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Mori F, Saretta F, Riscassi S, Caimmi S, Bottau P, Liotti L, Franceschini F, Bianchi A, Valluzzi RL, Crisafulli G, Caffarelli C. Risk factors for drug hypersensitivity reactions in children. Ital J Pediatr 2024; 50:127. [PMID: 39010141 PMCID: PMC11247891 DOI: 10.1186/s13052-024-01694-x] [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: 04/04/2024] [Accepted: 06/25/2024] [Indexed: 07/17/2024] Open
Abstract
Drug hypersensitivity reactions are common in children. Risk factors predisposing to IgE-mediated drug allergies and delayed drug reactions are a matter of debate. Gender, age, previous reactions to the same drug or to another drug, reduced drug metabolism, chronic diseases, polypharmacy, drug doses are linked with the onset of hypersensitivity reactions in some children. Novel advances in genetic polymorphisms can rapidly change the approach to the prevention of reactions since gene testing can be a useful screening test for severe cutaneous adverse reactions. Viral infections may act as cofactors in susceptible individuals. Polypharmacy, high doses, repeated doses and parental route of administration are also risk factors. Clinicians should take into account risk factors to allow the risk-benefit balance to be maintained.
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Affiliation(s)
- Francesca Mori
- Allergy Unit, Meyer Children's Hospital IRCCS, 50139, Florence, Italy
| | - Francesca Saretta
- Dipartimento Materno-Infantile, SC Pediatria, Ospedale Latisana-Palmanova, Azienda Sanitaria Universitaria Friuli Centrale, 33100, Udine, Italy
| | - Sara Riscassi
- UOC Di Pediatria, Ospedale Bolzano, Azienda Sanitaria Dell'Alto Adige, Bolzano, 39100, Italy
| | - Silvia Caimmi
- SC Di Pediatria, Fondazione IRCSS Policlinico San Matteo, 27100, Pavia, Italy
| | - Paolo Bottau
- UOC Di Pediatria E Neonatologia, Ospedale Imola (BO), Imola, 40026, Italy
| | - Lucia Liotti
- UOC Pediatria, Azienda Ospedaliero-Universitaria "Ospedali Riuniti", 60100, Ancona, Italy
| | | | - Annamaria Bianchi
- UOC Pediatria, Azienda Ospedaliera San Camillo Forlanini, 00152, Rome, Italy
| | - Rocco Luigi Valluzzi
- Translational Research in Pediatric Specialties Area, Division of Allergy, Bambino Gesù Children's Hospital, IRCCS, 00165, Rome, Italy
| | - Giuseppe Crisafulli
- Dipartimento Materno-Infantile, UOC Pediatria, University of Messina, Messina, 98122, Italy
| | - Carlo Caffarelli
- Department of Medicine and Surgery, Clinica Pediatrica, Azienda Ospedaliera-Universitaria, University of Parma, 43123, Parma, Italy.
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Arikoglu T, Tokmeci N, Demirhan A, Ozhan AK, Yalaki Aİ, Akbey V, Kuyucu S. Diagnostic evaluation of hypersensitivity reactions to arylpropionic acid derivatives: a descriptive observational study focusing on clinical characteristics and potential risk factors in children. Int J Clin Pharm 2024:10.1007/s11096-024-01756-4. [PMID: 38861048 DOI: 10.1007/s11096-024-01756-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 05/16/2024] [Indexed: 06/12/2024]
Abstract
BACKGROUND Arylpropionic acid derivatives (APs) are the main triggers of nonsteroidal anti-inflammatory drug (NSAID) hypersensitivity. Data on clinical patterns and risk factors for AP hypersensitivity in children are quite limited. AIM To assess the clinical characteristics and potential risk factors for proven AP hypersensitivity in children. METHOD Patients with a history of AP hypersensitivity were retrospectively assessed using a standardized diagnostic algorithm. Children with confirmed hypersensitivity were defined as selective responders or cross-intolerants based on the result of drug provocation tests and further categorized according to the EAACI/ENDA classification. A multivariable logistic regression analysis was performed to analyze the potential risk factors for proven AP hypersensitivity. RESULTS A total of 166 patients (51.2% male, median age of six years) with a history of AP hypersensitivity were included. Ibuprofen (89.2%) was the most frequently reported AP in the patients' histories. The reported hypersensitivity of 40 (22.4%) patients was confirmed by diagnostic testing: eight (13.6%) patients with a history of reaction only to APs and 32 (29.9%) patients with a history of reactions to multiple NSAIDs, including chemically unrelated NSAIDs in addition to APs. Five (12.5%) patients were classified as selective responders and 35 (87.5%) were cross-intolerants. Overall, five (12.5%) of the confirmed cases could not be categorized according to the EAACI/ENDA classification. Older age (aOR: 1.11, 95% CI 1.02-1.21, p = 0.015), chronic urticaria as an underlying disease (aOR: 2.87, 95% CI 1.09-7.54, p = 0.033) and a history of anaphylaxis (aOR: 7.84, 95% CI 1.86-33.04, p = 0.005) were related to confirmed AP hypersensitivity. CONCLUSION Almost a quarter of children and adolescents were confirmed to have AP hypersensitivity. Older age, the presence of chronic urticaria and a history of anaphylaxis were potential risk factors for proven AP hypersensitivity.
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Affiliation(s)
- Tugba Arikoglu
- Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Çiftlikköy Kampüsü, Yenişehir, Mersin, Turkey.
| | - Nazan Tokmeci
- Department of Pediatric Allergy and Immunology, Adıyaman University Training and Research Hospital, Adıyaman, Turkey
| | - Ali Demirhan
- Department of Pediatric Allergy and Immunology, Mersin City Training and Research Hospital, Mersin, Turkey
| | - Aylin Kont Ozhan
- Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Çiftlikköy Kampüsü, Yenişehir, Mersin, Turkey
| | - Aysu İlhan Yalaki
- Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Çiftlikköy Kampüsü, Yenişehir, Mersin, Turkey
| | - Veysi Akbey
- Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Çiftlikköy Kampüsü, Yenişehir, Mersin, Turkey
| | - Semanur Kuyucu
- Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Çiftlikköy Kampüsü, Yenişehir, Mersin, Turkey
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Doña I, Torres MJ, Celik G, Phillips E, Tanno LK, Castells M. Changing patterns in the epidemiology of drug allergy. Allergy 2024; 79:613-628. [PMID: 38084822 DOI: 10.1111/all.15970] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 11/23/2023] [Accepted: 11/26/2023] [Indexed: 03/01/2024]
Abstract
Drug allergy (DA) remains a complex and unaddressed problem worldwide that often deprives patients of optimal medication choices and places them at risk for life-threatening reactions. Underdiagnosis and overdiagnosis are common and due to the lack of standardized definitions and biomarkers. The true burden of DA is unknown, and recent efforts in data gathering through electronic medical records are starting to provide emerging patterns around the world. Ten percent of the general population engaged in health care claim to have a DA, and the most common label is penicillin allergy. Up to 20% of emergency room visits for anaphylaxis are due to DA and 15%-20% of hospitalized patients report DA. It is estimated that DA will increase based on the availability and use of new and targeted antibiotics, vaccines, chemotherapies, biologicals, and small molecules, which are aimed at improving patient's options and quality of life. Global and regional variations in the prevalence of diseases such as human immunodeficiency virus and mycobacterial diseases, and the drugs used to treat these infections have an impact on DA. The aim of this review is to provide an update on the global impact of DA by presenting emerging data on drug epidemiology in adult and pediatric populations.
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Affiliation(s)
- Immaculada Doña
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Malaga, Spain
- Allergy Unit, Hospital Regional Universitario de Málaga, Malaga, Spain
| | - Maria Jose Torres
- Allergy Research Group, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Malaga, Spain
- Allergy Unit, Hospital Regional Universitario de Málaga, Malaga, Spain
- Departamento de Medicina, Universidad de Málaga, Malaga, Spain
| | - Gulfem Celik
- Division of Immunology and Allergy, Department of Chest Diseases, Ankara University School of Medicine, Ankara, Turkey
| | - Elizabeth Phillips
- Department of Medicine, Center for Drug Safety and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia, Australia
| | - Luciana Kase Tanno
- Division of Allergy, Department of Pulmonology, Allergy and Thoracic Oncology, University Hospital of Montpellier, Montpellier, France
- Desbrest Institute of Epidemiology and Public Health, UMR UA11 University of Montpellier-INSERM, Montpellier, France
- WHO Collaborating Centre on Scientific Classification Support, Montpellier, France
| | - Mariana Castells
- Division of Allergy and Immunology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Arikoglu T, Tokmeci N, Demirhan A, Kont Ozhan A, Yalaki AI, Akbey V, Kuyucu S. Evaluation of different protocols for classification of pediatric hypersensitivity reactions to nonsteroidal anti-inflammatory drugs: Children with underlying allergic disease should be a separate subgroup. Allergy Asthma Proc 2024; 45:14-23. [PMID: 38151729 DOI: 10.2500/aap.2024.45.230081] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
Background: Different recommendations for the classification of nonsteroidal anti-inflammatory drug hypersensitivity reactions (NSHSR) in children have been reported but a shortage still exists. Objective: The aim of the present study was to evaluate the inclusivity of two European Academy of Allergy and Clinical Immunology (EAACI) position paper classifications and to characterize the factors that underlie classification discordance in children. Methods: Patients with a history of NSHSR were evaluated with a standardized diagnostic protocol according to EAACI/ European Network for Drug Allergy (ENDA) recommendations. Children were classified and compared according to the EAACI 2013 and the pediatric EAACI/ENDA 2018 classifications. Subjects who were unclassified and those who were classified were compared. Results: Of 232 patients (median [interquartile range] age 6 years (4-11 years) with a history of NSHSR, 52 (22.4%) were confirmed with diagnostic tests. Thirty-six (69.2%) were classified as having cross-intolerance, whereas 16 patients (30.8%) were classified as selective responders. Eleven of the confirmed cases (21.2%) could not be categorized according to the 2013 EAACI classification, whereas this number was six adolescents (11.5%) when the 2018 EAACI/ENDA pediatric classification was used. Patients who were unclassified and who were all cross-intolerant were more likely to have atopic sensitization (p = 0.001) and asthma as an underlying disease (p = 0.03), higher serum eosinophil count (p = 0.022), and total immunoglobulin E levels (p = 0.007) compared with those who fit well into the classification. In multivariate regression analysis, the presence of atopic sensitization (adjusted odds ratio 20.36 [95% confidence interval, 2.14-193.48]; p = 0.009) was found to be the only significant underlying factor for an unclassified and/or blended phenotype. Conclusion: The 2013 EAACI classification resulted in a high rate of subjects who were unclassified. Despite better clinical utility, the recent pediatric EAACI/ENDA classification system still has shortcomings in terms of inclusivity for adolescents. Mostly, children with underlying allergic diseases could not be classified by the current guidelines. We propose to classify them as a separate pediatric cross-intolerance subgroup because the underlying mechanism may involve more than cyclooxygenase 1 inhibition.
