Non-steroidal anti-inflammatory drug-induced anaphylaxis infrequent in 388 patients with mastocytosis: A two-center retrospective cohort study

Tryptase in drug-induced anaphylaxis: the need for acute and baseline values

PURPOSE OF REVIEW

The purpose of this narrative review was to summarize data and official recommendations purporting to paired tryptase determination in patients experiencing drug-induced anaphylaxis, published between January 1, 2023 and June 1, 2024.

RECENT FINDINGS

Three main lines of evidence obtained through paired acute and baseline tryptase determination were identified: diagnostic criterion for hypersensitivity reactions involving systemic mast cell activation; differential diagnostic criterion for hypersensitivity reactions involving other mechanisms of immediate reactions; and added value of acute and baseline tryptase levels for personalized management following drug-induced anaphylaxis: cause, risk of recurrence, underlying mast cell conditions including hereditary α-tryptasemia, familial clusters.

SUMMARY

The implementation of existing guidelines which consensually recommend paired tryptase measurement is a persistent unmet need hampering optimal diagnosis of drug-induced anaphylaxis and patient management. Another major unmet need is the lack of standardized recommendations for hereditary α-tryptasemia testing and counselling. Progress in this field is seen at a rapid pace, requiring significant efforts of continued medical education for practicing clinicians and laboratory specialists worldwide.

Mast cell conditions and drug allergy: when to suspect and how to manage

PURPOSE OF REVIEW

Patients with mast cell disorders frequently experience symptoms from excessive mediator release like histamine and tryptase, ranging from mild flushing to severe anaphylactic responses. Hypersensitivity reactions (HRs) to drugs are a major cause of anaphylaxis in these patients, who often worry about triggering mast cell degranulation when taking medications. The aim of this review is to explore the complex interactions between mast cell disorders and drug HRs, focusing on the clinical challenges of managing these conditions effectively to enhance understanding and guide safer clinical practices.

RECENT FINDINGS

Among the drugs most commonly associated with hypersensitivity reactions in patients with mast cell disorders are non-steroidal anti-inflammatory drugs, antibiotics, and perioperative agents. Recent studies have highlighted the role of Mas-related G-protein coupled receptor member X2 (MRGPRX2) - a receptor involved in non-immunoglobulin E mediated mast cell degranulation - in exacerbating HRs. Investigations reveal varied drug tolerance among patients, underscoring the need for individual risk assessments.

SUMMARY

Tailored diagnostic approaches are crucial for confirming drug allergies and assessing tolerance in patients with mastocytosis, preventing unnecessary medication avoidance and ensuring safety before acute situations arise.

Drug-Induced Anaphylaxis Uncommon in Mastocytosis: Findings From Two Large Cohorts

BACKGROUND

Anaphylaxis is a common feature of patients with mastocytosis, particularly with Hymenoptera venoms. Hence, it is hypothesized that patients with mastocytosis may have an increased susceptibility to developing drug-induced anaphylaxis (DIA). Patients and medical practitioners are therefore concerned when there is a need to use various drugs. However, this issue has not been systematically investigated.

OBJECTIVE

To investigate the prevalence and clinical characteristics of anaphylaxis to various types of drugs among patients with mastocytosis.

METHODS

A retrospective study was conducted among 470 consecutive patients (18 years and older) with confirmed clonal mast cell diseases recruited from 2 independent mastocytosis reference centers. All patients underwent a comprehensive, individualized allergy workup with evaluation of the (self)reported drug hypersensitivity.

RESULTS

The overall prevalence of DIA was 6.3%, accounting for one-third of the confirmed drug hypersensitivity reactions. Nonsteroidal anti-inflammatory drugs were the most common elicitors of DIA (56%), followed by perioperative agents (23%) and antibiotics (13%). Anaphylactic reactions were severe in most cases, with 43% of patients experiencing hypotensive syncope. All drug-related hypersensitivity reactions occurred before mastocytosis was diagnosed.

CONCLUSIONS

The prevalence of DIA in mastocytosis tends to be higher than in the general population, but is overall low. However, its severity is more pronounced. Our results suggest that patients with mastocytosis with a previous reaction to drugs should undergo a thorough allergy workup. Well-tolerated drugs can be further used without specific precautions.

Changing patterns in the epidemiology of drug allergy

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.

Challenges in Drug and Hymenoptera Venom Hypersensitivity Diagnosis and Management in Mastocytosis

Mastocytosis is a myeloproliferative neoplasm characterized by abnormal proliferation and activation of clonal mast cells typically bearing the KITD816V mutation. Symptoms manifest due to the release of bioactive mediators and the tissue infiltration by neoplastic mast cells. Mast cell activation symptoms include flushing, pruritus, urticaria, abdominal cramping, diarrhea, wheezing, neuropsychiatric symptoms, and anaphylaxis. Up to 50% of patients with mastocytosis report a history of provoked and unprovoked anaphylaxis, with Hymenoptera venom and drugs the most common culprits. NSAIDs, antibiotics, vaccines, perioperative medications, and radiocontrast media are often empirically avoided without evidence of reactions, depriving patients of needed medications and placing them at risk for unfavorable outcomes. The purpose of this review is to highlight the most common agents responsible for adverse drug reactions in patients with mastocytosis, with a review of current epidemiology, diagnosis, and management of drug hypersensitivity and Hymenoptera venom allergy.

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

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.

