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Ibáñez MD, Rodríguez Del Río P, Lasa EM, Joral A, Ruiz-Hornillos J, Muñoz C, Gómez Traseira C, Escudero C, Olaguibel Rivera JM, Garriga-Baraut T, González-de-Olano D, Rosado A, Sanchez-García S, Pérez Bustamante S, Padial Vilchez MA, Prieto Montaño P, Candón Morillo R, Macías Iglesia E, Feliú Vila A, Valbuena T, Lopez-Patiño A, Martorell A, Sastre J, Audícana MT. Prospective assessment of diagnostic tests for pediatric penicillin allergy: From clinical history to challenge tests. Ann Allergy Asthma Immunol 2018; 121:235-244.e3. [PMID: 29803713 DOI: 10.1016/j.anai.2018.05.013] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 05/10/2018] [Accepted: 05/14/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Diagnostic guidelines for penicillin allergy in children recommend cumbersome protocols based partially on data from adults, which may be suboptimal for pediatric use. OBJECTIVE To assess the accuracy of tools for diagnosis of penicillin allergy in children. METHODS A prospective, multicenter study was conducted in children with reported adverse events related to penicillin, excluding severe reactions. All patients underwent a uniform diagnostic protocol that consisted of clinical history, skin tests, serum specific IgE (sIgE), and, regardless of these results, drug provocation tests (DPTs). RESULTS A total of 732 children (mean age, 5.5 years; 51.2% males) completed the allergy workup, including DPTs. Amoxicillin triggered 96.9% of all reactions. None of the patients with an immediate index reaction (IR) developed a reaction on DPT. Penicillin allergy was confirmed in 35 children (4.8%): 6 immediate reactions (17%) and 29 nonimmediate reactions (83%) on the DPT. No severe reactions were recorded. The allergist diagnosis based on the clinical history was not associated with the DPT final outcome. In 30 of 33 allergic patients (91%), the results of all skin tests and sIgE tests were negative. A logistic regression model identified the following to be associated with penicillin allergy: a family history of drug allergy (odds ratio [OR], 3.03; 95% confidence interval [CI], 1.33-6.89; P = .008), an IR lasting more than 3 days vs 24 hours or less (OR, 8.96; 95% CI, 2.01-39.86; P = .004), and an IR treated with corticosteroids (OR, 2.68; 95% CI, 1.30-5.54; P = .007). CONCLUSION Conventional predictors of allergy to penicillin performed weakly. The authors propose straightforward penicillin provocation testing in controlled, experienced centers for the diagnosis of nonsevere penicillin allergy in children.
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Affiliation(s)
- María Dolores Ibáñez
- Allergy Department, Niño Jesús University Children's Hospital, Madrid, Spain; The Research Network ARADyAL RD16/0006/0026.
| | - Pablo Rodríguez Del Río
- Allergy Department, Niño Jesús University Children's Hospital, Madrid, Spain; The Research Network ARADyAL RD16/0006/0026
| | - Eva Maria Lasa
- Allergy Department, Hospital Universitario Donostia, Guipuzcoa, Spain
| | - Alejandro Joral
- Allergy Department, Hospital Universitario Donostia, Guipuzcoa, Spain
| | - Javier Ruiz-Hornillos
- Allergy Department, Hospital Universitario Infanta Elena, Valdemoro, Spain; Instituto de Investigación Sanitaria, Fundación Jiménez Díaz, Madrid, Spain
| | - Candelaria Muñoz
- Allergy Department. Children Hospital, University Regional Hospital, Málaga, Spain
| | | | - Carmelo Escudero
- Allergy Department, Niño Jesús University Children's Hospital, Madrid, Spain; The Research Network ARADyAL RD16/0006/0026
| | | | - Teresa Garriga-Baraut
