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Feldman K, Aaronson K, Gu T, Ige K, Southworth E, Sanchez L, Stieglitz E. Desensitization using pegaspargase in the era of commercially available Erwinia: A single-institution report on efficacy, cost, and resource utilization. Pediatr Blood Cancer 2024; 71:e30891. [PMID: 38311802 DOI: 10.1002/pbc.30891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 12/23/2023] [Accepted: 01/15/2024] [Indexed: 02/06/2024]
Abstract
BACKGROUND Pegaspargase is a therapeutic enzyme that is utilized in treatment regimens targeting pediatric acute lymphoblastic leukemia. However, many patients experience hypersensitivity reactions, requiring discontinuation of the therapy. Historically, this necessitated switching to an alternative form of the drug, most commonly asparaginase Erwinia chrysanthemi; however, in recent years this was difficult due to drug shortages and eventually commercial discontinuation. We report here our experience performing pegaspargase desensitizations in patients with prior hypersensitivity reactions. PROCEDURE Patients with a clinical hypersensitivity reaction to pegaspargase were identified. When due for their next dose, patients were admitted to the pediatric intensive care unit, bone marrow transplant unit, or oncology unit, and underwent desensitization utilizing a rigorous premedication and multistep dilution-based protocol. Serum asparaginase activity levels were drawn after desensitization to assess for therapeutic levels of enzyme activity. RESULTS We identified 11 patients who underwent a total of 33 desensitizations to pegaspargase and calaspargase pegol-mknl. No patients experienced clinically significant hypersensitivity reactions necessitating stopping the infusion, nor administration of rescue medications. All serum asparaginase activity levels collected demonstrated enzyme activity levels above predefined therapeutic thresholds. Cost analysis revealed substantial savings when patients received asparaginase desensitization over the now commercially available asparaginase E. chrysanthemi (recombinant) rywn. CONCLUSIONS Performing desensitization to pegaspargase in the pediatric acute lymphoblastic leukemia population is feasible, safe, and effective. It is financially advantageous over available alternative approaches, and requires fewer injections and presentations to care.
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Affiliation(s)
- Kira Feldman
- San Francisco Department of Pediatrics, University of California, San Francisco, California, USA
| | - Kathryn Aaronson
- Division of Pediatric Oncology, University of California, San Francisco Benioff Children's Hospital, San Francisco, California, USA
| | - Tina Gu
- Department of Pharmacy, University of California, San Francisco, California, USA
| | - Kelsey Ige
- Division of Pediatric Immunology, University of California, San Francisco Benioff Children's Hospital, San Francisco, California, USA
| | - Erica Southworth
- Division of Pediatric Oncology, University of California, San Francisco Benioff Children's Hospital, San Francisco, California, USA
| | - Lauren Sanchez
- Division of Pediatric Immunology, University of California, San Francisco Benioff Children's Hospital, San Francisco, California, USA
| | - Elliot Stieglitz
- Division of Pediatric Oncology, University of California, San Francisco Benioff Children's Hospital, San Francisco, California, USA
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2
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Butranova O, Zyryanov S, Gorbacheva A, Asetskaya I, Polivanov V. Drug-Induced Anaphylaxis: National Database Analysis. Pharmaceuticals (Basel) 2024; 17:90. [PMID: 38256923 PMCID: PMC10821106 DOI: 10.3390/ph17010090] [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: 11/27/2023] [Revised: 01/05/2024] [Accepted: 01/08/2024] [Indexed: 01/24/2024] Open
Abstract
(1) Background: National health system databases represent an important source of information about the epidemiology of adverse drug reactions including drug-induced allergy and anaphylaxis. Analysis of such databases may enhance the knowledge of healthcare professionals regarding the problem of drug-induced anaphylaxis. (2) Methods: A retrospective descriptive analysis was carried out of spontaneous reports (SRs) with data on drug-induced anaphylaxis (SRsAs) extracted from the Russian National Pharmacovigilance database (analyzed period 2 April 2019-21 June 2023). The percentage of SRsAs among SRs of drug-induced allergy (SRsDIAs) was calculated, as well as of pediatric, elderly, and fatal SrsAs. Drugs involved in anaphylaxis were assessed among total SRsAs, pediatric, and elderly SRsAs, and among fatal SRsAs. Demographic parameters of patients were assessed. (3) Results: SRsAs were reported in 8.3% of SRsDIAs (2304/27,727), the mean age of patients was 48.2 ± 15.8 years, and females accounted for 53.2% of cases. The main causative groups of drugs were antibacterials (ABs) for systemic use (44.6%), local anesthetics (20.0%), and cyclooxygenase (COX) inhibitors (10.1%). Fatal SRsAs were reported in 9.5% (218/2304) of cases, the mean age of patients was 48.0 ± 16.7 years, and females accounted for 56.4% of cases. Pediatric SRsAs accounted for 3.9% of pediatric SRsDIAs and 5.8% of all SRsAs, with a mean age of 11.8 ± 4.5 years, and females acccounted for 51.9% of cases. Elderly SRsAs accounted for 2% of elderly SRsDIAs and 2.8% of all SRsAs, and the mean age was 73.0 ± 5.3 years, and females accounted for 43.5% of cases. ABs caused 40% of SRsAs in the elderly, 42.9% in children, and 50% of fatal SRsAs. (4) Conclusions: Our study revealed a relatively high proportion of anaphylaxis among SRs of drug-induced allergy. ABs were the most prevalent causative agents, especially in fatal SRsAs.
