Atopy and systemic reactions to drugs

Local anesthetics allergy in children: Evaluation of diagnostic tests with Real-Life data

BACKGROUND

Local anesthetic (LA) drugs are commonly used in clinical practice to provide effective analgesia, including in dentistry and minor surgical procedures. The perception of a high risk of allergy in daily applications leads to the referral of atopic patients and those with other drug allergies to allergy clinics for the evaluation of allergic reactions to LA. The aim of this study was to determine who should be referred to the allergy clinic for LA allergy testing, assess the frequency of LA allergy in pediatric patients, and identify the negative predictive value of skin tests in diagnosis.

METHODS

January 2017-July 2023, the clinical and laboratory data, as well as the results of drug allergy tests, of patients referred to our pediatric allergy clinic by dentists and physicians performing minor surgical procedures with suspected LA allergy were retrospectively evaluated.

RESULTS

Our study included a total of 153 patients, comprising 84 girls (54.9%) and 69 boys (45.1%), with a mean age of 8.9 (±3.3) years. The most common reason for referral was a history of non-LA drug allergies (n = 66, 43.2%), followed by asthma (n = 25, 16.3%). Hypersensitivity reactions (HRs) with LA were most commonly associated with articaine (n = 7, 4.8%), followed by lidocaine (n = 6, 4.1%). When intradermal tests were evaluated, 17 patients (11.1%) had a positive test result. The positivity for lidocaine was 70.6% (n = 12), and prilocaine was 29.4% (n = 5). Subcutaneous provocation was administered to 109 patients (71.2%), and one patient exhibited local erythema and swelling with prilocaine.

CONCLUSION

Although LA allergy is a rare occurrence, consultations of this nature are frequently requested from allergy clinics in real life. Considering the negative predictive value of skin tests performed with LA drugs, the reaction rate appears to be low in patients with atopy or other drug allergies. It is crucial for all relevant healthcare professionals to be knowledgeable about the appropriate approach to suspected LA allergies to avoid unnecessary tests. To the best of our knowledge, our study is the most comprehensive work in the literature that evaluates the results of diagnostic tests in children referred with a suspicion of LA allergy.

Allergic rhinitis in Chinese young adults from the Singapore/Malaysia cross-sectional genetics epidemiology study (SMCGES) cohort: Prevalence, patterns, and epidemiology of allergic rhinitis

Background

Allergic rhinitis (AR) is characterized by the occurrence of at least 2 symptoms of nasal itching, nasal blockage, rhinorrhea, and sneezing, when not afflicted with a cold or flu, with defined atopic sensitization demonstrated by skin prick test or specific IgE responses. Besides the detriment to standard of living and economic burden of AR, both multicentre and single-cohort studies have observed an increase in AR prevalence in Asia over time.

Methods

In total, 12 872 individuals, with mean age 22.1 years (SD = 4.8), were recruited from universities in Singapore and Malaysia. Each participant provided epidemiological data based on an investigator-administered questionnaire adapted from the validated International Study of Allergies and Asthma in Childhood (ISAAC) protocol, and atopy status was determined using a skin prick test (SPT) performed by qualified staff. AR was diagnosed according to Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines and a positive SPT result.

Results

Sensitization (determined by SPT) to either Blomia tropicalis or Dermatophagoides pteronyssinus was prevalent in 66.5% of the cohort. Current rhinitis (manifesting ≥2 rhinitis symptoms, within the past 12 months) was observed in 48.9% of our population, while AR, which included atopy status, was estimated at 39.4%. Sneezing and rhinorrhea were the most common symptoms among AR cases. AR prevalence decreased with increasing age (OR: 0.979; 95% CI: 0.969-0.989), while male gender (OR: 2.053; 95% CI: 1.839-2.294), and a parental history of allergic diseases (OR: 2.750; 95% CI: 2.284-3.316) were significant risk factors for AR. Upon adjustment for age, gender, and parental history, housing type (OR: 0.632; 95% CI: 0.543-0.736) and income level (>$6000 vs <$2000; OR: 2.461; 95% CI: 2.058-2.947) remained as significant risk factors for AR, while ever having kept a pet (OR: 1.167; 95% CI: 1.025-1.328) emerged as a risk factor. Conflicting results were obtained for indicators of sedentary lifestyle: frequent physical activity (OR: 1.394; 95% CI: 1.150-1.694) and increased duration spent using the TV/computer (OR: 1.224; 95% CI: 1.006-1.489) both increased the risk of AR. Lastly, we used the Quality of Diet based on Glycaemic Index Score (QDGIS) to assess the Glycaemic Index (GI) level of overall diet. We identified lower GI level of overall diet as a protective factor against AR manifestation (OR: 0.682; 95% CI: 0.577-0.807).

Conclusion

While the previously established non-modifiable risk factors for AR were present in our study population, the identification of modifiable risk factors, such as TV/computer usage, and dietary habits, opens a new area for research, both in the areas of gene-environment interaction, and management of AR.

Anaphylaxis to drugs: Overcoming mast cell unresponsiveness by fake antigens

Our understanding of IgE‐mediated drug allergy relies on the hapten concept, which is well established in inducing adaptive reactions of the immune system to small molecules like drugs. The role of hapten‐carrier adducts in re‐challenge reactions leading to mast cell degranulation and anaphylaxis is unclear. Based on clinical observations, the speed of adduct formation, skin and in vitro tests to inert drug molecules, a different explanation of IgE‐mediated reactions to drugs is proposed: These are (a) A natural role of reduced mast cell (MC) reactivity in developing IgE‐mediated reactions to drugs. This MC unresponsiveness is antigen‐specific and covers the serum drug concentrations, but allows reactivity to locally higher concentrations. (b) Some non‐covalent drug‐protein complexes rely on rather affine bindings and have a similar appearance as covalent hapten‐protein adducts. Such drug‐protein complexes represent so‐called “fake antigens,” as they are unable to induce immunity, but may react with and cross‐link preformed drug‐specific IgE. As they are formed very rapidly and in high concentrations, they may cause fulminant MC degranulation and anaphylaxis. (c) The generation of covalent hapten‐protein adducts requires hours, either because the formation of covalent bonds requires time or because first a metabolic step for forming a reactive metabolite is required. This slow process of stable adduct formation has the advantage that it may give time to desensitize mast cells, even in already sensitized individuals. The consequences of this new interpretation of IgE‐mediated reactions to drugs are potentially wide‐reaching for IgE‐mediated drug allergy but also allergy in general.