- Unitat d'Al.lergologia Pediàtrica, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Grup Creixement i Desenvolupament, Institut de Recerca Vall d'Hebron, Barcelona, Spain
| | | | - Ana Rosado
- Unidad de Alergia, Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Silvia Sanchez-García
- Allergy Department, Niño Jesús University Children's Hospital, Madrid, Spain; The Research Network ARADyAL RD16/0006/0026
| | - Socorro Pérez Bustamante
- Allergy Department, Torrejon University Hospital, Madrid, Spain; Allergy Department, Rincon Health Group, Vithas, Málaga, Spain
| | | | | | - Rocío Candón Morillo
- Allergy Department, Hospital General La Mancha Centro, Alcázar de San Juan, Ciudad Real, Spain
| | - Eva Macías Iglesia
- Allergy Department, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | | | - Teresa Valbuena
- Servicio Alergología, Hospital Infanta Sofia, SS Reyes, Madrid, Spain
| | | | | | - Joaquín Sastre
- Instituto de Investigación Sanitaria, Fundación Jiménez Díaz, Madrid, Spain; Allergy Department, Fundación Jimenez Diaz, Madrid, Spain; Facultad de Universidad Autonoma de Madrid, Madrid, Spain
| | - María Teresa Audícana
- Allergy Department. Hospital Universitario Araba (HUA), Instituto Bioaraba, Vitoria, Spain
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Manevski N, Swart P, Balavenkatraman KK, Bertschi B, Camenisch G, Kretz O, Schiller H, Walles M, Ling B, Wettstein R, Schaefer DJ, Itin P, Ashton-Chess J, Pognan F, Wolf A, Litherland K. Phase II metabolism in human skin: skin explants show full coverage for glucuronidation, sulfation, N-acetylation, catechol methylation, and glutathione conjugation. Drug Metab Dispos 2014; 43:126-39. [PMID: 25339109 DOI: 10.1124/dmd.114.060350] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Although skin is the largest organ of the human body, cutaneous drug metabolism is often overlooked, and existing experimental models are insufficiently validated. This proof-of-concept study investigated phase II biotransformation of 11 test substrates in fresh full-thickness human skin explants, a model containing all skin cell types. Results show that skin explants have significant capacity for glucuronidation, sulfation, N-acetylation, catechol methylation, and glutathione conjugation. Novel skin metabolites were identified, including acyl glucuronides of indomethacin and diclofenac, glucuronides of 17β-estradiol, N-acetylprocainamide, and methoxy derivatives of 4-nitrocatechol and 2,3-dihydroxynaphthalene. Measured activities for 10 μM substrate incubations spanned a 1000-fold: from the highest 4.758 pmol·mg skin(-1)·h(-1) for p-toluidine N-acetylation to the lowest 0.006 pmol·mg skin(-1)·h(-1) for 17β-estradiol 17-glucuronidation. Interindividual variability was 1.4- to 13.0-fold, the highest being 4-methylumbelliferone and diclofenac glucuronidation. Reaction rates were generally linear up to 4 hours, although 24-hour incubations enabled detection of metabolites in trace amounts. All reactions were unaffected by the inclusion of cosubstrates, and freezing of the fresh skin led to loss of glucuronidation activity. The predicted whole-skin intrinsic metabolic clearances were significantly lower compared with corresponding whole-liver intrinsic clearances, suggesting a relatively limited contribution of the skin to the body's total systemic phase II enzyme-mediated metabolic clearance. Nevertheless, the fresh full-thickness skin explants represent a suitable model to study cutaneous phase II metabolism not only in drug elimination but also in toxicity, as formation of acyl glucuronides and sulfate conjugates could play a role in skin adverse reactions.
