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Study of Excipients in Delayed Skin Reactions to mRNA Vaccines: Positive Delayed Intradermal Reactions to Polyethylene Glycol Provide New Insights for COVID-19 Arm. Vaccines (Basel) 2022; 10:vaccines10122048. [PMID: 36560458 PMCID: PMC9788122 DOI: 10.3390/vaccines10122048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 11/25/2022] [Accepted: 11/28/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Skin local reactions to mRNA COVID-19 vaccines have been linked to the use of vaccine excipients. The aim of the study is to evaluate the role of skin testing excipients in delayed skin reactions due to mRNA COVID-19 vaccines. METHODS Skin testing among a group of healthcare workers with skin reactions due to mRNA vaccines was performed. Patch testing and intradermal testing (IDT) with polyethylene glycol (PEG)-400, PEG-2000, trometamol, and 1,2-dimyristoyl-sn-glycero-3-phosphocholine were performed. Healthcare workers without skin reactions to vaccines were used for skin testing as controls. RESULTS Thirty-one healthcare workers (from a total of 4315 vaccinated healthcare workers) experienced cutaneous adverse vaccine reactions. Skin testing was performed in sixteen of the healthcare workers (11 delayed large local reactions (DLLR) and 5 widespread reactions). Positive IDT for PEG-2000 1% in DLLR was seen in 10 (90.9%) patients, in comparison with one (16.6%) individual with a delayed widespread reaction. Delayed positive IDT reactions for PEG-2000 1% on day 2 were observed in three (27.3%) patients with DLLR. Patch testing of the excipients was negative. Among 10 controls, only one exhibited a transient positive IDT reaction to PEG-2000 1%. CONCLUSIONS Immediate and delayed reactions to IDT are frequently detected in patients with DLLR. The observation of positive delayed intradermal reactions to PEG disclosed only in patients with DLLR reinforces a possible role of PEG in the development of these reactions. Skin testing of other excipients is of little importance in clinical practice.
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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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Barbaud A, Garvey LH, Arcolaci A, Brockow K, Mori F, Mayorga C, Bonadonna P, Atanaskovic‐Markovic M, Moral L, Zanoni G, Pagani M, Soria A, Jošt M, Caubet J, Carmo A, Mona A, Alvarez‐Perea A, Bavbek S, Benedetta B, Bilo M, Blanca‐López N, Bogas HG, Buonomo A, Calogiuri G, Carli G, Cernadas J, Cortellini G, Celik G, Demir S, Doña I, Dursun AB, Eberlein B, Faria E, Fernandes B, Garcez T, Garcia‐Nunez I, Gawlik R, Gelincik A, Gomes E, Gooi JHC, Grosber M, Gülen T, Hacard F, Hoarau C, Janson C, Johnston SL, Joerg L, Kepil Özdemir S, Klimek L, Košnik M, Kowalski ML, Kuyucu S, Kvedariene V, Laguna JJ, Lombardo C, Marinho S, Merk H, Meucci E, Morisset M, Munoz‐Cano R, Murzilli F, Nakonechna A, Popescu F, Porebski G, Radice A, Regateiro FS, Röckmann H, Romano A, Sargur R, Sastre J, Scherer Hofmeier K, Sedláčková L, Sobotkova M, Terreehorst I, Treudler R, Walusiak‐Skorupa J, Wedi B, Wöhrl S, Zidarn M, Zuberbier T, Agache I, Torres MJ. Allergies and COVID-19 vaccines: An ENDA/EAACI Position paper. Allergy 2022; 77:2292-2312. [PMID: 35112371 DOI: 10.1111/all.15241] [Citation(s) in RCA: 46] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 12/17/2021] [Accepted: 01/03/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Anaphylaxis, which is rare, has been reported after COVID-19 vaccination, but its management is not standardized. METHOD Members of the European Network for Drug Allergy and the European Academy of Allergy and Clinical Immunology interested in drug allergy participated in an online questionnaire on pre-vaccination screening and management of allergic reactions to COVID-19 vaccines, and literature was analysed. RESULTS No death due to anaphylaxis to COVID-19 vaccines has been confirmed in scientific literature. Potential allergens, polyethylene glycol (PEG), polysorbate and tromethamine are excipients. The authors propose allergy evaluation of persons with the following histories: 1-anaphylaxis to injectable drug or vaccine containing PEG or derivatives; 2-anaphylaxis to oral/topical PEG containing products; 3-recurrent anaphylaxis of unknown cause; 4-suspected or confirmed allergy to any mRNA vaccine; and 5-confirmed allergy to PEG or derivatives. We recommend a prick-to-prick skin test with the left-over solution in the suspected vaccine vial to avoid waste. Prick test panel should include PEG 4000 or 3500, PEG 2000 and polysorbate 80. The value of in vitro test is arguable. CONCLUSIONS These recommendations will lead to a better knowledge of the management and mechanisms involved in anaphylaxis to COVID-19 vaccines and enable more people with history of allergy to be vaccinated.
