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Nishida Y, Yagami A, Takada S, Muramatsu D, Nobuoka Y, Okayama Y. Clinical investigation for the mechanisms of anaphylactic symptoms in osteoarthritis patients after diclofenac etalhyaluronate administration. Mod Rheumatol 2024; 34:820-830. [PMID: 37862589 DOI: 10.1093/mr/road100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 09/26/2023] [Accepted: 10/05/2023] [Indexed: 10/22/2023]
Abstract
OBJECTIVE This study was conducted to investigate the mechanisms of anaphylaxis in patients with osteoarthritis of the knee and hip after diclofenac etalhyaluronate [product name: JOYCLU® (JCL)] intra-articular injection and to determine the utility of tests to investigate the mechanism involved. METHODS In this observational study in Japan, patients aged ≥20 years with knee or hip osteoarthritis who received JCL intra-articular injection experienced anaphylactic symptoms considered related to JCL ('experienced patients') or did not experience allergic symptoms considered related to JCL ('non-experienced patients'). Basophil activation tests (BATs), specific immunoglobulin E (IgE) antibody testing by enzyme-linked immunosorbent assays (ELISAs) or immunochromatographic kit, and genome-wide association studies (GWASs) were conducted using patient blood and saliva. RESULTS Thirteen experienced patients and 14 non-experienced patients were tested. Seven experienced patients tested positive by BAT using diclofenac etalhyaluronate-containing test substances. Diclofenac-specific IgE antibodies were detected in four of seven BAT-positive patients but not in the non-experienced patients. Specific IgE antibody testing by immunochromatographic kit and genome-wide association study showed no clear results. CONCLUSIONS These findings suggest that anaphylaxis occurs after JCL administration via an IgE-mediated mechanism and that diclofenac etalhyaluronate may be involved in this mechanism. BAT and diclofenac -specific IgE enzyme-linked immunosorbent assay may be useful tests for investigating the mechanisms of anaphylactic reactions after JCL administration.
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Affiliation(s)
- Yoshihiro Nishida
- Department of Rehabilitation Medicine, Rare Cancer Center, Nagoya University Hospital, Nagoya, Aichi, Japan
| | - Akiko Yagami
- Department of Allergology, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan
| | - Shuhei Takada
- Research and Development Division, Seikagaku Corporation, Higashiyamato, Tokyo, Japan
| | - Dai Muramatsu
- Research and Development Division, Seikagaku Corporation, Higashiyamato, Tokyo, Japan
| | - Yuji Nobuoka
- Research and Development Division, Seikagaku Corporation, Tokyo, Japan
| | - Yoshimichi Okayama
- Department of Internal Medicine, Division of Allergology, Misato Kenwa Hospital, Misato, Saitama, Japan
- Department of Medicine, Division of Respiratory Medicine and Allergology, Showa University, Tokyo, Japan
- Department of Internal Medicine, Division of Respiratory Medicine, Nihon University School of Medicine, Tokyo, Japan
- Advanced Medical Science Research Center, Gunma Paz University Graduate School of Health Sciences, Takasaki, Gunma, Japan
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Schmidt S, Hoffmann H, Garbe LA, Harrer A, Steiner M, Himly M, Schneider RJ. Re-assessment of monoclonal antibodies against diclofenac for their application in the analysis of environmental waters. ANALYTICAL METHODS : ADVANCING METHODS AND APPLICATIONS 2024; 16:3349-3363. [PMID: 38742423 PMCID: PMC11138808 DOI: 10.1039/d3ay01333b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 05/07/2024] [Indexed: 05/16/2024]
Abstract
The non-steroidal anti-inflammatory drug (NSAID) diclofenac (DCF) is an important environmental contaminant occurring in surface waters all over the world, because, after excretion, it is not adequately removed from wastewater in sewage treatment plants. To be able to monitor this pollutant, highly efficient analytical methods are needed, including immunoassays. In a medical research project, monoclonal antibodies against diclofenac and its metabolites had been produced. Based on this monoclonal anti-DCF antibody, a new indirect competitive enzyme-linked immunosorbent assay (ELISA) was developed and applied for environmental samples. The introduction of a spacer between diclofenac and the carrier protein in the coating conjugate led to higher sensitivity. With a test midpoint of 3 μg L-1 and a measurement range of 1-30 μg L-1, the system is not sensitive enough for direct analysis of surface water. However, this assay is quite robust against matrix influences and can be used for wastewater. Without adjustment of the calibration, organic solvents up to 5%, natural organic matter (NOM) up to 10 mg L-1, humic acids up to 2.5 mg L-1, and salt concentrations up to 6 g L-1 NaCl and 75 mg L-1 CaCl2 are tolerated. The antibody is also stable in a pH range from 3 to 12. Cross-reactivity (CR) of 1% or less was determined for the metabolites 4'-hydroxydiclofenac (4'-OH-DCF), 5-hydroxydiclofenac (5-OH-DCF), DCF lactam, and other NSAIDs. Relevant cross-reactivity occurred only with an amide derivative of DCF, 6-aminohexanoic acid (DCF-Ahx), aceclofenac (ACF) and DCF methyl ester (DCF-Me) with 150%, 61% and 44%, respectively. These substances, however, have not been found in samples. Only DCF-acyl glucuronide with a cross-reactivity of 57% is of some relevance. For the first time, photodegradation products were tested for cross-reactivity. With the ELISA based on this antibody, water samples were analysed. In sewage treatment plant effluents, concentrations in the range of 1.9-5.2 μg L-1 were determined directly, with recoveries compared to HPLC-MS/MS averaging 136%. Concentrations in lakes ranged from 3 to 4.4 ng L-1 and were, after pre-concentration, determined with an average recovery of 100%.
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Affiliation(s)
- Stephan Schmidt
- Department of Analytical Chemistry, Reference Materials, BAM Federal Institute for Materials Research and Testing, Richard-Willstätter-Str. 11, 12489 Berlin, Germany.
- Technische Universität Berlin, Straße des 17. Juni 135, D-10623 Berlin, Germany
| | - Holger Hoffmann
- Department of Analytical Chemistry, Reference Materials, BAM Federal Institute for Materials Research and Testing, Richard-Willstätter-Str. 11, 12489 Berlin, Germany.
- Department of Chemistry, Humboldt-Universität zu Berlin, Brook-Taylor-Str. 2, D-12489 Berlin, Germany
| | - Leif-Alexander Garbe
- Hochschule Neubrandenburg, Fachbereich Agrarwirtschaft und Lebensmittelwissenschaften, D-17033 Neubrandenburg, Germany
| | - Andrea Harrer
- Department of Biosciences and Medical Biology, Division of Allergy and Immunology, Paris Lodron University of Salzburg, A-5020 Salzburg, Austria
| | - Markus Steiner
- Department of Biosciences and Medical Biology, Division of Allergy and Immunology, Paris Lodron University of Salzburg, A-5020 Salzburg, Austria
| | - Martin Himly
- Department of Biosciences and Medical Biology, Division of Allergy and Immunology, Paris Lodron University of Salzburg, A-5020 Salzburg, Austria
| | - Rudolf J Schneider
- Department of Analytical Chemistry, Reference Materials, BAM Federal Institute for Materials Research and Testing, Richard-Willstätter-Str. 11, 12489 Berlin, Germany.
- Technische Universität Berlin, Straße des 17. Juni 135, D-10623 Berlin, Germany
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Diclofenac Disrupts the Circadian Clock and through Complex Cross-Talks Aggravates Immune-Mediated Liver Injury-A Repeated Dose Study in Minipigs for 28 Days. Int J Mol Sci 2023; 24:ijms24021445. [PMID: 36674967 PMCID: PMC9863319 DOI: 10.3390/ijms24021445] [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: 11/22/2022] [Revised: 12/28/2022] [Accepted: 12/30/2022] [Indexed: 01/14/2023] Open
Abstract
Diclofenac effectively reduces pain and inflammation; however, its use is associated with hepato- and nephrotoxicity. To delineate mechanisms of injury, we investigated a clinically relevant (3 mg/kg) and high-dose (15 mg/kg) in minipigs for 4 weeks. Initially, serum biochemistries and blood-smears indicated an inflammatory response but returned to normal after 4 weeks of treatment. Notwithstanding, histopathology revealed drug-induced hepatitis, marked glycogen depletion, necrosis and steatosis. Strikingly, the genomic study revealed diclofenac to desynchronize the liver clock with manifest inductions of its components CLOCK, NPAS2 and BMAL1. The > 4-fold induced CRY1 expression underscored an activated core-loop, and the dose dependent > 60% reduction in PER2mRNA repressed the negative feedback loop; however, it exacerbated hepatotoxicity. Bioinformatics enabled the construction of gene-regulatory networks, and we linked the disruption of the liver-clock to impaired glycogenesis, lipid metabolism and the control of immune responses, as shown by the 3-, 6- and 8-fold induced expression of pro-inflammatory CXCL2, lysozyme and ß-defensin. Additionally, diclofenac treatment caused adrenocortical hypertrophy and thymic atrophy, and we evidenced induced glucocorticoid receptor (GR) activity by immunohistochemistry. Given that REV-ERB connects the circadian clock with hepatic GR, its > 80% repression alleviated immune responses as manifested by repressed expressions of CXCL9(90%), CCL8(60%) and RSAD2(70%). Together, we propose a circuitry, whereby diclofenac desynchronizes the liver clock in the control of the hepatic metabolism and immune response.