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Affiliation(s)
- Tugba Arikoglu
- From the Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Nazan Tokmeci
- Department of Pediatric Allergy and Immunology, Adıyaman University Training and Research Hospital, Adıyaman, Turkey, and
| | - Ali Demirhan
- Department of Pediatric Allergy and Immunology, Mersin City Training and Research Hospital, Mersin, Turkey
| | - Aylin Kont Ozhan
- From the Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Aysu Ilhan Yalaki
- From the Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Veysi Akbey
- From the Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Semanur Kuyucu
- From the Department of Pediatric Allergy and Immunology, Faculty of Medicine, Mersin University, Mersin, Turkey
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Salas-Casinello M, Sáenz-de Santa María R, López-Sánchez JD, Cornejo-Garcia JA, Pérez-Sánchez N, Casas R, Bartra J, Laguna JJ, Cortés-Collado JJ, Doña I, Torres MJ. Different Patterns of Response in Hypersensitivity Reactions to Arylpropionic Acid Derivatives. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:3715-3723. [PMID: 37586474 DOI: 10.1016/j.jaip.2023.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 07/27/2023] [Accepted: 08/06/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND Ibuprofen and other arylpropionic acid derivatives (APs) are among the most consumed nonsteroidal anti-inflammatory drugs worldwide at all age ranges; however, little is known about drug hypersensitivity reactions (DHRs) they induce. OBJECTIVE To characterize in detail patients reporting DHRs to APs. METHODS We prospectively evaluated patients with symptoms suggestive of AP-DHRs and analyzed their clinical characteristics, reported reactions, and diagnostic approaches. RESULTS Six hundred sixty-two patients confirmed as hypersensitive to APs were included: 489 with cross-reactive reactions (CRs) (73.86%) and 173 with selective reactions (SRs) (26.13%). The percentage of subjects reporting reactions to ibuprofen and dexketoprofen was higher in CRs (P = .005 and P = .01, respectively), whereas naproxen and ketoprofen were more frequently involved in SRs (P = .0002 and P = .00001, respectively). The most frequent symptoms induced by ibuprofen, dexketoprofen, and naproxen were isolated angioedema and urticaria, combined or not with angioedema in both CRs and SRs. The result of nasal provocation test with lysine acetylsalicylate was positive in 156 cases (77.14% in patients showing exclusively respiratory symptoms, and in 68.18% of those with both cutaneous and respiratory involvement). To confirm diagnosis, drug provocation test with acetylsalicylic acid was required in 246 CR patients (50.3%), whereas in 28 SR patients (16.18%) drug provocation test with the culprit AP was required. CONCLUSIONS Skin is the organ most commonly involved in AP-DHRs, with ibuprofen and dexketoprofen inducing most frequently CRs, and naproxen and ketoprofen SRs. More studies are necessary to clarify the underlying mechanism in DHRs induced by APs.
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Affiliation(s)
- María Salas-Casinello
- Allergy Unit, Hospital Regional Universitario de Málaga, Malaga, Spain; Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Malaga, Spain
| | - Rocío Sáenz-de Santa María
- Allergy Unit, Hospital Regional Universitario de Málaga, Malaga, Spain; Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Malaga, Spain
| | | | - José Antonio Cornejo-Garcia
- Allergy Unit, Hospital Regional Universitario de Málaga, Malaga, Spain; Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Malaga, Spain; Spanish Network for Allergy-RETICS de Asma, Reacciones adversas y Alérgicas, (ARADyAL), Madrid, Spain
| | - Natalia Pérez-Sánchez
- Allergy Unit, Hospital Regional Universitario de Málaga, Malaga, Spain; Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Malaga, Spain
| | - Rocío Casas
- Spanish Network for Allergy-RETICS de Asma, Reacciones adversas y Alérgicas, (ARADyAL), Madrid, Spain; Allergy Section, Pneumology Department, IDIBAPS, Universitat de Barcelona, Hospital Clinic, Barcelona, Spain
| | - Joan Bartra
- Spanish Network for Allergy-RETICS de Asma, Reacciones adversas y Alérgicas, (ARADyAL), Madrid, Spain; Allergy Section, Pneumology Department, IDIBAPS, Universitat de Barcelona, Hospital Clinic, Barcelona, Spain
| | - José Julio Laguna
- Spanish Network for Allergy-RETICS de Asma, Reacciones adversas y Alérgicas, (ARADyAL), Madrid, Spain; Allergy Unit, Hospital Central de la Cruz Roja, Madrid, Spain
| | | | - Inmaculada Doña
- Allergy Unit, Hospital Regional Universitario de Málaga, Malaga, Spain; Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Malaga, Spain; Spanish Network for Allergy-RETICS de Asma, Reacciones adversas y Alérgicas, (ARADyAL), Madrid, Spain.
| | - María José Torres
- Allergy Unit, Hospital Regional Universitario de Málaga, Malaga, Spain; Allergy Research Group, Instituto de Investigación Biomédica de Málaga-IBIMA, Malaga, Spain; Spanish Network for Allergy-RETICS de Asma, Reacciones adversas y Alérgicas, (ARADyAL), Madrid, Spain; Medicine Department, Universidad de Málaga, Malaga, Spain
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Tay SH, Santosa A, Goh ECH, Xu CX, Wu LH, Bigliardi-Qi M, Pakkiri LSS, Lee BTK, Drum CL, Bigliardi PL. Distinct transcriptomic and metabolomic profiles characterize NSAID-induced urticaria/angioedema patients undergoing aspirin desensitization. J Allergy Clin Immunol 2022; 150:1486-1497. [PMID: 35964779 DOI: 10.1016/j.jaci.2022.07.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 06/05/2022] [Accepted: 07/05/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND There is limited data on the mechanisms of aspirin desensitization in patients with nonsteroidal anti-inflammatory drug (NSAID)-induced urticaria/angioedema (NIUA). OBJECTIVES We sought to characterize the transcriptomic and metabolomic profiles of patients with NIUA undergoing aspirin desensitization. METHODS PBMCs and plasma were separated from the blood of patients with NIUA undergoing aspirin desensitization for coronary artery disease and NSAID-tolerant controls. RNA was isolated from PBMCs and subjected to messenger RNA (mRNA)- and long noncoding RNA (lncRNA)-sequencing. Plasma samples were analyzed using LC-MS/MS for metabolite shifts using a semitargeted metabolomics panel. RESULTS Eleven patients with NIUA and 10 healthy controls were recruited. The mRNA gene profiles of predesensitization versus postdesensitization and healthy control versus postdesensitization did not differ significantly. However, we identified 739 mRNAs and 888 lncRNAs as differentially expressed from preaspirin desensitization patients and controls. A 12-mRNA gene signature was trained using a machine learning algorithm to distinguish between controls, postdose, and predose samples. Ingenuity Pathway Analysis identified 5 canonical pathways that were significantly enriched in preaspirin desensitization samples. IL-22 was the most upregulated pathway. To investigate the potential regulatory roles of the differentially expressed lncRNA on the mRNAs, 9 lncRNAs and 12 mRNAs showed significantly correlated expression patterns in the IL-22 pathway. To validate the transcriptomics data, IL-22 was measured in the plasma samples of the subjects using ELISA. IL-22 was significantly higher in preaspirin desensitization patients compared with controls. In parallel, metabolomic analysis revealed stark differences in plasma profiles of preaspirin desensitization patients and healthy controls. In particular, 2-hydroxybenzoic acid (salicylic acid) was significantly lower in preaspirin desensitization patients compared with healthy controls. CONCLUSIONS This is the first study to combine both transcriptomic and metabolomic approaches in patients with NIUA, which contributes to a deeper understanding about the pathogenesis of NIUA and may potentially pave the way toward a molecular diagnosis of NSAID hypersensitivity.
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Affiliation(s)
- Sen Hee Tay
- Division of Rheumatology, Department of Medicine, National University Hospital, Singapore, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
| | - Amelia Santosa
- Division of Rheumatology, Department of Medicine, National University Hospital, Singapore, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Eugene Chen Howe Goh
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Chun Xiang Xu
- Department of Nursing, National University Hospital, Singapore, Singapore
| | - Lik Hang Wu
- Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore, Singapore
| | - Mei Bigliardi-Qi
- Department of Dermatology and Stem Cell Institute, University of Minnesota, Minneapolis, Minn
| | | | - Bernett Teck Kwong Lee
- Centre for Biomedical Informatics, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore; Singapore Immunology Network, Agency for Science, Technology and Research, Singapore, Singapore
| | - Chester Lee Drum
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore; Department of Cardiology, National University Heart Center, National University Hospital, Singapore, Singapore
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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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Lin Y, Li Y, Ma J, Li A, Liu Y, Shi L. Aspirin-Induced Delayed Urticaria in Children with Kawasaki Disease: A Retrospective Case-Control Study. Int J Gen Med 2021; 14:8211-8216. [PMID: 34815694 PMCID: PMC8605865 DOI: 10.2147/ijgm.s341398] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 11/09/2021] [Indexed: 12/18/2022] Open
Abstract
Background Aspirin remains a key component of the standard therapy for Kawasaki disease (KD) in children. Although it is well known that aspirin can cause hypersensitivity such as aspirin-induced urticaria (AIU), AIU in children with KD has not been described. Methods A retrospective case-control study was conducted to investigate AIU clinical features, biochemical parameters, treatment and outcomes in children with KD. Furthermore, biomarkers for predicting AIU were explored using the receiver operating characteristic (ROC) curve analysis. Results We identified 46 AIU cases with 22 boys and 24 girls during April 2015–May 2019. Eighty-nine age-matched KD patients without AIU were randomly chosen as controls. The proportions of children with allergy history and aspirin doses administered in the 2 groups were found not to be significantly different. AIU group had substantially higher baseline C-reactive protein and NT-proBNP levels, and increased neutrophil percent. AIU appeared 6.0 (4.0, 8.0) days after aspirin treatment. Aspirin withdrawal and anti-allergic treatment were applied for AIU, and AIU disappeared in 1–3 days. Baseline NT-proBNP predicted AIU with an AUC of 0.70 (95% CI [0.60 to 0.79]) for sensitivity and specificity of 72.1% and 62.5%, respectively, for a cut-off value of 612.9 mg/L. The length of hospital stay for AIU patients was significantly greater compared with controls. Conclusion AIU in KD children is not related to gender or aspirin dose, and those with AIU have more severe inflammation at admission. Aspirin should be withdrawn for AIU management. Baseline NT-proBNP may serve as a valuable biomarker to predict AIU.