Identification of Risk Factors and Cross-Reactivity of Local Anesthetics Hypersensitivity: Analysis of 14-Years' Experience

Purpose

Local anesthetics (LA) are widely used and adverse drug reactions (ADR) occur in 2.5–10%, but hypersensitivity reactions are rare (ranging between 0% and 4.3%). Risk is so overestimated causing too many allergy clinic referrals. There are limited and also conflicting results over the management of LA allergy. We aimed to find out who should be referred to an allergy clinic for a LA allergy testing, to define the subjects with an increased risk of LA allergy and to assess the need for testing for identifying alternative LA.

Patients and Methods

We performed a retrospective study of patients referred to our clinic for diagnostic workup of LA hypersensitivity from 2006 to 2020.

Results

In our cohort of 398 patients, tests were positive in 14 (3.52%) of them. Personal history of ADR with LA was the only independent risk factor for positive test (RR=4.007, p=0.033). Presence of generalized cutaneous symptoms and hypotension during past reaction were independent predictors of positive test (RR=9.043, p=0.021 and RR=10.445, p=0.038, respectively). The negative predictive value of intradermal test at dilution of 1:100 for immediate-type reaction was high (97.56%). Also, we demonstrated cross-reactivity within the amide-group LAs and co-occurrence of immediate- and delayed-type reactions.

Conclusion

Only patients with an LA-induced ADR should be referred to an allergy clinic. History of generalized cutaneous symptoms and/or hypotension during the reaction may define subjects with an increased risk of LA allergy. A stepwise test procedure may start with skin tests especially for these patients with increased risk factors. In presence of LA allergy, alternative LA should always be confirmed by performing a challenge test.

Importance of hypersensitivity in adverse reactions to drugs in the elderly

Background

The use of drugs in the elderly is very extensive because of the frequent occurrence of chronic diseases. Adverse drug reactions (ADRs) commonly occur in geriatric patients receiving multiple therapeutic regimens. In the literature, little attention has been given to ADRs in the elderly, and particularly to allergic reactions.

Objective

The aim of the present study is to provide data on possible inappropriate prescriptions in the elderly in relation to allergic reactions and to identify a list of drugs which are likely inducers of allergic reactions.

Methods

We retrospectively evaluated ADRs in patients referring to Immunoallergy Unit of Hospital Policlinico in Bari on the basis of Beers criteria. Among adverse reactions, hypersensitivity reactions were extracted and a comparison between different age groups was assessed.

Results

Out of 823 patients with ADRs, in 30.6% hypersensitivity drug reactions (HDR) were diagnosed. Data about drug intake, comorbidities and clinical presentation were collected, aiming to identify possible risk factors. An evaluation of drugs most commonly involved was assessed.

Conclusions

HDR are reported to represent 5-10% of all ADRs, while in our study population the prevalence was about 30%. This suggests the need to develop strategies to minimize the incidence of drug allergy in the elderly, as well to reduce the phenomenon of inappropriate prescriptions.

Asthma, Family History of Drug Allergy, and Age Predict Amoxicillin Allergy in Children

BACKGROUND

Suspected adverse reactions to amoxicillin are common, but there are no known factors that can predict amoxicillin allergy in children. In addition, methods used for the diagnosis of amoxicillin allergy are not standardized and their role in diagnosis is not clear.

OBJECTIVE

To identify predictive factors and to assess the role of skin test in the diagnosis of amoxicillin allergy in children.

METHODS

Children with a history of immediate (excluding anaphylaxis) or nonimmediate reactions to amoxicillin were tested by skin prick test, followed by oral graded challenge with amoxicillin. Clinical characteristics of the reaction before and after the challenge were recorded, and data of personal and relatives' drug allergies and atopy were collected for statistical analysis.

RESULTS

Skin prick tests followed by an oral graded challenge with amoxicillin were performed on 133 children. The skin test result was not of clinical value because it was negative in all children. Three children (2%) had an immediate reaction and 7 children (5%) had a nonimmediate reaction. Asthma (odds ratio [OR], 0.12; 95% CI, 0.017-0.869; P = .03), family history of drug allergy (OR, 0.12; 95% CI, 0.026-0.613; P = .01), older age at reaction (OR, 0.837; 95% CI, 0.699-1; P = .05), and angioedema (OR, 0.22; 95% CI, 0.043-1.12; marginally significant at P = .069) were associated with reduced chance to pass the oral challenge.

CONCLUSIONS

Skin prick test did not contribute to the diagnosis of amoxicillin allergy. The presence of asthma, family history of drug allergy, and older age at reaction can be used as predictive factors for true amoxicillin allergy in children.

Frequency of self-reported drug allergy: A systematic review and meta-analysis with meta-regression

BACKGROUND

Patients reporting drug allergy are treated with second-line therapies, with possible negative clinical and health consequences.

OBJECTIVE

To assess the prevalence of self-reported drug allergy.

METHODS

We performed a systematic review of observational studies assessing the prevalence of self-reported drug allergy. We searched 4 electronic databases. From selected studies, we extracted data on self-reported drug allergy prevalence, study design, participants' demographic characteristics, reported clinical manifestations, and suspected culprit drugs. We performed a random-effects meta-analysis followed by a meta-regression.

RESULTS

Fifty-three studies were included in the systematic review, assessing a total of 126,306 participants, of whom 8.3% (range across studies 0.7-38.5%) self-reported drug allergy. Cutaneous manifestations were reported by 68.2% of participants, and anaphylactic or systemic reactions were reported by 10.8%. Antibiotics, nonsteroidal anti-inflammatory drugs, and anesthetics were the most frequently reported culprit drug classes. The frequency of self-reported drug allergy was higher in female (11.4%) than in male (7.2%) patients, adults (10.0%) than in children (5.1%), and in studies in the medical setting (15.9% in inpatients, 11.4% in outpatients) than in the general population (5.9%). The meta-analysis rendered a pooled prevalence of 7.9% (95% confidence interval 6.4-9.6), and the meta-regression identified study region, participants' age group, and study setting as factors associated with significant heterogeneity. Confirmation tests (including skin, in vitro, and drug provocation tests) were performed in only 3 studies.