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Ecke A, Westphalen T, Hornung J, Voetz M, Schneider RJ. A rapid magnetic bead-based immunoassay for sensitive determination of diclofenac. Anal Bioanal Chem 2021; 414:1563-1573. [PMID: 34799751 PMCID: PMC8761716 DOI: 10.1007/s00216-021-03778-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 10/18/2021] [Accepted: 11/05/2021] [Indexed: 11/29/2022]
Abstract
Increasing contamination of environmental waters with pharmaceuticals represents an emerging threat for the drinking water quality and safety. In this regard, fast and reliable analytical methods are required to allow quick countermeasures in case of contamination. Here, we report the development of a magnetic bead-based immunoassay (MBBA) for the fast and cost-effective determination of the analgesic diclofenac (DCF) in water samples, based on diclofenac-coupled magnetic beads and a robust monoclonal anti-DCF antibody. A novel synthetic strategy for preparation of the beads resulted in an assay that enabled for the determination of diclofenac with a significantly lower limit of detection (400 ng/L) than the respective enzyme-linked immunosorbent assay (ELISA). With shorter incubation times and only one manual washing step required, the assay demands for remarkably shorter time to result (< 45 min) and less equipment than ELISA. Evaluation of assay precision and accuracy with a series of spiked water samples yielded results with low to moderate intra- and inter-assay variations and in good agreement with LC–MS/MS reference analysis. The assay principle can be transferred to other, e.g., microfluidic, formats, as well as applied to other analytes and may replace ELISA as the standard immunochemical method.
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Affiliation(s)
- Alexander Ecke
- Department of Analytical Chemistry; Reference Materials, Bundesanstalt für Materialforschung und -prüfung (BAM), 12489, Berlin, Germany.,Department of Chemistry, Humboldt-Universität zu Berlin, 12489, Berlin, Germany
| | - Tanja Westphalen
- Department of Analytical Chemistry; Reference Materials, Bundesanstalt für Materialforschung und -prüfung (BAM), 12489, Berlin, Germany
| | | | | | - Rudolf J Schneider
- Department of Analytical Chemistry; Reference Materials, Bundesanstalt für Materialforschung und -prüfung (BAM), 12489, Berlin, Germany. .,Technische Universität Berlin, Faculty III Process Sciences, 10623, Berlin, Germany.
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5
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Elst J, Sabato V, van der Poorten MLM, Van Gasse AL, Van Houdt M, Bridts CH, Walschot M, Timmermans JP, Pintelon I, Mertens C, Ebo DG. Basophil and mast cell activation tests by flow cytometry in immediate drug hypersensitivity: Diagnosis and beyond. J Immunol Methods 2021; 495:113050. [PMID: 33933471 DOI: 10.1016/j.jim.2021.113050] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 03/22/2021] [Accepted: 03/25/2021] [Indexed: 01/01/2023]
Abstract
Immediate drug hypersensitivity reactions (IDHRs) constitute a significant health issue with serious consequences of diagnostic error. The primary diagnostics to document IDHRs usually consists of quantification of drug-specific IgE (sIgE) antibodies and skin tests. Unfortunately, the positive predictive value (PPV) and negative predictive value (NPV) of these tests are not absolutely, which leaves room for new tests. Over the last two decades, the basophil activation test (BAT), in which ex vivo activation of individual basophils is quantified by flow cytometry, has emerged as a reliable complementary diagnostic to document IDHRs, to explore allergenic recognition, to study cross-reactivity and to monitor therapy. However, the BAT is technically challenging requiring specialized personnel and equipment, fresh samples and the technique is lost as a diagnostic in patients showing a non-responder status of their cells. By consequence, the BAT has still not entered mainstream application. In contrast, mast cell activation tests (MATs) use serum samples that can be frozen, stored, and shipped to a recognized reference centre experienced in mast cell (MC) lines and/or cultures and capable of offering batch testing with necessary quality controls. This review does not only highlight the use of the BAT and MAT as diagnostics in IDHRs, but also outlines the potential of both techniques in further exploring and unveiling the mechanisms that govern drug-induced basophil and MC activation and degranulation.
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Affiliation(s)
- Jessy Elst
- Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp (Belgium) and Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium
| | - Vito Sabato
- Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp (Belgium) and Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium; Department of Immunology, AZ Jan Palfijn Hospital Gent, Ghent, Belgium
| | - Marie-Line M van der Poorten
- Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp (Belgium) and Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium; Department of Pediatrics, Faculty of Medicine and Health Sciences, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Athina L Van Gasse
- Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp (Belgium) and Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium; Department of Pediatrics, Faculty of Medicine and Health Sciences, University of Antwerp and Antwerp University Hospital, Antwerp, Belgium
| | - Michel Van Houdt
- Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp (Belgium) and Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium
| | - Chris H Bridts
- Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp (Belgium) and Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium
| | - Mark Walschot
- Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp (Belgium) and Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium
| | - Jean-Pierre Timmermans
- Laboratory of Cell Biology and Histology, Department of Veterinary Sciences, University of Antwerp, Antwerp, Belgium
| | - Isabel Pintelon
- Laboratory of Cell Biology and Histology, Department of Veterinary Sciences, University of Antwerp, Antwerp, Belgium
| | - Christel Mertens
- Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp (Belgium) and Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium
| | - Didier G Ebo
- Department of Immunology, Allergology, Rheumatology and the Infla-Med Centre of Excellence, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp (Belgium) and Immunology, Allergology, Rheumatology, Antwerp University Hospital, Antwerp, Belgium; Department of Immunology, AZ Jan Palfijn Hospital Gent, Ghent, Belgium.
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6
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Ebo DG, Bridts CH, Mertens CH, Sabato V. Principles, potential, and limitations of ex vivo basophil activation by flow cytometry in allergology: A narrative review. J Allergy Clin Immunol 2021; 147:1143-1153. [DOI: 10.1016/j.jaci.2020.10.027] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 10/14/2020] [Accepted: 10/20/2020] [Indexed: 12/17/2022]
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7
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Lee J. A single nonsteroidal anti-inflammatory drugs-induced anaphylaxis to diclofenac confirmed by skin testing. ALLERGY ASTHMA & RESPIRATORY DISEASE 2021. [DOI: 10.4168/aard.2021.9.3.184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Jaechun Lee
- Department of Internal Medicine, College of Medicine, Jeju National University, Jeju, Korea
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8
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Pérez-Sánchez N, Doña I, Bogas G, Salas M, Testera A, Cornejo-García JA, Torres MJ. Evaluation of Subjects Experiencing Allergic Reactions to Non-Steroidal Anti-Inflammatory Drugs: Clinical Characteristics and Drugs Involved. Front Pharmacol 2020; 11:503. [PMID: 32425774 PMCID: PMC7212440 DOI: 10.3389/fphar.2020.00503] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 03/30/2020] [Indexed: 12/16/2022] Open
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs), the most commonly prescribed and consumed medicines worldwide, are the main triggers of drug hypersensitivity reactions (DHRs). The underlying mechanisms of NSAID-DHRs may be related to COX-1 inhibition (cross-hypersensitivity reactions, CRs) or to immunological recognition (selective reactions, SRs), being the latter remarkably less studied. SRs include those usually appearing within the first hour after drug intake (single-NSAID-induced urticaria/angioedema or anaphylaxis, SNIUAA), and those usually occurring more than 24 h after (single-NSAID-induced delayed reactions, SNIDR). We have evaluated the largest series of patients with SRs, analyzing the number of episodes and drugs involved, the latency for reaction onset, the clinical entities, among other variables, as well as the value of available diagnostic methods. Globally, pyrazolones and arylpropionics were the most frequent culprits (39.3% and 37.3%, respectively). Pyrazolones were the most frequent triggers in SNIUAA and arylpropionics in SNIDR. Urticaria was the most common clinical entity in SNIUAA (42.4%) followed by anaphylaxis (33.3%); whereas SNIDR induced mostly fixed drug eruption (41.1%) and maculopapular exanthema (32.6%). The percentage of patients diagnosed by clinical history was higher in SNIUAA compared with SNIDR (62.7% versus 35.3%, p = 0.00015), whereas the percentage of those diagnosed by skin tests was higher in SNIDR than in SNIUAA (47.1% versus 22.8%, p = 0.00015). Drug provocation test with the culprit was performed in 67 SNIUAA (14.5%) and in 9 SNIDR (17.6%) patients. Our results may be of interest not only for allergologists but also for other clinicians dealing with these drugs, and can be useful for the correct identification of subjects experiencing DHRs to NSAIDs, and for avoiding mislabeling. Moreover, as NSAIDs are highly consumed worldwide, our results may be of interest for evaluating other populations exposed to these drugs.