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Affiliation(s)
- Nenad Manevski
- Drug Metabolism and Pharmacokinetics (N.M., P.S., G.C., O.K., H.S., M.W., K.L.), Pre-clinical Safety (K.K.B., B.B., F.P., A.W.), and Clinical Sciences and Innovation Translational Medicine (J.A.-C.), Novartis Institutes for BioMedical Research, Novartis Pharma, Basel, Switzerland; and Department of Plastic, Reconstructive, Aesthetic and Hand Surgery (B.L., R.W., D.J.S.), and Department of Dermatology (P.I.), University Hospital Basel, Basel, Switzerland
| | - Piet Swart
- Drug Metabolism and Pharmacokinetics (N.M., P.S., G.C., O.K., H.S., M.W., K.L.), Pre-clinical Safety (K.K.B., B.B., F.P., A.W.), and Clinical Sciences and Innovation Translational Medicine (J.A.-C.), Novartis Institutes for BioMedical Research, Novartis Pharma, Basel, Switzerland; and Department of Plastic, Reconstructive, Aesthetic and Hand Surgery (B.L., R.W., D.J.S.), and Department of Dermatology (P.I.), University Hospital Basel, Basel, Switzerland
| | - Kamal Kumar Balavenkatraman
- Drug Metabolism and Pharmacokinetics (N.M., P.S., G.C., O.K., H.S., M.W., K.L.), Pre-clinical Safety (K.K.B., B.B., F.P., A.W.), and Clinical Sciences and Innovation Translational Medicine (J.A.-C.), Novartis Institutes for BioMedical Research, Novartis Pharma, Basel, Switzerland; and Department of Plastic, Reconstructive, Aesthetic and Hand Surgery (B.L., R.W., D.J.S.), and Department of Dermatology (P.I.), University Hospital Basel, Basel, Switzerland
| | - Barbara Bertschi
- Drug Metabolism and Pharmacokinetics (N.M., P.S., G.C., O.K., H.S., M.W., K.L.), Pre-clinical Safety (K.K.B., B.B., F.P., A.W.), and Clinical Sciences and Innovation Translational Medicine (J.A.-C.), Novartis Institutes for BioMedical Research, Novartis Pharma, Basel, Switzerland; and Department of Plastic, Reconstructive, Aesthetic and Hand Surgery (B.L., R.W., D.J.S.), and Department of Dermatology (P.I.), University Hospital Basel, Basel, Switzerland
| | - Gian Camenisch
- Drug Metabolism and Pharmacokinetics (N.M., P.S., G.C., O.K., H.S., M.W., K.L.), Pre-clinical Safety (K.K.B., B.B., F.P., A.W.), and Clinical Sciences and Innovation Translational Medicine (J.A.-C.), Novartis Institutes for BioMedical Research, Novartis Pharma, Basel, Switzerland; and Department of Plastic, Reconstructive, Aesthetic and Hand Surgery (B.L., R.W., D.J.S.), and Department of Dermatology (P.I.), University Hospital Basel, Basel, Switzerland
| | - Olivier Kretz
- Drug Metabolism and Pharmacokinetics (N.M., P.S., G.C., O.K., H.S., M.W., K.L.), Pre-clinical Safety (K.K.B., B.B., F.P., A.W.), and Clinical Sciences and Innovation Translational Medicine (J.A.-C.), Novartis Institutes for BioMedical Research, Novartis Pharma, Basel, Switzerland; and Department of Plastic, Reconstructive, Aesthetic and Hand Surgery (B.L., R.W., D.J.S.), and Department of Dermatology (P.I.), University Hospital Basel, Basel, Switzerland
| | - Hilmar Schiller
- Drug Metabolism and Pharmacokinetics (N.M., P.S., G.C., O.K., H.S., M.W., K.L.), Pre-clinical Safety (K.K.B., B.B., F.P., A.W.), and Clinical Sciences and Innovation Translational Medicine (J.A.-C.), Novartis Institutes for BioMedical Research, Novartis Pharma, Basel, Switzerland; and Department of Plastic, Reconstructive, Aesthetic and Hand Surgery (B.L., R.W., D.J.S.), and Department of Dermatology (P.I.), University Hospital Basel, Basel, Switzerland
| | - Markus Walles
- Drug Metabolism and Pharmacokinetics (N.M., P.S., G.C., O.K., H.S., M.W., K.L.), Pre-clinical Safety (K.K.B., B.B., F.P., A.W.), and Clinical Sciences and Innovation Translational Medicine (J.A.-C.), Novartis Institutes for BioMedical Research, Novartis Pharma, Basel, Switzerland; and Department of Plastic, Reconstructive, Aesthetic and Hand Surgery (B.L., R.W., D.J.S.), and Department of Dermatology (P.I.), University Hospital Basel, Basel, Switzerland