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Affiliation(s)
- Annick Barbaud
- Sorbonne UniversitéINSERMInstitut Pierre Louis d’Epidémiologie et de Santé PubliqueAP‐HP.Sorbonne Université, Hôpital TenonDépartement de dermatologie et allergologie Paris France
| | - Lene Heise Garvey
- Allergy ClinicCopenhagen University Hospital at Gentofte Copenhagen Denmark
- Department of Clinical Medicine University of Copenhagen Denmark
| | - Alessandra Arcolaci
- Immunology UnitUniversity Hospital of VeronaPoliclinico G.B. Rossi Verona Italy
| | - Knut Brockow
- Department of Dermatology and Allergy Biederstein Faculty of Medicine Technical University of Munich Munich Germany
| | - Francesca Mori
- Allergy Unit Department of Pediatrics Meyer Children’s University Hospital
| | - Cristobalina Mayorga
- Allergy Clinical Unit Hospital Regional Universitario de Málaga‐Instituto de Investigación Biomédica de Málaga‐IBIMA ARADyAL, Málaga Spain
| | | | | | - Luis Moral
- Moral Luis. Pediatric Allergy and Respiratory Unit Alicante University General Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL) Alicante Spain
| | - Giovanna Zanoni
- Giovanna Zanoni, Immunology Unit, Policlinico G.B. Rossi, Azienda Ospedaliera Universitaria Integrata Verona Italy
| | - Mauro Pagani
- Medicine Department Medicine Ward Mantova HospitalASST di Mantova Italy
| | - Angèle Soria
- Sorbonne UniversitéINSERM 1135 Cimi‐ParisHôpital TenonAssistance Publique‐Hôpitaux de ParisDepartement de dermatologie et d'allergologie Paris France
| | - Maja Jošt
- University Clinic of Respiratory and Allergic Diseases Golnik Golnik Slovenia
| | - Jean‐Christoph Caubet
- Department of Women‐Children‐Teenagers University Hospital of Geneva Geneva Switzerland
| | - Abreu Carmo
- Allergy and Clinical Immunology Unit Centro Hospitalar de Trás‐os‐Montes e Alto DouroVila Real and Allergy and Clinical Immunology UnitCentro Hospitalar do Baixo Vouga Aveiro Portugal
| | - Al‐Ahmad Mona
- Microbiology Department Faculty of MedicineKuwait University Kuwait
| | | | - Sevim Bavbek
- School of Medicine Department of Pulmonary Diseases Division of Allergy FAAAIAnkara University Ankara Turkey
| | - Biagioni Benedetta
- Division of Internal Medicine, Hepatobiliary and Immunoallergic Disease IRCCS Azienda Ospedaliero‐Universitaria di Bologna Italy
| | - M.Beatrice Bilo
- Department of Clinical and Molecular Sciences Università Politecnica delle Marche Ancona Italy
- Allergy Unit ‐ Department of Internal Medicine University Hospital Ospedali Riuniti di Ancona Italy
| | | | - Herrera Gádor Bogas
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA, and Allergy UnitHospital Regional Universitario de Málaga‐HRUM Málaga Spain
| | - Alessandro Buonomo
- Allergy Unit ‐ Fondazione Policlinico Gemelli IRCCS ‐ Largo Gemelli Rome Italy
| | | | - Giulia Carli
- SOS Allergologia e ImmunologiaAzienda USL Toscana CentroOspedale S. Stefano Prato Italy
| | - Josefina Cernadas
- Allergy and Clinical Immunology Department Centro Hospitalar Universitário de S. JoãoPorto and Allergy UnitHospital Lusíadas Porto Portugal
| | - Gabriele Cortellini
- Allergy Unit Departments of Internal Medicine Azienda Sanitaria della RomagnaRimini, Hospital Rimini Italy
| | - Gülfem Celik
- Department of Chest Diseases Division of Immunology and allergy Ankara University School of Medicine cebeci Hospital Ankara Turkey
| | - Semra Demir
- Istanbul UniversityIstanbul Faculty of MedicineInternal MedicineImmunology and Allergic Diseases Istanbul Turkey
| | - Inmaculada Doña
- Allergy Research Group Allergy UnitHospital Regional Universitario de MálagaInstituto de Investigación Biomédica de Málaga‐IBIMAPlaza del Hospital Civil s/n Málaga Spain
| | | | - Bernadette Eberlein
- Faculty of Medicine Department of Dermatology and Allergy Biederstein Technical University of Munich Munich Germany
| | - Emilia Faria
- Allergy and Clinical Immunology Unit Centro Hospitalar E Universitário de Coimbra Coimbra Portugal
