respectively. A drug provocation test was performed on 53 patients, and NSAID hypersensitivity was confirmed in 38 patients (71.6%). The independent factors identified, which could predict NSAID hypersensitivity, were personal history of allergic rhinitis/chronic rhinosinusitis (AR/CRS), onset of NSAID hypersensitivity over 15 years old, and immediate reaction. CONCLUSION Angioedema was the most typical symptom, and propionic acid derivatives were the most frequently reported culprit drugs. The significant risk factors predicting NSAID hypersensitivity were personal history of AR/CRS, onset of NSAID hypersensitivity reaction over 15 years old, and immediate reaction.
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Affiliation(s)
- Araya Yuenyongviwat
- Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand,
| | - Nisarat Chantaravisarut
- Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | | | - Vanlaya Koosakulchai
- Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Wipa Jessadapakorn
- Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Pasuree Sangsupawanich
- Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
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Results of NSAID provocation tests and difficulties in the classification of children with nonsteroidal anti-inflammatory drug hypersensitivity. Ann Allergy Asthma Immunol 2020; 125:202-207. [PMID: 32294526 DOI: 10.1016/j.anai.2020.04.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 03/28/2020] [Accepted: 04/02/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used in children and can frequently cause hypersensitivity reactions. Rates of confirmed NSAID hypersensitivity (NSAID-H) in children are low. OBJECTIVE To evaluate the results of drug provocation tests (DPTs) with NSAIDs and to evaluate the difficulties encountered in the classification of NSAID-H in children. METHODS The study included patients with suspected NSAID-H who were examined in our clinic between January 1, 2015, and December 31, 2018. Oral provocation tests with NSAIDs were performed and reactions were classified according to the European Academy of Allergy and Clinical Immunology position paper on NSAID-H. RESULTS A total of 243 patients (57.2% male patients) presented with suspected NSAID-H during the study period. Of these, 168 patients (69.1%) had a history of reaction to ibuprofen. Isolated skin involvement was the most frequent symptom (86%). A total of 238 DPTs were performed with the suspected agents and 34 had positive results. The families of 12 patients refused provocation testing with the suspected agent or aspirin and these patients could not be diagnosed. Of the 231 patients, 47 patients (20.3%) received a diagnosis of NSAID-H. Twenty patients with NSAID-H could not be classified because their guardians did not consent to further testing with aspirin. CONCLUSION Performing diagnostic tests is important in patients with no contraindications. Characterizing these reactions in children can be difficult because of the coexistence of indistinguishable symptoms in their history and DPTs, as well as the need for multiple provocation tests. Therefore, further research is needed on this subject.
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Mayorga C, Fernandez TD, Montañez MI, Moreno E, Torres MJ. Recent developments and highlights in drug hypersensitivity. Allergy 2019; 74:2368-2381. [PMID: 31557314 DOI: 10.1111/all.14061] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 09/18/2019] [Accepted: 09/19/2019] [Indexed: 12/12/2022]
Abstract
Drug hypersensitivity reactions (DHRs) are nowadays the third cause of allergy after rhinitis and asthma with a significant increase in prevalence in both adults and paediatric population with new drugs included as culprit. For this, DHRs represent not only a health problem but also a significant financial burden for affected individuals and health systems. Mislabelling DHRs is showing to be a relevant problem for both, false label of drug allergic and false label of nonallergic. All this reinforces the need to improve accurate diagnostic approaches that allow an appropriate management. Moreover, there is a need for training both, nonallergist stakeholders and patients to improve the reaction identification and therefore decrease the mislabelling. The use of allergy cards has shown to be relevant to avoid the induction of DHRs due to the prescription of wrong medication. Recent developments over the last 2 years and highlights about risk factors, diagnostic approaches, mechanisms involved as well as prevention actions, and management have been reviewed. In these papers, it has been outlined the need for correct diagnosis and de-labelling of patients previously false-reported as allergic, which will improve the management and treatment of patients with DHRs.