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Affiliation(s)
- Yao Lin
- Department of Cardiology, Children's Hospital, Capital Institute of Pediatrics, Beijing, People's Republic of China
| | - Yaqi Li
- Department of Cardiology, Children's Hospital, Capital Institute of Pediatrics, Beijing, People's Republic of China
| | - Jingjing Ma
- Department of Cardiology, Children's Hospital, Capital Institute of Pediatrics, Beijing, People's Republic of China
| | - Aijie Li
- Department of Cardiology, Children's Hospital, Capital Institute of Pediatrics, Beijing, People's Republic of China
| | - Yang Liu
- Department of Cardiology, Children's Hospital, Capital Institute of Pediatrics, Beijing, People's Republic of China
| | - Lin Shi
- Department of Cardiology, Children's Hospital, Capital Institute of Pediatrics, Beijing, People's Republic of China
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Grumach AS, Staubach-Renz P, Villa RC, Diez-Zuluaga S, Reese I, Lumry WR. Triggers of Exacerbation in Chronic Urticaria and Recurrent Angioedema-Prevalence and Relevance. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2160-2168. [PMID: 34112472 DOI: 10.1016/j.jaip.2021.04.023] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 04/09/2021] [Accepted: 04/15/2021] [Indexed: 02/06/2023]
Abstract
Patients with urticaria and angioedema often have triggers that cause an outbreak or a swelling episode or worsen their chronic condition. Exploring these factors with each patient may result in better understanding and control of their disease. Patients should be advised to avoid known triggers, if feasible, or prepare to prevent or control an exacerbation with appropriate pretreatment if avoidance is not possible. In this review, we describe and discuss a variety of factors for which there is evidence that they cause or exacerbate chronic spontaneous urticaria and angioedema. These potentially exacerbating factors include drugs, food additives, and naturally occurring pseudoallergens, mental stress, and trauma.
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Affiliation(s)
| | | | - Ricardo Cardona Villa
- Facultad de Medicina-Universidad de Antioquia, Grupo de Alergología Clínica y Experimental, Medellín, Colombia
| | - Susana Diez-Zuluaga
- Facultad de Medicina-Universidad de Antioquia, Grupo de Alergología Clínica y Experimental, Medellín, Colombia
| | - Imke Reese
- Dietary Counseling and Nutrition Therapy Centre, Munich, Germany
| | - William R Lumry
- Clinical Faculty, University of Texas Southwestern Medical School, Allergy and Asthma Specialists, Dallas, Texas.
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10
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Klaewsongkram J, Buranapraditkun S, Mongkolpathumrat P, Palapinyo S, Chantaphakul H. Clinical Characteristics, Urinary Leukotriene E4 Levels, and Aspirin Desensitization Results in Patients With NSAID-Induced Blended Reactions. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2021; 13:229-244. [PMID: 33474858 PMCID: PMC7840864 DOI: 10.4168/aair.2021.13.2.229] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 09/06/2020] [Accepted: 09/19/2020] [Indexed: 12/12/2022]
Abstract
Purpose Data on non-steroidal anti-inflammatory drug (NSAID) hypersensitivity in Southeast Asia are scarce. Increased urinary leukotriene E4 (uLTE4) levels have been suggested as a biomarker of NSAID-exacerbated respiratory disease (NERD). This study investigated clinical patterns of NSAID sensitivity in Thailand and the diagnostic roles of uLTE4 measurement in various phenotypes. Methods The clinical phenotypes in 92 Thai adults with cross-reactive NSAID hypersensitivity were characterized based on the clinical history and drug provocation. The uLTE4 levels were measured at baseline, after aspirin provocation and after desensitization. Results More than half of the patients (56.5%) presented with cutaneous symptoms (NSAID-exacerbated cutaneous disease), while one-third (33.7%) developed symptoms in at least 2 systems (NSAID-induced blended reactions; NIBR). Fifty-two patients underwent drug provocation and 59.6% of them yielded positive results. After drug provocation, a significant number of patients with confirmed NSAID cross-reactivity experienced clinical symptoms in more than one organ system. The uLTE4 levels at baseline were comparable between the NSAID-tolerant and NSAID-sensitive groups, but were substantially increased after aspirin provocation predominantly in NERD (983.4 pg/mg creatinine) and NIBR (501.0 pg/mg creatinine) compared to NSAID-tolerant subjects (122.1 pg/mg creatinine, P < 0.01 and 0.05, respectively). The uLTE4 levels were elevated after aspirin desensitization, although nasal polyposis and asthma were under control in 3 NERD and 3 NIBR subjects. Conclusions NIBR is not uncommon among NSAID-sensitive patients in Thailand. The diagnostic value of basal uLTE4 levels was limited, but increased uLTE4 levels upon aspirin provocation suggest NSAID cross-reactivity with respiratory components. This study indicates that aspirin desensitization, if necessary, might be effective in both NERD and NIBR. Trial Registration ClinicalTrials.gov Identifier: NCT03849625
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Affiliation(s)
- Jettanong Klaewsongkram
- Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,The Skin and Allergy Research Unit, Chulalongkorn University, Bangkok, Thailand.,King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.
| | - Supranee Buranapraditkun
- Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Pungjai Mongkolpathumrat
- Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Sirinoot Palapinyo
- Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
| | - Hiroshi Chantaphakul
- Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
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11
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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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12
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Thong BYH, Lucas M, Kang HR, Chang YS, Li PH, Tang MM, Yun J, Fok JS, Kim BK, Nagao M, Rengganis I, Tsai YG, Chung WH, Yamaguchi M, Rerkpattanapipat T, Kamchaisatian W, Leung TF, Yoon HJ, Zhang L, Latiff AHA, Fujisawa T, Thien F, Castells MC, Demoly P, Wang JY, Pawankar R. Drug hypersensitivity reactions in Asia: regional issues and challenges. Asia Pac Allergy 2020; 10:e8. [PMID: 32099830 PMCID: PMC7016324 DOI: 10.5415/apallergy.2020.10.e8] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 01/27/2020] [Indexed: 12/19/2022] Open
Abstract
There are geographical, regional, and ethnic differences in the phenotypes and endotypes of patients with drug hypersensitivity reactions (DHRs) in different parts of the world. In Asia, aspects of drug hypersensitivity of regional importance include IgE-mediated allergies and T-cell-mediated reactions, including severe cutaneous adverse reactions (SCARs), to beta-lactam antibiotics, antituberculous drugs, nonsteroidal anti-inflammatory drugs (NSAIDs) and radiocontrast agents. Delabeling of low-risk penicillin allergy using direct oral provocation tests without skin tests have been found to be useful where the drug plausibility of the index reaction is low. Genetic risk associations of relevance to Asia include human leucocyte antigen (HLA)-B*1502 with carbamazepine SCAR, and HLA-B*5801 with allopurinol SCAR in some Asian ethnic groups. There remains a lack of safe and accurate diagnostic tests for antituberculous drug allergy, other than relatively high-risk desensitization regimes to first-line antituberculous therapy. NSAID hypersensitivity is common among both adults and children in Asia, with regional differences in phenotype especially among adults. Low dose aspirin desensitization is an important therapeutic modality in individuals with cross-reactive NSAID hypersensitivity and coronary artery disease following percutaneous coronary intervention. Skin testing allows patients with radiocontrast media hypersensitivity to confirm the suspected agent and test for alternatives, especially when contrasted scans are needed for future monitoring of disease relapse or progression, especially cancers.
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Affiliation(s)
- Bernard Yu-Hor Thong
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore
| | - Michaela Lucas
- Department of Immunology, Pathwest and Sir Charles Gairdner Hospital, Medical School, University of Western Australia, Perth, Australia
| | - Hye-Ryun Kang
- Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Department of Internal Medicine, Seoul National University College of Medicine, Drug Safety Center, Seoul National University Hospital, Seoul, Korea
| | - Yoon-Seok Chang
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Philip Hei Li
- Division of Rheumatology and Clinical Immunology, Department of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong
| | | | - James Yun
- Faculty of Medicine and Health, The University of Sydney, Division of Medicine, Nepean Hospital, Sydney, Australia
| | - Jie Shen Fok
- Department of Respiratory Medicine, Box Hill Hospital, Eastern Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Byung-Keun Kim
- Department of Internal Medicine, Korea University Medical Center Anam Hospital, Seoul, Korea
| | - Mizuho Nagao
- Allergy Center of Mie National Hospital, Tsu, Japan
| | - Iris Rengganis
- Department of Internal Medicine, Faculty of Medicine Universitas Indonesia - Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Yi-Giien Tsai
- School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wen-Hung Chung
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Keelung and Linkou Branches, College of Medicine, Chang Gung University, Taipei, Taiwan
| | - Masao Yamaguchi
- Division of Respiratory Medicine and Allergology, Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Ticha Rerkpattanapipat
- Allergy, Immunology and Rheumatology Division, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Wasu Kamchaisatian
- Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Ratchathewi, Bangkok, Thailand
| | - Ting Fan Leung
- Department of Paediatrics, The Chinese University of Hong Kong, Hong Kong
| | - Ho Joo Yoon
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Luo Zhang
- Department of Otolaryngology Head and Neck Surgery, Beijing TongRen Hospital, Capital Medical University, Beijing Key Laboratory of Nasal Diseases, Beijing Institute of Otolaryngology, Beijing, China
| | | | | | - Francis Thien
- Eastern Health, Melbourne; Monash University, Melbourne, Australia
| | - Mariana C Castells
- Division of Rheumatology, Immunology, and Allergy, Department of Medicine, Mastocytosis Center, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Pascal Demoly
- Division of Allergy, Department of Pulmonology, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, UPMC Univ Paris 06, UMRS 1136, Equipe - EPAR - IPLESP, Sorbonne Universités, Paris, France
| | - Jiu-Yao Wang
- Graduate Institute of Medical Sciences, China Medical University, Taichung, Taiwan
| | - Ruby Pawankar
- Department of Pediatrics, Nippon Medical School, Tokyo, Japan
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13
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Shaikhain TA, Al-Husayni F, Elder K. Ibuprofen-induced Anaphylactic Shock in Adult Saudi Patient. Cureus 2019; 11:e6425. [PMID: 31993263 PMCID: PMC6970456 DOI: 10.7759/cureus.6425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) are one of the most prescribed medications globally. They act through inhibiting cyclooxygenase (COX)-1 and COX-2 enzymes. In contrast to other NSAIDs, anaphylaxis due to ibuprofen is quite rare, especially in adults. The management of anaphylaxis depends on early recognition of the symptoms, administering epinephrine, and avoidance of the causing allergen. Here, we report a case of a 23-year-old female who presented with anaphylactic shock after ingesting ibuprofen.
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Affiliation(s)
| | | | - Kareem Elder
- Internal Medicine, National Guard Hospital, Jeddah, SAU
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14
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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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15
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Li KL, Lee AY, Abuzeid WM. Aspirin Exacerbated Respiratory Disease: Epidemiology, Pathophysiology, and Management. Med Sci (Basel) 2019; 7:E45. [PMID: 30884882 PMCID: PMC6473909 DOI: 10.3390/medsci7030045] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 03/11/2019] [Accepted: 03/11/2019] [Indexed: 11/17/2022] Open
Abstract
The correlation between aspirin sensitivity, asthma, and nasal polyposis was recognized in the early 20th century. Today, this classic triad of symptoms, eponymously named Samter's Triad, is known as aspirin exacerbated respiratory disease (AERD). Aspirin exacerbated respiratory disease affects approximately 0.3⁻0.9% of the general population in the USA and approximately 7% of asthmatic patients. The management of AERD is challenging as no single modality has proven to have high rates of symptom control. Consequently, disease management typically involves a multimodality approach across both medical and surgical disciplines. This review describes the epidemiology of AERD and the current state-of-the-art as it relates to the underlying pathophysiologic mechanisms of this disease process. A significant proportion of the review is focused on the appropriate diagnostic workup for AERD patients including the utility of aspirin provocation testing. The spectrum of medical treatments, including aspirin desensitization and recently introduced immunotherapies, are discussed in detail. Furthermore, surgical approaches to disease control, including advanced endoscopic techniques, are reviewed and treatment outcomes presented.