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Affiliation(s)
- Natalia Pérez-Sánchez
- Allergy Unit, Malaga Regional University Hospital, Malaga, Spain.,Departamento de Medicina, Universidad de Málaga, Malaga, Spain
| | - Inmaculada Doña
- Allergy Unit, Malaga Regional University Hospital, Malaga, Spain
| | - Gador Bogas
- Allergy Unit, Malaga Regional University Hospital, Malaga, Spain
| | - María Salas
- Allergy Unit, Malaga Regional University Hospital, Malaga, Spain
| | - Almudena Testera
- Allergy Unit, Malaga Regional University Hospital, Malaga, Spain
| | - José A Cornejo-García
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, ARADyAL, Malaga, Spain
| | - María J Torres
- Allergy Unit, Malaga Regional University Hospital, Malaga, Spain.,Departamento de Medicina, Universidad de Málaga, Malaga, Spain.,Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, ARADyAL, Malaga, Spain.,Nanostructures for Diagnosing and Treatment of Allergic Diseases Laboratory, Andalusian Center for Nanomedicine and Biotechnology-BIONAND, Malaga, Spain
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9
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Doña I, Pérez‐Sánchez N, Eguiluz‐Gracia I, Muñoz-Cano R, Bartra J, Torres MJ, Cornejo‐García JA. Progress in understanding hypersensitivity reactions to nonsteroidal anti-inflammatory drugs. Allergy 2020; 75:561-575. [PMID: 31469167 DOI: 10.1111/all.14032] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 08/26/2019] [Accepted: 08/27/2019] [Indexed: 12/11/2022]
Abstract
Nonsteroidal anti-inflammatory drugs (NSAIDs), the medications most commonly used for treating pain and inflammation, are the main triggers of drug hypersensitivity reactions. The latest classification of NSAIDs hypersensitivity by the European Academy of Allergy and Clinical Immunology (EAACI) differentiates between cross-hypersensitivity reactions (CRs), associated with COX-1 inhibition, and selective reactions, associated with immunological mechanisms. Three phenotypes fill into the first group: NSAIDs-exacerbated respiratory disease, NSAIDs-exacerbated cutaneous disease and NSAIDs-induced urticaria/angioedema. Two phenotypes fill into the second one: single-NSAID-induced urticaria/angioedema/anaphylaxis and single-NSAID-induced delayed reactions. Diagnosis of NSAIDs hypersensitivity is hampered by different factors, including the lack of validated in vitro biomarkers and the uselessness of skin tests. The advances achieved over recent years recommend a re-evaluation of the EAACI classification, as it does not consider other phenotypes such as blended reactions (coexistence of cutaneous and respiratory symptoms) or food-dependent NSAID-induced anaphylaxis. In addition, it does not regard the natural evolution of phenotypes and their potential interconversion, the development of tolerance over time or the role of atopy. Here, we address these topics. A state of the art on the underlying mechanisms and on the approaches for biomarkers discovery is also provided, including genetic studies and available information on transcriptomics and metabolomics.
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Affiliation(s)
- Inmaculada Doña
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA ARADyAL Malaga Spain
- Allergy Unit Hospital Regional Universitario de Málaga Malaga Spain
| | - Natalia Pérez‐Sánchez
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA ARADyAL Malaga Spain
- Allergy Unit Hospital Regional Universitario de Málaga Malaga Spain
- Departamento de Medicina Universidad de Málaga Malaga Spain
| | - Ibon Eguiluz‐Gracia
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA ARADyAL Malaga Spain
- Allergy Unit Hospital Regional Universitario de Málaga Malaga Spain
| | - Rosa Muñoz-Cano
- Allergy Section Pneumology Department Hospital Clinic ARADyAL Universitat de Barcelona Barcelona Spain
- Clinical and Experimental Respiratory Immunoallergy (IRCE) August Pi i Sunyer Biomedical Research Institute (IDIBAPS) ARADyAL Barcelona Spain
| | - Joan Bartra
- Allergy Section Pneumology Department Hospital Clinic ARADyAL Universitat de Barcelona Barcelona Spain
- Clinical and Experimental Respiratory Immunoallergy (IRCE) August Pi i Sunyer Biomedical Research Institute (IDIBAPS) ARADyAL Barcelona Spain
| | - María José Torres
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA ARADyAL Malaga Spain
- Allergy Unit Hospital Regional Universitario de Málaga Malaga Spain
- Departamento de Medicina Universidad de Málaga Malaga Spain
- Nanostructures for Diagnosing and Treatment of Allergic Diseases Laboratory Andalusian Center for Nanomedicine and Biotechnology‐BIONAND Malaga Spain
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10
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Blanca-Lopez N, Soriano V, Garcia-Martin E, Canto G, Blanca M. NSAID-induced reactions: classification, prevalence, impact, and management strategies. J Asthma Allergy 2019; 12:217-233. [PMID: 31496752 PMCID: PMC6690438 DOI: 10.2147/jaa.s164806] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 02/03/2019] [Indexed: 12/20/2022] Open
Abstract
Nonsteroidal anti-inflammatory drugs (NSAIDs) are the leading cause of hypersensitivity drug reactions. The different chemical structures, cyclooxygenase 1 (COX-1) and/or COX-2 inhibitors, are taken at all ages and some can be easily obtained over the counter. Vasoactive inflammatory mediators like histamine and leukotriene metabolites can produce local/systemic effects. Responders can be selective (SR), IgE or T-cell mediated, or cross-intolerant (CI). Inhibition of the COX pathway is the common mechanism in CI, with the skin being the most frequent organ involved, followed by the lung and/or the nose. An important number of cases have skin and respiratory involvement, with systemic manifestations ranging from mild to severe anaphylaxis. Among SR, this is the most frequent entity, often being severe. Recent years have seen an increase in reactions involving the skin, with many cases having urticaria and/or angioedema in the absence of chronic urticaria. Aspirin, the classical drug involved, has now been replaced by other NSAIDs, with ibuprofen being the universal culprit. For CI, no in vivo/in vitro diagnostic methods exist and controlled administration is the only option unless the cases evaluated report repetitive and consistent episodes with different NSAIDs. In SR, skin testing (patch and intradermal) with 24-48 reading can be useful, mainly for delayed T-cell responses. Acetyl salicylic acid (ASA) is the test drug to establish the diagnosis and confirm/exclude CI by controlled administration. Desensitization to ASA has been extensively used in respiratory cases though it can also be applied in those cases where it is required.
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Affiliation(s)
| | - Victor Soriano
- General University Hospital of Alicante-ISABIAL
, Alicante, Madrid, Spain
| | - Elena Garcia-Martin
- Medical and Surgery Therapy Department, University of Extremadura, Caceres, Spain
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11
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Campos L, Galvão VR, Kalil J, Castells M, Giavina-Bianchi P. BAT in the Diagnosis of Drug Allergy: a Novel Tool in Clinical Daily Practice? Curr Allergy Asthma Rep 2019; 19:20. [PMID: 30859323 DOI: 10.1007/s11882-019-0852-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE OF REVIEW The aim of this study is to critically review the relevant literature published on basophil activation test, presenting the current knowledge and future perspectives. RECENT FINDINGS Basophil activation test (BAT) results varied accordingly to the class of the drug studied, and have promising results in immediate hypersensitivity reactions to pyrazolone (selective reactors), neuromuscular blockers, beta-lactams, and platinum compounds, all examples of classical IgE-mediated hypersensitivity drug reactions. Currently, BAT is applied in research settings, but based in the results of our review, the test can be considered as a diagnostic tool for daily practice for selected patients and selected drugs, when the test is available, particularly for patients who experienced severe reactions and when diagnosis cannot be stablished by serum-specific IgE and skin testing, in order to avoid unnecessary drug provocations tests.
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Affiliation(s)
- Lucila Campos
- Clinical Immunology and Allergy Division, University of São Paulo, R. Prof. Artur Ramos 178 ap.211A, Jd. América, São Paulo, SP, CEP: 01454-904, Brazil.
