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Heparin Allergy: Frequently Suspected, Seldom Proven, and Easily Circumvented. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY: IN PRACTICE 2022; 10:2984-2985. [DOI: 10.1016/j.jaip.2022.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 07/19/2022] [Indexed: 11/09/2022]
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2
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Stingeni L, Bianchi L, Tramontana M, Pigatto PD, Patruno C, Corazza M, Foti C, Fabbrocini G, Micali G, Romita P, Napolitano M, Hansel K. Skin tests in the diagnosis of adverse drug reactions. GIORN ITAL DERMAT V 2020; 155:602-621. [DOI: 10.23736/s0392-0488.20.06698-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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3
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Tramontana M, Hansel K, Bianchi L, Agostinelli D, Stingeni L. Skin tests in patients with delayed and immediate hypersensitivity to heparins: A case series. Contact Dermatitis 2018; 80:170-172. [DOI: 10.1111/cod.13147] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 09/17/2018] [Accepted: 09/18/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Marta Tramontana
- Section of Clinical, Allergological and Venereological Dermatology, Department of MedicineUniversity of Perugia Perugia Italy
| | - Katharina Hansel
- Section of Clinical, Allergological and Venereological Dermatology, Department of MedicineUniversity of Perugia Perugia Italy
| | - Leonardo Bianchi
- Section of Clinical, Allergological and Venereological Dermatology, Department of MedicineUniversity of Perugia Perugia Italy
| | - Daniela Agostinelli
- Section of Clinical, Allergological and Venereological Dermatology, Department of MedicineUniversity of Perugia Perugia Italy
| | - Luca Stingeni
- Section of Clinical, Allergological and Venereological Dermatology, Department of MedicineUniversity of Perugia Perugia Italy
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Tan E, Thompson G, Ekstrom C, Lucas M. Non-immediate heparin and heparinoid cutaneous allergic reactions: a role for fondaparinux. Intern Med J 2018; 48:73-77. [PMID: 29314514 DOI: 10.1111/imj.13659] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 05/11/2017] [Accepted: 06/12/2017] [Indexed: 12/01/2022]
Abstract
Non-immediate allergic cutaneous reactions to heparins have been increasingly reported, typically manifesting as large, eczematous plaques at sites of subcutaneous injection. Patients may demonstrate cross-reactivity between unfractionated heparin, low molecular weight heparin and semi-synthetic heparinoids, making finding an alternative difficult. Fondaparinux has been identified as a useful alternative in such patients; here we present the first two documented cases in Australia and a literature review.
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Affiliation(s)
- Elina Tan
- Department of Clinical Immunology, Sir Charles Gairdner Hospital, QEII Medical Centre, Perth, Western Australia, Australia
| | - Grace Thompson
- Department of Clinical Immunology, Sir Charles Gairdner Hospital, QEII Medical Centre, Perth, Western Australia, Australia.,Department of Clinical Immunology, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Charlotta Ekstrom
- Department of Clinical Immunology, Sir Charles Gairdner Hospital, QEII Medical Centre, Perth, Western Australia, Australia
| | - Michaela Lucas
- Department of Clinical Immunology, Sir Charles Gairdner Hospital, QEII Medical Centre, Perth, Western Australia, Australia.,PathWest Laboratory Medicine, Sir Charles Gairdner Hospital, QEII Medical Centre, Perth, Western Australia, Australia.,School of Medicine and Pharmacology, University of Western Australia, Perth, Western Australia, Australia.,Institute for Immunology and Infectious Diseases, Murdoch University, Perth, Western Australia, Australia
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The Society of Thoracic Surgeons, The Society of Cardiovascular Anesthesiologists, and The American Society of ExtraCorporeal Technology: Clinical Practice Guidelines ∗ —Anticoagulation During Cardiopulmonary Bypass. Ann Thorac Surg 2018; 105:650-662. [DOI: 10.1016/j.athoracsur.2017.09.061] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 09/09/2017] [Indexed: 01/01/2023]
