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Moral L, Mori F. Drug provocation tests in children: All that glitters is not gold. Pediatr Allergy Immunol 2023; 34:e14002. [PMID: 37622259 DOI: 10.1111/pai.14002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 06/21/2023] [Accepted: 07/11/2023] [Indexed: 08/26/2023]
Abstract
A proper allergy work-up, based on the gold standard drug provocation test (DPT), usually rules out suspected drug hypersensitivity in children. These tests are generally open, given their high efficiency compared with double-blind placebo-controlled DPTs. Although their negative predictive value is excellent, no studies have calculated their positive predictive value, highly dependent on the prevalence of the disease. Most studies have found a rate of <5%-10% of true beta-lactam hypersensitivity in children. Given this low prevalence (pre-test probability), a few false-positive results can significantly reduce the estimated positive predictive value. False positives may arise from the nocebo effect during the test, including nocebo by proxy, or from observer bias, which depends on professional expertise and organizational circumstances. Some studies have found a high rate of tolerance on a second DPT in children who failed the first, but these results may be affected by the interval between the two tests, of a year or more in most cases, reflecting a loss of hypersensitivity over time. Taking into account the low rate of positive DPTs, with commonly mild reactions, we suggest confirming nonsevere positive DPTs with a second provocation performed soon after the first, especially in the case of beta-lactam antibiotics, in order to improve the diagnostic accuracy, de-label more patients, and achieve a better estimation of true drug hypersensitivity prevalence. In case of mild immediate reactions, the potential benefits of a second DPT should be carefully weighed against the risk of anaphylaxis.
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Affiliation(s)
- Luis Moral
- Pediatric Allergy and Respiratory Unit, Dr. Balmis General University Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain
| | - Francesca Mori
- Allergy Unit, Meyer Children's Hospital, IRCCS Florence, Florence, Italy
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Popiolek I, Blasiak M, Kozak A, Pietak E, Bulanda M, Porebski G. Diagnostic Value of Oral Provocation Tests in Drug Hypersensitivity Reactions Induced by Nonsteroidal Anti-Inflammatory Drugs and Paracetamol. Diagnostics (Basel) 2022; 12:diagnostics12123074. [PMID: 36553081 PMCID: PMC9777020 DOI: 10.3390/diagnostics12123074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 12/02/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022] Open
Abstract
Oral drug provocation tests (DPT) are the basic diagnostic tool for the detection of hypersensitivity to non-opioid analgesics and for selecting a safe alternative for a patient. They are of great practical importance due to their common use, but the data on the follow-up of patients after negative DPT are still very scarce. We examined the further fate of 164 such adult patients after negative NSAID or paracetamol tests and analyzed which excipients in the studied drugs they could be exposed to after the diagnostic workup. A structured medical interview was performed 32.9 months (mean) after the provocation tests. Of the 164 patients, 131 (79.9%) retook the tested drug and 12 developed another hypersensitivity reaction, giving the estimated negative predictive value of 90.8%. These reactions were induced by acetylsalicylic acid, paracetamol, meloxicam, and diclofenac, and were clinically similar to the initial ones (most commonly urticaria and angioedema). There are 93 generics of these drugs on the local market, containing a total of 33 excipients for which hypersensitivity reactions have been reported. All available generics contain such excipients. Thirty-one patients (20.1%) did not take the previously tested drug again, most often because it was not needed or because they were afraid of another reaction. DPT with analgesics has a high diagnostic performance. A minority of patients had relapsed after reexposure. One of the underestimated reasons for this may be drug excipients provoking a reaction, so it is advisable to use exactly the same medical product that has been negatively tested. Many patients avoid reexposure to a given drug, despite negative tests, therefore very reliable patient education in connection with DPT is highly needed.