| | | | - Tomaz Garcez
- Immunology Department Manchester University NHS Foundation Trust Manchester UK
| | | | - Radoslaw Gawlik
- Department of Internal Diseases, Allergology and Clinical Immunology Medical University of Silesia Katowice Poland
| | - Asli Gelincik
- Istanbul UniversityIstanbul Faculty of Medicine, Internal Medicine, Immunology and Allergic Diseases Istanbul Turkey
| | - Eva Gomes
- Allergy Department Centro Hospitalar Universitário do Porto Porto Portugal
| | - Jimmy H. C. Gooi
- Department of Clinical Immunology King’s College Hospital London UK
| | - Martine Grosber
- Department of Dermatology Universitair ZiekenhuisVrije Universiteit Brussel Brussel Belgium
| | - Theo Gülen
- Department of Respiratory Medicine and Allergy Department of Medicine Karolinska University Hospital HuddingeKarolinska Institutet Stockholm Sweden
| | - Florence Hacard
- Allergology and Clinical Immunology Department Centre Hospitalier Lyon‐Sud Pierre‐Bénite France
| | - Cyrille Hoarau
- Service transversal d'allergologie et immunologie clinique CHR de Tours Tours France
| | | | | | - Lukas Joerg
- Division of Allergology and Clinical Immunology Department of Pneumology, Inselspital Bern University HospitalUniversity of Bern Bern Switzerland
| | - Seçil Kepil Özdemir
- Department of Chest Diseases Division of Allergy and Immunology Chest Diseases and Surgery Training and Research Hospital Izmir Turkey
| | - Ludger Klimek
- Center for Rhinology and Allergology Wiesbaden Germany
| | | | - Marek L. Kowalski
- Department of Immunology and Allergy Medical University of Lodz Poland
| | - Semanur Kuyucu
- Faculty of Medicine Dpt of Pediatric Allergy and Immunology Mersin University Mersin Turkey
| | - Violeta Kvedariene
- Institute of Biomedical Sciences Department of Pathology Faculty of Medicine Vilnius UniversityInstitute of Clinical Medicine, Clinic of Chest diseases, Immunology and Allergology, Faculty of Medicine Vilnius Lithuania
| | - Jose Julio Laguna
- Allergy Unit, Allergo‐Anaesthesia Unit Faculty of Medicine Hospital Central de la Cruz RojaAlfonso X El Sabio University Madrid Spain
| | | | - Susana Marinho
- Allergy Centre Wythenshawe HospitalManchester University NHS Foundation Trust and University of Manchester Manchester UK
| | | | - Elisa Meucci
- SOS Allergologia ed Immunologia clinicaAzienda USL Toscana CentroOspedale San Giovanni di Dio Firenze Italy
| | | | | | | | - Alla Nakonechna
- Allergy and Clinical Immunology Department University of LiverpoolRoyal Preston HospitalLancashire Teaching HospitalsNHS Foundation Trust UK
| | - Florin‐Dan Popescu
- Department of Allergology Carol Davila University of Medicine and PharmacyNicolae Malaxa Clinical Hospital Bucharest Romania
| | - Grzegorz Porebski
- Department of Clinical and Environmental Allergology Jagiellonian University Medical College Krakow Poland
| | - Anna Radice
- SOS Allergologia ed Immunologia clinicaAzienda USL Toscana CentroOspedale San Giovanni di Dio Firenze Italy
| | - Frederico S. Regateiro
- Allergy and Clinical Immunology Unit Centro Hospitalar E Universitário de Coimbra Coimbra Portugal
- Institute of Immunology Faculty of Medicine University of Coimbra Coimbra Portugal
- ICBR ‐ Coimbra Institute for Clinical and Biomedical ResearchCIBBFaculty of MedicineUniversity of Coimbra Coimbra Portugal
| | - Heike Röckmann
- Department of Dermatology University Medical Centre Utrecht‐Heidelberglaan 100 Utrecht The Netherlands
| | | | - Ravishankar Sargur
- Clinical Immunology and Allergy Unit Northern General HospitalSheffield Teaching Hospitals NHS Foundation Trust Sheffield UK
| | - Joaquin Sastre
- Allergy Department Fundación Jiménez DiazUniversidad Autonoma de MadridCIBERESInstituto de Salud Carlos III Spain
| | | | | | - Marta Sobotkova
- Department of Immunology Motol University Hospital and 2nd Faculty of Medicine Charles University Prague Czech Republic