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Affiliation(s)
- Cristobalina Mayorga
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyAL Málaga Spain
- Allergy Unit Hospital Regional Universitario de Málaga‐ARADyAL Málaga Spain
- Andalusian Center for Nanomedicine and Biotechnology‐BIONAND Málaga Spain
| | - Tahia D. Fernandez
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyAL Málaga Spain
| | - Maria Isabel Montañez
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyAL Málaga Spain
- Andalusian Center for Nanomedicine and Biotechnology‐BIONAND Málaga Spain
| | - Esther Moreno
- Allergy Unit Hospital Universitario de Salamanca‐ARADyAL IBSAL Salamanca Spain
| | - María José Torres
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA‐ARADyAL Málaga Spain
- Allergy Unit Hospital Regional Universitario de Málaga‐ARADyAL Málaga Spain
- Andalusian Center for Nanomedicine and Biotechnology‐BIONAND Málaga Spain
- Universidad de Málaga Málaga Spain
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Mori F, Atanaskovic-Markovic M, Blanca-Lopez N, Gomes E, Gaeta F, Sarti L, Bergmann MM, Tmusic V, Valluzzi RL, Caubet JC. A Multicenter Retrospective Study on Hypersensitivity Reactions to Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) in Children: A Report from the European Network on Drug Allergy (ENDA) Group. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 8:1022-1031.e1. [PMID: 31785410 DOI: 10.1016/j.jaip.2019.10.049] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 10/14/2019] [Accepted: 10/28/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND Diagnosis of hypersensitivity (HS) reactions to nonsteroidal anti-inflammatory drugs (NSAIDs) in children is complex. The real prevalence of NSAID HS remains unknown because a drug provocation test (DPT) is not always performed with the culprit NSAID. OBJECTIVE To describe and compare the diagnostic workup among different European centers and to find out the real proportion of NSAID HS by performing a DPT with the culprit drug. METHODS We retrospectively collected data from children (0-10 years) and adolescents (10-18 years) with a history of NSAID reactions and who underwent a complete allergy workup including DPTs with the culprit in 6 different pediatric centers: Belgrade, Florence, Geneva, Madrid, Porto, and Rome. RESULTS A total of 693 children with a history of NSAID reactions were enrolled, and a total of 526 DPTs were performed with the culprit NSAID. The diagnosis of NSAID HS was confirmed in 19.6% (103 of 526) of children by performing a DPT with the culprit drug. The major differences in the allergy workup among the 6 centers concerned the duration of the DPT and the practical use of skin tests for diagnosing NSAID HS. In addition, the use of acetyl salicylic acid to differentiate single reactor or cross-intolerance patients is not common, except in Spain. CONCLUSION The value of this study is that although different approaches are used around Europe to diagnose NSAID HS, we found that the percentage of confirmed NSAID HS is less than 20%. This highlights the importance of the DPT in confirming or excluding NSAID HS in the pediatric population.
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Affiliation(s)
- Francesca Mori
- Allergy Unit, Department of Pediatrics, Anna Meyer Children's University Hospital, Florence, Italy
| | | | | | - Eva Gomes
- Allergy and Clinical Immunology Service, Centro Hospitalar e Universitário do Porto, Porto, Portugal
| | - Francesco Gaeta
- Allergy Unit, Presidio Columbus, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Lucrezia Sarti
- Allergy Unit, Department of Pediatrics, Anna Meyer Children's University Hospital, Florence, Italy
| | - Marcel M Bergmann
- Pediatric Allergy Unit, Geneva University Hospitals, Geneva, Switzerland
| | - Vladimir Tmusic
- University Children's Hospital, Medical Faculty University of Belgrade, Belgrade, Serbia
| | - Rocco L Valluzzi
- Allergy Department, Pediatric Hospital Bambino Gesù, Rome, Vatican City
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Blanca-Lopez N, Soriano V, Garcia-Martin E, Canto G, Blanca M. NSAID-induced reactions: classification, prevalence, impact, and management strategies. J Asthma Allergy 2019; 12:217-233. [PMID: 31496752 PMCID: PMC6690438 DOI: 10.2147/jaa.s164806] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 02/03/2019] [Indexed: 12/20/2022] Open
Abstract
Nonsteroidal anti-inflammatory drugs (NSAIDs) are the leading cause of hypersensitivity drug reactions. The different chemical structures, cyclooxygenase 1 (COX-1) and/or COX-2 inhibitors, are taken at all ages and some can be easily obtained over the counter. Vasoactive inflammatory mediators like histamine and leukotriene metabolites can produce local/systemic effects. Responders can be selective (SR), IgE or T-cell mediated, or cross-intolerant (CI). Inhibition of the COX pathway is the common mechanism in CI, with the skin being the most frequent organ involved, followed by the lung and/or the nose. An important number of cases have skin and respiratory involvement, with systemic manifestations ranging from mild to severe anaphylaxis. Among SR, this is the most frequent entity, often being severe. Recent years have seen an increase in reactions involving the skin, with many cases having urticaria and/or angioedema in the absence of chronic urticaria. Aspirin, the classical drug involved, has now been replaced by other NSAIDs, with ibuprofen being the universal culprit. For CI, no in vivo/in vitro diagnostic methods exist and controlled administration is the only option unless the cases evaluated report repetitive and consistent episodes with different NSAIDs. In SR, skin testing (patch and intradermal) with 24-48 reading can be useful, mainly for delayed T-cell responses. Acetyl salicylic acid (ASA) is the test drug to establish the diagnosis and confirm/exclude CI by controlled administration. Desensitization to ASA has been extensively used in respiratory cases though it can also be applied in those cases where it is required.