CONCLUSION

The prevalence of self-reported drug allergy is highly variable and is higher in female patients, adults, and inpatients. To overcome this variability, further studies using confirmation tests are needed.

Patient-reported allergies cause inferior outcomes after total knee arthroplasty

PURPOSE

The main objective of this study was to analyse the outcomes after total knee arthroplasty (TKA) of a group of patients with at least one self-reported allergy and a group of patients without reported allergies. We hypothesized there is a significant negative influence on clinical outcome scores after TKA in patients with self-reported allergies.

METHODS

Four-hundred and seventy-five patients who had undergone TKA were analysed preoperatively and 1 year after surgery. The WOMAC, KSS and SF-36 scores were obtained. The patients' Yesavage depression questionnaire score was also recorded. The scores of the 330 (69.5 %) patients without self-reported allergies were compared to the scores of the 145 (30.5 %) patients with at least one self-reported allergy in the medical record.

RESULTS

Preoperative scores were similar in both groups. The WOMAC post-operative scores (23.6 vs 20.4; p = 0.037) and the KSS-Knee score (91.1 vs 87.6; p = 0.027) were worse in the group of patients with self-reported allergies than in the group without allergies. The scores from the Yesavage depression questionnaire and in the SF-36 were similar in both groups.

CONCLUSION

Patients with at least one self-reported allergy have worse post-operative outcomes in terms of the WOMAC and KSS-Knee scores after TKA than patients without allergies. These poor outcomes do not seem to be related to depression. Therefore, more research is needed to explain them. Reported allergies could be considered a prognostic factor and used when counselling TKA patients.

LEVEL OF EVIDENCE

I.

Patient-reported allergies cause inferior outcomes after total knee arthroplasty

PURPOSE

The main objective of this study was to analyse the outcomes after total knee arthroplasty (TKA) of a group of patients with at least one self-reported allergy and a group of patients without reported allergies. We hypothesized there is a significant negative influence on clinical outcome scores after TKA in patients with self-reported allergies.

METHODS

Four-hundred and seventy-five patients who had undergone TKA were analysed preoperatively and 1 year after surgery. The WOMAC, KSS and SF-36 scores were obtained. The patients' Yesavage depression questionnaire score was also recorded. The scores of the 330 (69.5 %) patients without self-reported allergies were compared to the scores of the 145 (30.5 %) patients with at least one self-reported allergy in the medical record.

RESULTS

Preoperative scores were similar in both groups. The WOMAC post-operative scores (23.6 vs 20.4; p = 0.037) and the KSS-Knee score (91.1 vs 87.6; p = 0.027) were worse in the group of patients with self-reported allergies than in the group without allergies. The scores from the Yesavage depression questionnaire and in the SF-36 were similar in both groups.

CONCLUSION

Patients with at least one self-reported allergy have worse post-operative outcomes in terms of the WOMAC and KSS-Knee scores after TKA than patients without allergies. These poor outcomes do not seem to be related to depression. Therefore, more research is needed to explain them. Reported allergies could be considered a prognostic factor and used when counselling TKA patients.

LEVEL OF EVIDENCE

I.

[Not Available]

AIM

To evaluate the value of research in the case-mix database to identify cases of drug-related anaphylactic or anaphylactoid shock.

METHODS

Hospital stays of patients discharged from the University Hospital of Saint-Étienne between July 1st 2009 and June 30th 2012. Five codes from the international classification of diseases were selected: T88.6, T88.2, J39.3, T80.5 and T78.2.

RESULTS

Among 89 cases identified by the programme for medicalization of information system (programme de médicalisation des systèmes d'information, PMSI), 40 were selected (45%). Of these, 16 cases were spontaneously reported by physicians. The unspecific code "anaphylactic shock unspecified (T78.2)" was coded for 57.5% of cases.

CONCLUSION

The study confirms the interest of the PMSI as a tool for health monitoring, in addition to spontaneous reporting. Nevertheless, coding with insufficient precision about the causal role of the drug, requires a return to the medical record and so an important time consuming process.

[Allergies to antibiotic drugs: their importance in otorhinolaryngology]

BACKGROUND

In 2009, over 40 million prescriptions for antibiotic drugs were counted in outpatient medical care in Germany. This represents a turnover of more than 750 million euros. With over 80 million daily defined doses (DDD), amoxicillin was the most frequently prescribed antibiotic in Germany in 2008. Given the average of 5775 DDD per doctor, otolaryngologists prescribed more antibiotics than specialists in any other field of medicine in 2008; approximately 82% of these were β-lactams and tetracyclines.

MATERIAL AND METHODS

This article is based on selective literature-based research using the PubMed database. The keywords used in the search were:"allergy","anaphylaxis" and"hypersensitivity", in combination with "penicillin","cephalosporin","carbapenem","cotrimoxazole","macrolide","aztreonam" and"tetracycline".

RESULTS

Allergic reactions to antibiotics are among the most frequently reported adverse side effects arising from drug treatment. However, non-allergic adverse side effects owing to drug intolerance are also very common and may be clinically indistinguishable from allergic reactions. Owing to a frequent lack of appropriate diagnostic investigation, the decision to withhold effective standard treatments from patients is often based solely upon anamnestic observations. Up to 10% of respondents in an unselected population report an allergy to penicillin. In 80% of these cases, however, no penicillin-specific IgE-antibodies can be detected.

CONCLUSION

A detailed understanding of the symptoms, diagnostic options and possible cross reactions pertaining to allergic reactions to antibiotics, as well to non-allergic adverse side effects with similar clinical appearance, is very important for otolaryngologists. This profound knowledge ensures that the correct diagnostic steps are taken and that appropriate treatment decisions prevent the unnecessary use of reserve antibiotics.

Identifying genetic susceptibility to sensitization to cephalosporins in health care workers

Exposure to cephalosporins could cause occupational allergic diseases in health care workers (HCWs). We evaluated the prevalence of serum specific IgE and IgG antibodies to cephalosporin-human serum albumin (HSA) conjugate and to identify potential genetic risk factors associated with sensitization to cephalosporins in exposed HCWs. The study population consisted of 153 HCWs who had been exposed to antibiotics in a single university hospital and 86 unexposed healthy controls. A questionnaire survey of work-related symptoms (WRS) was administered. A skin-prick test (SPT) was performed, and serum-specific IgE and IgG antibodies to 3 commonly prescribed cephalosporins were measured by ELISA. Four single-nucleotide polymorphisms of the candidate genes related to IgE sensitization were genotyped. The prevalence of WRS to cephalosporins was 2.6%. The prevalence rates of serum-specific IgE and IgG antibodies to cephalosporins were 20.3% and 14.7%, respectively. The FcεR1β-109T > C polymorphism was significantly associated with IgE sensitization to cephalosporins in HCWs (P = 0.036, OR = 3.553; CI, 1.324-9.532). The in vitro functional assay demonstrated that the T allele of FcεR1β-109T had greater promoter activity than did the C allele (P < 0.001). The FcεR1β-109T > C polymorphism may be a potential genetic risk factor for increased IgE sensitization to cephalosporins.