| | | | - Regina Treudler
- Department of Dermatology, Venerology and Allergology Universitätsmedizin Leipzig Leipzig Germany
| | - Jolanta Walusiak‐Skorupa
- Department of Occupational Diseases and Environmental Health Walusiak‐Skorupa JolantaNofer Institute of Occupational Medicine Lodz Poland
| | - Bettina Wedi
- Department of Dermatology & Allergy OE6600Comprehensive Allergy CenterHannover Medical School Hannover Germany
| | | | - Mihael Zidarn
- University Clinic of Respiratory and Allergic Diseases GolnikGolnik, and Internal Medicine, Faculty of MedicineUniversity of Ljubljana Ljubljana Slovenia
| | - Torsten Zuberbier
- Charité ‐ Universitätsmedizin BerlinKlinik für Dermatologie Berlin Germany
| | - Ioana Agache
- Faculty of Medicine Transylvania University Brasov Romania
| | - Maria J. Torres
- Allergy Unit Regional University Hospital of MalagaIBIMA‐UMA‐ARADyAL Malaga Spain
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A case series of cutaneous COVID-19 vaccine reactions at Loma Linda University Department of Dermatology. JAAD Case Rep 2021; 16:53-57. [PMID: 34423106 PMCID: PMC8372465 DOI: 10.1016/j.jdcr.2021.07.038] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
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5
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Novembre E, Calogero C, Mori F, Bernardini R, Pucci N, Neri P, Bonini M, Vierucci A, De Martino M. Biphasic Anaphylactic Reaction to Ketorolac Tromethamine. Int J Immunopathol Pharmacol 2016; 19:449-50. [PMID: 16831313 DOI: 10.1177/039463200601900223] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Ketorolac tromethamine is a recent injectable non-steroidal anti-inflammatory drug (NSAID) with analgesic properties approved for short-term pain management. In spite of its increasing use both in adults and children (1-2), relatively few allergic-like reactions have been reported (3–5). Reactions are often severe, and a death occurred following an intramuscular injection of ketorolac (6).
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Affiliation(s)
- E Novembre
- Allergy and Clinical Immunology Unit, Azienda Ospedaliero Universitaria A. Meyer, Via L. Giordano 13, 50132 Florence, Italy.
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6
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Pyrazolones metabolites are relevant for identifying selective anaphylaxis to metamizole. Sci Rep 2016; 6:23845. [PMID: 27030298 PMCID: PMC4814906 DOI: 10.1038/srep23845] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 03/15/2016] [Indexed: 11/22/2022] Open
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) are the most common cause of hypersensitivity reactions, with pyrazolones the most frequent drugs inducing selective reactions. Immediate selective hypersensitivity to pyrazolones is thought to be mediated by specific-IgE. Sensitivity of in vitro diagnostic tests is low and this may be due to the incomplete characterization of the structures involved. Here we investigated whether main metabolites of metamizole (dipyrone) in human could be involved in the immune response using the basophil activation test (BAT). We studied subjects with confirmed selective immediate hypersensitivity to metamizole and performed BAT with metamizole and its metabolites: 4-methylamino-antipyrine (MAA), 4-aminoantipyrine (AA), 4-acetylamino-antipyrine (AAA) and 4-formylamino-antipyrine (FAA). BAT results showed an increase of positive results from 37.5% to 62.5% using metamizole plus metabolites as compared with the BAT carried out only with the parent drug, demonstrating that metamizole metabolites have a role in the reaction and can induce specific basophil activation in patients with immediate hypersensitivity to this drug. Our findings indicate that pyrazolone metabolites are useful for improving the in vitro diagnosis of allergic reactions to metamizole.
