Anaphylactic reactions due to pantoprazole: case report of two cases

Investigating Skin Rashes Associated With Pantoprazole Medication: Causes and Clinical Implications

Pantoprazole is a proton-pump inhibitor mainly used in treating various gastroesophageal disorders and frequently as prophylaxis for stress ulcers and gastrointestinal bleeding in most patients admitted for in-hospital management. Hypersensitivity reactions to this medication have been reported, although the exact incidence and prevalence are unknown. Further studies on proton-pump inhibitor allergic reactions should be conducted to enable physicians to safely select and prescribe an alternative type of medication within the same drug class, confidently avoiding the allergenic molecular compound that the patient reacted to previously. We present a case of a 35-year-old male postoperative bariatric patient with no significant allergy history who developed an allergic skin rash a week after being discharged on pantoprazole 40 mg. His rash was itchy and distributed mainly over the torso and lower limbs, without any additional respiratory or gastrointestinal symptoms.

Anaphylaxis Caused by Taking Pantoprazole: Case Series

Introduction

Pantoprazole is one of the most widely used proton pump inhibitors, but anaphylaxis occurs rarely during its use. The purpose of reporting these two cases is to show that pantoprazole is not a drug without problems; it can also cause anaphylactic reactions.

Cases description

A 42-year-old woman presented to the emergency department due to dyspeptic complaints. Immediately at the end of the infusion of pantoprazole, there started to be numbness of the tongue, itching all over the body, and difficulty in breathing. Half an hour after taking a pantoprazole 40 mg capsule, a 58-year-old woman started to experience redness of the face, thickening of the tongue, itching, bloating, and dizziness. Arterial pressure was 80/60 mmHg, pulse 150/minute, while saturation had dropped to 88%. In both cases, fluids, adrenaline, antihistamines, methylprednisolone, and calcium were immediately started. After the improvement of their general conditions, both patients were discharged home.

Discussion

The first case relates to anaphylaxis after the intravenous administration of pantoprazole, and the second case relates to the appearance of anaphylaxis after its oral administration.

Conclusion

Health workers need to be informed about the possibility of anaphylaxis in patients taking both oral and parenteral pantoprazole.

LEARNING POINTS

PPIs are generally safe, with a low percentage of side effects of 1-3%.Although hypersensitive reactions to PPIs are rare, cases of anaphylactoid reactions have also been reported in the literature.Anaphylaxis caused by taking pantoprazole should be considered in the differential diagnosis of anaphylaxis in both oral and parenteral administration of the drug.Doctors and pharmacists should be very careful when prescribing pantoprazole and other PPIs, especially to the elderly.

Pharmacokinetics of Pantoprazole and Pantoprazole Sulfone in Goats After Intravenous Administration: A Preliminary Report

Background: Ruminant species are at risk of developing abomasal ulceration, but there is a lack of pharmacokinetic data for anti-ulcer therapies, such as the proton pump inhibitor pantoprazole, in goats.

Objective: The primary study objective was to estimate the plasma pharmacokinetic parameters for pantoprazole in adult goats after intravenous administration. A secondary objective was to describe the pharmacokinetic parameters for the metabolite, pantoprazole sulfone, in goats.

Methods: Pantoprazole was administered intravenously to six adult goats at a dose of 1 mg/kg. Plasma samples were collected over 36h and analyzed via reverse phase high performance liquid chromatography for determination of pantoprazole and pantoprazole sulfone concentrations. Pharmacokinetic parameters were determined by non-compartmental analysis.

Results: Plasma clearance, elimination half-life, and volume of distribution of pantoprazole were estimated at 0.345 mL/kg/min, 0.7 h, and 0.9 L/kg, respectively following IV administration. The maximum concentration, elimination half-life and area under the curve of pantoprazole sulfone were estimated at 0.1 μg/mL, 0.8 h, and 0.2 hr^*μg/mL, respectively. The global extraction ratio was estimated 0.00795 ± 0.00138. All animals had normal physical examinations after conclusion of the study.

Conclusion: The reported plasma clearance for pantoprazole is lower than reported for foals, calves, and alpacas. The elimination half-life appears to be < that reported for foals and calves. Future pharmacodynamic studies are necessary for determination of the efficacy of pantoprazole on acid suppression in goats.