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Affiliation(s)
- Iwona Popiolek
- Department of Toxicology and Environmental Diseases, Jagiellonian University Medical College, Jakubowskiego 2, 30-688 Krakow, Poland
| | - Magdalena Blasiak
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, sw. Anny 12, 31-008 Krakow, Poland
| | - Aleksandra Kozak
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, sw. Anny 12, 31-008 Krakow, Poland
| | - Ewelina Pietak
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, sw. Anny 12, 31-008 Krakow, Poland
| | - Malgorzata Bulanda
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Botaniczna 3, 31-503 Krakow, Poland
| | - Grzegorz Porebski
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Botaniczna 3, 31-503 Krakow, Poland
- Correspondence: ; Tel.: +48-12-424-86-38
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Khan DA, Banerji A, Blumenthal KG, Phillips EJ, Solensky R, White AA, Bernstein JA, Chu DK, Ellis AK, Golden DBK, Greenhawt MJ, Horner CC, Ledford D, Lieberman JA, Oppenheimer J, Rank MA, Shaker MS, Stukus DR, Wallace D, Wang J, Khan DA, Golden DBK, Shaker M, Stukus DR, Khan DA, Banerji A, Blumenthal KG, Phillips EJ, Solensky R, White AA, Bernstein JA, Chu DK, Ellis AK, Golden DBK, Greenhawt MJ, Horner CC, Ledford D, Lieberman JA, Oppenheimer J, Rank MA, Shaker MS, Stukus DR, Wallace D, Wang J. Drug allergy: A 2022 practice parameter update. J Allergy Clin Immunol 2022; 150:1333-1393. [PMID: 36122788 DOI: 10.1016/j.jaci.2022.08.028] [Citation(s) in RCA: 144] [Impact Index Per Article: 72.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 08/18/2022] [Accepted: 08/30/2022] [Indexed: 12/14/2022]
Affiliation(s)
- David A Khan
- Department of Internal Medicine, Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas, Tex
| | - Aleena Banerji
- Department of Internal Medicine, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Kimberly G Blumenthal
- Department of Internal Medicine, Division of Rheumatology, Allergy and Immunology, Massachusetts General Hospital, Boston, Mass
| | - Elizabeth J Phillips
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia; Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Roland Solensky
- Corvallis Clinic, Oregon State University/Oregon Health Science University College of Pharmacy, Corvallis, Ore
| | - Andrew A White
- Department of Allergy, Asthma and Immunology, Scripps Clinic, San Diego, Calif
| | - Jonathan A Bernstein
- Department of Internal Medicine, Division of Immunology, Allergy Section, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Derek K Chu
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; The Research Institute of St Joe's Hamilton, Hamilton, Ontario, Canada
| | - Anne K Ellis
- Division of Allergy and Immunology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
| | - David B K Golden
- Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Matthew J Greenhawt
- Food Challenge and Research Unit Section of Allergy and Immunology, Children's Hospital Colorado University of Colorado School of Medicine, Aurora, Colo
| | - Caroline C Horner
- Department of Pediatrics, Division of Allergy Pulmonary Medicine, Washington University School of Medicine, St Louis, Mo
| | - Dennis Ledford
- Division of Allergy and Immunology, Department of Medicine, University of South Florida Morsani College of Medicine, Tampa, Fla; James A. Haley Veterans Affairs Hospital, Tampa, Fla
| | - Jay A Lieberman
- Division of Allergy and Immunology, The University of Tennessee Health Science Center, Memphis, Tenn
| | - John Oppenheimer
- Division of Allergy, Rutgers New Jersey Medical School, Rutgers, NJ
| | - Matthew A Rank
- Division of Allergy, Asthma, and Clinical Immunology, Mayo Clinic in Arizona, Scottsdale, Ariz
| | - Marcus S Shaker
- Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - David R Stukus
- Division of Allergy and Immunology, Nationwide Children's Hospital, Columbus, Ohio; The Ohio State University College of Medicine, Columbus, Ohio
| | - Dana Wallace
- Nova Southeastern Allopathic Medical School, Fort Lauderdale, Fla
| | - Julie Wang
- Division of Allergy and Immunology, Department of Pediatrics, The Elliot and Roslyn Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
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Cavkaytar O, Arga M. NSAID Hypersensitivity in the Pediatric Population: Classification and Diagnostic Strategies. J Asthma Allergy 2022; 15:1383-1399. [PMID: 36199560 PMCID: PMC9527698 DOI: 10.2147/jaa.s267005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 09/11/2022] [Indexed: 11/23/2022] Open
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most frequently administered drugs, mainly for their anti-pyretic, but also for pain-relieving and anti-inflammatory effects in children. NSAIDs are composed of structurally divergent subgroups of drugs with similar pharmacological and adverse effects. Aspirin originates from salicin and was the first synthesized analgesic. As a prototype of NSAIDs; aspirin-induced hypersensitivity reactions were first reported, but subsequently, other phenotypes of hypersensitivity reactions were also described with aspirin and other NSAIDs. There are certain challenging aspects of NSAID-hypersensitivity in the pediatric population that need to be further investigated. These include the effect of age on drug metabolism and the natural history of the various phenotypes of NSAID-hypersensitivity, the effect of certain co-factors (infections, exercise) on NSAID-hypersensitivity, and diagnostic clinical and laboratory biomarkers clarifying the endotypes. In recent years, a non-negligible number of case series, studies and expert panel reports have been published in this field with some novel features and diagnostic modalities in the pediatric population. With the current review; the clinical phenotypes and diagnostic and management modalities of suspected NSAID-induced hypersensitivity reactions in childhood and adolescence were explained and updated by examining past and current publications.