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Affiliation(s)
- Olga Butranova
- Department of General and Clinical Pharmacology, Peoples’ Friendship University of Russia Named after Patrice Lumumba (RUDN), 6 Miklukho-Maklaya St., 117198 Moscow, Russia; (S.Z.); (A.G.); (I.A.)
| | - Sergey Zyryanov
- Department of General and Clinical Pharmacology, Peoples’ Friendship University of Russia Named after Patrice Lumumba (RUDN), 6 Miklukho-Maklaya St., 117198 Moscow, Russia; (S.Z.); (A.G.); (I.A.)
- Moscow City Health Department, City Clinical Hospital No. 24, State Budgetary Institution of Healthcare of the City of Moscow, Pistzovaya Srt. 10, 127015 Moscow, Russia
| | - Anastasia Gorbacheva
- Department of General and Clinical Pharmacology, Peoples’ Friendship University of Russia Named after Patrice Lumumba (RUDN), 6 Miklukho-Maklaya St., 117198 Moscow, Russia; (S.Z.); (A.G.); (I.A.)
| | - Irina Asetskaya
- Department of General and Clinical Pharmacology, Peoples’ Friendship University of Russia Named after Patrice Lumumba (RUDN), 6 Miklukho-Maklaya St., 117198 Moscow, Russia; (S.Z.); (A.G.); (I.A.)
| | - Vitaly Polivanov
- Pharmacovigilance Center, Information and Methodological Center for Expert Evaluation, Record and Analysis of Circulation of Medical Products under the Federal Service for Surveillance in Healthcare, 4-1 Slavyanskaya Square, 109074 Moscow, Russia;
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González-Bravo L, Sánchez-González MJ, Barbarroja-Escudero J, Monjo-Paz J, Matas-Dominguez D, Alvarez-Mon M. Immediate Reaction to Propranolol: An Extremely Rare but Important Condition. A Case Report. Curr Drug Saf 2024; 19:303-305. [PMID: 37073669 DOI: 10.2174/1574886318666230417103423] [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: 01/16/2023] [Revised: 02/18/2023] [Accepted: 02/22/2023] [Indexed: 04/20/2023]
Abstract
INTRODUCTION Beta-blockers involve a group of drugs widely used nowadays. Propranolol was the first beta-blocker available in the market. It is the most prescribed first-generation betablocker and is commonly used. Beta-blocker allergy is extremely unusual. Only an isolated case of an urticaria reaction to propranolol has been published in 1975. CASE PRESENTATION We present a 44-year-old man. In 2016, he was treated with a daily dose of 5 mg of propranolol prescribed for a diagnosis of essential tremor. On the third day of medical treatment, he experienced an episode of generalized urticaria directly related to the administration of propranolol. He continued with his habitual treatment and he had no other urticaria episodes. A drug provocation test was carried out with gradually increasing doses of the culprit drug. Thirty minutes after a total cumulative dose of 5 mg, the patient had several hives on the chest, abdominal region and arms. Two weeks later, a new drug provocation test was performed to bisoprolol as an alternative beta-blocker, with good tolerance. CONCLUSION We describe a new case of urticaria secondary to propranolol, presenting as an immediate hypersensitivity reaction. Bisoprolol has been succesfully proved to be a safe option. Bisoprolol is a second-generation beta-blocker, it is available and commercialized worldwide, which makes it a good alternative.
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Affiliation(s)
- Lucía González-Bravo
- Departamento de Medicina y Especialidades Médicas, Servicio de Enfermedades del Sistema Inmune-Alergia, Hospital Universitario Príncipe de Asturias, Universidad de Alcalá, Alcalá de Henares, Madrid, Spain
| | - María-José Sánchez-González
- Departamento de Medicina y Especialidades Médicas, Servicio de Enfermedades del Sistema Inmune-Alergia, Hospital Universitario Príncipe de Asturias, Universidad de Alcalá, Alcalá de Henares, Madrid, Spain
| | - José Barbarroja-Escudero
- Departamento de Medicina y Especialidades Médicas, Servicio de Enfermedades del Sistema Inmune-Alergia, Hospital Universitario Príncipe de Asturias, Universidad de Alcalá, Alcalá de Henares, Madrid, Spain
| | - Josefa Monjo-Paz
- Departamento de Medicina y Especialidades Médicas, Servicio de Enfermedades del Sistema Inmune-Alergia, Hospital Universitario Príncipe de Asturias, Universidad de Alcalá, Alcalá de Henares, Madrid, Spain
| | - Dorotea Matas-Dominguez
- Departamento de Medicina y Especialidades Médicas, Servicio de Enfermedades del Sistema Inmune-Alergia, Hospital Universitario Príncipe de Asturias, Universidad de Alcalá, Alcalá de Henares, Madrid, Spain
| | - Melchor Alvarez-Mon
- Departamento de Medicina y Especialidades Médicas, Servicio de Enfermedades del Sistema Inmune-Alergia, Hospital Universitario Príncipe de Asturias, Universidad de Alcalá, Alcalá de Henares, Madrid, Spain