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Affiliation(s)
| | - Victor Soriano
- General University Hospital of Alicante-ISABIAL
, Alicante, Madrid, Spain
| | - Elena Garcia-Martin
- Medical and Surgery Therapy Department, University of Extremadura, Caceres, Spain
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Eser Simsek I, Cogurlu MT, Aydogan M. Two approaches for diagnosis of nonsteroidal anti-inflammatory drug hypersensitivity in children. Ann Allergy Asthma Immunol 2019; 123:389-393. [PMID: 31323315 DOI: 10.1016/j.anai.2019.07.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 07/01/2019] [Accepted: 07/08/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND The oral provocation test (OPT) with culprit drug is the gold standard in the diagnosis of nonsteroidal anti-inflammatory drug hypersensitivity (NSAID-H). Some authors have proposed that the total number of OPTs required to diagnose NSAID-H is much lower with acetyl salicylic acid (ASA) provocations, regardless of patients' reaction history, and less time consuming. OBJECTIVE This study aims to evaluate the total number of OPTs required to confirm NSAID-H according to the drugs (ASA or culprit NSAID) used in the initial OPT. METHODS The study included patients with a history of NSAID-H. Data on the demographic and clinical features, coexisting chronic or allergic disease, and laboratory results were collected from medical records. The drug used for the initial OPT (ASA or culprit NSAID), results of the OPT, and the total number of OPTs were reviewed. RESULTS We included 56 children with suspected hypersensitivity reaction to NSAIDs. NSAID-H was confirmed in 21 children (37.5%). We calculated that if all OPTs were performed with culprit drugs as an initial choice, the number of OPTs required for diagnosis would be 3 or more in 85.7% of positive cases. The number of episodes was an independent risk factor for NSAID-H by multiple logistic regression analysis (odds ratio, 4.3; 95% confidence interval, 1.48-12.24; P = .007). CONCLUSION Performing an initial OPT with ASA regardless of patients' reaction history can result in much lower numbers of OPT to diagnose NSAID-H and can improve patient compliance.
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Affiliation(s)
- Isil Eser Simsek
- Division of Pediatric Allergy and Immunology, Kocaeli University, Kocaeli, Turkey.
| | - Mujde Tuba Cogurlu
- Division of Pediatric Allergy and Immunology, Kocaeli University, Kocaeli, Turkey
| | - Metin Aydogan
- Division of Pediatric Allergy and Immunology, Kocaeli University, Kocaeli, Turkey
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Kulhas Celik I, Dibek Misirlioglu E, Kocabas CN. Recent developments in drug hypersensitivity in children. Expert Rev Clin Immunol 2019; 15:723-733. [PMID: 31066307 DOI: 10.1080/1744666x.2019.1612241] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Introduction: Drug allergy is an important public health problem that causes 0.4-10.3% of hospital admissions in children. The epidemiology, clinical spectrum, diagnosis, and management of drug hypersensitivity reactions (DHRs) differ in pediatric and adult patients. However, the same algorithms used in adults have often been applied in the pediatric population due to a lack of evidence in the literature. Areas covered: In this review, we aimed to discuss recent developments in the area of pediatric DHRs based on the growing body of literature advancing our understanding of the epidemiology, clinical aspects, and diagnostic approaches to DHRs in children. Expert opinion: Misdiagnosis, under-diagnosis, and self-diagnosis are common problems related to drug allergies in children. Viral infections are particularly frequent in children and make diagnosis difficult. Identifying true DHR is a key step in the management of drug allergy in children. Therefore, a complete allergy work-up with standardized drug allergy tests is necessary. In order to eliminate non-standardized tests, future studies including larger numbers of children should be conducted to determine more accurate standardized tests for diagnosing DHRs in the pediatric population.