| | - Barbara Ling
- Drug Metabolism and Pharmacokinetics (N.M., P.S., G.C., O.K., H.S., M.W., K.L.), Pre-clinical Safety (K.K.B., B.B., F.P., A.W.), and Clinical Sciences and Innovation Translational Medicine (J.A.-C.), Novartis Institutes for BioMedical Research, Novartis Pharma, Basel, Switzerland; and Department of Plastic, Reconstructive, Aesthetic and Hand Surgery (B.L., R.W., D.J.S.), and Department of Dermatology (P.I.), University Hospital Basel, Basel, Switzerland
| | - Reto Wettstein
- Drug Metabolism and Pharmacokinetics (N.M., P.S., G.C., O.K., H.S., M.W., K.L.), Pre-clinical Safety (K.K.B., B.B., F.P., A.W.), and Clinical Sciences and Innovation Translational Medicine (J.A.-C.), Novartis Institutes for BioMedical Research, Novartis Pharma, Basel, Switzerland; and Department of Plastic, Reconstructive, Aesthetic and Hand Surgery (B.L., R.W., D.J.S.), and Department of Dermatology (P.I.), University Hospital Basel, Basel, Switzerland
| | - Dirk J Schaefer
- Drug Metabolism and Pharmacokinetics (N.M., P.S., G.C., O.K., H.S., M.W., K.L.), Pre-clinical Safety (K.K.B., B.B., F.P., A.W.), and Clinical Sciences and Innovation Translational Medicine (J.A.-C.), Novartis Institutes for BioMedical Research, Novartis Pharma, Basel, Switzerland; and Department of Plastic, Reconstructive, Aesthetic and Hand Surgery (B.L., R.W., D.J.S.), and Department of Dermatology (P.I.), University Hospital Basel, Basel, Switzerland
| | - Peter Itin
- Drug Metabolism and Pharmacokinetics (N.M., P.S., G.C., O.K., H.S., M.W., K.L.), Pre-clinical Safety (K.K.B., B.B., F.P., A.W.), and Clinical Sciences and Innovation Translational Medicine (J.A.-C.), Novartis Institutes for BioMedical Research, Novartis Pharma, Basel, Switzerland; and Department of Plastic, Reconstructive, Aesthetic and Hand Surgery (B.L., R.W., D.J.S.), and Department of Dermatology (P.I.), University Hospital Basel, Basel, Switzerland
| | - Joanna Ashton-Chess
- Drug Metabolism and Pharmacokinetics (N.M., P.S., G.C., O.K., H.S., M.W., K.L.), Pre-clinical Safety (K.K.B., B.B., F.P., A.W.), and Clinical Sciences and Innovation Translational Medicine (J.A.-C.), Novartis Institutes for BioMedical Research, Novartis Pharma, Basel, Switzerland; and Department of Plastic, Reconstructive, Aesthetic and Hand Surgery (B.L., R.W., D.J.S.), and Department of Dermatology (P.I.), University Hospital Basel, Basel, Switzerland
| | - Francois Pognan
- Drug Metabolism and Pharmacokinetics (N.M., P.S., G.C., O.K., H.S., M.W., K.L.), Pre-clinical Safety (K.K.B., B.B., F.P., A.W.), and Clinical Sciences and Innovation Translational Medicine (J.A.-C.), Novartis Institutes for BioMedical Research, Novartis Pharma, Basel, Switzerland; and Department of Plastic, Reconstructive, Aesthetic and Hand Surgery (B.L., R.W., D.J.S.), and Department of Dermatology (P.I.), University Hospital Basel, Basel, Switzerland
| | - Armin Wolf
- Drug Metabolism and Pharmacokinetics (N.M., P.S., G.C., O.K., H.S., M.W., K.L.), Pre-clinical Safety (K.K.B., B.B., F.P., A.W.), and Clinical Sciences and Innovation Translational Medicine (J.A.-C.), Novartis Institutes for BioMedical Research, Novartis Pharma, Basel, Switzerland; and Department of Plastic, Reconstructive, Aesthetic and Hand Surgery (B.L., R.W., D.J.S.), and Department of Dermatology (P.I.), University Hospital Basel, Basel, Switzerland
| | - Karine Litherland
- Drug Metabolism and Pharmacokinetics (N.M., P.S., G.C., O.K., H.S., M.W., K.L.), Pre-clinical Safety (K.K.B., B.B., F.P., A.W.), and Clinical Sciences and Innovation Translational Medicine (J.A.-C.), Novartis Institutes for BioMedical Research, Novartis Pharma, Basel, Switzerland; and Department of Plastic, Reconstructive, Aesthetic and Hand Surgery (B.L., R.W., D.J.S.), and Department of Dermatology (P.I.), University Hospital Basel, Basel, Switzerland
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