Pharmacokinetics and Tissue Levels of Pantoprazole in Neonatal Calves After Intravenous Administration

Background: Neonatal calves are at risk of developing abomasal ulceration, but there is a lack of pharmacokinetic data for potential anti-ulcerative therapies, such as pantoprazole, in ruminant species. Objective: The study objectives were to estimate plasma pharmacokinetic parameters for pantoprazole in neonatal dairy calves after intravenous (IV) administration. A secondary objective was to quantify the concentrations of pantoprazole in edible tissues after IV dosing. Methods: Pantoprazole was administered to 9 neonatal Holstein calves at a dose of 1 mg/kg IV. Plasma samples were collected over 24 h and analyzed via HPLC-MS for determining pantoprazole concentrations. Pharmacokinetic parameters were derived via non-compartmental analysis. Tissue samples were collected at 1, 3, and 5 days after administration and analyzed via HPLC-MS. Results: Following IV administration, plasma clearance, elimination half-life, and volume of distribution of pantoprazole were estimated at 4.46 mL/kg/min, 2.81 h, and 0.301 L/kg, respectively. The global extraction ratio was estimated at 0.053 ± 0.015. No pantoprazole was detected in the edible tissues 1, 3, or 5 days after administration. A metabolite, pantoprazole sulfone was detected in all the edible tissues 1 and 3 days after administration. Conclusion: The reported plasma clearance for pantoprazole is less than that reported for alpacas but higher than reported in foals. The elimination half-life in calves appears to be longer than observed in foals and alpacas. While pantoprazole sulfone was detected in the tissues after IV administration, further research is needed as to the metabolism and potential tissue accumulation of other pantoprazole metabolites in calves. Future pharmacodynamic studies are necessary to determine the efficacy of pantoprazole on abomasal acid suppression in calves.

A Retrospective Clinical Investigation of the Safety and Adverse Effects of Pantoprazole in Hospitalized Ruminants

Clinical safety data for the use of gastroprotectants in hospitalized ruminants is lacking. In human patients, multiple adverse effects are possible from the use of pantoprazole including hematologic and electrolyte abnormalities as well as anaphylaxis and edema. The medical records of all hospitalized cattle, goats, and sheep administered pantoprazole over an ~5-year period were retrospectively analyzed for adverse effects. Seventy-nine eligible patients were observed. Hypomagnesemia was observed after pantoprazole administration in 10 cattle; however, no significant changes were noted when compared to baseline before pantoprazole administration. Significant changes were noted in serum indicators of hepatic and renal function; however, these represented downward trends that were most likely clinically insignificant. Anaphylaxis after pantoprazole administration was not observed; however, seven cattle displayed edema after pantoprazole administration. Veterinary clinicians should be aware of the potential for hypomagnesemia in hospitalized ruminants being administered pantoprazole and monitor patients accordingly. While these preliminary retrospective results indicate that pantoprazole may be a safe adjunctive therapy in hospitalized ruminants, additional studies are necessary to further determine the safety and toxicity of pantoprazole in ruminants.

Evaluation of the Potential Risk Factors for Drug-Induced Anaphylaxis in Adult Patients

AIM

To investigate the potential risk factors in patients who have experienced anaphylaxis from drugs.

METHOD

The study included 281 adult patients (median age 40 years; 76.5% female) who experienced immediate types of hypersensitivity reaction to a drug. The patients were divided into an anaphylaxis group and a nonanaphylaxis group. The anaphylaxis group was diagnosed according to the criteria of the World Allergy Organization. Skin testing with culprit drugs was performed. In the nonanaphylaxis group, drug provocation tests were performed with culprit drugs, including aspirin or diclofenac, to determine nonsteroidal anti-inflammatory drug (NSAID) hypersensitivity. Atopy was determined by skin prick tests with the common inhalant allergens. Patients' demographics, clinical features, and baseline tryptase and total IgE levels were compared between the 2 groups.

RESULTS

The median interval between the last reaction in the patient's history and the study evaluation was 7 months (range 1-120 months). In 52.3% of the patients, reactions were defined as anaphylaxis. The most common culprit drugs were NSAIDs (56.9%) and β-lactams (34.7%). The culprit drugs were used parenterally in 13.2% of the patients. 34.9% of the patients had comorbid diseases and 24.6% used additional drugs, the most common being antihypertensives (10%). Atopy was determined in 28.8% and 28.1% of the patients were smokers. The median serum level of baseline tryptase and total IgE was 3.5 µg/L and 77 kU/L, respectively. In 46.3% of the patients, skin tests with culprit drugs were positive and the positivity ratio was higher in the anaphylaxis group (p = 0.002). Anapyhlaxis was more common in patients who were: hypertensive, atopic, using angio-tensin-converting enzyme inhibitors/angiotensin receptor blockers, and received the culprit drug parenterally (p = 0.034, p = 0.04, p = 0.03, p = 0.035, p = 0.013, and p < 0.001). In the multivariate analysis, it was observed that the parenteral usage of the drug and the presence of atopy were significantly higher in the anaphylaxis group (p < 0.001, odds ratio [OR] = 20.05, confidence interval [CI] 4.75-88.64; p = 0.012, OR = 2.1, CI 1.17-3.74). Age, smoking, family history, and serum levels of baseline tryptase and total IgE did not differ between groups.

CONCLUSION

The parenteral route and atopy increase the risk of drug-induced anaphylaxis. IgE-mediated sensitivity to the culprit drug seems to facilitate anaphylaxis.