Clinical characteristics of patients with drug hypersensitivity in Norway: a single-centre study

BACKGROUND

Drug hypersensitivity reactions (DHRs) represent an important public health problem. Knowledge of their clinical characteristics will provide improved diagnostic approaches to this topic.

OBJECTIVES

The aim of the present study was to describe the clinical characteristics of patients with suspected DHRs.

METHODS

The medical records of 206 outpatients with suspected DHRs, who consulted a Norwegian allergy centre from January 2005 to December 2009, were investigated in a retrospective study.

RESULTS

Mean age (range) was 44.3 (11-84) years, and 72% of the patients were women. The most common underlying diseases justifying the use of drugs were infections (49%) and pain-related diseases (23%). Antibiotics (53%), non-steroidal anti-inflammatory drugs (NSAIDs) (32%), paracetamol (15%) and other drugs (46%), used as monotherapy or combinations, were the most often suspected drugs. Cutaneous symptoms were the most frequently reported symptoms (83%). Hospitalisation or prolonged hospitalisation was needed in 38% of the cases, and anaphylaxis was reported in 28% of all the patients. Skin prick tests were performed in 185 patients, of which 14 patients had positive test results. Drug provocation tests (DPTs) were performed in only 86 patients, six of which had positive reactions. DHRs were confirmed in 24 and rejected in 81 patients. Unsettled cases (39%) were mainly due to not performing DPTs.

CONCLUSIONS

Suspected DHRs occur predominantly in women. The most common manifestations are cutaneous symptoms, but life-threatening reactions justifying hospitalisation may occur. Antibiotics and NSAIDs are the two drug families most frequently suspected. DPTs need to be included in diagnostic protocols in order to evaluate suspected DHRs.

Epidemiology and risk factors for drug allergy

The aim of this review was to describe the current evidence-based knowledge of the epidemiology, prevalence, incidence, risk factors and genetic associations of drug allergy. Articles published between 1966 and 2010 were identified in MEDLINE using the key words adult, adverse drug reaction reporting systems, age factors, anaphylactoid, anaphylaxis, anaesthetics, antibiotics, child, drug allergy, drug eruptions, ethnic groups, hypersensitivity, neuromuscular depolarizing agents, neuromuscular nondepolarizing agents, sex factors, Stevens Johnson syndrome and toxic epidermal necrolysis. Additional studies were identified from article reference lists. Relevant, peer-reviewed original research articles, case series and reviews were considered for review. Current epidemiological studies on adverse drug reactions (ADRs) have used different definitions for ADR-related terminology, often do not differentiate immunologically and non-immunologically mediated drug hypersensitivity, study different study populations (different ethnicities, inpatients or outpatients, adults or children), utilize different methodologies (spontaneous vs. non-spontaneous reporting, cohort vs. case-control studies), different methods of assessing drug imputability and different methods of data analyses. Potentially life-threatening severe cutaneous adverse reactions (SCAR) are associated with a high risk of morbidity and mortality. HLA associations for SCAR associated with allopurinol, carbamazepine and abacavir have been reported with the potential for clinical use in screening prior to prescription. Identification of risk factors for drug allergy and appropriate genetic screening of at-risk ethnic groups may improve the outcomes of drug-specific SCAR. Research and collaboration are necessary for the generation of clinically-relevant, translational pharmacoepidemiological and pharmacogenomic knowledge, and success of health outcomes research and policies on drug allergies.

Drug provocation tests to betalactam antibiotics: experience in a paediatric setting

BACKGROUND

Few studies have been performed in children with suspected betalactam allergy. We aimed to assess the role of the drug provocation test (DPT) with betalactams in a paediatric setting and to study the association between allergy to betalactam antibiotics and other allergic diseases.

METHODS

We included all the patients under 15 years old who were consecutively referred to the Immunoallergy Department, Dona Estefânia Hospital, Portugal (January 2002 to April 2008) for a compatible history of allergic reaction to betalactam. All were submitted to a DPT. Children were proposed to perform skin tests (ST) to betalactam antibiotics followed by DPT. If they decline ST, a DPT with the culprit drug was performed.

RESULTS

We studied 161 children, 60% were boys, with a median age of 5 years old at the time of the DPT. Thirty-three patients (20.5%) had an immediate reaction and 33 (20.5%) a non-immediate reaction. The severity of the reported reactions was low in most cases. Skin tests to betalactams were performed in 47 children and were positive in 8. DPT was positive in only one (3.4%) of the patients skin tested and in 11 (13.4%) of those not skin tested. The severity of the DPT reaction was low. Asthma and food allergy were associated with a positive DPT in the later group.

CONCLUSIONS

DPT seems a safe procedure even in the absence of ST in non-severe cases. This could be a practical option in infants and pre-school children, where ST are painful and difficult to perform. Additional caution should be taken in children with asthma and food allergy.

Drug allergy claims in children: from self-reporting to confirmed diagnosis

BACKGROUND

Poorly documented self-reported drug allergy (DAll) is a frequent problem in daily clinical practice and has a considerable impact on prescription choices. The diagnostic work-up of drug hypersensitivity (DHs) allows a better classification of the reactions and provides patients with more reliable information and recommendations for future treatments.

OBJECTIVE

To assess the prevalence of self-reported adverse drug reactions (ADRs) and DAll in a paediatric population and to investigate children reporting suspected DAll in order to achieve a firm diagnosis.

DESIGN

The first phase was based on a cross-sectional survey assessing the life occurrence of ADRs and self-reported DAll carried out at the outpatient clinic of a paediatric hospital. The second phase was based on the diagnostic work-up in children with parent-reported DAll, including detailed anamnesis and in vitro and in vivo investigations (skin and provocation tests). Participants One thousand four hundred and twenty-six parents responded to the initial survey. Sixty of the 67 patients with reported DAll were evaluated at the allergy clinic.