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Affiliation(s)
- Ozlem Cavkaytar
- Department of Pediatric Allergy and Immunology, Istanbul Medeniyet University Faculty of Medicine, Istanbul, Turkey
- Correspondence: Ozlem Cavkaytar, Department of Pediatric Allergy and Immunology, Istanbul Medeniyet University Faculty of Medicine, Prof. Dr. Suleyman Yalcin City Hospital, Kadıköy, Istanbul, Turkey, Tel +90 216 6065200, Email
| | - Mustafa Arga
- Department of Pediatric Allergy and Immunology, Istanbul Medeniyet University Faculty of Medicine, Istanbul, Turkey
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Yilmaz Topal O, Turgay Yagmur I, Kulhas Celik I, Uneri OS, Toyran M, Karaatmaca B, Civelek E, Dibek Misirlioglu E. Psychological Distress and Drug Provocation Test-Related Anxiety Levels of Pediatric Patients and Their Parents. PEDIATRIC ALLERGY, IMMUNOLOGY, AND PULMONOLOGY 2022; 35:58-64. [PMID: 35723659 DOI: 10.1089/ped.2021.0092] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Background: Drug provocation tests (DPTs) are the gold standard for the diagnosis of drug hypersensitivity reaction (DHR). To the best of our knowledge, there is no previous study reporting DPT-related anxiety levels in children and their parents. This study aimed to determine the difference in pre- and post-DPT anxiety levels of parents and children who were informed of the possibility of another DHR during the DPT, and to evaluate the relationship between parental psychological distress and anxiety levels. Methods: The study included children who underwent DPT in our clinic between July 1, 2019, and February 29, 2020, and accompanying parents who consented to participate. Age-appropriate State-Trait Anxiety Inventory scales were used to assess levels of state and trait anxiety in the patients and parents. The Symptom Checklist-90-Revised (SCL-90-R) was used to screen for psychological symptoms in parents. Results: Data were collected from the parents of 69 children who underwent DPTs. The patients' median age was 7.28 (interquartile range: 4.52-10.06) and their parents' mean age was 35.28 ± 5.38 years. Anxiety-related data were collected from 21 pediatric patients. The children and parents had higher state anxiety scores before DPT compared to after DPT. There was a positive correlation between the parents' trait anxiety and pre-DPT state anxiety scores. In addition, parental pre-DPT state anxiety scores were positively correlated with SCL-90-R general severity index, somatization, anxiety, obsessive-compulsive, and depression subscale scores. Conclusion: The risk of allergic reaction in DPT may cause anxiety. A high level of parental anxiety before DPT, which gradually decreased after negative test results, was associated with history of drug-induced anaphylaxis in their children and high trait anxiety. Appropriate evaluation of patients and parents before DPT and providing detailed information may be important to reduce this anxiety.