| | - Violeta Régnier Galvão
- Clinical Immunology and Allergy Division, University of São Paulo, R. Prof. Artur Ramos 178 ap.211A, Jd. América, São Paulo, SP, CEP: 01454-904, Brazil
| | - Jorge Kalil
- Clinical Immunology and Allergy Division, University of São Paulo, R. Prof. Artur Ramos 178 ap.211A, Jd. América, São Paulo, SP, CEP: 01454-904, Brazil
| | - Mariana Castells
- Harvard medical School, Boston, MA, USA
- Adverse Drug Reactions and Desesitization Program, Brigham and Women's Hospital, Jimmy Fund Way, Smith Building, Boston, MA, USA
- Allergy and Immunology Training Program, department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Division of Rheumatology, Allergy and Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Pedro Giavina-Bianchi
- Clinical Immunology and Allergy Division, University of São Paulo, R. Prof. Artur Ramos 178 ap.211A, Jd. América, São Paulo, SP, CEP: 01454-904, Brazil
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12
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Perkins JR, Acosta-Herrera M, Plaza-Serón MC, Jurado-Escobar R, Doña I, García-Martín E, Isidoro-García M, Bartra J, Ribas-Perez D, Mayorga C, Torres MJ, Flores C, Cornejo-García JA. Polymorphisms in CEP68 gene associated with risk of immediate selective reactions to non-steroidal anti-inflammatory drugs. THE PHARMACOGENOMICS JOURNAL 2018; 19:191-199. [DOI: 10.1038/s41397-018-0038-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Revised: 05/12/2018] [Accepted: 06/19/2018] [Indexed: 11/09/2022]
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13
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Advances in hypersensitivity drug reactions. Curr Opin Allergy Clin Immunol 2018; 18:281-283. [PMID: 29889139 DOI: 10.1097/aci.0000000000000460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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14
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Smith DA, Hammond T, Baillie TA. Safety Assessment of Acyl Glucuronides-A Simplified Paradigm. Drug Metab Dispos 2018; 46:908-912. [PMID: 29559442 DOI: 10.1124/dmd.118.080515] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Accepted: 03/16/2018] [Indexed: 11/22/2022] Open
Abstract
While simple O- (ether-linked) and N-glucuronide drug conjugates generally are unreactive and considered benign from a safety perspective, the acyl glucuronides that derive from metabolism of carboxylic acid-containing xenobiotics can exhibit a degree of chemical reactivity that is dependent upon their molecular structure. As a result, concerns have arisen over the safety of acyl glucuronides as a class, several members of which have been implicated in the toxicity of their respective parent drugs. However, direct evidence in support of these claims remains sparse, and due to frequently encountered species differences in the systemic exposure to acyl glucuronides (both of the parent drug and oxidized derivatives thereof), coupled with their instability in aqueous media and potential to undergo chemical rearrangement (acyl migration), qualification of these conjugates by traditional safety assessment methods can be very challenging. In this Commentary, we discuss alternative (non-acyl glucuronide) mechanisms by which carboxylic acids may cause serious adverse reactions, and propose a novel, practical approach to compare systemic exposure to acyl glucuronide metabolites in humans to that in animal species used in preclinical safety assessment based on relative estimates of the total body burden of these circulating conjugates.
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Affiliation(s)
- Dennis A Smith
- 4 The Maltings, Walmer, Kent, United Kingdom (D.A.S.); Preclinical Safety Consulting Ltd., Loughborough, Leicestershire, United Kingdom (T.H.); and Department of Medicinal Chemistry, School of Pharmacy, University of Washington, Seattle, Washington (T.A.B.)
| | - Timothy Hammond
- 4 The Maltings, Walmer, Kent, United Kingdom (D.A.S.); Preclinical Safety Consulting Ltd., Loughborough, Leicestershire, United Kingdom (T.H.); and Department of Medicinal Chemistry, School of Pharmacy, University of Washington, Seattle, Washington (T.A.B.)
| | - Thomas A Baillie
- 4 The Maltings, Walmer, Kent, United Kingdom (D.A.S.); Preclinical Safety Consulting Ltd., Loughborough, Leicestershire, United Kingdom (T.H.); and Department of Medicinal Chemistry, School of Pharmacy, University of Washington, Seattle, Washington (T.A.B.)
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15
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Abstract
Background For most physicians, quantification of drug-specific immunoglobulin E (drug-sIgE) antibodies constitutes the primary in vitro measure to document immediate drug hypersensitivity reactions (IDHR). Unfortunately, this is often insufficient to correctly identify patients with IgE-mediated IDHR and impossible for non-IgE-mediated IDHR that result from alternative routes of basophil and mast cell activation. In these difficult cases, diagnosis might benefit from cellular tests such as basophil activation tests (BAT). Aim The aim was to review the potential and limitations of quantification of sIgE and BAT in diagnosing IDHR. The utility of quantification of serum tryptase is discussed. Methods A literature search was conducted using the key words allergy, basophil activation, CD63, CD203c, diagnosis, drugs, hypersensitivity, flow cytometry, specific IgE antibodies; this was complemented by the authors’ own experience. Results The drugs that have been most studied with both techniques are β-lactam antibiotics and curarizing neuromuscular blocking agents (NMBA). For sIgE morphine, data are available on the value of this test as a biomarker for sensitization to substituted ammonium structures that constitute the major epitope of NMBA, especially rocuronium and suxamethonium. For the BAT, there are also data on non-steroidal anti-inflammatory drugs (NSAIDs) and iodinated radiocontrast media. For β-lactam antibiotics, sensitivity and specificity of sIgE varies between 0 and 85% and 52 and 100%, respectively. For NMBA, sensitivity and specificity varies between 38.5 and 92% and 85.7 and 100%, respectively. Specific IgE to morphine should not be used in isolation to diagnose IDHR to NMBA nor opiates. For the BAT, sensitivity generally varies between 50 and 60%, whereas specificity attains 80%, except for quinolones and NSAIDs. Conclusions Although drug-sIgE assays and BAT can provide useful information in the diagnosis of IDHR, their predictive value is not absolute. Large-scale collaborative studies are mandatory to harmonize and optimize test protocols and to establish drug-specific decision thresholds.
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16
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Abstract
INTRODUCTION Diagnosing and managing drug hypersensitivity is challenging because there are no clear limits between different types of drug reactions. Distinguishing between type A (predictable) and type B (hypersensitivity) reactions when a drug is introduced on the market is not easy. When many people use a drug, adverse reactions can occur, conditioned by diverse genetic profiles, viral infections or concomitant therapy. Occasionally the only tool clinicians have on which to base the diagnosis is the clinical history. Skins tests or in vitro tests sometimes have low sensitivity or are unavailable, and drug provocation tests may be dangerous or strictly forbidden in case of severe cutaneous reactions. Areas covered: This paper reviews the diagnosis and management of the two main types of immunological reactions: IgE-mediated immediate drug hypersensitivity reactions (IDHRs) and non-immediate drug hypersensitivity reactions (NIDHRs). Expert commentary: Although Europe and the United States use different diagnostic methods, patients with history of drug hypersensitivity must avoid the suspicious drug, and clinicians must assess tolerance to safe alternatives under medical surveillance. Sometimes desensitization may be required. There is a consensus about the need to perform genetic testing for specific drugs and give patients proper documentation to prevent future exposure to culprit drugs.
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Affiliation(s)
- Javier Fernandez
- a Allergy Section , Alicante University Hospital, UMH-ISABIAL , Alicante , Spain
| | - Inmaculada Doña
- b Allergy Service , Carlos Haya Hospital (Pavilion C) , Malaga , Spain
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17
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Aktuelle Diagnostik der NSAR-Überempfindlichkeit. ALLERGO JOURNAL 2017. [DOI: 10.1007/s15007-017-1434-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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18
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The Evolution of Human Basophil Biology from Neglect towards Understanding of Their Immune Functions. BIOMED RESEARCH INTERNATIONAL 2016; 2016:8232830. [PMID: 28078302 PMCID: PMC5204076 DOI: 10.1155/2016/8232830] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 11/16/2016] [Indexed: 12/03/2022]
Abstract
Being discovered long ago basophils have been neglected for more than a century. During the past decade evidence emerged that basophils share features of innate and adaptive immunity. Nowadays, basophils are best known for their striking effector role in the allergic reaction. They hence have been used for establishing new diagnostic tests and therapeutic approaches and for characterizing natural and recombinant allergens as well as hypoallergens, which display lower or diminished IgE-binding activity. However, it was a long way from discovery in 1879 until identification of their function in hypersensitivity reactions, including adverse drug reactions. Starting with a historical background, this review highlights the modern view on basophil biology.
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19
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Mayorga C, Celik G, Rouzaire P, Whitaker P, Bonadonna P, Rodrigues-Cernadas J, Vultaggio A, Brockow K, Caubet JC, Makowska J, Nakonechna A, Romano A, Montañez MI, Laguna JJ, Zanoni G, Gueant JL, Oude Elberink H, Fernandez J, Viel S, Demoly P, Torres MJ. In vitro tests for drug hypersensitivity reactions: an ENDA/EAACI Drug Allergy Interest Group position paper. Allergy 2016; 71:1103-34. [PMID: 26991315 DOI: 10.1111/all.12886] [Citation(s) in RCA: 185] [Impact Index Per Article: 23.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2016] [Indexed: 12/15/2022]
Abstract
Drug hypersensitivity reactions (DHRs) are a matter of great concern, both for outpatient and in hospital care. The evaluation of these patients is complex, because in vivo tests have a suboptimal sensitivity and can be time-consuming, expensive and potentially risky, especially drug provocation tests. There are several currently available in vitro methods that can be classified into two main groups: those that help to characterize the active phase of the reaction and those that help to identify the culprit drug. The utility of these in vitro methods depends on the mechanisms involved, meaning that they cannot be used for the evaluation of all types of DHRs. Moreover, their effectiveness has not been defined by a consensus agreement between experts in the field. Thus, the European Network on Drug Allergy and Drug Allergy Interest Group of the European Academy of Allergy and Clinical Immunology has organized a task force to provide data and recommendations regarding the available in vitro methods for DHR diagnosis. We have found that although there are many in vitro tests, few of them can be given a recommendation of grade B or above mainly because there is a lack of well-controlled studies, most information comes from small studies with few subjects and results are not always confirmed in later studies. Therefore, it is necessary to validate the currently available in vitro tests in a large series of well-characterized patients with DHR and to develop new tests for diagnosis.