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Snider CS, Hasara SL, Wilson KM, Glueck JA, Barbera AR. Impact of Outpatient Antihypertensive Medication Use on Epinephrine Resistance in Anaphylaxis. Cureus 2023; 15:e35119. [PMID: 36945274 PMCID: PMC10024959 DOI: 10.7759/cureus.35119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2023] [Indexed: 02/19/2023] Open
Abstract
BACKGROUND There has been an increase in allergy-related emergency department (ED) visits over the past several years. Underlying cardiovascular disease or respiratory disease and concurrent beta blocker or angiotensin-converting enzyme inhibitor use have been identified as potential risk factors for severe or refractory anaphylactic reactions. Conflicting evidence exists regarding the association between antihypertensive (AH) use and the incidence of refractory anaphylaxis. OBJECTIVE The purpose of this study was to determine the incidence of refractory anaphylaxis in patients presenting to the ED while prescribed select AH medications outpatient. METHODS This was a retrospective cohort study of all adult and pediatric patients presenting to the ED between February 16, 2021, and August 31, 2021, with a diagnosis of anaphylaxis. The primary objective was to compare the proportion of patients experiencing refractory anaphylaxis that were prescribed versus not prescribed AH medications in the outpatient setting. RESULTS A total of 101 patients were treated for anaphylaxis in the ED during the study timeframe with 13 patients in the AH group and 88 patients in the no AH group. There was no difference in the incidence of refractory anaphylaxis between groups (0% vs 9%; p=0.48). Significantly fewer patients in the AH group required any epinephrine doses compared to the no AH group (38% vs 88%; p<0.001). CONCLUSIONS Outpatient use of select AH medications was not associated with an increased incidence of refractory anaphylaxis in patients presenting to the ED.
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Affiliation(s)
| | | | - Kayla M Wilson
- Department of Pharmacy, Lakeland Regional Health, Lakeland, USA
| | - Jesse A Glueck
- Department of Emergency Medicine, Lakeland Regional Health, Lakeland, USA
| | - Andrew R Barbera
- Department of Emergency Medicine, Lakeland Regional Health, Lakeland, USA
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5
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Kumar R, Gaur S, Agarwal M, Menon B, Goel N, Mrigpuri P, Spalgais S, Priya A, Kumar K, Meena R, Sankararaman N, Verma A, Gupta V, Sonal, Prakash A, Safwan MA, Behera D, Singh A, Arora N, Prasad R, Padukudru M, Kant S, Janmeja A, Mohan A, Jain V, Nagendra Prasad K, Nagaraju K, Goyal M. Indian Guidelines for diagnosis of respiratory allergy. INDIAN JOURNAL OF ALLERGY, ASTHMA AND IMMUNOLOGY 2023. [DOI: 10.4103/0972-6691.367373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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6
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Koracevic G, Micic S, Stojanovic M, Radovanovic RV, Pavlovic MP, Kostic T, Djordjevic D, Antonijevic N, Koracevic M, Atanaskovic V, Dakic S. Beta Blockers can mask not only Hypoglycemia, but also Hypotension. Curr Pharm Des 2022; 28:1660-1668. [DOI: 10.2174/1381612828666220421135523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 02/01/2022] [Indexed: 11/22/2022]
Abstract
Background:
Beta-adrenergic (β-AR) receptor blockers (BBs) are an essential class of drugs as they have numerous indications. On the other hand, they have numerous unwanted effects which decrease the compliance, adherence, and persistence of this very useful group of drugs.
Objective:
The paper aims to analyze the possibility that an unnoticed side effect may contribute to a less favorable pharmacologic profile of BBs, e.g., a diminished reaction to a sudden fall in BP.
Methods:
We searched two medical databases for abstracts and citations (Medline and SCOPUS). Moreover, we searched the internet for drug prescription leaflets (of the individual BBs).
Results:
Whichever cause of stress is considered, the somatic manifestations of stress will be (partially) masked if a patient takes BB. Stress–induced hypercatecholaminemia acts on β-AR of cardiomyocytes; it increases heart rate and contractility, effects suppressed by BBs. The answers of the organism to hypoglycemia and hypotension share the main mechanisms such as sympathetic nervous system activation and hypercatecholaminemia. Thus, there is a striking analogy: BBs can cover up symptoms of both hypoglycemia (which is widely known) and of hypotension (which is not recognized). It is widely known that BBs can cause hypotension. However, they can also complicate recovery by spoiling the defense mechanisms in hypotension as they interfere with the crucial compensatory reflex to increase blood pressure in hypotension.
Conclusion:
Beta blockers can cause hypotension, mask it, and make recovery more difficult. This is clinically important and deserves to be more investigated and probably to be stated as a warning.