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Affiliation(s)
- Ozge Yilmaz Topal
- Division of Pediatric Allergy and Immunology, Ankara City Hospital, Ankara, Turkey
| | - Irem Turgay Yagmur
- Division of Pediatric Allergy and Immunology, Ankara City Hospital, Ankara, Turkey
| | - Ilknur Kulhas Celik
- Division of Pediatric Allergy and Immunology, Ankara City Hospital, Ankara, Turkey
| | - Ozden Sukran Uneri
- Department of Psychology, Faculty of Economics, Admınıstrative And Social Sciences, Istanbul Gelisim University, Istanbul, Turkey
| | - Muge Toyran
- Division of Pediatric Allergy and Immunology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Betul Karaatmaca
- Division of Pediatric Allergy and Immunology, Ankara City Hospital, Ankara, Turkey
| | - Ersoy Civelek
- Division of Pediatric Allergy and Immunology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
| | - Emine Dibek Misirlioglu
- Division of Pediatric Allergy and Immunology, University of Health Sciences, Ankara City Hospital, Ankara, Turkey
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Liccioli G, Giovannini M, Caubet JC, Barni S, Sarti L, Parronchi P, Capone M, Tomei L, Mori F. Simplifying the drug provocation test in non-immediate hypersensitivity reactions to amoxicillin in children: The experience of a tertiary care allergy unit. Pediatr Allergy Immunol 2022; 33:e13809. [PMID: 35754120 PMCID: PMC9328376 DOI: 10.1111/pai.13809] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 04/29/2022] [Accepted: 05/17/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Mild non-immediate reactions (NIR) to beta-lactams (βLs) are the most common manifestation of adverse drug reactions in children, and the drug provocation test (DPT) remains the gold standard for diagnosis. However, there are still controversies about the protocol that should be used, especially regarding the administration of doses and the DPT length. OBJECTIVE This study aimed to evaluate a pediatric population with a history of mild NIR to amoxicillin (AMX) or to amoxicillin-clavulanic acid (AMX/CL) who underwent a diagnostic workup including a DPT with the culprit drug, to understand if a graded DPT or, instead, a single full dose could be the most appropriate way of administration in clinical practice. METHODS The data of children were retrospectively analyzed for a 5-year period, with demographic and clinical characteristics collected. We reported the allergy workup and the results of the DPT performed with the administration of incremental doses and a prolonged DPT at home for a total of 5 days. RESULTS Three hundred fifty-four patients were included. Overall, 23/354 (6.5%) DPTs were positive: 11/23 patients showed a reaction after 2-8 h after the last dose on the 1st or 2nd day (1 reacted 30 min after the last dose), 1/23 reacted with urticaria 30 min after the first dose, 11/23 reacted at home on the 5th day of the DPT. CONCLUSION This paper indirectly suggests that a single therapeutic dose administered on the 1st day of a DPT could be safe in the diagnostic workup of mild NIR to AMX/CL. Moreover, this could be less time-consuming as patients would spend less time in the hospital, also considering the public health restrictions imposed during the COVID-19 pandemic.
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Affiliation(s)
- Giulia Liccioli
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Mattia Giovannini
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Jean-Christoph Caubet
- Pediatric Allergy Unit, Department of Child and Adolescent, University Hospitals of Geneva, Geneva, Switzerland
| | - Simona Barni
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Lucrezia Sarti
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Paola Parronchi
- Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Manuela Capone
- Department of Clinical and Experimental Medicine, University of Florence, Florence, Italy
| | - Leonardo Tomei
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
| | - Francesca Mori
- Allergy Unit, Department of Pediatrics, Meyer Children's University Hospital, Florence, Italy
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Prosty C, Copaescu AM, Gabrielli S, Mule P, Ben-Shoshan M. Pediatric Drug Allergy. Immunol Allergy Clin North Am 2022; 42:433-452. [DOI: 10.1016/j.iac.2022.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Romano A, Atanaskovic‐Markovic M, Barbaud A, Bircher AJ, Brockow K, Caubet J, Celik G, Cernadas J, Chiriac A, Demoly P, Garvey LH, Mayorga C, Nakonechna A, Whitaker P, Torres MJ. Towards a more precise diagnosis of hypersensitivity to beta-lactams - an EAACI position paper. Allergy 2020; 75:1300-1315. [PMID: 31749148 DOI: 10.1111/all.14122] [Citation(s) in RCA: 153] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 10/08/2019] [Accepted: 10/23/2019] [Indexed: 02/07/2023]
Abstract
A recent survey of the European Academy of Allergy and Clinical Immunology (EAACI) Drug Allergy Interest Group (DAIG) on how European allergy specialists deal with beta-lactam (BL) hypersensitivity demonstrated a significant heterogeneity in current practice, suggesting the need to review and update existing EAACI guidelines in order to make the diagnostic procedures as safe and accurate, but also as cost-effective, as possible. For this purpose, a bibliographic search on large studies regarding BL hypersensitivity diagnosis was performed by an EAACI task force, which reviewed and evaluated the literature data using the GRADE system for quality of evidence and strength of recommendation. The updated guidelines provide a risk stratification in BL hypersensitivity according to index reaction(s), as well as an algorithmic approach, based on cross-reactivity studies, in patients with a suspicion of BL hypersensitivity and an immediate need for antibiotic therapy, when referral to an allergist is not feasible. Furthermore, the update addresses availability and concentrations of skin test (ST) reagents, ST and drug provocation test (DPT) protocols, and diagnostic algorithms and administration of alternative BL in allergic subjects. Specifically, distinct diagnostic algorithms are suggested depending on risk stratification of the patient into high and low risk based on the morphology and chronology of the reaction, immediate (ie, occurring within 1-6 hours after the last administered dose) or nonimmediate (ie, occurring more than 1 hour after the initial drug administration), and the reaction severity. Regarding the allergy workup, the main novelty of this document is the fact that in some low-risk nonimmediate reactions ST are not mandatory, especially in children. For DPT, further studies are necessary to provide data supporting the standardization of protocols, especially of those regarding nonimmediate reactions, for which there is currently no consensus.