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Affiliation(s)
- Kevin L Li
- Department of Otorhinolaryngology: Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY 10467, USA.
| | - Andrew Y Lee
- Department of Otorhinolaryngology: Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY 10467, USA.
| | - Waleed M Abuzeid
- Department of Otorhinolaryngology: Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY 10467, USA.
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16
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Cavkaytar O, du Toit G, Caimmi D. Characteristics of NSAID-induced hypersensitivity reactions in childhood. Pediatr Allergy Immunol 2019; 30:25-35. [PMID: 30194799 DOI: 10.1111/pai.12980] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 08/27/2018] [Accepted: 09/03/2018] [Indexed: 12/26/2022]
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) are available as over-the-counter drugs, and they are commonly used in children for their antipyretic, analgesic, and anti-inflammatory effects. NSAIDs are among the most frequently reported drugs associated with hypersensitivity reactions and even with anaphylaxis. A complete evaluation of the patients based on reported clinical manifestations, timing of the reaction, the presence of underlying disease, and reactions to other NSAIDs allows clinicians to stratify children with a history of reaction to NSAIDs. Although NSAID-induced hypersensitivity reactions have mainly been investigated in adults, recent studies have aimed to explore their epidemiology in the pediatric population. This review will cover the current understanding of clinical manifestations, the risk factors, and the different phenotypes of NSAID-induced hypersensitivity reactions with a comprehensive overview of the epidemiologic data from past to present and the practical approach to the management of NSAID hypersensitivity in children and adolescents.
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Affiliation(s)
- Ozlem Cavkaytar
- Department of Pediatric Allergy, Istanbul Medeniyet University, Goztepe Training and Research Hospital, Istanbul, Turkey
| | - George du Toit
- Department of Pediatric Allergy, Division of Asthma, Allergy and Lung Biology, King's College London and Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Davide Caimmi
- Allergy Unit, Department of respiratory diseases, University Hospital of Montpellier, Univ Montpellier, Montpellier, France.,Epidemiology of Allergic and Respiratory Diseases Department (EPAR), Pierre Louis Institute of Epidemiology and Public Health, Saint-Antoine Medical School, Sorbonne Université, INSERM, Paris, France
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17
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Kont Özhan A, Doğruel D, Ufuk Altıntaş D, Yılmaz M. Erken tip ilaç reaksiyonlarında beş yıllık Çukurova Üniversitesi Çocuk Alerji Kliniği deneyimi. EGE TIP DERGISI 2019. [DOI: 10.19161/etd.418143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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18
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NSAIDs-hypersensitivity often induces a blended reaction pattern involving multiple organs. Sci Rep 2018; 8:16710. [PMID: 30420763 PMCID: PMC6232098 DOI: 10.1038/s41598-018-34668-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 10/23/2018] [Indexed: 12/22/2022] Open
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs)-induced hypersensitivity reactions are classified by the European Network on Drug Allergy (ENDA) as either cross-reactive or selective. The former is the most frequent type and includes patients with exclusively respiratory symptoms (NSAIDs-exacerbated respiratory disease, NERD) or exclusively cutaneous symptoms: NSAIDs-induced urticaria/angioedema (NIUA); and NSAIDs-exacerbated cutaneous disease (NECD). However, although not reflected in the current classification scheme (ENDA), in clinical practice a combination of both skin and respiratory symptoms or even other organs such as gastrointestinal tract symptoms (mixed or blended reactions) is frequently observed. This entity has not been sufficiently characterised. Our aim was to clinically characterize blended reactions to NSAIDs, comparing their clinical features with NERD and NIUA. We evaluated patients with symptoms suggestive of hypersensitivity to NSAIDs who attended the Allergy Unit of the Regional University Hospital of Malaga (Malaga, Spain) between 2008 and 2015. We included 880 patients confirmed as cross-reactive based on clinical history, positive nasal provocation test with lysine acetylsalicylate (NPT-LASA), and/or positive drug provocation test (DPT) with acetylsalicylic acid (ASA), who were classified as blended (261; 29.6%), NERD (108; 12.3%) or NIUA (511; 58.1%). We compared symptoms, drugs, underlying diseases and diagnostic methods within and between groups. Among blended patients the most common sub-group comprised those developing urticaria/angioedema plus rhinitis/asthma (n = 138), who had a higher percentage of underlying rhinitis (p < 0.0001) and asthma (p < 0.0001) than NIUA patients, showing similarities to NERD. These differences were not found in the sub-group of blended patients who developed such respiratory symptoms as glottis oedema; these were more similar to NIUA. The percentage of positive NPT-LASA was similar for blended (77%) and NERD groups (78.7%). We conclude that blended reactions are hypersensitivity reactions to NSAIDs affecting at least two organs. In addition to classical skin and respiratory involvement, in our population a number of patients also develop gastrointestinal symptoms. Given the high rate of positive responses to NPT-LASA in NERD as well as blended reactions, we suggest that all patients reporting respiratory symptoms, regardless of whether they have other associated symptoms, should be initially evaluated using NPT-LASA, which poses less risk than DPT.
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19
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Thong BYH. Nonsteroidal anti-inflammatory drug hypersensitivity in the Asia-Pacific. Asia Pac Allergy 2018; 8:e38. [PMID: 30402405 PMCID: PMC6209595 DOI: 10.5415/apallergy.2018.8.e38] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 10/19/2018] [Indexed: 12/19/2022] Open
Abstract
Nonsteroidal anti-inflammatory drug (NSAID) hypersensitivity reactions (HSRs) are often nonimmunologically mediated reactions which present with immediate HSR type manifestations. These are mediated by cyclooxygenase inhibition resulting in shunting towards the excessive production of leukotrienes. Important disease associations include asthma, nasal polyposis, and chronic spontaneous urticaria, especially among adults. The European Network on Drug Allergy/Global Allergy and Asthma European Network 2013 classification of NSAID HSR comprises nonselective HSR i.e., NSAID exacerbated respiratory disease (NERD), NSAIDs exacerbated cutaneous disease (NECD), NSAIDs induced urticarial-angioedema (NIUA); and selective (allergic) HSR i.e., single NSAID induced urticaria/angioedema or anaphylaxis, NSAIDs-induced delayed HSR. Much of the literature on genetic associations with NSAID HSR originate from Korea and Japan; where genetic polymorphisms have been described in genes involved in arachidonic acid metabolism, basophil/mast cell/eosinophil activation, various inflammatory mediators/cytokines, and different HLA genotypes. The Asian phenotype for NSAID HSR appears to be predominantly NIUA with overlapping features in some adults and children. NECD also appears to be more common than NERD, although both are not common in the Asian paediatric population. Between adults and children, children seem to be more atopic, although over time when these children grow up, it is likely that the prevalence of atopic adults with NSAID HSR will increase. Low-dose aspirin desensitization has been shown to be effective in the treatment of coronary artery disease, especially following percutaneous coronary intervention.
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Affiliation(s)
- Bernard Yu-Hor Thong
- Department of Rheumatology, Allergy and Immunology, Tan Tock Seng Hospital, Singapore 308433
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20
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Kidon M, Blanca-Lopez N, Gomes E, Terreehorst I, Tanno L, Ponvert C, Chin CW, Caubet JC, Soyer O, Mori F, Blanca M, Atanaskovic-Markovic M. EAACI/ENDA Position Paper: Diagnosis and management of hypersensitivity reactions to non-steroidal anti-inflammatory drugs (NSAIDs) in children and adolescents. Pediatr Allergy Immunol 2018; 29:469-480. [PMID: 29693290 DOI: 10.1111/pai.12915] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/19/2018] [Indexed: 01/02/2023]
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used in the pediatric population as antipyretics/analgesics and anti-inflammatory medications. Hypersensitivity (HS) reactions to NSAID in this age group, while similar to adults, have unique diagnostic and management issues. Although slowly accumulating, published data in this age group are still relatively rare and lacking a unifying consensus. This work is a summary of current knowledge and consensus recommendations utilizing both published data and expert opinion from the European Network of Drug Allergy (ENDA) and the Drug Hypersensitivity interest group in the European Academy of Allergy and Clinical Immunology (EAACI). This position paper summarizes diagnostic and management guidelines for children and adolescents with NSAIDs hypersensitivity.
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Affiliation(s)
- Mona Kidon
- The Pediatric Allergy Clinic, Sheba Medical Center, Tel Hashomer and the Sackler Faculty of Medicine, Safra Children's Hospital, Tel Aviv University, Tel Aviv, Israel
| | | | - Eva Gomes
- Allergy and Clinical Immunology Department, CHP, Porto, Portugal
| | - Ingrid Terreehorst
- Department of ENT and Pediatrics, Academisch Medisch Centrum, Amsterdam, The Netherlands
| | - Luciana Tanno
- Hospital Sírio Libanês, São Paulo, Brazil.,Division of Allergy, Department of Pulmonology, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, Montpellier, France.,UPMC Paris 06, UMR-S 1136, IPLESP, Equipe EPAR, Sorbonne Universités, Paris, France
| | - Claude Ponvert
- Paediatric Pulmonology & Allergy Service, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants Malades, Paris, France
| | - Chiang Wen Chin
- Department of Paediatrics, Kandang Kerbau Women's and Children's Hospital, Singapore, Singapore
| | | | - Ozge Soyer
- Pediatric Allergy Department, School of Medicine, Hacettepe University, Ankara, Turkey
| | - Francesca Mori
- Allergy Unit, Department of Pediatric Medicine, Anna Meyer Children's University Hospital, Florence, Italy
| | - Miguel Blanca
- Allergy Service, Infanta Leonor University Hospital, Spain University, Madrid, Spain
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21
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Sánchez-Borges M, Kidon MI. Reactions to Nonsteroidal Anti-Inflammatory Drugs in Children. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 6:1236-1237. [DOI: 10.1016/j.jaip.2017.09.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 09/28/2017] [Indexed: 10/28/2022]
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22
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Kim SD, Cho KS. Samter's Triad: State of the Art. Clin Exp Otorhinolaryngol 2018; 11:71-80. [PMID: 29642688 PMCID: PMC5951071 DOI: 10.21053/ceo.2017.01606] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 01/13/2018] [Accepted: 01/14/2018] [Indexed: 01/01/2023] Open
Abstract
Samter’s triad (ST) is a well-known disease characterized by the triad of bronchial asthma, nasal polyps, and aspirin intolerance. Over the past few years, a rapid development in the knowledge of the pathogenesis and clinical characteristics of ST has happened. The aim of this paper is to review the recent investigations on the pathophysiological mechanisms and genetic background, diagnosis, and different therapeutic options of ST to advance our understanding of the mechanism and the therapeutic control of ST. As concern for ST increase, more application of aspirin desensitization will be required to manage this disease successfully. There is also a need for continued research efforts in pathophysiology, treatment, and possible prevention.