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Affiliation(s)
- Ilknur Kulhas Celik
- a Division of Pediatric Allergy and Immunology , University of Health Sciences, Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital , Ankara , Turkey
| | - Emine Dibek Misirlioglu
- a Division of Pediatric Allergy and Immunology , University of Health Sciences, Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital , Ankara , Turkey
| | - Can Naci Kocabas
- b Division of Pediatric Allergy and Immunology, Department of Children's Health and Diseases, Faculty of Medicine , Mugla Sitki Kocman University , Mugla , Turkey
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Abstract
PURPOSE OF REVIEW Pediatric drug hypersensitivity is a rapidly evolving field. The purpose of this paper is to review the current state of pediatric drug hypersensitivity and highlight new developments in diagnosis and management. RECENT FINDINGS This paper will discuss the safety and use of risk stratification to proceed directly to oral challenge without prior skin testing for β-lactam reactions. We review unique aspects of pediatric drug challenges and desensitizations. It is important to accurately diagnose pediatric drug hypersensitivity reactions through a detailed history, physical examination, and available diagnostic testing. Understanding of the underlying mechanism leads to appropriate classification which is necessary to direct management. The decision to perform drug challenge, desensitization, or recommend avoidance of a medication can have a significant impact on a patient's treatment. Utilization of weight-based dose and infusion rate adjustments for current drug challenge and desensitization protocols optimize success.
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Cavkaytar O, du Toit G, Caimmi D. Characteristics of NSAID-induced hypersensitivity reactions in childhood. Pediatr Allergy Immunol 2019; 30:25-35. [PMID: 30194799 DOI: 10.1111/pai.12980] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 08/27/2018] [Accepted: 09/03/2018] [Indexed: 12/26/2022]
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) are available as over-the-counter drugs, and they are commonly used in children for their antipyretic, analgesic, and anti-inflammatory effects. NSAIDs are among the most frequently reported drugs associated with hypersensitivity reactions and even with anaphylaxis. A complete evaluation of the patients based on reported clinical manifestations, timing of the reaction, the presence of underlying disease, and reactions to other NSAIDs allows clinicians to stratify children with a history of reaction to NSAIDs. Although NSAID-induced hypersensitivity reactions have mainly been investigated in adults, recent studies have aimed to explore their epidemiology in the pediatric population. This review will cover the current understanding of clinical manifestations, the risk factors, and the different phenotypes of NSAID-induced hypersensitivity reactions with a comprehensive overview of the epidemiologic data from past to present and the practical approach to the management of NSAID hypersensitivity in children and adolescents.
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Affiliation(s)
- Ozlem Cavkaytar
- Department of Pediatric Allergy, Istanbul Medeniyet University, Goztepe Training and Research Hospital, Istanbul, Turkey
| | - George du Toit
- Department of Pediatric Allergy, Division of Asthma, Allergy and Lung Biology, King's College London and Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Davide Caimmi
- Allergy Unit, Department of respiratory diseases, University Hospital of Montpellier, Univ Montpellier, Montpellier, France.,Epidemiology of Allergic and Respiratory Diseases Department (EPAR), Pierre Louis Institute of Epidemiology and Public Health, Saint-Antoine Medical School, Sorbonne Université, INSERM, Paris, France
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Thong BYH. Nonsteroidal anti-inflammatory drug hypersensitivity in the Asia-Pacific. Asia Pac Allergy 2018; 8:e38. [PMID: 30402405 PMCID: PMC6209595 DOI: 10.5415/apallergy.2018.8.e38] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 10/19/2018] [Indexed: 12/19/2022] Open
Abstract
Nonsteroidal anti-inflammatory drug (NSAID) hypersensitivity reactions (HSRs) are often nonimmunologically mediated reactions which present with immediate HSR type manifestations. These are mediated by cyclooxygenase inhibition resulting in shunting towards the excessive production of leukotrienes. Important disease associations include asthma, nasal polyposis, and chronic spontaneous urticaria, especially among adults. The European Network on Drug Allergy/Global Allergy and Asthma European Network 2013 classification of NSAID HSR comprises nonselective HSR i.e., NSAID exacerbated respiratory disease (NERD), NSAIDs exacerbated cutaneous disease (NECD), NSAIDs induced urticarial-angioedema (NIUA); and selective (allergic) HSR i.e., single NSAID induced urticaria/angioedema or anaphylaxis, NSAIDs-induced delayed HSR. Much of the literature on genetic associations with NSAID HSR originate from Korea and Japan; where genetic polymorphisms have been described in genes involved in arachidonic acid metabolism, basophil/mast cell/eosinophil activation, various inflammatory mediators/cytokines, and different HLA genotypes. The Asian phenotype for NSAID HSR appears to be predominantly NIUA with overlapping features in some adults and children. NECD also appears to be more common than NERD, although both are not common in the Asian paediatric population. Between adults and children, children seem to be more atopic, although over time when these children grow up, it is likely that the prevalence of atopic adults with NSAID HSR will increase. Low-dose aspirin desensitization has been shown to be effective in the treatment of coronary artery disease, especially following percutaneous coronary intervention.