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Affiliation(s)
- Goran Koracevic
- Department for Cardiovascular Diseases, University Clinical Centre Nis, Nis, Serbia
| | | | | | | | - Milan Pavlovic Pavlovic
- Department for Cardiovascular Diseases, University Clinical Centre Nis, Nis, Serbia
- Faculty of Medicine, University of Nis, Nis, Serbia
| | - Tomislav Kostic
- Department for Cardiovascular Diseases, University Clinical Centre Nis, Nis, Serbia
- Faculty of Medicine, University of Nis, Nis, Serbia
| | - Dragan Djordjevic
- Faculty of Medicine, University of Nis, Nis, Serbia
- Institute for Treatment and Rehabilitation Niska Banja, Nis, Serbia
| | - Nebojsa Antonijevic
- Clinic for Cardiology, University Clinical Centre of Serbia, Belgrade, Serbia
| | - Maja Koracevic
- Faculty of Medicine, University of Nis, Nis, Serbia
- Innovation Centre, University of Nis, Nis, Serbia
| | - Vesna Atanaskovic
- Department for Cardiovascular Diseases, University Clinical Centre Nis, Nis, Serbia
| | - Sonja Dakic
- Department for Cardiovascular Diseases, University Clinical Centre Nis, Nis, Serbia
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7
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Matveev AV, Egorova EA, Konyaeva EI, Dormidor AG, Bekirova EY. Peculiarities of Adverse Events Manifested by Injury of Skin and Skin Derivatives and Associated with Beta-blockers Use. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2021. [DOI: 10.20996/1819-6446-2021-10-12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
More than 50 years after Propranolol was introduced to the pharmaceutical market as a drug that can lower the heart rate, beta-blockers (BAB) are still widely used in the pharmacotherapy of cardiovascular diseases. However, the use of BAB has a number of limitations, first of all, due to adverse drug events (AE) that develop during their use. The purpose of our review was to study the features of the BAB AE manifested by injuries of the skin and its appendages. The clinical manifestations of them are the development or exacerbation of psoriasis, lichen planus, contact dermatitis, acrocyanosis, Raynaud's disease, alopecia, hyperhidrosis, vitiligo, anaphylaxis, and allergic skin reactions. True medicinal psoriasis occurs in patients taking BAB with no family or previous history and most often mimics erythrodermic psoriasis and palmar-plantar pustular psoriasis. Systemic use of BAB can also be accompanied by exacerbation of vitiligo. In patients with segmental vitiligo, the results of Doppler flowmetry and iontophoresis showed increased blood flow in vitiligo foci compared with normal skin. The development of anaphylactic reactions against the background of BAB therapy may be due to the modulation of adenylate cyclase, which can affect the release of anaphylactogenic mediators, as well as a decrease in the severity of cardiovascular compensatory changes. The peculiarities of the development of such reactions may be the resistance of patients to traditional treatment, which is due to the development of paradoxical reflex vagotonic effects when using adrenaline. Some of the mentioned AE may pose a potential threat to the life and health of the patient and therefore require additional discussion.
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Affiliation(s)
- A. V. Matveev
- Medical Academy named after S. I. Georgievsky, V.I. Vernadsky Crimean Federal University; Russian Medical Academy of Continuing Professional Education
| | - E. A. Egorova
- Medical Academy named after S. I. Georgievsky, V.I. Vernadsky Crimean Federal University
| | - E. I. Konyaeva
- Medical Academy named after S. I. Georgievsky, V.I. Vernadsky Crimean Federal University
| | | | - E. Yu. Bekirova
- Medical Academy named after S. I. Georgievsky, V.I. Vernadsky Crimean Federal University
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Herr S, Ferdman R, Braskett M. Safe administration of drug desensitizations in pediatric patients. J SPEC PEDIATR NURS 2021; 26:e12322. [PMID: 33378570 DOI: 10.1111/jspn.12322] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 11/19/2020] [Accepted: 12/04/2020] [Indexed: 01/22/2023]
Abstract
PURPOSE Patients with certain types of allergic reactions to medication may safely receive the culprit medication through an elaborate allergy procedure called a drug desensitization. Nurses play a key role in this process which is only performed when a certain medication is absolutely indicated as optimal therapy. Nurses are instrumental in the planning stages of drug desensitizations for coordination of interdisciplinary care and anticipation of adverse effects. Thus, it is paramount that nurses performing this procedure understand the mechanism of desensitizations and have access to the resources needed to safely complete these procedures in pediatric patients. CONCLUSION Excellence in nursing clinical acumen and a detailed order set are essential to patient safety during dug desensitization. With the following methodology and coordination by nursing, we have had great success at Children's Hospital Los Angeles in over one hundred drug desensitizations in pediatric patients which allowed them to received first line therapies. We have created order sets from published references and years of clinical experience. The nursing care of adult patients undergoing drug desensitization procedures is well described in the literature but few resources exist for pediatric nurses. There is paucity of published nursing resources for pediatric drug desensitizations. Repeated PubMed searches for "pediatric drug desensitizations" in 2019-2020, revealed only one recent reference geared toward physicians. PRACTICE IMPLICATIONS With appropriate training, staffing, and coordination, drug desensitizations can be safely performed in pediatric patients with close observation by a multi-disciplinary team. The bedside nurse has a pivotal role as coordinator and clinician for these high-risk resource-intensive procedures.