RESULTS

The prevalences of self-reported ADRs and DAll were 10.2% and 6.0%, respectively. Most of the suspected allergic reactions were non-immediate cutaneous events attributable to beta-lactam antibiotics and occurred in very young children. Thirty-nine of the 60 patients consulting for evaluation had a plausible clinical history and were recommended further investigation. DHs was diagnosed in three children only, based on positive responses in skin (n=1) and oral provocation (n=2) tests.

CONCLUSION

ADRs are frequently reported in children, and many children are classified as having a DAll. After complete evaluation, only a few of these reactions can be attributed to DHs and DAll. Most of the patients (94% in this study) could actually tolerate the initially suspected drug.

Multiple-drug intolerance syndrome: clinical findings and usefulness of challenge tests

BACKGROUND

Multiple-drug intolerance syndrome (MDIS) is characterized by adverse reactions to several classes of chemically unrelated drugs.

OBJECTIVE

To analyze all patients with a history of adverse reactions to at least 3 drugs at the Allergy Unit of Policlinico Gemelli in a 6-year period to better characterize patients with MDIS and to find safe alternative drugs.

METHODS

We studied 480 patients (aged >16 years) with a history of adverse reactions to at least 3 unrelated drugs and with negative allergy test results. Patients who had experienced mild adverse reactions that remitted spontaneously underwent challenge tests without any premedication (group A). Patients with a clinical history of moderate reactions received sodium cromolyn, 500 mg, before the challenge (group B). Patients with a clinical history of severe reactions or undergoing parenteral challenges were given an antihistamine 30 minutes before the challenge (group C).

RESULTS

In group A, 491 tolerance challenge tests were performed: 414 had negative results and 77 had positive results. In group B, 1,077 tolerance challenge tests were performed: 956 had negative results and 121 had positive results. In group C, 240 tolerance challenge tests were performed: 214 had negative results and 26 had positive results. Comparing the tolerance of alternative drugs in groups A and B, groups A and C, and groups B and C, no significant results were observed (P = .24, .14, and .44, respectively).

CONCLUSIONS

Patients with MDIS can tolerate alternative drugs. Premedication with sodium cromolyn or oral H1-antihistamines may be useful in preventing adverse reactions.

Drug-induced anaphylaxis : case/non-case study based on an italian pharmacovigilance database

OBJECTIVE

To identify the number of cases of anaphylaxis reported in association with different classes of drugs and compare it with other reports contained in the same database.

METHODS

The data were obtained from a database containing all of the spontaneous reports of adverse drug reactions (ADRs) coming from the Italian regions of Emilia Romagna, Lombardy and the Veneto, which are the main contributors to the Italian spontaneous surveillance system. The ADRs reported between January 1990 and December 2003 with a causality assessment of certainly, probably or possibly drug related (according to the WHO criteria) were analysed using a case/non-case design. The cases were defined as the reactions already coded by the WHO preferred terms of 'anaphylactic shock' or 'anaphylactoid reaction' (this last term also included anaphylactic reaction) and those with a time of event onset that suggested an allergic reaction and involved at least two of the skin, respiratory, gastrointestinal, CNS or cardiovascular systems; the non-cases were all of the other ADR reports. The frequency of the association between anaphylaxis and the suspected drug in comparison with the frequency of anaphylaxis associated to all of the other drugs was calculated using the ADR reporting odds ratio (ROR) as a measure of disproportionality.

RESULTS

Our database contained 744 cases (including 307 cases of anaphylactic shock with 10 deaths) and 27 512 non-cases. The percentage of anaphylaxis cases reported in inpatients was higher than that among outpatients (59.1% vs 40.9%). This distribution is significantly different from that of the other ADR reports that mainly refer to outpatients. After intravenous drug administrations, anaphylactic shock cases were more frequent than anaphylactoid reactions or other ADRs, but more than one-third of these reactions were caused by an oral drug. Blood substitutes and radiology contrast agents had the highest RORs. Among the systemic antibacterial agents, anaphylaxis was disproportionally reported more often for penicillins, quinolones, cephalosporins and glycopeptides, but diclofenac was the only NSAID with a significant ROR. As a category, vaccines had a significantly lower ROR, thus indicating that anaphylaxis is reported proportionally less than other ADRs.

CONCLUSIONS

Anaphylaxis is a severe ADR that may also occur with commonly used drugs. It represents 2.7% of all of the ADRs reported in an Italian spontaneous reporting database.

IL-10 promoter and IL4-Ralpha gene SNPs are associated with immediate beta-lactam allergy in atopic women

BACKGROUND

Allergic reactions to beta-lactam antibiotics represent the most frequent cause of immunological drug reactions.

OBJECTIVE

This study evaluates the involvement of genetic susceptibility factors in patients with immediate allergic reactions to beta-lactams. We examined 15 single nucleotide polymorphisms (SNP) of genes coding proteins implicated in immunoglobulin (Ig)E synthesis regulation.

METHODS

We performed a case-control study involving 44 patients with immediate beta-lactam allergy and 44 control subjects, all matched for sex and atopy. Interleukin (IL)-4, IL-13, IL-4Ralpha, signal transducer and activator of transcription 6 (STAT6), interferon (IFN)-gammaR1, IFN-gammaR2 and FcepsilonRIbeta gene polymorphisms were determined using polymerase chain reaction (PCR) restriction fragment length polymorphism, and IL-21R gene and IL-10 promoter polymorphisms by direct sequencing.

RESULTS

Our analysis did not reveal differences in the distribution of the 15 SNPs between allergic patients and controls. However, among atopic subjects, we found two distinct significant associations between immediate beta-lactam allergy in women and the Ile75Val variant of IL-4Ralpha gene (P = 0.012, OR = 5.4, CI: 1.16-27.7), and two linked IL-10 promoter gene polymorphisms, -819C>T and -592 C>A (P = 0.023, OR = 17.5, CI: 1.26-533.07). In contrast, we observed no association in allergic male subjects in the atopic population. Interestingly, the IL-4Ralpha Ile75Val variant could have a paradoxal protective effect in atopic male patients (P = 0.004, OR = 0.07, CI: 0.01-0.66).