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Shore-Lesserson L, Baker RA, Ferraris VA, Greilich PE, Fitzgerald D, Roman P, Hammon JW. The Society of Thoracic Surgeons, The Society of Cardiovascular Anesthesiologists, and The American Society of ExtraCorporeal Technology. Anesth Analg 2018; 126:413-424. [DOI: 10.1213/ane.0000000000002613] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Schindewolf M, Recke A, Zillikens D, Lindhoff-Last E, Ludwig RJ. Nadroparin carries a potentially high risk of inducing cutaneous delayed-type hypersensitivity responses. Contact Dermatitis 2017; 77:35-41. [DOI: 10.1111/cod.12764] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 12/09/2016] [Accepted: 12/21/2016] [Indexed: 12/01/2022]
Affiliation(s)
- Marc Schindewolf
- Division of Haemostaseology, Department of Internal Medicine; Goethe University Hospital; 60590 Frankfurt am Main Germany
- Division of Vascular Medicine, Swiss Cardiovascular Centre; University Hospital Bern; 3010 Bern Switzerland
| | - Andreas Recke
- Department of Dermatology and Lübeck Institute of Experimental Dermatology; University of Lübeck; 23538 Lübeck Germany
| | - Detlef Zillikens
- Department of Dermatology and Lübeck Institute of Experimental Dermatology; University of Lübeck; 23538 Lübeck Germany
| | - Edelgard Lindhoff-Last
- Division of Haemostaseology, Department of Internal Medicine; Goethe University Hospital; 60590 Frankfurt am Main Germany
- Agaplesion Bethanien Hospital, Cardiovascular Centre Bethanien (CCB); 60389 Frankfurt am Main Germany
| | - Ralf J. Ludwig
- Department of Dermatology and Lübeck Institute of Experimental Dermatology; University of Lübeck; 23538 Lübeck Germany
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Low-Molecular-Weight Heparins as Immunomodulators in Dermatology Practice. Am J Ther 2015; 23:e1911-e1917. [PMID: 25853237 DOI: 10.1097/mjt.0000000000000251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Low-molecular-weight heparins (LMWHs) have some effects on cell proliferation and inflammation beyond mere anticoagulation. They have been tried on treatment of a few dermatological disorders such as lichen planus, skin wound healing, recurrent aphtous stomatitis, chronic urticaria, and contact hypersensitivity. LMWHs are generally well-tolerated drugs, rarely can lead to severe reactions. In this article, we will review the novel indications of LMWHs in dermatology practice and common skin reactions associated with their use.
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Bemiparin, an effective and safe low molecular weight heparin: A review. Vascul Pharmacol 2014; 62:32-7. [PMID: 24657810 DOI: 10.1016/j.vph.2014.03.001] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2013] [Revised: 02/13/2014] [Accepted: 03/11/2014] [Indexed: 02/07/2023]
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10
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Schindewolf M, Ludwig RJ. Need for an increasing awareness for heparin-induced skin lesions. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/edm.09.66] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Delayed-type heparin allergy: diagnostic procedures and treatment alternatives-a case series including 15 patients. World Allergy Organ J 2013; 1:194-9. [PMID: 23282847 PMCID: PMC3650972 DOI: 10.1097/wox.0b013e31818def58] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Delayed-type hypersensitivity reactions (DTHRs) after subcutaneous application of unfractionated heparins or low-molecular-weight heparins are not uncommon. Standard allergological testing usually includes intracutaneous skin tests and patch testing of different heparins, heparinoids, and thrombin inhibitors followed by subcutaneous and/or intravenous challenge with skin test-negative drugs. We present data from a single-center case series of 15 patients with DTHR after low-molecular-weight heparin administration. Intracutaneous testing that can be considered as gold standard identified the suspicious elicitor in 11 (73.4%) of 15 of the patients. Patch testing was positive in 5 (33.4%) of 15 of the patients and was only positive in patients who were also reacting in the intradermal testing. Intravenous challenge with heparin sodium was performed in 10 of 15 patients and was well tolerated in all cases, despite prior positive intracutaneous tests with the same substance. Intracutaneous documentation of DTHR was not an adequate predictor of intravenous challenge.