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Affiliation(s)
- Sarah Herr
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Heath System, Los Angeles, California, USA
| | - Ronald Ferdman
- Clinical Immunology and Allergy, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Melinda Braskett
- Clinical Immunology and Allergy, Children's Hospital Los Angeles, Los Angeles, California, USA
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Labella M, Castells M. Hypersensitivity reactions and anaphylaxis to checkpoint inhibitor-monoclonal antibodies and desensitization. Ann Allergy Asthma Immunol 2021; 126:623-629. [PMID: 33781937 DOI: 10.1016/j.anai.2021.03.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 03/07/2021] [Accepted: 03/16/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To review type 1 hypersensitivity reactions and anaphylaxis to checkpoint inhibitor-monoclonal antibodies and its management with drug desensitization. DATA SOURCES English-language literature on MEDLINE regarding hypersensitivity, anaphylaxis, and checkpoint inhibitor-monoclonal antibodies. STUDY SELECTIONS References were selected based on relevance, novelty, robustness, and applicability. RESULTS There are well-known tissue toxicities associated to checkpoint inhibitors, but hypersensitivity reactions and anaphylaxis have been underreported. The presentation of these reactions is based on clinical phenotypes with underlying endotypes identified by specific biomarkers. Drug desensitizations have been successfully applied to checkpoint inhibitor drugs to allow patients with cancer to receive first-line therapies. This review provides current best practices for the recognition and diagnosis of hypersensitivity reactions and anaphylaxis to checkpoint inhibitors and their management using drug desensitization. CONCLUSION Hypersensitivity reactions and anaphylaxis have been identified as potential adverse effects induced by checkpoint inhibitor-monoclonal antibodies. Drug desensitization is a safe and effective treatment option for patients who experience hypersensitivity reactions in need of these monoclonal antibodies to improve cancer outcomes.
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Affiliation(s)
- Marina Labella
- Allergy Clinical Unit, Hospital Regional Universitario de Málaga, Málaga, Spain; Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Málaga, Spain.
| | - Mariana Castells
- Division of Rheumatology, Immunology, and Allergy, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Abstract
PURPOSE OF REVIEW This review describes improvement in diagnostic accuracy, prediction of outcomes, identifying high-risk factors, and refinements of treatment that continue to evolve over the past 5-10 years. RECENT FINDINGS The risk of anaphylaxis is relatively low (< 5%) in patients with previous large local reactions or strictly cutaneous systemic reactions, but much higher in those with moderate-to-severe anaphylaxis (40%-70%) or mastocytosis (> 90%). Use of recombinant venom allergens and basophil activation tests may improve diagnostic accuracy. Elevated serum tryptase (and possible mastocytosis) occurs in 10% of patients with insect sting allergy, and in 25% of those with hypotensive reactions. Rush VIT is proven safe and rapidly effective. There are known high-risk factors that justify treatment beyond 5 years. Diagnostic accuracy and prediction of risk have improved in recent years. There are still knowledge gaps related to prediction and management of risk with current diagnostic and therapeutic modalities.
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11
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Critical Care Management of the Patient With Anaphylaxis: A Concise Definitive Review. Crit Care Med 2021; 49:838-857. [PMID: 33653974 DOI: 10.1097/ccm.0000000000004893] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Anaphylaxis is a rapidly progressive life-threatening syndrome manifesting as pruritus, urticaria, angioedema, bronchospasm and shock. The goal of this synthetic review is to provide a practical, updated approach to the evaluation and management of this disorder and associated complications. DATA SOURCES A MEDLINE search was conducted with the MeSH of anaphylaxis, anaphylactic reaction, anaphylactic shock, refractory anaphylaxis and subheadings of diagnosis, classification, epidemiology, complications and pharmacology. The level of evidence supporting an intervention was evaluated based on the availability of randomized studies, expert opinion, case studies, reviews, practice parameters and other databases (including Cochrane). STUDY SELECTION Selected publications describing anaphylaxis, clinical trials, diagnosis, mechanisms, risk factors and management were retrieved (reviews, guidelines, clinical trials, case series) and their bibliographies were also reviewed to identify relevant publications. DATA EXTRACTION Data from the relevant publications were reviewed, summarized and the information synthesized. DATA SYNTHESIS This is a synthetic review and the data obtained from a literature review was utilized to describe current trends in the diagnosis and management of the patient with anaphylaxis with a special emphasis on newer evolving concepts of anaphylaxis endotypes and phenotypes, management of refractory anaphylaxis in the ICU setting and review of therapeutic options for the elderly patient, or the complicated patient with severe cardiorespiratory complications. Most of the recommendations come from practice parameters, case studies or expert opinions, with a dearth of randomized trials to support specific interventions. CONCLUSION Anaphylaxis is a rapidly progressive life-threatening disorder. The critical care physician needs to be familiar with the diagnosis, differential diagnosis, evaluation, and management of anaphylaxis. Skilled intervention in ICUs may be required for the patient with complicated, severe, or refractory anaphylaxis.
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Greenberger PA. Evidence Accumulates Against Angiotensin-Converting Enzyme Inhibitors and Beta-Adrenergic Blockers as Important Co-factors for Anaphylactic Reactions. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:1906-1907. [PMID: 32499036 DOI: 10.1016/j.jaip.2020.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 04/01/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Paul A Greenberger
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Ill.