CONCLUSION

Our findings suggest that polymorphisms in the IL-10 promoter and IL-4Ralpha genes are genetic factors that favour beta-lactam immediate allergies in female patients with atopy.

Epidemiology of hypersensitivity drug reactions

PURPOSE OF REVIEW

Hypersensitivity drug reactions are but one of the many different types of adverse drug reactions. They may be potentially life-threatening, prolong hospitalization, affect drug prescribing patterns of physicians and result in socioeconomic costs. This review summarizes current knowledge on the incidence, prevalence, mortality and risk factors for these reactions in different populations.

RECENT FINDINGS

Hypersensitivity reactions represent about one third of all adverse drug reactions. Adverse drug reactions affect 10-20% of hospitalized patients and more than 7% of the general population. Severe reactions including anaphylaxis, drug hypersensitivity syndromes, Stevens Johnson syndrome and toxic epidermal necrolysis are also associated with significant morbidity and mortality. Although several risk factors have been identified, their clinical importance has not been fully understood. Future progress in immunogenetics and pharmacogenetics may help identify populations at risk for specific types of reactions.

SUMMARY

Well designed epidemiological studies on hypersensitivity drug reactions are lacking as most studies have been on adverse drug reactions. Such studies will be helpful in identifying patients at risk of developing such reactions, in particular severe reactions, and implementing early preventive measures.

Self-reported drug allergy in a general adult Portuguese population

AIM

To estimate the prevalence of self-reported drug allergy in adults.

METHODS

Cross-sectional survey of a general adult population from Porto (all of whom were living with children involved in the International Study of Asthma and Allergies in Childhood-phase three), during the year 2002, using a self-administered questionnaire.

RESULTS

The prevalence of self-reported drug allergy was 7.8% (181/2309): 4.5% to penicillins or other beta-lactams, 1.9% to aspirin or other non-steroidal anti-inflammatory drugs (NSAIDs) and 1.5% to other drugs. In the group 'allergic to beta-lactams', the most frequently implicated drug was penicillin G or V (76.2%) followed by the association of amoxicillin and clavulanic acids (14.3%). In the group 'allergic to NSAIDs', acetylsalicylic acid (18.2%) and ibuprofen (18.2%) were the most frequently identified drugs, followed by nimesulide and meloxicam. Identification of the exact name of the involved drug was possible in less than one-third of the patients, more often within the NSAID group (59.5%). Women were significantly more likely to claim a drug allergy than men (10.2% vs. 5.3%). The most common manifestations were cutaneous (63.5%), followed by cardiovascular symptoms (35.9%). Most of the reactions were immediate, occurring on the first day of treatment (78.5%). Only half of the patients were submitted to drug allergy investigations. The majority (86.8%) completely avoided the suspected culprit drug thereafter.

CONCLUSIONS

The results showed that self-reported allergy to drugs is highly prevalent and poorly explored. Women seem to be more susceptible. beta-lactams and NSAIDs are the most frequently concerned drugs.

Classification and epidemiology of hypersensitivity drug reactions

Nonimmune hypersensitivity reactions are unpredictable adverse drug reactions that are clinically similar to allergic reactions for which no drug-specific antibodies or T lymphocytes are identified. Few tools allow a definite diagnosis, and most of the available ones need to be validated. True epidemiologic data are limited, and most of the available information on the incidence, mortality, and socioeconomic impact should be discussed with caution.

[Identifying and understanding drug allergies]

Drug hypersensitivity reactions frequently occur in hospitalized and out-patients. Clinical presentations are numerous and heterogeneous, from a mild urticaria to a dramatic anaphylactic shock and an extensive bullous skin disease. Allergic reactions are unpredictable reactions, related to immunologic mechanisms. Some reactions mimic allergic reactions but no drug specific antibody or T cell proliferation can be demonstrated. A true diagnosis is rarely set up and the tools for it are lacking. In this review, we will focus on the available epidemiological data concerning these reactions, including data on incidence and mortality and on the most recent advances in the pathophysiology and allergy diagnosis of drug hypersensitivity reactions.

Tolerance test in patients with multiple drug allergy syndrome

Multiple Drug Allergy Syndrome (MDAS) is a frequent clinical condition characterized by reactions to more than one different class of antibiotics. Even if some studies have previously reported an increased rate of allergic reactions to drugs in patients with a history of antimicrobials and NSAIDs allergy, risk factors and pathogenesis of MDAS are still object of investigation. Moreover, in these subjects it is often difficult to prescribe a safe alternative antibiotic without a tolerance test. In this study we carried out 504 tests in 460 patients with a history of immediate adverse reactions to antibiotics. From the analysis of our results it emerges that risk factors for MDAS are female sex and intolerance to NSAIDs. Risk factors for positive tolerance test are male sex, intolerance to NSAIDs and a history of MDAS, respectively. In conclusion, it seems that tolerance test may represent a valid approach to detect a safe antibiotic in these patients.

Anaphylaxis during anaesthesia. Results of a two-year survey in France

Between January 1, 1997 and December 31, 1998, 467 patients were referred to one of the allergo-anaesthesia centres of the French GERAP (Groupe d'Etudes des Réactions Anaphylactoïdes Peranesthésiques) network and were diagnosed as having anaphylaxis during anaesthesia. Diagnosis was established on the basis of clinical history, skin tests and/or a specific IgE assay. The most frequent cause of anaphylaxis was a neuromuscular blocking agent (69.2%). Latex was less frequently incriminated (12.1%) than in previous reports. A significant difference was observed between the incidence of anaphylactic reactions observed with each neuromuscular blocking agent and the number of patients who received each drug during anaesthesia in France throughout the study period (P<0.0001). Succinylcholine and rocuronium were most frequently incriminated. Clinical reactions to neuromuscular blocking drugs were more severe than to latex. The diagnostic value of specific IgE assays was confirmed. These results are consistent with changes in the epidemiology of anaphylaxis related to anaesthesia and are an incentive for the further development of allergo-anaesthesia clinical networks.

The incremental challenge test in the diagnosis of adverse reactions to local anesthetics

OBJECTIVE

The aim of this study was to assess the reliability of a diagnostic protocol, the incremental challenge test (ICT), for patients with and without a history of adverse reactions to local anesthetics (LAs) or other drugs, to select an LA that could be safely used.