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Affiliation(s)
- Sung-Dong Kim
- Department of Otorhinolaryngology-Head and Neck Surgery and Biomedical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Kyu-Sup Cho
- Department of Otorhinolaryngology-Head and Neck Surgery and Biomedical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
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Doña I, Barrionuevo E, Salas M, Cornejo-García JA, Perkins JR, Bogas G, Prieto A, Torres MJ. Natural evolution in patients with nonsteroidal anti-inflammatory drug-induced urticaria/angioedema. Allergy 2017; 72:1346-1355. [PMID: 28226401 DOI: 10.1111/all.13147] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND Nonsteroidal anti-inflammatory drugs (NSAIDs) are the most frequent triggers of drug hypersensitivity with NSAIDs-induced urticaria/angioedema (NIUA) the most common phenotype. Loss of hypersensitivity has been reported for IgE-mediated reactions; however, it has not been assessed in nonimmunological reactions such as NIUA. We evaluated NSAID-hypersensitivity over time in NIUA patients. METHODS Patients confirmed as NIUA by positive drug provocation test (DPT) with acetylsalicylic acid (ASA) during 2005-2012 (V1) were included (n=38). Subjects were prospectively re-evaluated by DPT with ASA/other NSAIDs at two time points between 2013 and 2015 (V2 and V3). Atopy was assessed by skin prick test (SPT) using inhalant and food allergens. RESULTS Patients were evaluated at V1 and re-evaluated after 60 months (V2; IR:48-81) and a further 18 months (V3; IR:14-24). At V2, the majority (24; 63.15%) tolerated ASA and other NSAIDs (Group A) while 14 (36.84%) still reacted (Group B). At V3, all Group A patients remained tolerant; all Group B patients remained hypersensitive. The number of previous episodes reported at V1 and the percentage of reactions induced by ASA/ibuprofen were significantly lower in Group A (P=.005 and P=.006, respectively). Group A patients developed tolerance 72 months (IR:45-87) after their last evaluated reaction (V1); this interval was shorter in nonatopics (P=.003), patients who experienced reactions over 1 hour after NSAIDs administration (P=.001), and those who experienced isolated urticaria after NSAID intake (P=.024). CONCLUSIONS NIUA patients may develop tolerance to NSAIDs over time, a process that seems to be influenced by atopy and type of clinical reaction.
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Affiliation(s)
- I. Doña
- Allergy Unit; Regional University Hospital of Malaga-IBIMA; Malaga Spain
| | - E. Barrionuevo
- Allergy Unit; Regional University Hospital of Malaga-IBIMA; Malaga Spain
| | - M. Salas
- Allergy Unit; Regional University Hospital of Malaga-IBIMA; Malaga Spain
| | - J. A. Cornejo-García
- Research Laboratory; IBIMA-Regional University Hospital of Malaga-UMA; Malaga Spain
| | - J. R. Perkins
- Research Laboratory; IBIMA-Regional University Hospital of Malaga-UMA; Malaga Spain
| | - G. Bogas
- Allergy Unit; Regional University Hospital of Malaga-IBIMA; Malaga Spain
| | - A. Prieto
- Allergy Unit; Regional University Hospital of Malaga-IBIMA; Malaga Spain
| | - M. J. Torres
- Allergy Unit; Regional University Hospital of Malaga-IBIMA; Malaga Spain
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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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Alves C, Romeira A, Abreu C, Carreiro-Martins P, Gomes E, Leiria-Pinto P. Non-steroidal anti-inflammatory drug hypersensitivity in children. Allergol Immunopathol (Madr) 2017; 45:40-47. [PMID: 27475775 DOI: 10.1016/j.aller.2016.04.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Revised: 03/12/2016] [Accepted: 04/01/2016] [Indexed: 12/29/2022]
Abstract
INTRODUCTION There are rather few publications about hypersensitivity reactions to non-steroidal anti-inflammatory drugs (NSAID) in the paediatric age. In this study, we aimed to assess the frequency of confirmed NSAID hypersensitivity in children with a previous reported reaction to NSAID in order to investigate the role of the drug provocation test (DPT) in the diagnostic workup and to explore the factors associated with confirmed NSAID hypersensitivity. METHODS We conducted a retrospective analysis of the clinical files from every patient under 18 years old who attended two Portuguese paediatric allergy outpatient clinics, from January 2009 to August 2014, due to a suspected NSAID hypersensitivity. RESULTS We included 119 patients, with a median age of nine years (P25-P75: 5-14). Ibuprofen was the commonest implicated NSAID in the patients' reports (n=94-79%). After DPT, NSAID hypersensitivity was confirmed in nine (7.6%) patients, excluded in 93 (78.2%) and was inconclusive in 17 (14.3%). In the majority (n=95-79.8%), the reaction occurred in the first 24h after intake. Eighty-four patients (70.6%) reported only cutaneous manifestations and 18 (15.1%) had systemic symptoms. Anaphylaxis represented a relative risk to NSAID hypersensitivity confirmation. No association was found for atopy and the number of previous reactions. CONCLUSION In our study, NSAID hypersensitivity was confirmed in a small proportion of the patients with a previous reported reaction. Ibuprofen was the most implicated drug with urticaria/angio-oedema as the commonest manifestation. Anaphylaxis was associated with confirmed drug hypersensitivity. The drug provocation test was essential to establish the diagnosis.
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Atanaskovic-Markovic M, Caubet JC. Management of drug hypersensitivity in the pediatric population. Expert Rev Clin Pharmacol 2016; 9:1341-1349. [DOI: 10.1080/17512433.2016.1213131] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
Nonsteroidal anti-inflammatory drugs (NSAIDs) are one of the most widely used classes of medications in children. Despite a reported positive safety profile, NSAIDs have been associated with toxicities in both overdose and routine use. Most children with NSAID overdoses are asymptomatic and should be managed conservatively, whereas a small number may present with severe symptoms. We review NSAID exposures in children and strategies for their clinical evaluation and management.
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Short-term ibuprofen treatment and pulmonary function in children with asthma. Indian Pediatr 2016; 52:691-3. [PMID: 26388628 DOI: 10.1007/s13312-015-0698-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To investigate the association between ibuprofen use and pulmonary function in children with Asthma. METHODS Ninety 9- to 10-year-old children were classified into 3 groups: Study group, mild to moderate stable asthmatic children with self-reported aspirin allergy and no history of anaphylaxis; Allergy control group: atopic children (allergic rhinitis/atopic dermatitis); Healthy control group: non-atopic healthy children. None of the participants in the atopic and healthy control groups had a history of aspirin allergy. All received ibuprofen 4 times a day for 3 consecutive days. Forced expiratory volume in the first second (FeV1) and fractional exhaled nitric oxide (FeNO) measurements were performed before and after ingestion of ibuprofen daily for 3 days. RESULTS In the study group, a decrease in FeV1 and increase in FeNO levels were observed after taking ibuprofen for 2 days. The atopic control group showed only an increase in FeNO but not FEV1. In the healthy control group, both FeV1 and FeNO were unchanged from baseline. CONCLUSION The results showed that cross-reactive non-steroidal anti-inflammatory drug hypersensitivity may exist between ibuprofen and aspirin. This raises the possibility that asthma exacerbation could be mediated by ibuprofen ingestion.
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Calvo Campoverde K, Giner-Muñoz M, Martínez Valdez L, Rojas Volquez M, Lozano Blasco J, Machinena A, Plaza A. Hypersensitivity reactions to non-steroidal anti-inflammatory drugs and tolerance to alternative drugs. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2016. [DOI: 10.1016/j.anpede.2015.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Gomes ER, Brockow K, Kuyucu S, Saretta F, Mori F, Blanca-Lopez N, Ott H, Atanaskovic-Markovic M, Kidon M, Caubet JC, Terreehorst I. Drug hypersensitivity in children: report from the pediatric task force of the EAACI Drug Allergy Interest Group. Allergy 2016; 71:149-61. [PMID: 26416157 DOI: 10.1111/all.12774] [Citation(s) in RCA: 179] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2015] [Indexed: 12/22/2022]
Abstract
When questioned, about 10% of the parents report suspected hypersensitivity to at least one drug in their children. However, only a few of these reactions can be confirmed as allergic after a diagnostic workup. There is still a lack of knowledge on drug hypersensitivity (DH) epidemiology, clinical spectrum, and appropriate diagnostic methods particularly in children. Meanwhile, the tools used for DH management in adults are applied also for children. Whereas this appears generally acceptable, some aspects of DH and management differ with age. Most reactions in children are still attributed to betalactams. Some manifestations, such as nonsteroidal anti-inflammatory drug-associated angioedema and serum sickness-like reactions, are more frequent among young patients as compared to adults. Risk factors such as viral infections are particularly frequent in children, making the diagnosis challenging. The practicability and validity of skin test and other diagnostic procedures need further assessment in children. This study presents an up-to-date review on epidemiology, clinical spectrum, diagnostic tools, and current management of DH in children. A new general algorithm for the study of these reactions in children is proposed. Data are presented focusing on reported differences between pediatric and adult patients, also identifying unmet needs to be addressed in further research.
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Affiliation(s)
- E. R. Gomes
- Allergology Department; Centro Hospitalar do Porto; Porto Portugal
| | - K. Brockow
- Division Environmental Dermatology and Allergology Helmholtz Zentrum München/TUM; Department of Dermatology und AllergologyBiederstein; Technical University Munich; Munich Germany
| | - S. Kuyucu
- Department of Pediatric Allergy and Clinical Immunology; Faculty of Medicine; Mersin University; Mersin Turkey
| | - F. Saretta
- Pediatric Department; Hospital of Palmanova; A.S.S.5 ‘Bassa Friulana’; Palmanova UD Italy
| | - F. Mori
- Allergy Unit; Department of Pediatric; Anna Meyer Children's Hospital; University of Florence; Florence Italy
| | - N. Blanca-Lopez
- Allergy Department; Infanta Leonor University Hospital; Madrid Spain
| | - H. Ott
- Division of Pediatric Dermatology; Children's Hospital Auf der Bult; Hannover Germany
| | - M. Atanaskovic-Markovic
- University Children's Hospital of Belgrade; Medical Faculty University of Belgrade; Belgrade Serbia
| | - M. Kidon
- Allergy and Clinical Immunology Unit and Institute for Pediatric Pulmonology and National CF Center; Safra Children's Hospital; Tel Hashomer Israel
| | - J.-C. Caubet
- Division of Pediatric Allergy; University Hospital of Geneva; Geneva Switzerland
| | - I. Terreehorst
- Department of ENT and Pediatrics; AMC; Amsterdam The Netherlands
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Lee XHM, Ong LX, Cheong JYV, Sultana R, Rao R, Lim HH, Ding XM, Loh WY, Punan M, Chiang WC. A stepwise approach in the management of chronic spontaneous urticaria in children. Asia Pac Allergy 2016; 6:16-28. [PMID: 26844216 PMCID: PMC4731476 DOI: 10.5415/apallergy.2016.6.1.16] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Accepted: 01/19/2016] [Indexed: 12/03/2022] Open
Abstract
Background There is limited literature in the management of chronic urticaria in children. Treatment algorithms are generally extrapolated from adult studies. Objective Utility of a weight and age-based algorithm for antihistamines in management of chronic spontaneous urticaria (CSU) in childhood. To document associated factors that predict for step of control of CSU and time taken to attain control of symptoms in children. Methods A workgroup comprising of allergists, nurses, and pharmacists convened to develop a stepwise treatment algorithm in management of children with CSU. Sequential patients presenting to the paediatric allergy service with CSU were included in this observational, prospective study. Results Ninety-eight patients were recruited from September 2012 to September 2013. Majority were male, Chinese with median age 4 years 7 months. A third of patients with CSU had a family history of acute urticaria. Ten point two percent had previously resolved CSU, 25.5% had associated angioedema, and 53.1% had a history of atopy. A total of 96.9% of patients achieved control of symptoms, of which 91.8% achieved control with cetirizine. Fifty percent of all the patients were controlled on step 2 or higher. Forty-seven point eight percent of those on step 2 or higher were between 2 to 6 years of age compared to 32.6% and 19.6% who were 6 years and older and lesser than 2 years of age respectively. Eighty percent of those with previously resolved CSU required an increase to step 2 and above to achieve chronic urticaria control. Conclusion We propose a weight- and age-based titration algorithm for different antihistamines for CSU in children using a stepwise approach to achieve control. This algorithm may improve the management and safety profile for paediatric CSU patients and allow for review in a more systematic manner for physicians dealing with CSU in children.