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7
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Hypersensitivity Reactions to Nonsteroidal Anti-Inflammatory Drugs. Immunol Allergy Clin North Am 2014; 34:507-24, vii-viii. [DOI: 10.1016/j.iac.2014.04.001] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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8
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Ariza A, Fernandez TD, Doña I, Aranda A, Blanca-Lopez N, Melendez L, Canto G, Blanca M, Torres MJ, Mayorga C. Basophil activation after nonsteroidal anti-inflammatory drugs stimulation in patients with immediate hypersensitivity reactions to these drugs. Cytometry A 2014; 85:400-7. [PMID: 24443418 DOI: 10.1002/cyto.a.22443] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Revised: 11/21/2013] [Accepted: 12/27/2013] [Indexed: 11/10/2022]
Abstract
Nonsteroidal anti-inflammatory drugs (NSAIDs) are the drugs most frequently involved in allergic reactions of which two main types exist: IgE-mediated and crossintolerance. The diagnosis of crossintolerance reactions is often based on the drug provocation test. The potential value of the basophil activation test (BAT) was evaluated using different basophil markers in the diagnosis of patients with crossintolerance to NSAIDs and cutaneous symptoms. We studied 46 patients with crossintolerance to NSAIDs and 45 tolerant controls. BAT was performed with acetyl salicylic acid, paracetamol, diclofenac, dipyrone, naproxen, and ibuprofen at four different concentrations using CD193 and CD203c as basophil markers and CD63 as activation marker. We compared BAT results using CD193⁺ or CD193⁺ CD203c⁺ for basophil selection and found a significant increase in the stimulation index when using CD193⁺ CD203c⁺ in both patients and controls (P = 0.004 and P = 0.017, respectively). Selection of living cells only produced an increase in basophil stimulation in patients for both CD193⁺ and CD193⁺ CD203c⁺ (P < 0.001 for both), whereas in controls there was no change with CD193⁺ and a decrease with CD193⁺ CD203c⁺ (P = 0.001). We found that CD193⁺ CD203c⁺ increased the percentage of positive cases in patients and controls when compared with CD193⁺. When excluding dead cells, there was an increase of 21.7% in patients and 10% in controls. These results indicate that using CD193⁺ CD203⁺, excluding dead cells, is the best approach for BAT although this test is not recommended for the diagnosis of patients with crossintolerance to NSAIDs owing to its low sensitivity and specificity.
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Affiliation(s)
- Adriana Ariza
- Research Laboratory, Instituto de Investigación Biomédica de Málaga (IBIMA), Hospital Universitario Regional de Málaga, UMA, Málaga, Spain
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9
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Blanca-Lopez N, J Torres M, Doña I, Campo P, Rondón C, Seoane Reula ME, Salas M, Canto G, Blanca M. Value of the clinical history in the diagnosis of urticaria/angioedema induced by NSAIDs with cross-intolerance. Clin Exp Allergy 2013; 43:85-91. [PMID: 23278883 DOI: 10.1111/cea.12013] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Revised: 07/15/2012] [Accepted: 08/13/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND Multiple Non-steroidal anti-inflammatory drugs (NSAID)-induced urticaria/angioedema is the most common manifestation of hypersensitivity reactions to NSAIDs. Diagnostic evaluation is based on the clinical history and a drug provocation test. OBJECTIVE To evaluate the role of the clinical history in the diagnosis of multiple NSAID-induced urticaria/angioedema. METHODS We studied a group of patients with an unequivocal history of urticaria and/or angioedema after NSAID intake. Subjects had to have had at least two episodes of cutaneous symptoms with two different COX-1 inhibitors. The diagnosis was confirmed in all cases by a drug provocation test with acetyl salicylic acid (ASA). Multivariate analysis was done by analysing different variables, including number of drugs involved, episodes and time elapsed between drug intake and symptom onset. RESULTS Of the total group of 75 cases with multiple NSAID-induced urticaria/angioedema diagnosed according to the clinical history, 76% developed a positive drug provocation test with ASA. The risk for having hypersensitivity was 17 times higher in patients who developed symptoms within the first 60 min after drug intake, 13 times higher in those who experienced reactions with more than two non-chemically related NSAIDs, and 10 times higher in women. CONCLUSIONS Drug provocation testing with ASA confirms the diagnosis of multiple NSAID-induced urticaria/angioedema in up to 92% of cases with an unequivocal clinical history, when reactions occur within 1 h and more than two different NSAIDs are involved.