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Affiliation(s)
- Antonino Romano
- Casa di Cura Quisisana Rome & Fondazione Mediterranea G.B. Catania Italy
| | | | - Annick Barbaud
- Departement of Dermatology and Allergology Institut Pierre Louis d'Epidemiologie et de Sante Publique INSERM Tenon Hospital Sorbonne Université Paris France
| | | | - Knut Brockow
- Department of Dermatology and Allergy Biederstein Technische Universität München Munich Germany
| | | | - Gulfem Celik
- Department of Immunology and Allergy Ankara University School of Medicine Ankara Turkey
| | - Josefina Cernadas
- Department of Allergy and Immunology Centro Hospitalar Universitário de S João Porto Portugal
| | - Anca‐Mirela Chiriac
- Division of Allergy Department of Pulmonology Hôpital Arnaud de Villeneuve University Hospital of Montpellier Montpellier France
- UMRS 1136 Equipe ‐ EPAR ‐ IPLESP UPMC Univ Sorbonne Universités Paris France
| | - Pascal Demoly
- Division of Allergy Department of Pulmonology Hôpital Arnaud de Villeneuve University Hospital of Montpellier Montpellier France
- UMRS 1136 Equipe ‐ EPAR ‐ IPLESP UPMC Univ Sorbonne Universités Paris France
| | - Lene H. Garvey
- Allergy Clinic Department of Dermatology and Allergy Herlev and Gentofte Hospital University of Copenhagen Copenhagen Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - Cristobalina Mayorga
- Allergy Research Group Instituto de Investigación Biomédica de Málaga-IBIMA Malaga Spain
- Allergy Unit Hospital Regional Universitario de Málaga-UMA-ARADyAL Malaga Spain
| | - Alla Nakonechna
- Clinical Immunology and Allergy Unit Sheffield Teaching Hospital Sheffield UK
- University of Liverpool Liverpool UK
| | - Paul Whitaker
- Regional Adult Cystic Fibrosis Unit St James's Hospital Leeds UK
| | - María José Torres
- Allergy Unit Hospital Regional Universitario de Málaga-UMA-ARADyAL Malaga Spain
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Regateiro F, Rezende I, Pinto N, Abreu C, Carreiro-Martins P, Gomes E. Short and extended provocation tests have similar negative predictive value in non-immediate hypersensitivity to beta-lactams in children. Allergol Immunopathol (Madr) 2019; 47:477-483. [PMID: 30910271 DOI: 10.1016/j.aller.2019.01.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 01/02/2019] [Accepted: 01/04/2019] [Indexed: 10/27/2022]
Abstract
INTRODUCTION AND OBJECTIVES Drug provocation tests (DPTs) are the gold-standard method to diagnose non-immediate hypersensitivity reactions (NIHSR) to beta-lactam antibiotics (BL) in children. Our aim was to compare the negative predictive value (NPV) of one-day (short) DPT versus 3-7 days (extended) DPT for the diagnosis of NIHSR to BL in paediatric age. A secondary aim was to compare confidence on drug re-exposure after short and extended negative DPTs. METHODS The occurrence of HSR on drug re-exposure and drug refusal after negative diagnostic DPTs were evaluated in children/adolescents with a history of NIHSR to BL using a questionnaire performed six months to ten years after DPT. Patients were divided into two groups according to the protocol performed: short DPT vs. extended DPT. RESULTS We enrolled 212 children and adolescents (86 females, 126 males, mean age at DPT 5.52 years, p25=3 years, p75=7.25 years): 69 tested with short DPT, and 143 with extended DPT. The NPV of both types of DPT together was 95.2%. The NPV of short DPT was 97.5% and the NPV of extended DPT was 93.8% (p=0.419). After negative DPT, beta-lactams were refused by carers in 14.75% of the children requiring subsequent treatment, 6.98% in the short DPT group and 18.99% in the extended DPT group (p=0.074). CONCLUSIONS In our paediatric sample, prolonging drug administration did not increase the NPV of diagnostic DPT for NIHSR to BL or reduce drug refusal. Altogether, the data here reported suggest that, however intuitive, prolonging DPT is not beneficial in the parameters analysed.