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Affiliation(s)
- Xin Hui Magdeline Lee
- Pharmacy Department, Kandang Kerbau Women's and Children's Hospital, Singapore 229899, Singapore
| | - Lin Xin Ong
- Allergy Service, Kandang Kerbau Women's and Children's Hospital, Singapore 229899, Singapore
| | - Jing Yi Vanessa Cheong
- Pharmacy Department, Kandang Kerbau Women's and Children's Hospital, Singapore 229899, Singapore
| | - Rehena Sultana
- Duke-NUS Graduate Medical School Singapore, Singapore 169857, Singapore
| | - Rajeshwar Rao
- Allergy Service, Kandang Kerbau Women's and Children's Hospital, Singapore 229899, Singapore
| | - Hwee Hoon Lim
- Allergy Service, Kandang Kerbau Women's and Children's Hospital, Singapore 229899, Singapore
| | - Xiao Mei Ding
- Allergy Service, Kandang Kerbau Women's and Children's Hospital, Singapore 229899, Singapore
| | - Wen Yin Loh
- Allergy Service, Kandang Kerbau Women's and Children's Hospital, Singapore 229899, Singapore
| | - Monika Punan
- Pharmacy Department, Kandang Kerbau Women's and Children's Hospital, Singapore 229899, Singapore
| | - Wen Chin Chiang
- Allergy Service, Kandang Kerbau Women's and Children's Hospital, Singapore 229899, Singapore
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Song HS, Choi WH, Choi WB, Yang S, Hwang IT, Baek HS. Drug reaction with eosinophilia and systemic symptom induced in a 9-year-old boy. ALLERGY ASTHMA & RESPIRATORY DISEASE 2016. [DOI: 10.4168/aard.2016.4.4.296] [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)
- Han Sol Song
- Department of Pediatrics, Hallym University Kangdong Sacred Heart Hospital, Seoul, Korea
| | - Woo Hyeok Choi
- Department of Pediatrics, Hallym University Kangdong Sacred Heart Hospital, Seoul, Korea
| | - Won-Bok Choi
- Department of Pediatrics, Hallym University Kangdong Sacred Heart Hospital, Seoul, Korea
| | - Seung Yang
- Department of Pediatrics, Hallym University Kangdong Sacred Heart Hospital, Seoul, Korea
| | - Il-Tae Hwang
- Department of Pediatrics, Hallym University Kangdong Sacred Heart Hospital, Seoul, Korea
| | - Hey-Sung Baek
- Department of Pediatrics, Hallym University Kangdong Sacred Heart Hospital, Seoul, Korea
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Liew WK, Loh W, Chiang WC, Goh A, Chay OM, Iancovici Kidon M. Pilot study of the use of Yin Qiao San in children with conventional antipyretic hypersensitivity. Asia Pac Allergy 2015; 5:222-9. [PMID: 26539405 PMCID: PMC4630461 DOI: 10.5415/apallergy.2015.5.4.222] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 10/10/2015] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Children with a diagnosis of cross-reactive hypersensitivity to both paracetamol and nonsteroidal anti-inflammatory drugs are limited in their choice of antipyretics. OBJECTIVE The aim of this pilot study is to evaluate the feasibility of using a Chinese proprietary medicine, Yin Qiao San (YQS), for fever relief. METHODS A single centre, open label, prospective clinical trial exploring the tolerability and feasibility of using YQS for fever relief in children who are unable to use conventional antipyretic medications. Children between 1-18 years of age with hypersensitivity to multiple antipyretics were recruited. Eligible participants underwent an oral provocation test with YQS. Children who passed the oral provocation test were instructed to take a prescribed dose of YQS when the temperature was >38.0℃ and continued till the fever settled. Time taken for fever resolution and any adverse events were collected. RESULTS A total of 21 children, mean age 10.7 years, had a diagnosis of paracetamol and ibuprofen hypersensitivity. All except one patient successfully tolerated an oral challenge of YQS. Of the 88 doses of YQS taken for fever over 38.0℃, 16 (18%) had documented temperature reduction 2 hours after ingestion and 30 (34%) had documented temperature reduction 4 hours after ingestion. There were 2 reports of urticaria after YQS use which were attributed to flare of recurrent spontaneous urticaria during the illness. None of the patients developed symptoms of circulatory compromise or respiratory distress. CONCLUSION YQS is generally well tolerated in patients with paracetamol and ibuprofen hypersensitivity.
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Affiliation(s)
- Woei Kang Liew
- Department of Paediatric Medicine, Allergy Service, KK Women's and Children's Hospital, Singapore 229899, Singapore
| | - Wenyin Loh
- Department of Paediatric Medicine, Allergy Service, KK Women's and Children's Hospital, Singapore 229899, Singapore
| | - Wen Chin Chiang
- Department of Paediatric Medicine, Allergy Service, KK Women's and Children's Hospital, Singapore 229899, Singapore
| | - Anne Goh
- Department of Paediatric Medicine, Allergy Service, KK Women's and Children's Hospital, Singapore 229899, Singapore
| | - Oh Moh Chay
- Department of Paediatric Medicine, Allergy Service, KK Women's and Children's Hospital, Singapore 229899, Singapore
| | - Mona Iancovici Kidon
- Allergy and Clinical Immunology Unit, Sheba Medical Center, Tel Hashomer 5262100, Israel
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Kowalski ML, Woessner K, Sanak M. Approaches to the diagnosis and management of patients with a history of nonsteroidal anti-inflammatory drug-related urticaria and angioedema. J Allergy Clin Immunol 2015; 136:245-51. [PMID: 26254051 DOI: 10.1016/j.jaci.2015.06.021] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 06/09/2015] [Accepted: 06/12/2015] [Indexed: 12/13/2022]
Abstract
Nonsteroidal anti-inflammatory drug (NSAID)-induced urticarial and angioedema reactions are among the most commonly encountered drug hypersensitivity reactions in clinical practice. Three major clinical phenotypes of NSAID-induced acute skin reactions manifesting with angioedema, urticaria, or both have been distinguished: NSAID-exacerbated cutaneous disease, nonsteroidal anti-inflammatory drug-induced urticaria/angioedema (NIUA), and single NSAID-induced urticaria and angioedema. In some patients clinical history alone might be sufficient to establish the diagnosis of a specific type of NSAID hypersensitivity, whereas in other cases oral provocation challenges are necessary to confirm the diagnosis. Moreover, classification of the type of cutaneous reaction is critical for proper management. For example, in patients with single NSAID-induced reactions, chemically nonrelated COX-1 inhibitors can be safely used. However, there is cross-reactivity between the NSAIDs in patients with NSAID-exacerbated cutaneous disease and NIUA, and thus only use of selective COX-2 inhibitors can replace the culprit drug if the chronic treatment is necessary, although aspirin desensitization will allow for chronic treatment with NSAIDs in some patients with NIUA. In this review we present a practical clinical approach to the patient with NSAID-induced urticaria and angioedema.
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Affiliation(s)
- Marek L Kowalski
- Department of Immunology, Rheumatology and Allergy, Medical University of Lodz, Lodz, Poland.
| | | | - Marek Sanak
- Department of Medicine, Jagiellonian University Medical College, Krakow, Poland
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Calvo Campoverde K, Giner-Muñoz MT, Martínez Valdez L, Rojas Volquez M, Lozano Blasco J, Machinena A, Plaza AM. [Hypersensitivity reactions to non-steroidal anti-inflammatory drugs and tolerance to alternative drugs]. An Pediatr (Barc) 2015. [PMID: 26195066 DOI: 10.1016/j.anpedi.2015.05.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
INTRODUCTION Hypersensitivity reactions to non-steroidal anti-inflammatory drugs (NSAIDs) are the most common reactions to drugs. The prevalence varies from 0.6 to 5.7% in general population, but there are no data available in children. The aim of this study is to determine the frequency of patients diagnosed with hypersensitivity to NSAIDs, and describe their clinical characteristics, type of hypersensitivity, and tolerance to alternative drugs. METHODS Retrospective study was conducted on children with suspected hypersensitivity to NSAIDs from January 2012 to December 2013. The diagnosis was confirmed by oral drug provocation test (DPT) to the drug involved in the group with a history of one episode, while in the group with a history of more than one episode with the same drug the diagnosis was based on clinical data. Subsequently, a DPT with acetylsalicylic acid (ASA) was done in order to classify hypersensitivity into selective or multiple. In those cases with a positive result, a DPT was performed with alternative drugs. RESULTS Out of a total of 93 children studied, 26 were diagnosed with hypersensitivity to NSAIDs: 7 confirmed by oral DPT, and 19 based on clinical data. Multiple hypersensitivity was diagnosed in 50% of patients. Ibuprofen was involved in all reactions. The most common clinical manifestation was angioedema (44%). Acetaminophen was the best tolerated alternative drug. CONCLUSIONS More than one quarter (28%) of the population studied was diagnosed with hypersensitivity to NSAIDs, and 50% had multiple hypersensitivity. Acetaminophen is a safe alternative in children with hypersensitivity to NSAIDs. Meloxicam may be an alternative in cases that do not tolerate acetaminophen.
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Affiliation(s)
- K Calvo Campoverde
- Servicio de Alergia e Inmunología Clínica Pediátrica, Hospital Sant Joan de Déu, Universitat de Barcelona, Esplugues de Llobregat, Barcelona, España
| | - M T Giner-Muñoz
- Servicio de Alergia e Inmunología Clínica Pediátrica, Hospital Sant Joan de Déu, Universitat de Barcelona, Esplugues de Llobregat, Barcelona, España
| | - L Martínez Valdez
- Servicio de Alergia e Inmunología Clínica Pediátrica, Hospital Sant Joan de Déu, Universitat de Barcelona, Esplugues de Llobregat, Barcelona, España
| | - M Rojas Volquez
- Servicio de Alergia e Inmunología Clínica Pediátrica, Hospital Sant Joan de Déu, Universitat de Barcelona, Esplugues de Llobregat, Barcelona, España
| | - J Lozano Blasco
- Servicio de Alergia e Inmunología Clínica Pediátrica, Hospital Sant Joan de Déu, Universitat de Barcelona, Esplugues de Llobregat, Barcelona, España
| | - A Machinena
- Servicio de Alergia e Inmunología Clínica Pediátrica, Hospital Sant Joan de Déu, Universitat de Barcelona, Esplugues de Llobregat, Barcelona, España
| | - A M Plaza
- Servicio de Alergia e Inmunología Clínica Pediátrica, Hospital Sant Joan de Déu, Universitat de Barcelona, Esplugues de Llobregat, Barcelona, España.