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Affiliation(s)
- N Blanca-Lopez
- Allergy Service, Infanta Leonor Hospital, Madrid, Spain.
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10
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Abstract
Hypersensitivity diseases caused by nonsteroidal anti-inflammatory agents are
relatively common in the population. This article summarizes the present
understanding on the various allergic and nonallergic clinical pictures produced
through hypersensitivity to these drugs using the pathogenic classification of
hypersensitivity reactions recently proposed by the Nomenclature Committee of the
World Allergy Organization to guide clinicians in the diagnosis and management of
patients with these conditions.
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11
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Viola M, Rumi G, Valluzzi RL, Gaeta F, Caruso C, Romano A. Assessing potential determinants of positive provocation tests in subjects with NSAID hypersensitivity. Clin Exp Allergy 2010; 41:96-103. [DOI: 10.1111/j.1365-2222.2010.03648.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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12
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Gómez E, Blanca-Lopez N, Torres MJ, Requena G, Rondon C, Canto G, Blanca M, Mayorga C. Immunogloblin E-mediated immediate allergic reactions to dipyrone: value of basophil activation test in the identification of patients. Clin Exp Allergy 2009; 39:1217-24. [DOI: 10.1111/j.1365-2222.2009.03237.x] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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13
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Asero R. Clinical management of adult patients with a history of nonsteroidal anti-inflammatory drug-induced urticaria/angioedema: update. Allergy Asthma Clin Immunol 2007; 3:24-30. [PMID: 20525150 PMCID: PMC2873629 DOI: 10.1186/1710-1492-3-1-24] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
In the large majority of previous studies, patients with a history of acute urticaria induced by nonsteroidal anti-inflammatory drugs (NSAIDs) seeking safe alternative drugs have undergone tolerance tests uniquely with compounds exerting little or no inhibitory effect on the cyclooxygenase 1 enzyme. In light of recently published studies, however, this approach seems inadequate and should be changed. The present article critically reviews the clinical management of patients presenting with a history of urticaria induced by a single NSAID or multiple NSAIDs and suggests a simple, updated diagnostic algorithm that may assist clinicians in correctly classifying their patients.
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Affiliation(s)
- Riccardo Asero
- Ambulatorio di Allergologia, Clinica San Carlo, Paderno Dugnano (MI), Italy.
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Castillo-Zamora C, Castillo-Peralta LA, Nava-Ocampo AA. Report of an Anaphylactoid and an Anaphylactic Reaction to Ketorolac in Two Pediatric Surgical Patients. Ther Drug Monit 2006; 28:458-62. [PMID: 16778734 DOI: 10.1097/01.ftd.0000196661.97607.d4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Ketorolac is a potent analgesic drug that has been restricted in dosage and use because of its potential adverse effects. The diagnostic and ethical challenges of 2 children who had unpredictable adverse drug reactions to ketorolac are reported. Case 1: A 3-year-old boy received ketorolac 1 mg/kg for prevention of postoperative pain at the end of an orthopedic surgical procedure. Ten minutes later, he had bilateral palpebral edema, erythema in thorax, hypotension, and tachycardia. The adverse event was classified as a mixed reaction probably related to ketorolac. Case 2: A 7-year-old girl, who had previously received ketorolac in 2 different surgical procedures, underwent a third orthopedic surgery. She received ketorolac 1 mg/kg as pre-emptive analgesia at 1.5 hours of anesthetic time (approximately 1 hour of surgical time). The patient developed palpebral edema 5 minutes later in addition to erythema in thorax, hypotension, tachycardia, tachypnea, oxygen desaturation, and wheezing. The adverse event was classified as a systemic reaction probably related to ketorolac. The 2 patients were successfully treated with symptomatic therapy. Although rare in its frequency, ketorolac administration may be associated to anaphylactic and anaphylactoid reactions in children with or without history of previous exposure. Because ketorolac is off-licensed for pediatric patients, it should be administered only after the risks and benefits have been discussed with the child's parents in the preanesthetic consultation.