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Pouessel G, Winter N, Lejeune S, Thumerelle C, Deschildre A. Oral challenge without skin testing in children with suspected non-severe betalactam hypersensitivity. Pediatr Allergy Immunol 2019; 30:488-490. [PMID: 30817036 DOI: 10.1111/pai.13048] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Guillaume Pouessel
- Department of Pediatrics, Children's Hospital, Roubaix, France.,Pediatric Pulmonology and Allergy Department, Hôpital Jeanne de Flandre, CHU Lille, Lille, France
| | - Nicolas Winter
- Department of Pediatrics, Children's Hospital, Roubaix, France
| | - Stéphanie Lejeune
- Pediatric Pulmonology and Allergy Department, Hôpital Jeanne de Flandre, CHU Lille, Lille, France
| | - Caroline Thumerelle
- Pediatric Pulmonology and Allergy Department, Hôpital Jeanne de Flandre, CHU Lille, Lille, France
| | - Antoine Deschildre
- Pediatric Pulmonology and Allergy Department, Hôpital Jeanne de Flandre, CHU Lille, Lille, France
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Kulhas Celik I, Dibek Misirlioglu E, Kocabas CN. Recent developments in drug hypersensitivity in children. Expert Rev Clin Immunol 2019; 15:723-733. [PMID: 31066307 DOI: 10.1080/1744666x.2019.1612241] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Introduction: Drug allergy is an important public health problem that causes 0.4-10.3% of hospital admissions in children. The epidemiology, clinical spectrum, diagnosis, and management of drug hypersensitivity reactions (DHRs) differ in pediatric and adult patients. However, the same algorithms used in adults have often been applied in the pediatric population due to a lack of evidence in the literature. Areas covered: In this review, we aimed to discuss recent developments in the area of pediatric DHRs based on the growing body of literature advancing our understanding of the epidemiology, clinical aspects, and diagnostic approaches to DHRs in children. Expert opinion: Misdiagnosis, under-diagnosis, and self-diagnosis are common problems related to drug allergies in children. Viral infections are particularly frequent in children and make diagnosis difficult. Identifying true DHR is a key step in the management of drug allergy in children. Therefore, a complete allergy work-up with standardized drug allergy tests is necessary. In order to eliminate non-standardized tests, future studies including larger numbers of children should be conducted to determine more accurate standardized tests for diagnosing DHRs in the pediatric population.
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Affiliation(s)
- Ilknur Kulhas Celik
- a Division of Pediatric Allergy and Immunology , University of Health Sciences, Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital , Ankara , Turkey
| | - Emine Dibek Misirlioglu
- a Division of Pediatric Allergy and Immunology , University of Health Sciences, Ankara Child Health and Diseases Hematology Oncology Training and Research Hospital , Ankara , Turkey
| | - Can Naci Kocabas
- b Division of Pediatric Allergy and Immunology, Department of Children's Health and Diseases, Faculty of Medicine , Mugla Sitki Kocman University , Mugla , Turkey
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12
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Chiriac AM, Romano A, Ben Fadhel N, Gaeta F, Molinari N, Maggioletti M, Demoly P. Follow‐up of patients with negative drug provocation tests to betalactams. Clin Exp Allergy 2019; 49:729-732. [DOI: 10.1111/cea.13314] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Revised: 09/30/2018] [Accepted: 10/16/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Anca Mirela Chiriac
- Département de Pneumologie et Addictologie Hôpital Arnaud‐de‐Villeneuve Centre Hospitalier Universitaire de Montpellier Univ Montpellier Montpellier France
- Equipe EPAR ‐ IPLESP Sorbonne Université Paris France
| | - Antonino Romano
- Allergy Unit Presidio Columbus Fondazione Policlinico Universitario Agostino Gemelli IRCCS Rome Italy
- IRCCS Oasi Maria S.S. Troina Italy
| | - Najah Ben Fadhel
- Département de Pneumologie et Addictologie Hôpital Arnaud‐de‐Villeneuve Centre Hospitalier Universitaire de Montpellier Univ Montpellier Montpellier France