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Cavkaytar O, Arik Yilmaz E, Buyuktiryaki B, Sekerel BE, Sackesen C, Soyer OU. Challenge-proven aspirin hypersensitivity in children with chronic spontaneous urticaria. Allergy 2015; 70:153-60. [PMID: 25353369 DOI: 10.1111/all.12539] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND Nonsteroidal anti-inflammatory drug (NSAID) exacerbated cutaneous disease is defined as the exacerbation of wheals and/or angioedema in patients with a history of chronic spontaneous urticaria (CSU). The objective of this study was to define 'aspirin-hypersensitive' children and adolescents in a clearly defined group of patients with CSU and to describe their clinical features. METHODS Eighty-one children with a history of CSU were enrolled over a 3-year period. The daily or almost daily (>4 days a week) presence of urticaria was defined as 'chronic persistent urticaria' (CPU), while the presence of urticaria for 2-4 days a week was defined as 'chronic recurrent urticaria' (CRU). Single-blind, placebo-controlled provocation tests (SBPCPTs) with aspirin were performed for children with CSU. RESULTS Patients with CRU had a longer duration of cutaneous symptoms [1.6 (0.5-4) vs 0.6 (0.3-1.5) years], and stress was less frequently experienced as an eliciting factor in patients with CRU compared with the patients with CPU (P < 0.016, P = 0.024, respectively). SBPCPTs with aspirin revealed that 14 of 58 patients (24%) with CPU and one of 10 patients with CRU (10%) were aspirin hypersensitive. Aspirin hypersensitivity rate was 26.5% in patients <12 years of age. All of the 15 aspirin-hypersensitive patients (aged between 6.6 and 17.4 years), except for three, experienced an unequivocal angioedema of the lips as a positive reaction in SBPCPT. CONCLUSIONS Nearly a quarter of children and adolescents with CSU were hypersensitive to aspirin. For children with chronic urticaria, determination of NSAID hypersensitivity in a well-controlled clinical setting will help to avoid severe drug hypersensitivity reactions.
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Affiliation(s)
- Ozlem Cavkaytar
- Department of Pediatric Allergy; School of Medicine; Hacettepe University; Ankara Turkey
| | - Ebru Arik Yilmaz
- Department of Pediatric Allergy; School of Medicine; Hacettepe University; Ankara Turkey
| | - Betul Buyuktiryaki
- Department of Pediatric Allergy; School of Medicine; Hacettepe University; Ankara Turkey
| | - Bulent E. Sekerel
- Department of Pediatric Allergy; School of Medicine; Hacettepe University; Ankara Turkey
| | - Cansin Sackesen
- Department of Pediatric Allergy; School of Medicine; Hacettepe University; Ankara Turkey
| | - Ozge U. Soyer
- Department of Pediatric Allergy; School of Medicine; Hacettepe University; Ankara Turkey
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Loh W, Lim HH, Rao R, Goh A, Ong LX, Chiang WC. Tolerance to etoricoxib in children with nonsteroidal anti-inflammatory drug hypersensitivity. Asia Pac Allergy 2015; 5:40-6. [PMID: 25653919 PMCID: PMC4313751 DOI: 10.5415/apallergy.2015.5.1.40] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Accepted: 01/12/2015] [Indexed: 11/27/2022] Open
Abstract
Background Cyclooxygenase-2 (COX-2) inhibitors have been found to be safe alternatives in adults with cross-intolerant hypersensitivity to nonsteroidal anti-inflammatory drugs (NSAIDs). However they are usually not prescribed in children and there is little information about their tolerance in the pediatric age group. Objective This study aims to evaluate the tolerance to etoricoxib in children with hypersensitivity to multiple antipyretics. Methods A retrospective case series of children diagnosed with hypersensitivity reactions to NSAIDs and/or paracetamol who underwent a drug provocation test (DPT) with etoricoxib. Information on atopy, family history of allergic diseases, and medication usage was collected. Outcomes of the DPTs and tolerance to etoricoxib were also evaluated. Results A total of 24 children, mean age 13.5 years, had a diagnosis of cross-intolerant hypersensitivity to NSAIDs and/or paracetamol. All except one patient successfully tolerated an oral challenge with etoricoxib. Of those who passed the DPT, the majority continued to use etoricoxib with no problems. It was found to be moderately effective in reducing fever and pain. Conclusion Etoricoxib can be used as a safe alternative in older children with hypersensitivity to multiple antipyretics.
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Affiliation(s)
- Wenyin Loh
- Allergy Service, Department of Pediatric Medicine, KK Women's and Children's Hospital, Singapore 229899, Singapore
| | - Hwee Hoon Lim
- Allergy Service, Department of Pediatric Medicine, KK Women's and Children's Hospital, Singapore 229899, Singapore
| | - Rajeshwar Rao
- Allergy Service, Department of Pediatric Medicine, KK Women's and Children's Hospital, Singapore 229899, Singapore
| | - Anne Goh
- Allergy Service, Department of Pediatric Medicine, KK Women's and Children's Hospital, Singapore 229899, Singapore
| | - Lin Xin Ong
- Allergy Service, Department of Pediatric Medicine, KK Women's and Children's Hospital, Singapore 229899, Singapore
| | - Wen Chin Chiang
- Allergy Service, Department of Pediatric Medicine, KK Women's and Children's Hospital, Singapore 229899, Singapore
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Corzo JL, Zambonino MA, Muñoz C, Mayorga C, Requena G, Urda A, Gallego C, Blanca M, Torres MJ. Tolerance to COX-2 inhibitors in children with hypersensitivity to nonsteroidal anti-inflammatory drugs. Br J Dermatol 2014; 170:725-9. [PMID: 24116718 DOI: 10.1111/bjd.12674] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/02/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Hypersensitivity to nonsteroidal anti-inflammatory drugs (NSAIDs) can affect children, with the mechanism proposed being inhibition of the cyclooxygenase enzyme-1 (COX-1). In these patients nonchemically related NSAIDs, including COX-2 inhibitors, can induce the reaction, hampering treatment of fever and inflammatory processes. OBJECTIVES To analyse retrospectively tolerance to etoricoxib, a selective COX-2 inhibitor, and to meloxicam, a preferential COX-2 inhibitor, in children with hypersensitivity to NSAIDs. METHODS Clinical records of children (aged 1-14 years) diagnosed with hypersensitivity reactions to NSAIDs from January 2006 to January 2013 were included. The diagnosis was confirmed by oral drug provocation test (DPT) with the culprit NSAIDs and acetylsalicylic acid (ASA). Tolerance to paracetamol, etoricoxib and meloxicam was also evaluated. RESULTS The study included 41 children with a positive DPT with ASA and the culprit NSAID. DPT with paracetamol and etoricoxib was negative in all children, although two (4.9%) children developed a reaction after the administration of meloxicam. CONCLUSIONS These data indicate that both etoricoxib and meloxicam are good alternatives for treatment in older children with hypersensitivity to NSAIDs.
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Affiliation(s)
- J L Corzo
- Pediatric Service, Carlos Haya Hospital/IBIMA, Plaza del Hospital Civil s/n, pabellón 5, sótano, 29009, Malaga, Spain
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Jung JW, Cho SH, Kim KH, Min KU, Kang HR. Clinical features of fixed drug eruption at a tertiary hospital in Korea. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2014; 6:415-20. [PMID: 25228998 PMCID: PMC4161682 DOI: 10.4168/aair.2014.6.5.415] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Revised: 10/08/2013] [Accepted: 11/05/2013] [Indexed: 01/17/2023]
Abstract
Purpose Fixed drug eruption (FDE) is characterized by a well-defined erythematous patch, plaque, or bullous eruption that recurs at the same site as the result of systemic exposure to a causative drug, and resolves with or without hyperpigmentation. This study was carried out to identify the common causative drugs and clinical features of FDE in Korea. Methods We reviewed electronic medical records of all patients diagnosed with FDE from January 2000 to December 2010 at a tertiary hospital in Korea. Results A total of 134 cases were diagnosed as FDE. The mean age was 35.9 years (range, 0-82 years) and 69 (51.5%) of the patients were male. The mean duration from the first event to attending hospital was 1.9 years (range, 1-20 years). The mean number of recurrences was 2.6 (1-10), and 72.6% of patients sought medical care after experiencing symptoms twice or more. Four patients (3.1%) needed hospitalization. The most common sites were the upper extremities (47.7%), followed by the lower extremities, face, abdomen, chest, buttocks and perineum. Clear documentation on the causative drugs was available for 38 patients (28.4%), and among these, non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen accounted for 71.1% of cases, and antibiotics accounted for 15.8%. Eighty patients (59.7%) underwent active treatment for FDE, and topical steroids were most frequently prescribed (43.3%), with systemic steroids used in 11.2% of patients. Conclusions NSAIDs and acetaminophen were the main causative agents of FDE, however, the causative agents were not assessed in 25% of patients.
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Affiliation(s)
- Jae-Woo Jung
- Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul, Korea. ; Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
| | - Sang-Heon Cho
- Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul, Korea. ; Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Kyu-Han Kim
- Department of Dermatology, Seoul National University College of Medicine, Seoul, Korea
| | - Kyung-Up Min
- Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul, Korea. ; Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Hye-Ryun Kang
- Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul, Korea. ; Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
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Scott DR, White AA. Approach to desensitization in aspirin-exacerbated respiratory disease. Ann Allergy Asthma Immunol 2014; 112:13-7. [PMID: 24331387 DOI: 10.1016/j.anai.2013.09.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Revised: 08/28/2013] [Accepted: 09/01/2013] [Indexed: 11/26/2022]
Affiliation(s)
- David R Scott
- Scripps Clinic Division of Allergy, Asthma and Immunology, San Diego, California.
| | - Andrew A White
- Scripps Clinic Division of Allergy, Asthma and Immunology, San Diego, California
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Yilmaz O, Ertoy Karagol IH, Bakirtas A, Topal E, Celik GE, Demirsoy MS, Turktas I. Challenge-proven nonsteroidal anti-inflammatory drug hypersensitivity in children. Allergy 2013; 68:1555-61. [PMID: 24117618 DOI: 10.1111/all.12266] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2013] [Indexed: 02/04/2023]
Abstract
BACKGROUND Few studies investigated hypersensitivity to nonsteroidal anti-inflammatory drugs (NSAIDs) in children. The objective was to determine the frequency of true NSAID hypersensitivity (NSAID-H) and whether there were any parameters in the history of children that would predict NSAID-H. Secondly, an investigation was conducted into whether NSAID-hypersensitive children could tolerate safe alternatives. Differing from previous studies, the researchers followed the recent diagnostic algorithm proposed for acute reactions in NSAID-H. METHODS Children with a history suggesting NSAID-H were evaluated by an allergist. The patients with a single NSAID in history were tested first with a skin prick test and if negative challenged with the culprit NSAID. The patients who had reactions with multiple NSAIDs were directly challenged with their culprit drugs. Safe alternatives in children with a confirmed NSAID-H were found by oral provocation tests (OPTs). RESULTS Fifty-eight of 61 patients participated in the study. Thirty-eight patients (65.5%) described a reaction to a single NSAID and 20 mentioned reactions with ≥2 different NSAIDs. Single-drug-induced and cross-reactive NSAID-Hs were proven in 5 of 36 (14%) and 8 of 18 (44%) of patients, respectively. Acetaminophen and nimesulide were tolerated in 60% and 88.8% of the study patients as safe alternatives, respectively. Family history of NSAID-H was found as the only significant predictor of OPT (OR: 5.4; 95% CI: 1.02-28.6). CONCLUSION Histories of both single and multiple NSAID-Hs are poor predictors of actual drug hypersensitivity. Therefore, diagnostic tests should be performed in all children if no contraindication exits. Family history of NSAID-H is the only significant parameter predicting OPT results.