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Viola M, Quaratino D, Volpetti S, Gaeta F, Romano A. Parecoxib tolerability in patients with hypersensitivity to nonsteroidal anti-inflammatory drugs. J Allergy Clin Immunol 2006; 117:1189-91. [PMID: 16675352 DOI: 10.1016/j.jaci.2006.02.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2005] [Revised: 02/06/2006] [Accepted: 02/08/2006] [Indexed: 11/20/2022]
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Asero R. Oral aspirin challenges in patients with a history of intolerance to single non-steroidal anti-inflammatory drugs. Clin Exp Allergy 2005; 35:713-6. [PMID: 15969659 DOI: 10.1111/j.1365-2222.2005.2228.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED Summary Background In the clinical practice patients with a history of acute urticaria induced by a single non-steroidal anti-inflammatory drug (NSAID) and seeking for safe alternative drugs generally undergo tolerance tests with alternative NSAIDs that have little or no cyclooxygenase-1 (COX-1) enzyme inhibitory activity. This practice does not allow for the detection of single NSAID reactors and may lead to unnecessary avoidance of many potentially useful NSAIDs. OBJECTIVE Evaluate aspirin challenge as a means to distinguish single from multiple NSAID intolerance in patients with a clinical history of acute urticaria induced by a single NSAID. Methods One hundred and seventeen otherwise normal subjects with a history of acute urticaria following the ingestion of a single NSAID (pyrazolones (n=58), nimesulide (n=17), propionic acid derivatives (n=13), aryl acetic acid derivatives (n=14), acetaminophen (n=9), piroxicam (n=5), and indometacin (n=1)) underwent single-blind placebo-controlled oral challenges with aspirin. Aspirin-intolerant subjects underwent further tolerance tests drugs exerting little or no inhibitory activity on COX-1 enzyme (including paracetamol, nimesulide, rofecoxib, tramadol, and floctafenine). Results Aspirin induced urticaria in 28/117 (24%) patients. Five out of 28 (18%) aspirin reactors did not tolerate alternative NSAID on subsequent oral challenges. Conclusion In subjects with a history of urticaria induced by a single NSAID (other than aspirin) the diagnostic workup should start with an aspirin challenge in order to detect single/multiple NSAID reactors.
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Affiliation(s)
- R Asero
- Ambulatorio di Allergologia, Clinica San Carlo, Paderno Dugnano (MI), Italy.
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Abstract
Aspirin and the older nonsteroidal anti-inflammatory drugs (NSAIDs) that block cyclo-oxygenase-1 (COX-1) induce asthma attacks in patients with aspirin-exacerbated respiratory disease and urticaria in patients with chronic idiopathic urticaria. Weak inhibitors of COX-1, such as acetaminophen and salsalate, crossreact also but only with high doses of the drugs. Partial inhibitors of both COX-1 and COX-2, such as nimesulide and meloxicam, also cross-react but only at high drug doses. COX-2 inhibitors do not cross-react; however, all NSAIDs, including the selective COX-2 inhibitors, can sensitize patients and induce urticaria or anaphylaxis on next exposure to the drug.
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Affiliation(s)
- Donald D Stevenson
- Division of Allergy, Asthma, and Immunology, Department of Medicine, Scripps Clinic and The Scripps Research Institute, W 205, 10666 North Torrey Pines Road, La Jolla, CA 92037, USA.
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Sánchez-Borges M, Capriles-Behrens E, Caballero-Fonseca F. Hypersensitivity to non-steroidal anti-inflammatory drugs in childhood. Pediatr Allergy Immunol 2004; 15:376-80. [PMID: 15305949 DOI: 10.1111/j.1399-3038.2004.00159.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Although largely investigated in adults, the issue of hypersensitivity to non-steroidal anti-inflammatory drugs (NSAIDs) in childhood is unsettled due to lack of sufficient data. The purpose of this study is to examine the clinical syndromes of hypersensitivity to NSAIDs in children and adolescents. We performed a review of relevant papers on cutaneous and respiratory adverse reactions triggered by NSAIDs in pediatric patients, and a recount of our own experience in 43 well-characterized NSAID-sensitive children with cutaneous reactions who were submitted to controlled oral challenges with NSAIDs and the new inhibitors of the enzyme isoform cyclooxygenase-2 (COX-2). Although it has been suggested that allergic and pseudoallergic reactions to NSAIDs in children occur rarely, their prevalence remains largely unknown due to the scarcity of studies. About 23% of NSAID-sensitive patients seen in our institutions are young patients aged 8-18 yr who more frequently develop facial angioedema as their main clinical manifestation. Most patients are atopic and show reactions to more than one drug (cross-reactors). Drugs that inhibit COX-2 with higher specificity than classic NSAIDs are better tolerated in young NSAID-hypersensitive patients.