STUDY DESIGN

The ICT was performed on 432 subjects, 314 female and 118 male. Four hundred thirty-two challenges were carried out with LAs that were free of adrenaline and preservatives. Chi-square analysis was performed to evaluate the existence of different predispositions to ICT positivity among subjects of the 4 categories studied.

RESULTS

Four hundred fifteen tests were completed with no clinical events occurring. The analysis did not show any significant difference (chi-square = 6.17; P >.05).

CONCLUSIONS

Our results confirm that immunoglobulin E-mediated reactions to LAs are uncommon and that the ICT offers safety and specificity in diagnosing adverse reactions to LAs, allowing for the selection of a safe and reliable LA.

Multiple drug allergy syndrome: a distinct clinical entity

Multiple drug allergy syndrome is a clinical condition characterized by a propensity to react against different, chemically unrelated antibiotic or nonantibiotic drugs. The origin of this syndrome is still elusive. This article critically examines the medical literature on multiple drug allergy syndrome, compares and discusses recent personal observations obtained in patients with intolerance to multiple antibiotic or anti-inflammatory drugs, suggests possible pathogenic mechanisms for this type of drug allergy, and reports on current personal research in this field.

[Epidemiology of anesthetic anaphylactoid reactions. Fourth multicenter survey (July 1994-December 1996)]

Since 1984 an epidemiological survey of anaphylactoid reactions occurring during anaesthesia has been obtained in France with regular repeated inquiries by the Perioperative Anaphylactoid Reactions Study Group (Gerap). The members of this group collected during the study period cases of patients having suffered from an anaphylactoid reaction and subsequently tested in their allergoanaesthetic outpatient clinic. The three previous surveys published in the Annales françaises d'anesthésie et de réanimation in 1990, 1993 (in English) and 1996 included 1,240, 1,585 and 1,730 patients respectively. The current survey concerned 1,648 patients, tested by the GERAP (38 diagnostic centres) from July 1994 to December 1996. The diagnostic tests for IgE anaphylaxis were cutaneous tests (prick tests and intradermal tests), which minimal dilutions for specific positive skin test were previously determined by comparison with control subjects. The cutaneous tests were performed by all the centres. These tests were associated, in 29 centres, with the detection of specific IgEs against quaternary ammonium compound and inhibition test, and detection of IgEs against propofol, thiopental and latex. Moreover, leukocyte histamine release test was performed in seven centres. The mechanism of the reaction was: anaphylaxis in 692 patients (characteristic clinical symptoms and positive allergological tests), anaphylactoid reactions in 611 patients (characteristic clinical symptoms and negative allergological tests), and other causes in 345 patients (unusual clinical symptoms and negative allergological tests). An immune mechanism was found in 53% of the reactions, with characteristic clinical symptoms occurring during anaesthesia. The 692 cases of anaphylaxis were due to 734 substances (double anaphylaxis in 42 patients): muscle relaxants (61.6%), latex (16.6%), antibiotics (8.3%), hypnotics (5.1%), colloids (3.1%), opioids (2.7%) and others (2.6%) among which aprotinin (four cases) ethylene oxide (five cases) local anaesthetics (two cases). The muscle relaxants implicated in anaphylactic reactions included: vecuronium (n = 130), atracurium (n = 107), suxamethonium (n = 106), pancuronium (n = 41), rocuronium (n = 41), mivacurium (n = 18), and gallamine (n = 9). These results reflected French anaesthetic practice, except for suxamethonium (5% of the French market share of curares). In 70% of the patients who were allergic to one muscle relaxant, cross-sensitivity was found with the other relaxants. The comparison with the three previous surveys confirms that the mechanism of about half of the anaphylatoid reactions occurring during anaesthesia is of immune origin, due to specific IgE antibodies. Muscle relaxants remain the most common cause of anaphylaxis, followed by latex whose incidence seems to decrease, whereas the incidence of anaphylaxis to antibiotics increases. Incidence of reactions to suxamethonium decreased, corresponding however to one quarter of all muscle relaxant anaphylaxis, similar with vecuronium and atracurium. For this survey, more clinical information was obtained in 583 patients, allowing the following conclusions: reactions were always more severe in case of anaphylaxis than nonspecific histamine release; reactions occurred more frequently in females (F/M = 2.5); 17% of patients allergic to a muscle relaxant were never anaesthetized beforehand; a history of reactions during previous anaesthetics was a risk factor for a reaction during subsequent anaesthetics; neither drug allergy nor atopy (except for latex allergy) were a predisposing factor for reactions with anaesthetic agents. Considering that in 1996, 8 million anaesthetics were administered in France, of which 2.5 million included the use of muscle relaxants, the overall incidence for anaphylactic reactions, all agents included, was evaluated as 1 in 13,000 anaesthetics, while the incidence of anaphylaxis to muscle relaxants was 1 in 6,500 anaesthetics.

Atopy and intolerance of antimicrobial drugs increase the risk of reactions to acetaminophen and nimesulide in patients allergic to nonsteroidal anti-inflammatory drugs

This study evaluated the risk factors for developing allergic reactions to alternative drugs such as acetaminophen and nimesulide in 367 patients intolerant of nonsteroidal anti-inflammatory drugs (NSAID) compared to 243 healthy controls. All subjects were given test doses (TD) of acetaminophen and nimesulide, and age, sex, atopy, and history of reactions also to unrelated drugs were compared in those who reacted and those who were tolerant of the challenge. TD was positive in 49 of 367 (14%) NSAID-allergic patients and in one (0.4%) of the controls (P<0.001). No difference was found in age and sex between the TD-positive and TD-negative subjects, although a significantly larger number of females were NSAID allergic (P<0.01). Of the 367 patients, 208 had a history of reactions only to NSAID, and 148 to NSAID and antimicrobial drugs (AMD). TD with acetaminophen or nimesulide was positive in 6% of patients intolerant only of NSAID and in 24% of those intolerant of both NSAID and AMD, with an odds ratio of 4.82. Atopy was more frequent among patients (36%) than controls (23%) (P=0.004), among TD-positive (51%) than TD-negative patients (33.5%) (P<0.02), and among patients intolerant of NSAID and AMD (48%) than those intolerant only of NSAID (P=0.006). The odds ratios were, respectively, 1.87, 2.57, and 3.16. This study provides evidence that atopy and history of allergic reactions to AMD increase the likelihood of intolerance of usually well-tolerated alternative drugs such as acetaminophen and nimesulide in subjects allergic to NSAID.