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Affiliation(s)
- O. Yilmaz
- Department of Pediatric Allergy and Asthma; Gazi University; School of Medicine; Ankara Turkey
| | - I. H. Ertoy Karagol
- Department of Pediatric Allergy and Asthma; Gazi University; School of Medicine; Ankara Turkey
| | - A. Bakirtas
- Department of Pediatric Allergy and Asthma; Gazi University; School of Medicine; Ankara Turkey
| | - E. Topal
- Department of Pediatric Allergy and Asthma; Gazi University; School of Medicine; Ankara Turkey
| | - G. E. Celik
- Department of Immunology and Allergy; Ankara University; School of Medicine; Ankara Turkey
| | - M. S. Demirsoy
- Department of Pediatric Allergy and Asthma; Gazi University; School of Medicine; Ankara Turkey
| | - I. Turktas
- Department of Pediatric Allergy and Asthma; Gazi University; School of Medicine; Ankara Turkey
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Zambonino MA, Torres MJ, Muñoz C, Requena G, Mayorga C, Posadas T, Urda A, Blanca M, Corzo JL. Drug provocation tests in the diagnosis of hypersensitivity reactions to non-steroidal anti-inflammatory drugs in children. Pediatr Allergy Immunol 2013; 24:151-9. [PMID: 23506290 DOI: 10.1111/pai.12039] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/11/2012] [Indexed: 01/07/2023]
Abstract
INTRODUCTION Hypersensitivity reactions to non-steroidal anti-inflammatory drugs (NSAIDs) are the most frequently reported reaction to drugs. They can be induced by pharmacological mechanisms (cyclooxygenase inhibition), with patients classified as cross-intolerant (CI), or by specific immunological mechanisms, IgE or T cell, with patients classified as selective reactors (SR). OBJECTIVE To analyse a large group of children with a history of NSAID hypersensitivity diagnosed by drug provocation test (DPT). METHODS A group of 63 children with a history of NSAID hypersensitivity were evaluated by DPT. The children were classified as CI or SR depending on the acetyl salicylic acid (ASA) response in DPT. The atopic status was also assessed by prick tests and total IgE in serum. RESULTS Using DPT, 68.2% were confirmed as having hypersensitivity, 58.1% classified as CI and 41.9% as SR. Of the 119 DPT performed, 73 were positive (53.4% to ibuprofen, 37% to ASA, 8.2% to metamizol and 14% to paracetamol); angio-oedema was present in 86.3% of cases. All CI cases tolerated the administration of paracetamol. A significant number of the CI children were atopic compared with the SR children and non-allergic controls. CONCLUSION In these children, CI hypersensitivity to NSAIDs was the most frequent type of hypersensitivity reaction. Ibuprofen was the drug most often involved, angio-oedema the most common entity, and frequently associated with atopy. DPT proved a safe approach for diagnosing these patients.
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Abstract
Non-steroidal anti-inflammatory (NSAIDs) drugs are a group of medications acting through cyclooxygenase (COX-1) and cyclooxygenase (COX-2) enzymes inhibition. Hypersensitivity reactions to NSAIDs, although not rare, are poorly characterised and often go undiagnosed especially in children. We present in this paper a case of ibuprofen anaphylaxis that exemplifies the challenges involved in diagnosis and management of hypersensitivity reactions to NSAIDs.
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Affiliation(s)
- Emily Kay
- Department of Paediatrics, Montreal Children's Hospital, McGill University Health Center, Montreal, Quebec, Canada
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Wismol P, Putivoranat P, Buranapraditkun S, Pinnobphun P, Ruxrungtham K, Klaewsongkram J. The values of nasal provocation test and basophil activation test in the different patterns of ASA/NSAID hypersensitivity. Allergol Immunopathol (Madr) 2012; 40:156-63. [PMID: 21492991 DOI: 10.1016/j.aller.2010.12.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2010] [Revised: 12/22/2010] [Accepted: 12/24/2010] [Indexed: 11/30/2022]
Abstract
BACKGROUND The oral provocation test (OPT) is the current gold standard to diagnose aspirin hypersensitivity syndrome although it is time-consuming and contains some systemic risks. Other reliable methods with lower side effects and shorter test duration are being investigated. OBJECTIVE The purpose of this study was to evaluate the efficacy of the nasal provocation test (NPT) and the basophil activation test (BAT) in the diagnosis of different subtypes of aspirin sensitivity. METHODS Thirty aspirin sensitivity patients with cutaneous and respiratory manifestations underwent NPT and BAT with lysine-ASA. NPT result was interpreted as recommended in EAACI/GA2LEN guidelines and receiver operating characteristic analysis of BAT was performed by using 15 NSAIDs tolerant volunteers as a control group. RESULTS NPT was positive in 60% (18/30) of patients and BAT was positive in 76.7% (23/30) of patients. The incubation of basophils with 0.31 mg/ml of lysine-aspirin and using 4.6% activated basophils gives the best predictive values to diagnose aspirin sensitivity. The combination of both tests yielded positive results in 80% and 93.3% of aspirin-induced cutaneous and respiratory patterns. The agreement between NPT and BAT results was 63.3%. CONCLUSIONS NPT and BAT are beneficial to detect patients with aspirin sensitivity. The combination of both tests have additional diagnostic values; less time-consuming than OPT and their complications are negligible. A reliable alternative method with minimum side effects is needed to diagnose aspirin sensitivity in suspected patients who have contraindications for OPT.
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Affiliation(s)
- P Wismol
- Division of Allergy and Clinical Immunology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Ponvert C. [Allergic and non-allergic hypersensitivity to non-opioid analgesics, antipyretics and nonsteroidal anti-inflammatory drugs in children: epidemiology, clinical aspects, pathophysiology, diagnosis and prevention]. Arch Pediatr 2012; 19:556-60. [PMID: 22381666 DOI: 10.1016/j.arcped.2012.01.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2011] [Revised: 01/23/2012] [Accepted: 01/25/2012] [Indexed: 11/17/2022]
Abstract
Non-opioid analgesics, antipyretics and nonsteroidal anti-inflammatory drugs are widely used, but suspected allergic reactions to these drugs are rare, especially in children. Most frequent reactions are cutaneous (urticaria, angioedema) and respiratory (rhinitis, asthma). Other reactions (anaphylaxis, potentially harmful toxidermias) are rare. In a few patients, reactions may result from a specific (allergic) hypersensitivity, with positive responses in prick and intradermal tests (anaphylaxis, immediate urticaria and/or angioedema) and in intradermal and patch tests (non-immediate reactions). However, most reactions result from a non-specific (non-allergic) hypersensitivity (intolerance), with a frequent cross-reactivity between the various families of analgesics, antipyretics and nonsteroidal anti-inflammatory drugs, including paracetamol. Based on a convincing clinical history and/or positive responses in challenge tests, intolerance to non-opioid analgesics, antipyretics and nonsteroidal anti-inflammatory drugs has been diagnosed in 13 to 50% of the patients with allergic-like reactions to these drugs. Risk factors are a personal atopy and age. Prevention is based on administration of other (families of) analgesics, antipyretics and nonsteroidal anti-inflammatory drugs in patients with allergic hypersensitivity to these drugs. In patients with non-allergic hypersensitivity, prevention is based on administration of drugs with a low cyclo-oxygenase-1 inhibitory activity (if tolerated). Desensitization is efficient in patients with respiratory reactions, but does not work in patients with mucocutaneous reactions and anaphylaxis.
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Affiliation(s)
- C Ponvert
- Service de pneumologie et allergologie pédiatriques, département de pédiatrie, université Paris Descartes, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75015 Paris, France.
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Diagnostic des réactions d’hypersensibilité allergique et non allergique aux médicaments courants de l’enfant : arbre décisionnel. Arch Pediatr 2011; 18:486-92. [DOI: 10.1016/j.arcped.2011.01.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2010] [Revised: 01/10/2011] [Accepted: 01/10/2011] [Indexed: 11/18/2022]
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Abou Chakra CN, Pariente A, Pinet M, Nkeng L, Moore N, Moride Y. Case series in drug safety: a review to determine characteristics and quality. Drug Saf 2011; 33:1081-8. [PMID: 21077699 DOI: 10.2165/11539300-000000000-00000] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Case series and case reports are a cornerstone of drug safety research; however, the characteristics of case series published in the literature remain poorly examined. A narrative review of case series addressing drug safety, published in the literature between 1 January 2003 and 15 July 2009, and identified through a PubMed search, was conducted in order to determine their characteristics and quality according to the criteria found in the US FDA Pharmacovigilance Guidance 2005. Of 130 publications that met the search criteria, 11.5% included an analytical component and 88.5% were descriptive. The median number of cases included in a given case series was 7 (range 2-2195) and the median time period for recruitment of the cases was 23 months (range 0.5-96). Overall, 43.1% of case series consisted of individual case reports, while 24.6% originated from cohorts and 21% from pharmacovigilance databases. Of the case series, 65.1% concerned adults (age ≥18 years), 11.6% elderly (age ≥65 years) and 8.5% youth (<18 years). Adverse effects involved mainly the skin (18.5%) and the circulatory system (13.8%). The main suspected drug classes (Anatomical Therapeutic Chemical classification) were nervous system drugs (23.1%) and antineoplastic and immunomodulating agents (20.0%). On average, six out of the possible nine US FDA Pharmacovigilance Guidance Criteria were fulfilled, with 27% of publications fulfilling at least seven criteria. Only 10% reported data on co-morbidity. In conclusion, this review highlights the reporting gaps and heterogeneity in published case series with respect to size, recruitment period and quality.
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Lavaud F, Mouton C, Ponvert C. Les tests cutanés dans le bilan diagnostique des réactions d’hypersensibilité peranesthésiques. ACTA ACUST UNITED AC 2011; 30:264-79. [DOI: 10.1016/j.annfar.2010.12.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Ibuprofen: pharmacology, efficacy and safety. Inflammopharmacology 2009; 17:275-342. [DOI: 10.1007/s10787-009-0016-x] [Citation(s) in RCA: 256] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2009] [Accepted: 09/04/2009] [Indexed: 12/26/2022]
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