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Abstract
Heparins are widely used for prophylaxis and treatment of thromboembolic diseases. Besides bleeding complications, heparin-induced skin lesions are the most frequent unwanted adverse effects of subcutaneous heparin treatment. Evidence suggests that these lesions are more common than previously thought. Lesions are most frequently due to either allergic reactions or to possibly life-threatening heparin-induced thrombocytopenia. Early recognition and adequate treatment are highly important, because although both complications initially show a similar clinical picture, their treatment should be fundamentally different. Furthermore, risk factors associated with the patient, drug, and treatment regimen have been identified. We review the clinical range of heparin-induced skin lesions, emphasise evidence and controversies in epidemiology, diagnosis, and differential diagnosis, and discuss the management of patients with these skin lesions.
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Affiliation(s)
- Marc Schindewolf
- Division of Vascular Medicine and Haemostaseology, Department of Internal Medicine, Hospital of the Johann Wolfgang Goethe University, Frankfurt am Main, Germany
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Abstract
All the adverse effects of heparins are related to their wide variety of biological activities, with bleeding being the most important safety issue, resulting directly from the potency of heparin as an anticoagulant. However, it is hard to define the bleeding risk, since it depends on numerous parameters including the indication, dosage, method, and duration of heparin application, the clinical study design and definition of bleeding as well as patient characteristics and determinants of bleeding such as type of surgery and co-medication. Nonbleeding complications of heparins are caused by binding of heparin molecules to proteins other than antithrombin and to cells, which is generally more pronounced with unfractionated heparin than with low-molecular-weight heparins. Accordingly, heparin-induced thrombocytopenia, the most severe nonbleeding adverse reaction, occurs about 10 times less with low-molecular-weight heparins than with unfractionated heparin. Frequent and therefore important adverse reactions of heparins are skin lesions resulting from delayed-type hypersensitivity reactions. All the other undesirable effects are discussed as well, but they are mostly clinically irrelevant.
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Affiliation(s)
- S Alban
- Pharmazeutisches Institut, Abteilung Pharmazeutische Biologie, Christian-Albrechts-Universität zu Kiel, Kiel, Germany.
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Moreno Escobosa M, Moya Quesada M, Granados SC, Amat López J. Delayed hypersensitivity challenged by subcutaneous Bemiparin. Allergol Immunopathol (Madr) 2011; 39:309-10. [PMID: 21129837 DOI: 10.1016/j.aller.2010.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2010] [Revised: 08/19/2010] [Accepted: 08/23/2010] [Indexed: 11/26/2022]
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Weberschock T, Meister AC, Bohrt K, Schmitt J, Boehncke WH, Ludwig RJ. The risk for cross-reactions after a cutaneous delayed-type hypersensitivity reaction to heparin preparations is independent of their molecular weight: a systematic review. Contact Dermatitis 2011; 65:187-94. [DOI: 10.1111/j.1600-0536.2011.01932.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Garcia-Ortega P, Asencio J. Dabigatran offers the simplest solution for thromboprophylaxis after orthopaedic surgery in patients allergic to low-molecular-weight heparins. Br J Haematol 2010; 151:84-5. [DOI: 10.1111/j.1365-2141.2010.08290.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Fondaparinux y lepirudina como alternativas terapéuticas ante una reacción cutánea eccematosa diseminada a heparina de bajo peso molecular. ACTAS DERMO-SIFILIOGRAFICAS 2010. [DOI: 10.1016/j.ad.2009.12.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Abstract
Provocation tests are regarded as the "gold standard" to establish or exclude the presence of hypersensitivity to a certain drugs because they reproduce not only allergy symptoms but other adverse manifestations, irrespective of their pathomechanism. Provocation testing is potentially harmful and should be considered only after balancing the risk-benefit ratio in the individual patient. The reasons for false-positive and false-negative results are numerous, including loss of sensitization, cofactors not being included in the diagnostic procedure, and the potential induction of tolerance during provocation. When conducted by experienced clinicians in a carefully monitored setting, however, drug provocation testing is a safe method to confirm or exclude drug hypersensitivity.