Association of pyrazolone drug hypersensitivity with HLA-DQ and DR antigens

BACKGROUND

In sensitive patients pyrazolone drugs can precipitate adverse reactions ranging from urticaria and angioedema to anaphylactic shock, presumably by immunological, IgE-mediated mechanism. However, up to now no genetic factors influencing the development of allergic reaction have been reported in this type of hypersensitivity.

OBJECTIVE

The aim of our study was the investigation whether the susceptibility to development of pyrazolone drugs hypersensitivity (PDH) reactions was associated with HLA class II antigens.

METHODS

To test this hypothesis we studied the distribution of HLA-DR and DQ antigens in 26 pyrazolone sensitive patients and control groups including unselected general population and clearly defined atopic and non-atopic groups.

RESULTS

Significantly higher frequencies of DQ 7 and DR11 antigens were found in PDH group as compared with control unselected population (RR= 16.48, P < 0.0001; P(cor)< 0.002 and RR = 4.57, P = 0.0002; Pcor = 0.003 for DQ and DR antigen respectively). Similarly, statistically significant increased frequencies of DQ 7 and DR11 in patients with PDH were observed compared with atopic control group (RR= 18.43, P < 0.0001; Pcor <0.002 and RR= 6.33, P= 0.0007; Pcor =0.01, for DQ and DR antigen respectively). However, in comparison to non-atopic control group only the frequency of DQ 7 antigen was significantly increased (RR = 15.42, P = 0.0001; Pcor = 0.0015). DQ 7 antigen was present in 46.1% of PDH patients compared with 4.9%, 4.4% and 5.3% in the general population, atopic and non-atopic groups respectively, suggesting pyrazolone hypersensitivity as a trait positively correlated with this HLA antigen.

CONCLUSION

Our data suggest a genetic predisposition to pyrazolone hypersensitivity reactions, linked to HLA-DQ locus.

Detection of patients with multiple drug allergy syndrome by elective tolerance tests

BACKGROUND

Multiple drug allergy syndrome (MDAS) caused by antibiotics is frequently observed in allergy departments; however, risk factors for such a condition as well as the means to detect patients prone to MDAS are poorly defined.

OBJECTIVE

The identification of patients prone to MDAS and the detection of risk factors for multiple antibiotic sensitivity.

METHODS

Two hundred fifty-three elective oral challenges with alternative antimicrobial drugs were performed in 120 patients with histories of recent allergic reactions to antibiotics.

RESULTS

Twenty-three (19%) subjects reacted to at least one antibiotic class. All reactions were mild and easily controlled by conventional therapy. Female sex, history of multiple antibiotic reactions, and reactions to nonsteroidal antinflammatory drugs were the main risk factors for reactions to alternative antibiotics. To date, no patient has reported immediate adverse reactions to drugs negative on oral challenge tests but one had urticaria/angioedema on the fifth day of full dose treatment with ofloxacin.

CONCLUSIONS

Elective oral challenges with alternative antibiotics are a sensitive, specific, and safe means to detect patients with MDAS, thus sparing them more severe adverse reactions caused by full dose therapies. The recommendation to perform oral challenge tests with antibiotics just before their therapeutic use seems unnecessary and should be reconsidered.

The atopy trait in hypersensitivity to nonsteroidal anti-inflammatory drugs

The prevalence of atopy was evaluated in two groups of subjects with hypersensitivity to nonsteroidal anti-inflammatory drugs (NSAID): 1) 78 patients with aspirin-induced asthma (AIA) confirmed by oral or bronchial provocation challenges 2) 42 subjects with hypersensitivity to pyrazolone drugs (case history and positive skin tests to noramidopyrine/aminophenazone) who tolerated aspirin well. Fifty sex- and age-matched persons from an unselected general population, with no hypersensitivity to NSAID, formed the control group. Atopy was estimated from the results of the following clinical and biologic parameters: 1) personal and family history of atopic diseases 2) skin prick tests with 16 aeroallergens 3) serum levels of specific IgE to five aeroallergens 4) total serum IgE level. Different definitions of atopy were used, consisting of constellations of two or three of the above-mentioned features. The results of the study revealed that the prevalence of atopy varied according to the criteria used for its definition. Irrespective of the definition used, a similar distribution of atopy was observed in both groups of patients with hypersensitivity to NSAID. Atopy was more frequent in either group of patients with intolerance of NSAID than in the control group. Thus, atopy is related to adverse drug reactions to NSAID.

Incidence and risk factors for latent sensitization to chymopapain: predictive skin-prick tests in 700 candidates for chemonucleolysis

Seven hundred patients were investigated prospectively before undergoing chemonucleolysis. A past history of allergy and/or previous exposure to papain, either in food, beverages or drugs, was sought, and a skin-prick test with chymopapain was performed. Based on the results obtained, the subjects were classified into four groups: Group I--225 non-atopic non-papain-exposed subjects; Group II--285 non-atopic papain-exposed subjects; Group III--69 atopic non-papain-exposed subjects; and Group IV--121 atopic papain-exposed subjects. Latent sensitization to papain was observed in 0.4% of subjects in Group I, 3.16% in Group II, 5.8% in Group III and 7.4% in Group IV. The odds ratios were 13.8 for atopy and 7.3 for exposure to papain. Interaction between atopy and papain exposure did not result in a significantly greater risk. Neither sex nor age nor a history of a previous drug reaction were risk factors. Only one patient out of the 23 who were sensitive to papain had no risk factor. The 677 skin-test negative patients then underwent chemonucleolysis and none of them had an anaphylactic reaction. This was significantly less frequent: (P = 0.04) than the incidence in a random population (0.45%). Prick tests performed 6 weeks and 6 months after chemonucleolysis revealed newly acquired sensitization in 36% of the patients. Atopy was not a risk factor for this event.(ABSTRACT TRUNCATED AT 250 WORDS)

Coronary artery spasm and acute myocardial infarction in naproxen-associated anaphylactic reaction

We present the case of a 43-year-old man who suffered an acute myocardial infarction after oral administration of 250 mg of naproxen, prescribed as antiinflammatory-analgesic agent after tooth extraction. Both intradermal skin test and human basophil degranulation test were positive to naproxen. These findings suggest a naproxen-associated anaphylactic reaction with concomitant coronary artery spasm and posteroinferior infarction, a clinical event previously not reported with the use of this drug.