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Affiliation(s)
- C. Mayorga
- Research Laboratory; IBIMA-Regional University Hospital of Malaga-UMA; Malaga Spain
- Allergy Unit; IBIMA-Regional University Hospital of Malaga-UMA; Malaga Spain
| | - G. Celik
- Division of Immunology and Allergy; Department of Chest Diseases; Ankara University School of Medicine; Ankara Turkey
| | - P. Rouzaire
- Department of Immunology and ERTICa Research Group; University Hospital of Clermont-Ferrand and Auvergne University; Clermont-Ferrand France
| | - P. Whitaker
- Regional Adult Cystic Fibrosis Unit; St James's Hospital; Leeds UK
| | - P. Bonadonna
- Allergy Unit; Azienda Ospedaliera Universitaria Intergata of Verona; Verona Italy
| | - J. Rodrigues-Cernadas
- Immunoallergology Department; Faculty of Medicine; Centro Hospitalar São João; Porto Portugal
| | - A. Vultaggio
- Immunoallergology Unit; Department of Biomedicine; Careggi Hospital; Florence Italy
| | - K. Brockow
- Department of Dermatology and Allergology Biederstein; Technische Universität München; Munich Germany
| | - J. C. Caubet
- Pediatric Allergy Unit; Department of Child and Adolescent; University Hospitals of Geneva; Geneva Switzerland
| | - J. Makowska
- Department of Immunology, Rheumatology and Allergy; Healthy Ageing Research Center; Medical University of Łódź; Łódź Poland
| | - A. Nakonechna
- Allergy and Immunology Clinic; Royal Liverpool and Broadgreen University Hospital; Liverpool UK
| | - A. Romano
- Allergy Unit Complesso Integrato Columbus; Rome and IRCCS Oasi Maria S.S.; Troina Italy
| | - M. I. Montañez
- BIONAND-Andalusian Centre for Nanomedicine and Biotechnology; Malaga Spain
| | - J. J. Laguna
- Allergy Unit; Hospital de la Cruz Roja; Madrid Spain
| | - G. Zanoni
- Section of Immunology; Department of Pathology and Diagnostics; University of Verona; Verona Italy
| | - J. L. Gueant
- Department of Molecular Medicine and Personalized Therapeutics and Inserm UMRS 954N-GERE (Nutrition-Genetics-Environmental Risks); University Hospital of Nancy and University of Lorraine; Nancy France
| | - H. Oude Elberink
- Department of Allergology; GRIAC Research Institute; University Medical Center Groningen; University of Groningen; Groningen The Netherlands
| | - J. Fernandez
- Allergy Section; Alicante University Hospital; UMH; Alicante Spain
| | - S. Viel
- Laboratory of Immunology; Centre Hospitalier Lyon Sud; Hospices Civils de Lyon; Lyon France
| | - P. Demoly
- Hôpital Arnaud de Villeneuve; University Hospital of Montpellier, and Sorbonne Universités; UPMC Paris 06, UMR-S 1136, IPLESP, Equipe EPAR; Paris France
| | - M. J. Torres
- Allergy Unit; IBIMA-Regional University Hospital of Malaga-UMA; Malaga Spain
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20
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Pérez-Alzate D, Blanca-López N, Doña I, Agúndez JA, García-Martín E, Cornejo-García JA, Perkins JR, Blanca M, Canto G. Asthma and Rhinitis Induced by Selective Immediate Reactions to Paracetamol and Non-steroidal Anti-inflammatory Drugs in Aspirin Tolerant Subjects. Front Pharmacol 2016; 7:215. [PMID: 27489545 PMCID: PMC4951487 DOI: 10.3389/fphar.2016.00215] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Accepted: 07/04/2016] [Indexed: 12/15/2022] Open
Abstract
In subjects with non-steroidal anti-inflammatory drugs (NSAIDs)- exacerbated respiratory disease (NERD) symptoms are triggered by acetyl salicylic acid (ASA) and other strong COX-1 inhibitors, and in some cases by weak COX-1 or by selective COX-2 inhibitors. The mechanism involved is related to prostaglandin pathway inhibition and leukotriene release. Subjects who react to a single NSAID and tolerate others are considered selective responders, and often present urticaria and/or angioedema and anaphylaxis (SNIUAA). An immunological mechanism is implicated in these reactions. However, anecdotal evidence suggests that selective responders who present respiratory airway symptoms may also exist. Our objective was to determine if subjects might develop selective responses to NSAIDs/paracetamol that manifest as upper/lower airways respiratory symptoms. For this purpose, we studied patients reporting asthma and/or rhinitis induced by paracetamol or a single NSAID that tolerated ASA. An allergological evaluation plus controlled challenge with ASA was carried out. If ASA tolerance was found, we proceeded with an oral challenge with the culprit drug. The appearance of symptoms was monitored by a clinical questionnaire and by measuring FEV1 and/or nasal airways volume changes pre and post challenge. From a total of 21 initial cases, we confirmed the appearance of nasal and/or bronchial manifestations in ten, characterized by a significant decrease in FEV1% and/or a decrease in nasal volume cavity after drug administration. All cases tolerated ASA. This shows that ASA tolerant subjects with asthma and/or rhinitis induced by paracetamol or a single NSAID without skin/systemic manifestations exist. Whether these patients represent a new clinical phenotype to be included within the current classification of hypersensitivity reactions to NSAIDs requires further investigation.
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Affiliation(s)
| | | | - Inmaculada Doña
- Allergy Unit, IBIMA-Regional University Hospital of Malaga-UMAMálaga, Spain
| | - José A. Agúndez
- Department of Pharmacology, University of ExtremaduraCaceres, Spain
| | | | - José A. Cornejo-García
- Allergy Unit, IBIMA-Regional University Hospital of Malaga-UMAMálaga, Spain
- Research Laboratory, IBIMA-Regional University Hospital of Malaga-UMAMálaga, Spain
| | - James R. Perkins
- Research Laboratory, IBIMA-Regional University Hospital of Malaga-UMAMálaga, Spain
| | - Miguel Blanca
- Allergy Unit, IBIMA-Regional University Hospital of Malaga-UMAMálaga, Spain
| | - Gabriela Canto
- Allergy Service, Infanta Leonor University HospitalMadrid, Spain
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21
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Blanca-López N, Pérez-Alzate D, Andreu I, Doña I, Agúndez JA, García-Martín E, Salas M, Miranda MÁ, Torres MJ, Cornejo-García JA, Blanca M, Canto G. Immediate hypersensitivity reactions to ibuprofen and other arylpropionic acid derivatives. Allergy 2016; 71:1048-56. [PMID: 26841325 DOI: 10.1111/all.12855] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND Although ibuprofen and other arylpropionic acid derivatives (APs) are the most common medicines involved in hypersensitivity drug reactions (HDRs) to NSAIDs, no patient series studies have been performed regarding immediate selective reactions (SRs) to these drugs. OBJECTIVE To characterize patients with immediate selective HDRs to ibuprofen and other APs through clinical history and challenge. METHODS Subjects who developed an HDR to APs less than 1 h after drug intake were included. Tolerance to aspirin was assessed and challenge was performed with ibuprofen in all cases, and additionally with the culprit drug (if different) in those patients that tolerated ibuprofen. Serum tryptase levels and tryptase immunohistochemical staining in skin biopsies were also assessed in some patients with a positive DPT to ibuprofen. RESULTS From a total of 245 patients with a confirmed history of HDRs to APs, 17% were classified as selective immediate hypersensitivity reactors by both clinical history and challenge. A selective response to naproxen and dexketoprofen with tolerance to ibuprofen was found in 16 of 20 cases. Significant differences in serum tryptase levels were observed between 2 and 24 h in the 11 cases that were studied further. CONCLUSIONS Within the group of patients with HDRs to NSAIDs, APs can induce immediate SRs. Within this group, selective responses to a single drug or responders to several APs may exist, suggesting potential immunological cross-reactivity.