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13
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Jaiswal A, Maurya M, Maurya P, Barthwal MK. Lin28B Regulates Angiotensin II-Mediated Let-7c/miR-99a MicroRNA Formation Consequently Affecting Macrophage Polarization and Allergic Inflammation. Inflammation 2020; 43:1846-1861. [DOI: 10.1007/s10753-020-01258-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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14
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Fehr D, Micaletto S, Moehr T, Schmid-Grendelmeier P. Risk factors for severe systemic sting reactions in wasp ( Vespula spp.) and honeybee ( Apis mellifera) venom allergic patients. Clin Transl Allergy 2019; 9:54. [PMID: 31632639 PMCID: PMC6788055 DOI: 10.1186/s13601-019-0292-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 09/21/2019] [Indexed: 11/21/2022] Open
Abstract
Background Hymenoptera stings are a major cause of anaphylaxis. Various risk factors are discussed in literature. This study aims to investigate potential risk factors for severe sting reactions in wasp (Vespula spp.) and honeybee (Apis mellifera) venom allergic patients and analyses the correlation between diagnostic test results and the severity of the allergic reaction. Methods 480 patients suffering from wasp or honeybee venom allergy were included in this retrospective case series. Only individuals allergic to Vespula spp. but not to other vespids such as Polistes were considered. The severity of their systemic field sting reaction was analysed with regard to the amount of specific IgE antibodies to whole venom extracts and to major allergens of honeybee and/or wasp venom. Furthermore, the following potential risk factors for severe sting reactions were examined: age, sex, latency time, skin symptoms, baseline serum tryptase levels and the concentration of venom inducing a positive intracutaneous test. Results The two following indicators for severe systemic sting reactions in honeybee and wasp venom allergic patients have been identified: a short latency time and the absence of skin symptoms. The patient’s age and baseline serum tryptase levels have been found to positively correlate with the grade of the sting reaction only in individuals allergic to wasp venom. No correlation could be found between the degree of sensitisation and the severity of the allergic reaction. Neither the amount of specific IgE antibodies to whole venom extracts nor to major allergens were significantly associated with the severity of the sting reaction. Conclusion The clinical history is essential for the allergological workup and therapeutic decision on Hymenoptera venom allergies. A short latency time and the absence of skin symptoms are indicators for severe systemic sting reactions, followed by the patient’s age and baseline serum tryptase levels.
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Affiliation(s)
- Danielle Fehr
- 1Allergy Unit, Department of Dermatology, University Hospital Zurich, Gloriastrasse 31, 8091 Zurich, Switzerland
| | - Sara Micaletto
- 1Allergy Unit, Department of Dermatology, University Hospital Zurich, Gloriastrasse 31, 8091 Zurich, Switzerland
| | - Thomas Moehr
- B,S,S. Economic Consultants, Aeschengraben 9, 4051 Basel, Switzerland
| | - Peter Schmid-Grendelmeier
- 1Allergy Unit, Department of Dermatology, University Hospital Zurich, Gloriastrasse 31, 8091 Zurich, Switzerland
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Garvey LH, Ebo DG, Mertes P, Dewachter P, Garcez T, Kopac P, Laguna JJ, Chiriac AM, Terreehorst I, Voltolini S, Scherer K. An EAACI position paper on the investigation of perioperative immediate hypersensitivity reactions. Allergy 2019; 74:1872-1884. [PMID: 30964555 DOI: 10.1111/all.13820] [Citation(s) in RCA: 114] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Accepted: 03/19/2019] [Indexed: 12/12/2022]
Abstract
Perioperative immediate hypersensitivity reactions are rare. Subsequent allergy investigation is complicated by multiple simultaneous drug exposures, the use of drugs with potent effects and the many differential diagnoses to hypersensitivity in the perioperative setting. The approach to the investigation of these complex reactions is not standardized, and it is becoming increasingly apparent that collaboration between experts in the field of allergy/immunology/dermatology and anaesthesiology is needed to provide the best possible care for these patients. The EAACI task force behind this position paper has therefore combined the expertise of allergists, immunologists and anaesthesiologists. The aims of this position paper were to provide recommendations for the investigation of immediate-type perioperative hypersensitivity reactions and to provide practical information that can assist clinicians in planning and carrying out investigations.