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Asero R. Intolerance to nonsteroidal anti-inflammatory drugs might precede by years the onset of chronic urticaria. J Allergy Clin Immunol 2003; 111:1095-8. [PMID: 12743575 DOI: 10.1067/mai.2003.1444] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Recent studies have found that most otherwise normal subjects with a history of acute urticaria induced by several nonsteroidal anti-inflammatory drugs (NSAIDs) show a wheal-and-flare reaction on intradermal injection of autologous serum. This phenomenon has been previously observed in patients with chronic urticaria (CU) and suggests a possible common background in CU and NSAID-induced urticaria. A relationship between these 2 conditions is further suggested by the fact that up to 30% of patients with CU have a worsening of their skin disorders after the ingestion of chemically unrelated NSAIDs. OBJECTIVE I sought to assess whether otherwise normal subjects with multiple or single NSAID intolerance show a propensity to have CU. METHODS Two hundred eighty otherwise normal patients with an unequivocal history of acute urticaria induced by NSAIDs seen during the last 10 years were studied. On the basis of both clinical history and oral challenge tests with at least 2 alternative NSAIDs, the patients were classified as having single or multiple NSAID intolerance. All the patients were re-evaluated within the end of 2002, 1 to 10 years after the first visit, to assess the onset of CU. One hundred allergic adults without a history of CU and of drug allergy followed up for 1 to 10 years were used as control subjects. RESULTS One hundred fifty-nine and 121 patients were finally considered as having single or multiple NSAID intolerance, respectively. At the follow-up visit, 93 (33%) of 280 patients had CU. The prevalence of CU was very similar in subjects with single or multiple NSAID intolerance (48/159 [30%] vs 45/121 [37%], respectively; P = not significant). Only 1 (1%) of 100 atopic control subjects had CU during the follow-up period (P <.001). Among single NSAID reactors, patients who had CU had a significantly higher prevalence of intolerance to aspirin than those who did not have CU (36/48 [75%] vs 41/111 [37%], P <.001), whereas the latter had a markedly higher prevalence of intolerance to pyrazolone drugs (52/111 [47%] vs 10/48 [21%], P <.01). Altogether, only 12 (15%) of 82 patients intolerant to drugs other than aspirin versus 36 (47%) of 77 aspirin reactors had CU (P <.001). CONCLUSION NSAID intolerance might precede the onset of CU by years. Both multiple and single NSAID reactors with a history of aspirin-induced urticaria seem at higher risk for CU than patients with a history of single intolerance to NSAIDs other than aspirin.
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Affiliation(s)
- Riccardo Asero
- Ambulatorio di Allergologia, Clinica San Carlo, Paderno Dugnano (MI), Italy
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20
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Abstract
Aspirin and non-steroidal antiinflammatory drugs (NSAIDs) may cause anaphylactic or anaphylactoid reactions. Constitutively-expressed cyclooxygenase (COX-1) inhibition is likely to be responsible for the cross-reactions and side effects associated with these drugs, as well as the anaphylactoid reactions sometimes seen in aspirin-sensitive respiratory disease. Though anaphylactic and anaphylactoid reactions may be clinically indistinguishable, they involve different mechanisms. Anaphylactic reactions are due to immediate hypersensitivity involving cross-linking of drug-specific IgE. Regardless of COX selectivity pattern, NSAIDs may function as haptens capable of inducing allergic sensitization. Unlike anaphylaxis, anaphylactoid reactions are most likely related to inhibition of COX-l by NSAIDS. Thus, an anaphylactoid reaction caused by a particular COX-1 inhibiting NSAID will occur with a chemically unrelated NSAID which also inhibits COX-1 enzymes. Selective COX-2 inhibitors appear to be safe in patients with a history of NSAID-related anaphylactoid reactions but can function as haptens, with resulting sensitization and anaphylaxis upon next exposure. This article will discuss the mechanisms, prevalence and population-based studies of anaphylactic and anaphylactoid reactions caused by aspirin and NSAIDs. The evaluation and management of patients suspected of having experienced an anaphylactic or anaphylactoid reaction to aspirin or other NSAIDs will also be reviewed.
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Affiliation(s)
- Eva A Berkes
- Sarasota Allergy and Asthma Specialty Clinic, FL 34233, USA.
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