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Affiliation(s)
- N. Blanca-López
- Allergy Service; Infanta Leonor University Hospital; Madrid Spain
| | - D. Pérez-Alzate
- Allergy Service; Infanta Leonor University Hospital; Madrid Spain
| | - I. Andreu
- Chemical Technology Institute; UPV-CSIC; Polytechnic University of Valencia; Valencia Spain
| | - I. Doña
- Allergy Unit; Malaga Regional University Hospital-IBIMA, UMA; Malaga Spain
| | - J. A. Agúndez
- Department of Pharmacology; University of Extremadura; Caceres Spain
| | - E. García-Martín
- Department of Pharmacology; University of Extremadura; Caceres Spain
| | - M. Salas
- Allergy Unit; Malaga Regional University Hospital-IBIMA, UMA; Malaga Spain
| | - M. Á. Miranda
- Chemical Technology Institute; UPV-CSIC; Polytechnic University of Valencia; Valencia Spain
| | - M. J. Torres
- Allergy Unit; Malaga Regional University Hospital-IBIMA, UMA; Malaga Spain
| | - J. A. Cornejo-García
- Allergy Unit; Malaga Regional University Hospital-IBIMA, UMA; Malaga Spain
- Research Laboratory; IBIMA; Malaga Regional University Hospital, UMA; Malaga Spain
| | - M. Blanca
- Allergy Unit; Malaga Regional University Hospital-IBIMA, UMA; Malaga Spain
| | - G. Canto
- Allergy Service; Infanta Leonor University Hospital; Madrid Spain
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22
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Jakič M, Jager M, Košnik M. Predictive value of a negative oral provocation test in patients with hypersensitivity to analgesics. ACTA DERMATOVENEROLOGICA ALPINA PANNONICA ET ADRIATICA 2016; 25:27-30. [PMID: 27348454 DOI: 10.15570/actaapa.2016.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Nonsteroidal anti-inflammatory drugs (NSAIDs) take first or second place as the cause of drug-induced hypersensitivity reactions. The oral provocation test (OPT) is a gold standard for the diagnosis of NSAID hypersensitivity. We investigated which analgesics patients took after a negative OPT and determined the proportion of patients that experienced a hypersensitivity reaction despite a negative OPT. METHODS We selected 115 patients (67.8% female, age 54.9 ± 16.7 years) with a negative aspirin OPT and a convincing history of immediate hypersensitivity to aspirin or NSAIDs. In a telephone survey, we identified the analgesics taken after the OPT and possible adverse events. RESULTS The mean follow-up time was 5.1 ± 2.0 years. All subjects needed at least one analgesic drug. Despite the negative outcome of the aspirin OPT, only 33.9% of subjects took aspirin and 0.9% had a hypersensitivity reaction. The negative predictive value (NPV) of the aspirin OPT was 97.4%. Overall, 16 (13.9%) subjects experienced a hypersensitivity reaction, 12 of which occurred after taking a drug not tested with the OPT. The NPV of the OPT for all NSAIDs was 96.4%. CONCLUSIONS Our results support the available data that most subjects do not re-take the tested drug regardless of the high NPV of the OPT.
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Affiliation(s)
- Maja Jakič
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia; Maja Jakič and Miha Jager contributed equally as the first authors
| | - Miha Jager
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia; Maja Jakič and Miha Jager contributed equally as the first authors
| | - Mitja Košnik
- Medical Faculty, University of Ljubljana, Ljubljana, Slovenia.,University Clinic of Respiratory and Allergic Diseases, Golnik, Slovenia
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Steiner M, Harrer A, Himly M. Basophil Reactivity as Biomarker in Immediate Drug Hypersensitivity Reactions-Potential and Limitations. Front Pharmacol 2016; 7:171. [PMID: 27378928 PMCID: PMC4911350 DOI: 10.3389/fphar.2016.00171] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 06/03/2016] [Indexed: 12/17/2022] Open
Abstract
Immediate drug hypersensitivity reactions (DHRs) resemble typical immunoglobulin E (IgE)-mediated symptoms. Clinical manifestations range from local skin reactions, gastrointestinal and/or respiratory symptoms to severe systemic involvement with potential fatal outcome. Depending on the substance group of the eliciting drug the correct diagnosis is a major challenge. Skin testing and in vitro diagnostics are often unreliable and not reproducible. The involvement of drug-specific IgE is questionable in many cases. The culprit substance (parent drug or metabolite) and potential cross-reacting compounds are difficult to identify, patient history and drug provocation testing often remain the only means for diagnosis. Hence, several groups proposed basophil activation test (BAT) for the diagnosis of immediate DHRs as basophils are well-known effector cells in allergic reactions. However, the usefulness of BAT in immediate DHRs is highly variable and dependent on the drug itself plus its capacity to spontaneously conjugate to serum proteins. Stimulation with pure solutions of the parent drug or metabolites thereof vs. drug-protein conjugates may influence sensitivity and specificity of the test. We thus, reviewed the available literature about the use of BAT for diagnosing immediate DHRs against drug classes such as antibiotics, radio contrast media, neuromuscular blocking agents, non-steroidal anti-inflammatory drugs, and biologicals. Influencing factors like the selection of stimulants or of the identification and activation markers, the stimulation protocol, gating strategies, and cut-off definition are addressed in this overview on BAT performance. The overall aim is to evaluate the suitability of BAT as biomarker for the diagnosis of immediate drug-induced hypersensitivity reactions.
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Affiliation(s)
- Markus Steiner
- Division Allergy and Immunology, Department Molecular Biology, University of SalzburgSalzburg, Austria; Laboratory for Immunological and Molecular Cancer Research, Paracelsus Medical UniversitySalzburg, Austria
| | - Andrea Harrer
- Division Allergy and Immunology, Department Molecular Biology, University of SalzburgSalzburg, Austria; Department Neurology, Paracelsus Medical UniversitySalzburg, Austria
| | - Martin Himly
- Division Allergy and Immunology, Department Molecular Biology, University of Salzburg Salzburg, Austria
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Blanca-López N, Pérez-Sánchez N, Agúndez JA, García-Martin E, Torres MJ, Cornejo-García JA, Perkins JR, Miranda MA, Andreu I, Mayorga C, Canto G, Blanca M, Doña I. Allergic Reactions to Metamizole: Immediate and Delayed Responses. Int Arch Allergy Immunol 2016; 169:223-30. [DOI: 10.1159/000444798] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 02/18/2016] [Indexed: 11/19/2022] Open
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Pyrazolones metabolites are relevant for identifying selective anaphylaxis to metamizole. Sci Rep 2016; 6:23845. [PMID: 27030298 PMCID: PMC4814906 DOI: 10.1038/srep23845] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 03/15/2016] [Indexed: 11/22/2022] Open
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) are the most common cause of hypersensitivity reactions, with pyrazolones the most frequent drugs inducing selective reactions. Immediate selective hypersensitivity to pyrazolones is thought to be mediated by specific-IgE. Sensitivity of in vitro diagnostic tests is low and this may be due to the incomplete characterization of the structures involved. Here we investigated whether main metabolites of metamizole (dipyrone) in human could be involved in the immune response using the basophil activation test (BAT). We studied subjects with confirmed selective immediate hypersensitivity to metamizole and performed BAT with metamizole and its metabolites: 4-methylamino-antipyrine (MAA), 4-aminoantipyrine (AA), 4-acetylamino-antipyrine (AAA) and 4-formylamino-antipyrine (FAA). BAT results showed an increase of positive results from 37.5% to 62.5% using metamizole plus metabolites as compared with the BAT carried out only with the parent drug, demonstrating that metamizole metabolites have a role in the reaction and can induce specific basophil activation in patients with immediate hypersensitivity to this drug. Our findings indicate that pyrazolone metabolites are useful for improving the in vitro diagnosis of allergic reactions to metamizole.
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Abstract
PURPOSE OF REVIEW The aim of the present review was to discuss recent advances supporting a role of drug metabolism, and particularly of the generation of reactive metabolites, in hypersensitivity reactions to drugs. RECENT FINDINGS The development of novel mass-spectrometry procedures has allowed the identification of reactive metabolites from drugs known to be involved in hypersensitivity reactions, including amoxicillin and nonsteroidal antiinflammatory drugs such as aspirin, diclofenac or metamizole. Recent studies demonstrated that reactive metabolites may efficiently bind plasma proteins, thus suggesting that drug metabolites, rather than - or in addition to - parent drugs, may elicit an immune response. As drug metabolic profiles are often determined by variability in the genes coding for drug-metabolizing enzymes, it is conceivable that an altered drug metabolism may predispose to the generation of reactive drug metabolites and hence to hypersensitivity reactions. These findings support the potential for the use of pharmacogenomics tests in hypersensitivity (type B) adverse reactions, in addition to the well known utility of these tests in type A adverse reactions. SUMMARY Growing evidence supports a link between genetically determined drug metabolism, altered metabolic profiles, generation of highly reactive metabolites and haptenization. Additional research is required to developing robust biomarkers for drug-induced hypersensitivity reactions.
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Mangodt EA, Van Gasse AL, Decuyper I, Uyttebroek A, Faber MA, Sabato V, Bridts CH, Hagendorens MM, Ebo DG. In vitro Diagnosis of Immediate Drug Hypersensitivity: Should We Go with the Flow. Int Arch Allergy Immunol 2015; 168:3-12. [PMID: 26524156 DOI: 10.1159/000440663] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Diagnosis of immediate drug hypersensitivity reactions (IDHRs) is based upon history taking, skin prick or intradermal tests and quantification of specific immunoglobulin E (IgE) antibodies. Unfortunately, this is often insufficient to correctly identify patients with IgE-mediated IDHRs and is impossible in the case of non-IgE-mediated IDHRs. Drug provocation tests (DPT) are considered the 'gold standard' diagnostic but are not always possible, for ethical and practical reasons. Therefore, the validation of new cellular tests such as basophil activation testing (BAT) was necessary. This review focuses on the applications of BAT in IDHRs. METHODS A literature search was conducted, using the words basophil, flow cytometry, immediate drug allergy and drugs; this was complemented by the authors' own expertise. RESULTS BAT/HistaFlow® is a useful diagnostic tool in IDHRs, mainly used to diagnose allergy to neuromuscular blocking agents (NMBAs), antibiotics, nonsteroidal anti-inflammatory drugs (NSAIDs) and iodinated radiocontrast media. Its sensitivity varies between 50 and 60%, and specificity attains 80%, except for with quinolones and NSAIDs. CONCLUSIONS The diagnostic utility of BAT (and to lesser extent HistaFlow) has been demonstrated and is mostly applied in IDHRs. However, larger-scale collaborative studies are necessary to optimize test protocols and validate the entry of BAT as a diagnostic instrument in drug allergy.