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Schindewolf M, Schwaner S, Wolter M, Kroll H, Recke A, Kaufmann R, Boehncke WH, Lindhoff-Last E, Ludwig RJ. Incidence and causes of heparin-induced skin lesions. CMAJ 2009; 181:477-81. [PMID: 19786468 DOI: 10.1503/cmaj.081729] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Little is known about the incidence and causes of heparin-induced skin lesions. The 2 most commonly reported causes of heparin-induced skin lesions are immune-mediated heparin-induced thrombocytopenia and delayed-type hypersensitivity reactions. METHODS We prospectively examined consecutive patients who received subcutaneous heparin (most often enoxaparin or nadroparin) for the presence of heparin-induced skin lesions. If such lesions were identified, we performed a skin biopsy, platelet count measurements, and antiplatelet-factor 4 antibody and allergy testing. RESULTS We enrolled 320 patients. In total, 24 patients (7.5%, 95% confidence interval [CI] 4.7%-10.6%) had heparin-induced skin lesions. Delayed-type hypersensitivity reactions were identified as the cause in all 24 patients. One patient with histopathologic evidence of delayed-type hypersensitivity tested positive for antiplatelet-factor 4 antibodies. We identified the following risk factors for heparin-induced skin lesions: a body mass index greater than 25 (odds ratio [OR] 4.6, 95% CI 1.7-15.3), duration of heparin therapy longer than 9 days (OR 5.9, 95% CI 1.9-26.3) and female sex (OR 3.0, 95% CI 1.1-8.8). INTERPRETATION Heparin-induced skin lesions are relatively common, have identifiable risk factors and are commonly caused by a delayed-type hypersensitivity reaction (type IV allergic response).
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Affiliation(s)
- Marc Schindewolf
- Department of Internal Medicine, Division of Angiology, Hospital of the Johann Wolfgang Goethe University, Frankfurt am Main, Germany
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Lopez S, Torres M, Rodríguez-Pena R, Blanca-Lopez N, Fernandez T, Antunez C, Canto G, de Luque V, Mayorga C. Lymphocyte proliferation response in patients with delayed hypersensitivity reactions to heparins. Br J Dermatol 2009; 160:259-65. [DOI: 10.1111/j.1365-2133.2008.08875.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Palacios Colom L, Alcántara Villar M, Luis Anguita Carazo J, Ruiz Villaverde R, Quiralte Enríquez J. Delayed-type hypersensitivity to heparins: different patterns of cross-reactivity. Contact Dermatitis 2008; 59:375-7. [DOI: 10.1111/j.1600-0536.2008.01441.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Gómez-Outes A, Gómez de la Bárcena C, Martínez-González J. Delayed-type hypersensitivity to low molecular weight heparins and heparinoids: cross-reactivity does not depend on molecular weight. Commentary. Br J Dermatol 2008; 158:869-70. [DOI: 10.1111/j.1365-2133.2008.08453.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Ludwig RJ, Schindewolf M, Lindhoff-Last E, Boehncke WH. The influence of heparin's molecular weight and the incidence of delayed type hypersensitivity reactions revisited; in response to Grims et al., Br J Dermatol 2007; 157:514-17. Br J Dermatol 2008; 158:849-51. [PMID: 18205866 DOI: 10.1111/j.1365-2133.2007.08402.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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