Management of Mediator Symptoms, Allergy, and Anaphylaxis in Mastocytosis

Mastocytosis is characterized by expansion and activation of clonally aberrant mast cells (MCs) in one or more organ systems. Inappropriate MC activation is a key finding in both allergy and mastocytosis; therefore, symptoms in both conditions show some degree of overlap. When mediator release is excessive and involves multiple systems, anaphylaxis may occur. In mastocytosis, the prevalence of atopy is similar to those of the general population, whereas the incidence of anaphylaxis is significantly higher. The purpose of this review is to discuss features of allergy and anaphylaxis as well as the principles of managing MC mediator release symptoms in mastocytosis.

A Puzzling Mast Cell Trilogy: Anaphylaxis, MCAS, and Mastocytosis

Our knowledge of biology and mast cell (MC) function, as well as disorders associated with the pathologic activation of MCs, has evolved over the last few decades. Anaphylaxis, mast cell activation syndrome (MCAS), and mastocytosis are interrelated yet distinct conditions within the spectrum of mast cell activation disorders. Nevertheless, all three conditions can co-exist in one and the same patient, as pathologic MC activation is the key finding in all three. When mediator release is excessive and involves multiple systems, anaphylaxis and MCAS may occur. Furthermore, mastocytosis is a clonal disorder of MCs and often presents with anaphylaxis and MCAS. Nevertheless, in some cases, even the proliferative and accumulative features of MCs in mastocytosis can account for symptoms and disease progression. In each case, diagnosis can be only made when the diagnostic consensus criteria are fulfilled. The current article aims to provide a concise clinical update and pinpoint the main difficulties in diagnosing these puzzling disorders of MCs in medical practice.

Ketorolac-induced anaphylaxis following oral administration: a case series

Background

Ketorolac is a commonly used non-steroidal anti-inflammatory drug for reducing pain and inflammation. Anaphylaxis is a medical emergency that occurs after exposure to an allergen, with a varied clinical presentation requiring prompt and appropriate measures to prevent or manage it. Although uncommon, ketorolac can cause anaphylaxis requiring immediate medical care. The authors present two cases of anaphylaxis in females induced after oral intake of ketorolac with successful outcomes.

Case presentations

The cases involve two adult women who experienced an allergic reaction to ketorolac. The first woman, aged 36, and the second woman, aged 26, on her second postpartum day, both developed similar types of symptoms like periorbital swelling, itching, and difficulty breathing after taking oral ketorolac. The second woman had a history of allergic rashes. They received immediate treatment with epinephrine, oxygen therapy, intravenous fluids, and other medications. They showed a rapid improvement and were discharged after observation.

Clinical discussion

Anaphylactic reactions to ketorolac, a commonly used pain management drug, have been reported. Symptoms include swelling, difficulty breathing, and hypotension. Treatment involves medications like epinephrine, hydrocortisone, and pheniramine. A detailed medical history, laboratory investigations, appropriate medication, oxygen therapy, and follow-up care are important in managing anaphylactic reactions, which can be life-threatening.

Conclusion

Although rare, ketorolac can cause anaphylactic reactions in patients with or without a history of drug allergy. Immediate recognition and management are essential, along with a detailed medical history and follow-up care.

Serum tryptase and drug hypersensitivity: why, how and what? A systematic review

PURPOSE OF REVIEW

Serum tryptase, a mast cell marker, provides clues for the mechanism, severity, and management of drug hypersensitivity induced by immunoglobulin E dependent or independent mast cell activation.

RECENT FINDINGS

The interpretation of serum tryptase levels has been challenged during the last 2 years by major advances in tryptase genetics and their rapid incorporation into clinical practice. On the contrary, new pathophysiological insight into nonmast cell-dependent immediate hypersensitivity has been gained.

SUMMARY

This review provides up-to-date information on the pathophysiology and recommended use and interpretation of tryptase in the context of drug hypersensitivity reactions as a function of their endotype.

Diagnostic Evaluation of Hypersensitivity Reactions to Antibiotics in a Large Cohort of Mastocytosis Patients

BACKGROUND

Anaphylactic reactions are a well-known feature of mastocytosis, particularly in relation to hymenoptera venom stings. Although data on the frequency of drug hypersensitivity reactions is limited in mastocytosis, it is hypothesized that these patients may be predisposed to hypersensitivity reactions to certain drugs, including antibiotics. Nevertheless, this issue has not been systematically investigated. Thus, we investigate the prevalence and clinical features of hypersensitivity reactions to antibiotics (HRA) in mastocytosis.

METHODS

A 15-year retrospective study was conducted among 239 (≥18 years old) consecutive mastocytosis patients who were investigated in our center. All patients underwent a thorough allergy work-up, where self-reported reactions were individually evaluated by an allergist.

RESULTS

Overall, 34 patients (14.2%) were deemed to have HRA. Most patients reacted with cutaneous symptoms (74%), and anaphylaxis was rare, confirmed only in two of 34 patients (0.8%). Beta-lactams were the most common elicitors (63%). There were no differences in age, gender, atopic status and tryptase levels between mastocytosis patients with and without antibiotic hypersensitivity.

CONCLUSIONS

The present study indicates a similar prevalence of HRA in mastocytosis compared to those of the general population. Moreover, antibiotics appear to be rare elicitors of anaphylaxis in these patients. Hence, our results suggest that mastocytosis patients without a history of HRA may be treated with these drugs without special precautions.