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Affiliation(s)
- Lene Heise Garvey
- Danish Anaesthesia Allergy Centre, Allergy Clinic, Department of Dermatology and Allergy Copenhagen University Hospital Gentofte Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - Didier G. Ebo
- Faculty of Medicine and Health Science, Department of Immunology – Allergology – Rheumatology Antwerp University Hospital, University of Antwerp Antwerp Belgium
| | - Paul‐Michel Mertes
- Department of Anesthesia and Intensive Care Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, EA 3072, FMTS de Strasbourg Strasbourg France
| | - Pascale Dewachter
- Service d’Anesthésie‐Réanimation, Groupe Hospitalier de Paris‐Seine‐Saint‐Denis Assistance Publique‐Hôpitaux de Paris & Université Paris 13, Sorbonne Paris Cité Paris France
| | - Tomaz Garcez
- Immunology Department Manchester University NHS Foundation Trust Manchester UK
| | - Peter Kopac
- University Clinic of Respiratory and Allergic Diseases Golnik Slovenia
| | - José Julio Laguna
- Allergy Unit, Allergo‐Anaesthesia Unit, Faculty of Medicine Hospital Central de la Cruz Roja, Alfonso X El Sabio University, ARADyAL Madrid Spain
| | - Anca Mirela Chiriac
- Allergy Unit, Département de Pneumologie et Addictologie, Hôpital Arnaud de Villeneuve University Hospital of Montpellier Montpellier France
- Sorbonnes Universités, UPMC Paris 06, UMR‐S 1136, IPLESP, Equipe EPAR Paris France
| | - Ingrid Terreehorst
- Department of ENT and DPAC AUMCAmsterdam University Medical Center Amsterdam The Netherlands
| | | | - Kathrin Scherer
- Allergy Unit, Department of Dermatology, University Hospital University of Basel Basel Switzerland
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Garvey LH, Ebo DG, Krøigaard M, Savic S, Clarke R, Cooke P, Dewachter P, Garcez T, Guttormsen AB, Hopkins PM, Hepner DL, Khan DA, Kolawole H, Kopac P, Marshall S, Mertes PM, Platt P, Rose M, Sabato V, Sadleir P, Savic L, Scherer K, Takazawa T, Volcheck GW, Voltolini S, Laguna JJ. The use of drug provocation testing in the investigation of suspected immediate perioperative allergic reactions: current status. Br J Anaesth 2019; 123:e126-e134. [DOI: 10.1016/j.bja.2019.03.018] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 03/09/2019] [Accepted: 03/12/2019] [Indexed: 01/23/2023] Open
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Tejedor-Alonso MA, Farias-Aquino E, Pérez-Fernández E, Grifol-Clar E, Moro-Moro M, Rosado-Ingelmo A. Relationship Between Anaphylaxis and Use of Beta-Blockers and Angiotensin-Converting Enzyme Inhibitors: A Systematic Review and Meta-Analysis of Observational Studies. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 7:879-897.e5. [PMID: 30408615 DOI: 10.1016/j.jaip.2018.10.042] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 09/29/2018] [Accepted: 10/19/2018] [Indexed: 01/11/2023]
Abstract
BACKGROUND Beta-blockers (BBs) and angiotensin-converting enzyme inhibitors (ACEIs) have been associated with an increased risk and severity of anaphylaxis. However, the evidence supporting these findings is contradictory. OBJECTIVE We carried out a systematic review and meta-analysis of studies that assess the influence of BBs and ACEIs on anaphylaxis. METHODS We searched PubMed/MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews, and the Web of Science for relevant observational studies. We searched for studies where the presence and severity of anaphylaxis were compared between patients taking BBs, ACEIs, both types of drug, or neither type of drug. We performed a meta-analysis using a random-effects model. RESULTS A total of 21 studies met the study criteria. Of these, 15 assessed the severity and 9 the incidence of anaphylaxis. The studies brought together 22,313 anaphylaxis episodes for the severity studies and 18,101 anaphylaxis episodes for the studies of new cases of anaphylaxis. BBs and ACEIs increased the severity of anaphylaxis (BBs, odds ratio [OR] 2.19, 95% confidence interval [CI] 1.25-3.84; ACEIs, OR 1.56, 95% CI 1.12-2.16), but not the presence of new cases of anaphylaxis (BBs, OR 1.40, 95% CI 0.91-2.14; ACEIs, OR 1.38, 95% CI 0.39-4.86). It was not possible to perform an analysis adjusted for cardiovascular diseases, because only 1 study each for BBs and ACEIs, respectively, had adjusted data. CONCLUSIONS The quality of evidence showing that the use of BBs and ACEI increases the severity of anaphylaxis is low owing to differences in the control of confounders arising from the concomitant presence of cardiovascular diseases.
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Affiliation(s)
- Miguel A Tejedor-Alonso
- Allergy Unit, Hospital Universitario Fundación Alcorcón, Madrid, Spain; Facultad Ciencias de la Salud, Universidad Rey Juan Carlos, Madrid, Spain.
| | | | | | | | - Mar Moro-Moro
- Allergy Unit, Hospital Universitario Fundación Alcorcón, Madrid, Spain
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Jimenez-Rodriguez TW, Garcia-Neuer M, Alenazy LA, Castells M. Anaphylaxis in the 21st century: phenotypes, endotypes, and biomarkers. J Asthma Allergy 2018; 11:121-142. [PMID: 29950872 PMCID: PMC6016596 DOI: 10.2147/jaa.s159411] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Anaphylaxis is the most serious of all allergic reactions and can be fatal. The diagnosis is frequently delayed, and misdiagnosis often occurs with asthma or urticaria. Biomarkers such as tryptase are not routinely checked, and appropriate treatment with epinephrine is not administered in a majority of cases, increasing the risk of poor outcomes. The objective of this review is to provide a better understanding of the pathophysiology of anaphylaxis with a description of phenotypes, endotypes, and biomarkers available in both the clinical and research settings. Expanding knowledge with regard to the presentation, causes, and triggers for anaphylaxis among health care providers will improve its diagnosis and management, increase patient safety, and decrease morbidity and mortality.