- Department of Clinical Pharmacology University Hospital of Fattouma Bourguiba Monastir Tunisia
| | - Francesco Gaeta
- Allergy Unit Presidio Columbus Fondazione Policlinico Universitario Agostino Gemelli IRCCS Rome Italy
| | - Nicolas Molinari
- Department of Statistics IMAG CNRS Univ Montpellier CHU Montpellier Montpellier France
| | - Michela Maggioletti
- Allergy Unit Presidio Columbus Fondazione Policlinico Universitario Agostino Gemelli IRCCS Rome Italy
| | - Pascal Demoly
- Département de Pneumologie et Addictologie Hôpital Arnaud‐de‐Villeneuve Centre Hospitalier Universitaire de Montpellier Univ Montpellier Montpellier France
- Equipe EPAR ‐ IPLESP Sorbonne Université Paris France
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Tonson la Tour A, Michelet M, Eigenmann PA, Caubet JC. Natural History of Benign Nonimmediate Allergy to Beta-Lactams in Children: A Prospective Study in Retreated Patients After a Positive and a Negative Provocation Test. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:1321-1326. [DOI: 10.1016/j.jaip.2017.10.008] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 10/04/2017] [Accepted: 10/05/2017] [Indexed: 12/01/2022]
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Gelincik A, Celik GE. How Can We Influence the Performance of Drug Challenge in Future Treatment. CURRENT TREATMENT OPTIONS IN ALLERGY 2018. [DOI: 10.1007/s40521-018-0158-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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15
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Aspirin and Nonsteroidal Antiinflammatory Drugs Hypersensitivity and Management. Immunol Allergy Clin North Am 2017; 37:727-749. [PMID: 28965637 DOI: 10.1016/j.iac.2017.07.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Aspirin and nonsteroidal antiinflammatory drugs (NSAIDs) are widely used in the United States and throughout the world for a variety of indications. Several unique hypersensitivity syndromes exist to this class of medications, making them one of the common reasons for consultation to the allergist. The lack of any laboratory-based diagnostic studies to assist in identifying the culprits in these reactions make evaluation of aspirin and NSAID hypersensitivity challenging. Identifying patients appropriate for oral challenge and/or desensitization protocols is the standard pragmatic approach to this issue when it arises.
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Soyer O, Sahiner UM, Sekerel BE. Pro and Contra: Provocation Tests in Drug Hypersensitivity. Int J Mol Sci 2017; 18:ijms18071437. [PMID: 28677662 PMCID: PMC5535928 DOI: 10.3390/ijms18071437] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2017] [Revised: 06/24/2017] [Accepted: 06/27/2017] [Indexed: 02/06/2023] Open
Abstract
Drug provocation test (DPT) is the controlled administration of a drug to diagnose immune- or non-immune-mediated drug hypersensitivity and the last step for accurate recognition of drug hypersensitivity reactions when the previous diagnostic evaluations are negative or unavailable. A DPT is performed only if other conventional tests fail to yield conclusive results. In each clinical presentation, "to provoke or not to provoke" a patient should be decided after careful assessment of the risk-benefit ratio. Well-defined benefits of DPT include confirmative exclusion of diagnoses of drug hypersensitivity and provision of safe alternatives. However, disadvantages such as safety, difficulty in interpretations of results, lack of objective biomarkers, risks of resensitization, efficiency in daily practice, and lack of standardized protocols, are poorly debated. This review summarizes the current published research concerning DPT, with particular emphasis on the advantages and disadvantages of DPT in an evidence-based manner.
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Affiliation(s)
- Ozge Soyer
- Department of Pediatric Allergy Ankara, School of Medicine, Hacettepe University, Ankara 06100, Turkey.
| | - Umit Murat Sahiner
- Department of Pediatric Allergy Ankara, School of Medicine, Hacettepe University, Ankara 06100, Turkey.
| | - Bulent Enis Sekerel
- Department of Pediatric Allergy Ankara, School of Medicine, Hacettepe University, Ankara 06100, Turkey.