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Affiliation(s)
- Bernard Yu-Hor Thong
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore 308433
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Ponvert C. Quoi de neuf en allergologie pédiatrique de fin 2015 à début 2018 ? Anaphylaxie, allergie médicamenteuse et aux venins et salives d’insectes (une revue de la littérature internationale). REVUE FRANCAISE D ALLERGOLOGIE 2018. [DOI: 10.1016/j.reval.2018.02.219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Interaction between foods and nonsteroidal anti-inflammatory drugs and exercise in the induction of anaphylaxis. Curr Opin Allergy Clin Immunol 2018; 18:310-316. [DOI: 10.1097/aci.0000000000000461] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Graham F, Caubet JC. Diagnosis of drug causality in non-immediate drug hypersensitivity in children. Expert Rev Clin Pharmacol 2018; 11:655-658. [DOI: 10.1080/17512433.2018.1494570] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- François Graham
- Pediatric Allergy Unit, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland
| | - Jean-Christoph Caubet
- Pediatric Allergy Unit, University Hospitals of Geneva and University of Geneva, Geneva, Switzerland
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Acetyl Salicylic Acid Challenge in Children with Hypersensitivity Reactions to Nonsteroidal Anti-Inflammatory Drugs Differentiates Between Cross-Intolerant and Selective Responders. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:1226-1235. [DOI: 10.1016/j.jaip.2017.08.029] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 08/18/2017] [Accepted: 08/24/2017] [Indexed: 11/23/2022]
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25
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Blanca-Lopez N, Perez-Alzate D, Canto G, Blanca M. Practical approach to the treatment of NSAID hypersensitivity. Expert Rev Clin Immunol 2017; 13:1017-1027. [PMID: 28893093 DOI: 10.1080/1744666x.2017.1377072] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Non-steroidal anti-inflammatory drugs (NSAIDs) are the most frequently involved in drug hypersensitivity reactions (DHR). NSAIDs are prescribed for different processes and some NSAIDs can be obtained over the counter. Areas covered: We analyse the practical approaches for managing and treating NSAID-DHR considering the five major groups of entities recognised, divided into two categories: those responding to strong COX-1 inhibitors and possibly weak COX-1 or selective COX-2 inhibitors named cross-intolerant (CI), and those induced by a single drug or drug group with good tolerance to strong COX-1 inhibitors, known as allergic reactions (SR). An analysis of the recent literature indicates that two approaches can be followed for CI: to give acetyl salicylic acid to confirm NSAID hypersensitivity or to give alternative drugs to provide a solution for the treatment of pain, fever, inflammation or other conditions. Desensitisation approaches have been undertaken, but mainly for CI cases with respiratory airway involvement and they are very rarely used for CI with cutaneous involvement or SR. Expert commentary: DHR to NSAIDs are now recognised as one of the most important problems in the evaluation and management of drug allergy. Because no diagnostic tests exist, important resources are needed to evaluate these patients.