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Affiliation(s)
- Teodorikez Wilfox Jimenez-Rodriguez
- Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Allergy Section, Alicante General University Hospital, Alicante, Spain
- PhD Program in Public Health, Medical and Surgical Sciences, Miguel Hernandez University, Alicante, Spain
| | - Marlene Garcia-Neuer
- Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Leila A Alenazy
- Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Mariana Castells
- Division of Rheumatology, Immunology and Allergy, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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Application of precision medicine to the treatment of anaphylaxis. Curr Opin Allergy Clin Immunol 2018; 18:190-197. [DOI: 10.1097/aci.0000000000000435] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Schatz M, Sicherer SH, Zeiger RS. The Journal of Allergy and Clinical Immunology: In Practice 2017 Year in Review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:328-352. [PMID: 29397373 DOI: 10.1016/j.jaip.2017.12.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 12/19/2017] [Indexed: 12/29/2022]
Abstract
An impressive number of clinically impactful studies and reviews were published in The Journal of Allergy and Clinical Immunology: In Practice in 2017. As a service to our readers, the editors provide this Year in Review article to highlight and contextualize the advances published over the past year. We include information from articles on asthma, allergic rhinitis, rhinosinusitis, immunotherapy, atopic dermatitis, contact dermatitis, food allergy, anaphylaxis, drug hypersensitivity, urticarial/angioedema, eosinophilic disorders, and immunodeficiency. Within each topic, epidemiologic findings are presented, relevant aspects of prevention are described, and diagnostic and therapeutic advances are enumerated. Treatments discussed include behavioral therapy, allergen avoidance therapy, positive and negative effects of pharmacologic therapy, and various forms of immunologic and desensitization management. We hope this review will help readers consolidate and use this extensive and practical knowledge for the benefit of patients.
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Affiliation(s)
- Michael Schatz
- Department of Allergy, Kaiser Permanente Southern California, San Diego, Calif.
| | - Scott H Sicherer
- Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Robert S Zeiger
- Department of Allergy, Kaiser Permanente Southern California, San Diego, Calif
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Park HJ, Suk KS, Park JW. A Case of Intraoperative Anaphylaxis Caused by Bovine-Derived Thrombin. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2018; 10:184-186. [PMID: 29411561 PMCID: PMC5809769 DOI: 10.4168/aair.2018.10.2.184] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 11/02/2017] [Accepted: 11/06/2017] [Indexed: 12/02/2022]
Abstract
Intraoperative bovine-derived topical thrombin is still widely used for hemostasis during surgery. A 38-year-old woman with chronic spontaneous urticaria was referred to the orthopedic surgery department for herniated disk and myelopathy. During the first stage of operation, bovine-derived thrombin powder soaked in Gelfoam was used as a hemostatic aid. After 30 minutes, the patient developed anaphylactic shock with systemic skin rash and angioedema. Repeated intravenous bolus and infusion of vasopressor were carried out, and her blood pressure normalized. Skin test and specific immunoglobulin E test showed positive results for bovine thrombin and beef, respectively. During the second stage of operation (After 10 days from first stage of operation), bovine-derived thrombin powder was excluded and the operation was successful without any unexpected events. Therefore, bovine thrombin should be used with caution because it might cause anaphylaxis.
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Affiliation(s)
- Hye Jung Park
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
| | - Kyung Soo Suk
- Department of Orthopedic Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jung Won Park
- Division of Allergy and Immunology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Incorvaia C, Mauro M, Gritti BL, Makri E, Ridolo E. Venom immunotherapy in patients with allergic reactions to insect stings. Expert Rev Clin Immunol 2017; 14:53-59. [PMID: 29202591 DOI: 10.1080/1744666x.2018.1413350] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Allergy to Hymenoptera (Apis mellifera, Vespula species, Polistes species, Vespa crabro) venom can be safely and effectively treated by venom immunotherapy (VIT), which in the 40 years since its introduction has been able to prevent reactions to stings, and to treatment as well, though systemic reactions, occasionally severe, are possible. Areas covered: We reviewed the recent literature on VIT by searching in PubMed for the terms 'venom immunotherapy' and 'Hymenoptera venom immunotherapy' to highlight the current status of VIT and the likely development in the coming years. Expert commentary: VIT, provided the correct choice of the venom and adequate venom preparations and maintenance doses are used, is a treatment of great value in preventing systemic reactions to Hymenoptera stings. A 5-year duration ensures a prolonged tolerance to stings following VIT discontinuation, unless patients suffer from mastocytosis. In fact, due to reports of fatal reactions after stopping VIT, patients with mastocytosis, or with very severe reactions to stings, need an indefinite duration of treatment.
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Affiliation(s)
| | - Marina Mauro
- b Department of Clinical & Experimental Medicine , University of Parma , Parma , Italy
| | - Bruna L Gritti
- a Cardiac/Pulmonary Rehabilitation , ASST Pini/CTO , Milan , Italy
| | - Eleni Makri
- a Cardiac/Pulmonary Rehabilitation , ASST Pini/CTO , Milan , Italy
| | - Erminia Ridolo
- c Allergy Unit , Sant'Anna Hospital, ASST Lariana , Como , Italy
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Golden DB. Anaphylaxis: Recognizing Risk and Targeting Treatment. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:1224-1226. [DOI: 10.1016/j.jaip.2017.06.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 06/20/2017] [Indexed: 02/08/2023]
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