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17
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Fernandez TD, Mayorga C, Salas M, Barrionuevo E, Posadas T, Ariza A, Laguna JJ, Moreno E, Torres MJ, Doña I, Montañez MI. Evolution of diagnostic approaches in betalactam hypersensitivity. Expert Rev Clin Pharmacol 2017; 10:671-683. [PMID: 28375040 DOI: 10.1080/17512433.2017.1313110] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Betalactams are the most widely used drugs against infections and the primary cause of antibiotic hypersensitivity reactions. Reaction patterns for different betalactams have been changing in accordance with consumption trends, and vary among countries. As a consequence, in vivo and in vitro tests have had to change with to keep up with new tendencies. Areas covered: This review is focused on advances in betalactam hypersensitivity diagnosis. Changes in in vivo methods have been limited to the inclusion of new haptens. In contrast, major progress has been achieved for in vitro tests since the 1960s, from the first description of immunoassays, the basophil activation test and the lymphocyte transformation test, to the more sophisticated assays developed in last years. Expert commentary: Issues with diagnosis are related to test sensitivity. In vivo tests show higher sensitivity, however they can be risky, especially in severe and life-threatening reactions. Therefore, we believe that in vitro tests should be the preferred method. Current efforts are under way to enhance their sensitivity. Only multidisciplinary approaches involving immunology, proteomics, nanotechnology and chemistry can help us to fully understand conjugate structures and mechanisms involved in hypersensitivity reactions to betalactams, and consequently lead to advances in in vitro methods.
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Affiliation(s)
- Tahia D Fernandez
- a Research Laboratory , IBIMA - Regional University Hospital of Malaga - UMA , Málaga , Spain
| | - Cristobalina Mayorga
- a Research Laboratory , IBIMA - Regional University Hospital of Malaga - UMA , Málaga , Spain.,b Allergy Unit , IBIMA - Regional University Hospital of Malaga - UMA , Málaga , Spain
| | - Maria Salas
- b Allergy Unit , IBIMA - Regional University Hospital of Malaga - UMA , Málaga , Spain
| | - Esther Barrionuevo
- b Allergy Unit , IBIMA - Regional University Hospital of Malaga - UMA , Málaga , Spain
| | - Teresa Posadas
- b Allergy Unit , IBIMA - Regional University Hospital of Malaga - UMA , Málaga , Spain
| | - Adriana Ariza
- a Research Laboratory , IBIMA - Regional University Hospital of Malaga - UMA , Málaga , Spain
| | - Jose J Laguna
- c Allergy Unit , Hospital de la Cruz Roja , Madrid , Spain
| | - Esther Moreno
- d Allergy Service , University Hospital of Salamanca , Salamanca , Spain
| | - Maria J Torres
- b Allergy Unit , IBIMA - Regional University Hospital of Malaga - UMA , Málaga , Spain.,e Laboratory of Nanostructures for Diagnosing and Treatment of Allergic Diseases , Andalusian Center for Nanomedicine and Biotechnology - BIONAND , Málaga , Spain
| | - Inmaculada Doña
- b Allergy Unit , IBIMA - Regional University Hospital of Malaga - UMA , Málaga , Spain
| | - Maria I Montañez
- a Research Laboratory , IBIMA - Regional University Hospital of Malaga - UMA , Málaga , Spain.,e Laboratory of Nanostructures for Diagnosing and Treatment of Allergic Diseases , Andalusian Center for Nanomedicine and Biotechnology - BIONAND , Málaga , Spain
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18
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19
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Capanoglu M, Vezir E, Misirlioglu ED, Guvenir H, Buyuktiryaki B, Toyran M, Kocabas CN. Additional provocation testing in patients with negative provocation test results with β-lactam antibiotics. Ann Allergy Asthma Immunol 2015; 116:82-3. [PMID: 26522258 DOI: 10.1016/j.anai.2015.10.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Revised: 10/07/2015] [Accepted: 10/08/2015] [Indexed: 11/19/2022]
Affiliation(s)
- Murat Capanoglu
- Department of Pediatric Allergy and İmmunology, Ankara Children's Hematology and Oncology Hospital, Ankara, Turkey
| | - Emine Vezir
- Department of Pediatric Allergy and İmmunology, Ankara Children's Hematology and Oncology Hospital, Ankara, Turkey
| | - Emine Dibek Misirlioglu
- Department of Pediatric Allergy and İmmunology, Ankara Children's Hematology and Oncology Hospital, Ankara, Turkey
| | - Hakan Guvenir
- Department of Pediatric Allergy and İmmunology, Ankara Children's Hematology and Oncology Hospital, Ankara, Turkey
| | - Betul Buyuktiryaki
- Department of Pediatric Allergy and İmmunology, Ankara Children's Hematology and Oncology Hospital, Ankara, Turkey
| | - Muge Toyran
- Department of Pediatric Allergy and İmmunology, Ankara Children's Hematology and Oncology Hospital, Ankara, Turkey
| | - Can N Kocabas
- Department of Pediatric Allergy, Faculty of Medicine, Mugla Sitki Kocman University, Mugla, Turkey.
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