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Affiliation(s)
| | | | - Gabriela Canto
- a Allergy Service , Hospital Infanta Leonor , Madrid , Spain
| | - Miguel Blanca
- a Allergy Service , Hospital Infanta Leonor , Madrid , Spain
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26
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Aspirin and Nonsteroidal Antiinflammatory Drugs Hypersensitivity and Management. Immunol Allergy Clin North Am 2017; 37:727-749. [PMID: 28965637 DOI: 10.1016/j.iac.2017.07.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Aspirin and nonsteroidal antiinflammatory drugs (NSAIDs) are widely used in the United States and throughout the world for a variety of indications. Several unique hypersensitivity syndromes exist to this class of medications, making them one of the common reasons for consultation to the allergist. The lack of any laboratory-based diagnostic studies to assist in identifying the culprits in these reactions make evaluation of aspirin and NSAID hypersensitivity challenging. Identifying patients appropriate for oral challenge and/or desensitization protocols is the standard pragmatic approach to this issue when it arises.
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Soyer O, Sahiner UM, Sekerel BE. Pro and Contra: Provocation Tests in Drug Hypersensitivity. Int J Mol Sci 2017; 18:ijms18071437. [PMID: 28677662 PMCID: PMC5535928 DOI: 10.3390/ijms18071437] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Revised: 06/24/2017] [Accepted: 06/27/2017] [Indexed: 02/06/2023] Open
Abstract
Drug provocation test (DPT) is the controlled administration of a drug to diagnose immune- or non-immune-mediated drug hypersensitivity and the last step for accurate recognition of drug hypersensitivity reactions when the previous diagnostic evaluations are negative or unavailable. A DPT is performed only if other conventional tests fail to yield conclusive results. In each clinical presentation, "to provoke or not to provoke" a patient should be decided after careful assessment of the risk-benefit ratio. Well-defined benefits of DPT include confirmative exclusion of diagnoses of drug hypersensitivity and provision of safe alternatives. However, disadvantages such as safety, difficulty in interpretations of results, lack of objective biomarkers, risks of resensitization, efficiency in daily practice, and lack of standardized protocols, are poorly debated. This review summarizes the current published research concerning DPT, with particular emphasis on the advantages and disadvantages of DPT in an evidence-based manner.
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Affiliation(s)
- Ozge Soyer
- Department of Pediatric Allergy Ankara, School of Medicine, Hacettepe University, Ankara 06100, Turkey.
| | - Umit Murat Sahiner
- Department of Pediatric Allergy Ankara, School of Medicine, Hacettepe University, Ankara 06100, Turkey.
| | - Bulent Enis Sekerel
- Department of Pediatric Allergy Ankara, School of Medicine, Hacettepe University, Ankara 06100, Turkey.
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Elzagallaai AA, Greff M, Rieder MJ. Adverse Drug Reactions in Children: The Double-Edged Sword of Therapeutics. Clin Pharmacol Ther 2017; 101:725-735. [PMID: 28295234 DOI: 10.1002/cpt.677] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 03/06/2017] [Accepted: 03/08/2017] [Indexed: 12/14/2022]
Abstract
Adverse drug reactions (ADRs) represent a major health problem worldwide, with high morbidity and mortality rates. ADRs are classified into Type A (augmented) and Type B (bizarre) ADRs, with the former group being more common and the latter less common but often severe and clinically more problematic due to their unpredictable nature and occurrence at any dose. Pediatric populations are especially vulnerable to ADRs due to the lack of data for this age group from the drug development process and because of the wide use of off-label and unlicensed use of drugs. Children are more prone to specific types of ADRs because of the level of maturity of body systems involved in absorption, metabolism, transportation, and elimination of drugs. This state-of-the-art review provides an overview of definitions, classifications, epidemiology, and pathophysiology of ADRs and discusses the available evidence for related risk factors and causes of ADRs in the pediatric population.
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Affiliation(s)
- A A Elzagallaai
- Department of Pediatrics, University of Western Ontario, London, Ontario, Canada.,Physiology and Pharmacology, University of Western Ontario, London, Ontario, Canada.,Robarts Research Institute, University of Western Ontario, London, Ontario, Canada
| | - Mje Greff
- Department of Pediatrics, University of Western Ontario, London, Ontario, Canada.,Robarts Research Institute, University of Western Ontario, London, Ontario, Canada
| | - M J Rieder
- Department of Pediatrics, University of Western Ontario, London, Ontario, Canada.,Physiology and Pharmacology, University of Western Ontario, London, Ontario, Canada.,Robarts Research Institute, University of Western Ontario, London, Ontario, Canada.,Division of Clinical Pharmacology, Department of Medicine, Schulich School of Medicine and Dentistry, London, Ontario, Canada
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