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Affiliation(s)
- Evelyne A Mangodt
- Department of Immunology-Allergology-Rheumatology, Faculty of Medicine and Health Science, University of Antwerp, Antwerp University Hospital, Antwerp, Belgium
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Stone SF, Phillips EJ, Wiese MD, Heddle RJ, Brown SGA. Immediate-type hypersensitivity drug reactions. Br J Clin Pharmacol 2015; 78:1-13. [PMID: 24286446 DOI: 10.1111/bcp.12297] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Accepted: 11/18/2013] [Indexed: 11/27/2022] Open
Abstract
Hypersensitivity reactions including anaphylaxis have been reported for nearly all classes of therapeutic reagents and these reactions can occur within minutes to hours of exposure. These reactions are unpredictable, not directly related to dose or the pharmacological action of the drug and have a relatively high mortality risk. This review will focus on the clinical presentation, immune mechanisms, diagnosis and prevention of the most serious form of immediate onset drug hypersensitivity reaction, anaphylaxis. The incidence of drug-induced anaphylaxis deaths appears to be increasing and our understanding of the multiple and complex reasons for the unpredictable nature of anaphylaxis to drugs is also expanding. This review highlights the importance of enhancing our understanding of the biology of the patient (i.e. immune response, genetics) as well as the pharmacology and chemistry of the drug when investigating, diagnosing and treating drug hypersensitivity. Misdiagnosis of drug hypersensitivity leads to substantial patient risk and cost. Although oral provocation is often considered the gold standard of diagnosis, it can pose a potential risk to the patient. There is an urgent need to improve and standardize diagnostic testing and desensitization protocols as other diagnostic tests currently available for assessment of immediate drug allergy are not highly predictive.
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Affiliation(s)
- Shelley F Stone
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research and the University of Western Australia, Perth, Western Australia; Department of Emergency Medicine, Royal Perth Hospital, Perth, Western Australia
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29
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Hypersensitivity reactions to nonsteroidal anti-inflammatory drugs: from phenotyping to genotyping. Curr Opin Allergy Clin Immunol 2015; 14:271-7. [PMID: 24915547 DOI: 10.1097/aci.0000000000000077] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Nonsteroidal anti-inflammatory drugs (NSAIDs) are the most frequent drugs involved in hypersensitivity drugs reactions. Both immunological and nonimmunological mechanisms can be involved. We describe the different phenotypes as well as analyze the genetic basis for NSAIDs hypersensitivity. RECENT FINDINGS Five major clinical entities are currently accepted in the classification of hypersensitivity reactions to NSAIDs. Three are mediated by nonspecific immunological mechanisms: NSAIDs-exacerbated respiratory disease, NSAIDs-exacerbated cutaneous disease and NSAIDs-induced urticaria/angioedema. Two are mediated by specific immunological mechanisms: single-NSAID-induced urticaria/angioedema or anaphylaxis and single-NSAID-induced delayed hypersensitivity reactions. The classification becomes more complex if we consider that in an important number of cases skin and airway involvement can occur, as well as the participation of other organs. SUMMARY Hypersensitivity reactions to NSAIDs are more complex than for other drugs like betalactams in terms of the number and types of reactions elicited, and mechanisms involved. As NSAIDs are the most frequent cause of drug hypersensitivity, it is feasible to gather a sufficient number of cases for undertaking pharmacogenetic studies.
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30
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Picaud J, Beaudouin E, Renaudin JM, Pirson F, Metz-Favre C, Dron-Gonzalvez M, Moneret-Vautrin DA. Anaphylaxis to diclofenac: nine cases reported to the Allergy Vigilance Network in France. Allergy 2014; 69:1420-3. [PMID: 24931488 DOI: 10.1111/all.12458] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2014] [Indexed: 11/29/2022]
Abstract
Nine cases of diclofenac hypersensitivity recorded by the Allergy Vigilance Network in France from 2002 to 2012 were studied. Data from history, symptoms, skin tests, basophil activation tests, and oral challenge (OC) were recorded. Grade 3 severe anaphylactic reactions occurred in seven cases of nine. IgE-dependent anaphylaxis was confirmed in six cases: positive intradermal tests (n = 4), a syndromic reaction during skin tests (n = 1), and one case with grade 1 reaction and negative skin tests had an anaphylactic shock to the OC. A nonimmune reaction was suspected in one case. An IgE-dependent mechanism may be the predominant cause of adverse reactions to diclofenac. Allergy skin tests must be carried out sequentially at the recommended concentrations. BATs may be helpful because they can support the diagnosis of anaphylaxis. Given the risks of a direct challenge to diclofenac, OC to aspirin should be performed first to exclude a nonimmunologic hypersensitivity to NSAIDs. Tests for specific IgEs to most frequently used NSAIDs such as diclofenac and ibuprofen are urgently needed.
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Affiliation(s)
- J. Picaud
- Allergy Department; Emile Durkheim Hospital; Epinal France
- Allergy Vigilance Network; Vandoeuvre les Nancy France
| | - E. Beaudouin
- Allergy Department; Emile Durkheim Hospital; Epinal France
- Allergy Vigilance Network; Vandoeuvre les Nancy France
| | - J. M. Renaudin
- Allergy Department; Emile Durkheim Hospital; Epinal France
- Allergy Vigilance Network; Vandoeuvre les Nancy France
| | - F. Pirson
- Allergy Vigilance Network; Vandoeuvre les Nancy France
- Pneumology Department; Saint-Luc University Hospital; Bruxelles Belgium
| | - C. Metz-Favre
- Allergy Vigilance Network; Vandoeuvre les Nancy France
- Pneumology Department; New Civil Hospital; Strasbourg France
| | - M. Dron-Gonzalvez
- Allergy Vigilance Network; Vandoeuvre les Nancy France
- Allergy Vigilance Network; Martigues France
| | - D. A. Moneret-Vautrin
- Allergy Department; Emile Durkheim Hospital; Epinal France
- Allergy Vigilance Network; Vandoeuvre les Nancy France
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31
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Uyttebroek AP, Sabato V, Faber MA, Cop N, Bridts CH, Lapeere H, De Clerck LS, Ebo DG. Basophil activation tests: time for a reconsideration. Expert Rev Clin Immunol 2014; 10:1325-35. [DOI: 10.1586/1744666x.2014.959498] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Hypersensitivity Reactions to Nonsteroidal Anti-Inflammatory Drugs. Immunol Allergy Clin North Am 2014; 34:507-24, vii-viii. [DOI: 10.1016/j.iac.2014.04.001] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Wechwithan S, Suwankesawong W, Sornsrivichai V, McNeil EB, Jiraphongsa C, Chongsuvivatwong V. Signal detection for Thai traditional medicine: examination of national pharmacovigilance data using reporting odds ratio and reported population attributable risk. Regul Toxicol Pharmacol 2014; 70:407-12. [PMID: 24945744 DOI: 10.1016/j.yrtph.2014.06.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Revised: 06/02/2014] [Accepted: 06/06/2014] [Indexed: 11/17/2022]
Abstract
Herbal containing medicine consumption has increased while the awareness of adverse drug reaction (ADR) was less than conventional medicine. Early detection of unexpected numbers of ADRs from herbal medicines' reports which are abnormal from the whole database needs quantification. Disproportionality analysis has been performed for signal detection by using reporting odds ratio (ROR) as measurement. The impact of having medicine as exposures in each ADR should be measured by using reported population attributable risks (RPAR). This study aimed to quantify the contribution of Thai traditional medicine (TTM) to ADR reports and to assess the association between TTMs and serious adverse drug reactions. Data were retrieved from the adverse drug reaction surveillance database, Thai-Food and Drug Administration from 2002 to 2013. Crude and adjusted RORs for each drug-ADR pair and RPARs were computed. TTM contributed only 0.001% of all serious ADRs reported. Out of 4208 TTM-ADR pairs were examined, three had the statistically significant RORs, namely Andrographis paniculata and anaphylactic shock (ROR 2.32, 95% CI 1.03, 5.21); green traditional medicine and Stevens-Johnson syndrome (ROR 13.04, 95% CI 5.4-31.51) and Derris scandens Benth and angioedema (ROR 2.71, 95% CI 1.05-6.95). Their RPARs ranged from 0.05% to 0.16%. We conclude that TTMs need more intensive surveillance.
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Affiliation(s)
- Sareeya Wechwithan
- Health Product Vigilance Center, Food and Drug Administration, Ministry of Public Health, 11000, Thailand; Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Hatyai, Songkhla 90110, Thailand
| | - Wimon Suwankesawong
- Health Product Vigilance Center, Food and Drug Administration, Ministry of Public Health, 11000, Thailand
| | - Vorasith Sornsrivichai
- Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Hatyai, Songkhla 90110, Thailand
| | - Edward B McNeil
- Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Hatyai, Songkhla 90110, Thailand
| | - Chuleeporn Jiraphongsa
- Field Epidemiology Training Program (FETP), Bureau of Epidemiology, Department of Disease Control, Ministry of Public Health, 11000, Thailand
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Song WJ, Chang YS. Recent applications of basophil activation tests in the diagnosis of drug hypersensitivity. Asia Pac Allergy 2013; 3:266-80. [PMID: 24260732 PMCID: PMC3826605 DOI: 10.5415/apallergy.2013.3.4.266] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2013] [Accepted: 10/03/2013] [Indexed: 01/17/2023] Open
Abstract
Immediate-type drug hypersensitivity is an increasingly significant clinical issue; however, the diagnosis is frequently hindered due to lack of safe and precise diagnostic tests. Flow cytometry-assisted basophil activation test is a safe in vitro diagnostic tool for assessing basophil activation upon allergen stimulation. In this review, we have summarized current literature on the diagnostic utilities, new indications, and methodological aspects of the basophil activation test for the diagnosis of drug hypersensitivity.
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Affiliation(s)
- Woo-Jung Song
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul 100-799, Korea. ; Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul 100-799, Korea
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35
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Renaudin JM, Beaudouin E, Ponvert C, Demoly P, Moneret-Vautrin DA. Severe drug-induced anaphylaxis: analysis of 333 cases recorded by the Allergy Vigilance Network from 2002 to 2010. Allergy 2013; 68:929-37. [PMID: 23741979 DOI: 10.1111/all.12168] [Citation(s) in RCA: 100] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND A few series of well-documented cases of severe drug-induced anaphylaxis (SDA) are available. METHODS Cases collected by the Allergy Vigilance Network from 2002 to 2010 were analyzed for clinical signs, causative drugs, and efficacy of a stepwise approach to diagnosis, using skin tests, laboratory tests, and oral challenges. RESULTS Three hundred and thirty-three cases concerned 300 adults (90.1%) and 33 children (9.9%): 206 females (61.9%) and 127 males (38.1%). Mean age was 42.7 ± 18 years. Anaphylactic shock (76.6%), severe systemic reactions (10.5%), acute laryngeal edema (9%), severe bronchospasm (2.1%), and six fatal cases (1.8%) were recorded. There were 270 cases (81.1%) of ambulatory anaphylaxis. Sixty-three cases (18.9%) occurred during anesthesia. Hospitalization was required in 94.8% of cases. 23.7% of patients were admitted to an intensive care unit. Epinephrine was used in 57.9% of cases. Eighty-four drugs were incriminated: antibiotics (49.6%), muscle relaxants, latex and anesthetics (15%), nonsteroidal anti-inflammatory drugs (10.2%), acetaminophen (3.9%), iodinated or magnetic resonance imaging contrast media (4.2%), immunotherapy and vaccines (3.9%), and other drugs (13%). Among antibiotics, amoxicillin (97 cases), other penicillins (four cases), cephalosporins (41 cases), quinolones (15 cases), and pristinamycin (seven cases) were the most common. The diagnosis of drug hypersensitivity was obtained by skin tests in 72.9%, laboratory tests only in 2.4% of cases, and oral challenges (OCs) only in 3.9% of cases. CONCLUSIONS Three hundred and thirty-three case reports provided data on drugs involved in severe anaphylaxis. The efficacy of skin tests and poor use of laboratory tests are underlined. Further progress may depend on OCs.
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Affiliation(s)
- J-M Renaudin
- Department of Allergy, E Durkheim Hospital, Epinal, France
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36
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37
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Abstract
A range of mediators are generated during anaphylaxis, with redundancy of effects, multiple overlapping pathways, and involvement of several cell types. Key steps in the reaction occur at the site of initial contact, and mediators may not be detectable systemically. Furthermore, the potencies of various mediators vary enormously, and clinical effects may occur below our level of detection. We also do not know what converts (amplifies) a local reaction into systemic anaphylaxis. Murine models have identified several novel mediators that may propagate and/or regulate this process and also indicate that circulating neutrophils may play an important role in reaction amplification. Differential expression of various genes within specific intracellular signalling pathways of mediator release may further explain the varying severities of anaphylactic reactions. As our knowledge of the mechanisms of activation, key mediators, and the regulation of mediator release improves, new treatments for prevention and acute management may emerge.
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Affiliation(s)
- Shelley F Stone
- Centre for Clinical Research in Emergency Medicine, Western Australian Institute for Medical Research, University of Western Australia, Perth, Western Australia, Australia.
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38
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Caimmi S, Caimmi D, Bousquet PJ, Demoly P. How can we better classify NSAID hypersensitivity reactions?--validation from a large database. Int Arch Allergy Immunol 2012; 159:306-12. [PMID: 22739440 DOI: 10.1159/000337660] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2011] [Accepted: 02/22/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Hypersensitivity to nonsteroidal anti-inflammatory drugs (NSAIDs) is one of the most common drug hypersensitivities. Several clinical subtypes have been distinguished depending on symptomatology (respiratory, cutaneous, anaphylaxis), timing (immediate, delayed), underlying chronic disease (asthma, chronic urticaria) or putative mechanism of the reaction (allergic, nonallergic mediated). The aim of the present study was to better classify the many hypersensitivity reactions to NSAIDs. METHODS In the present retrospective study, during an 11-year study period, we collected data from all patients with a proven NSAID hypersensitivity. Reactions were classified according to clinical patterns, chronology, underlying diseases and the results of oral provocation tests into 5 and 7 groups in line with two published classifications, respectively. RESULTS Forty-nine and 88 out of 307 reactions (in 122 patients) could not be classified on the basis of the two previously published classifications. We created a new classification which could include all patient reactions. CONCLUSIONS Our new classification is more suitable for clinical expression of NSAID hypersensitivity. It allows clinicians to identify patients at a high risk, based on the clinical history and clinical manifestations. Moreover, it is helpful for a better understanding and teaching of these reactions.
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Affiliation(s)
- Silvia Caimmi
- Allergy Department and INSERM U657, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France
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Chaudhry T, Hissaria P, Wiese M, Heddle R, Kette F, Smith WB. Oral drug challenges in non-steroidal anti-inflammatory drug-induced urticaria, angioedema and anaphylaxis. Intern Med J 2012; 42:665-71. [DOI: 10.1111/j.1445-5994.2011.02601.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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40
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Chaudhry T, Hissaria P, Wiese M, Heddle R, Kette F, Smith WB. Oral drug challenges in non-steroidal anti-inflammatory drug-induced urticaria, angioedema and anaphylaxis. Intern Med J 2012. [DOI: 10.1111/j.1445-5994.2011.02601.x 671] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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41
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Steiner M, Harrer A, Lang R, Schneider M, Ferreira T, Hawranek T, Himly M. Basophil activation test for investigation of IgE-mediated mechanisms in drug hypersensitivity. J Vis Exp 2011:3263. [PMID: 21946858 PMCID: PMC3230192 DOI: 10.3791/3263] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Hypersensitivity reactions against non-steroidal anti-inflammatory drugs (NSAIDs) like propyphenazone (PP) and diclofenac (DF) can manifest as Type I-like allergic reactions 1. In clinical practice, diagnosis of drug hypersensitivity is mainly performed by patient history, as skin testing is not reliable and oral provocation testing bears life-threatening risks for the patient 2. Hence, evidence for an underlying IgE-mediated pathomechanism is hard to obtain. Here, we present an in vitro method based on the use of human basophils derived from drug-hypersensitive patients that mimics the allergic effector reaction in vivo. As basophils of drug-allergic patients carry IgE molecules specific for the culprit drug, they become activated upon IgE receptor crosslinking and release allergic effector molecules. The activation of basophils can be monitored by the determination of the upregulation of CD63 surface expression using flow cytometry 3. In the case of low molecular weight drugs, conjugates are designed to enable IgE receptor crosslinking on basophils. As depicted in Figure 1, two representatives of NSAIDs, PP and DF, are covalently bound to human serum albumin (HSA) via a carboxyl group reacting with the primary amino group of lysine residues. DF carries an intrinsic carboxyl group and, thus, can be used directly 4, whereas a carboxyl group-containing derivative of PP had to be organochemically synthesized prior to the study 1. The coupling degree of the low molecular weight compounds on the protein carrier molecule and their spatial distribution is important to guarantee crosslinking of two IgE receptor molecules. The here described protocol applies high performance-size exclusion chromatography (HPSEC) equipped with a sequential refractive index (RI) and ultra violet (UV) detection system for determination of the coupling degree. As the described methodology may be applied for other drugs, the basophil activation test (BAT) bears the potential to be used for the determination of IgE-mediated mechanisms in drug hypersensitivity. Here, we determine PP hypersensitivity as IgE-mediated and DF hypersensitivity as non-IgE-mediated by BAT.
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