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Yan C, Ong HH, Grabowska ME, Krantz MS, Su WC, Dickson AL, Peterson JF, Feng Q, Roden DM, Stein CM, Kerchberger VE, Malin BA, Wei WQ. Large language models facilitate the generation of electronic health record phenotyping algorithms. J Am Med Inform Assoc 2024:ocae072. [PMID: 38613820 DOI: 10.1093/jamia/ocae072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 02/21/2024] [Accepted: 03/22/2024] [Indexed: 04/15/2024] Open
Abstract
OBJECTIVES Phenotyping is a core task in observational health research utilizing electronic health records (EHRs). Developing an accurate algorithm demands substantial input from domain experts, involving extensive literature review and evidence synthesis. This burdensome process limits scalability and delays knowledge discovery. We investigate the potential for leveraging large language models (LLMs) to enhance the efficiency of EHR phenotyping by generating high-quality algorithm drafts. MATERIALS AND METHODS We prompted four LLMs-GPT-4 and GPT-3.5 of ChatGPT, Claude 2, and Bard-in October 2023, asking them to generate executable phenotyping algorithms in the form of SQL queries adhering to a common data model (CDM) for three phenotypes (ie, type 2 diabetes mellitus, dementia, and hypothyroidism). Three phenotyping experts evaluated the returned algorithms across several critical metrics. We further implemented the top-rated algorithms and compared them against clinician-validated phenotyping algorithms from the Electronic Medical Records and Genomics (eMERGE) network. RESULTS GPT-4 and GPT-3.5 exhibited significantly higher overall expert evaluation scores in instruction following, algorithmic logic, and SQL executability, when compared to Claude 2 and Bard. Although GPT-4 and GPT-3.5 effectively identified relevant clinical concepts, they exhibited immature capability in organizing phenotyping criteria with the proper logic, leading to phenotyping algorithms that were either excessively restrictive (with low recall) or overly broad (with low positive predictive values). CONCLUSION GPT versions 3.5 and 4 are capable of drafting phenotyping algorithms by identifying relevant clinical criteria aligned with a CDM. However, expertise in informatics and clinical experience is still required to assess and further refine generated algorithms.
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Affiliation(s)
- Chao Yan
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN 37203, United States
| | - Henry H Ong
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN 37203, United States
| | - Monika E Grabowska
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN 37203, United States
| | - Matthew S Krantz
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN 37203, United States
| | - Wu-Chen Su
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN 37203, United States
| | - Alyson L Dickson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37203, United States
| | - Josh F Peterson
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN 37203, United States
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37203, United States
| | - QiPing Feng
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37203, United States
| | - Dan M Roden
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN 37203, United States
| | - C Michael Stein
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37203, United States
| | - V Eric Kerchberger
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN 37203, United States
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37203, United States
| | - Bradley A Malin
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN 37203, United States
- Department of Computer Science, Vanderbilt University, Nashville, TN 37203, United States
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN 37203, United States
| | - Wei-Qi Wei
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN 37203, United States
- Department of Computer Science, Vanderbilt University, Nashville, TN 37203, United States
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Yan C, Ong HH, Grabowska ME, Krantz MS, Su WC, Dickson AL, Peterson JF, Feng Q, Roden DM, Stein CM, Kerchberger VE, Malin BA, Wei WQ. Large Language Models Facilitate the Generation of Electronic Health Record Phenotyping Algorithms. medRxiv 2024:2023.12.19.23300230. [PMID: 38196578 PMCID: PMC10775330 DOI: 10.1101/2023.12.19.23300230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
Objectives Phenotyping is a core task in observational health research utilizing electronic health records (EHRs). Developing an accurate algorithm demands substantial input from domain experts, involving extensive literature review and evidence synthesis. This burdensome process limits scalability and delays knowledge discovery. We investigate the potential for leveraging large language models (LLMs) to enhance the efficiency of EHR phenotyping by generating high-quality algorithm drafts. Materials and Methods We prompted four LLMs-GPT-4 and GPT-3.5 of ChatGPT, Claude 2, and Bard-in October 2023, asking them to generate executable phenotyping algorithms in the form of SQL queries adhering to a common data model (CDM) for three phenotypes (i.e., type 2 diabetes mellitus, dementia, and hypothyroidism). Three phenotyping experts evaluated the returned algorithms across several critical metrics. We further implemented the top-rated algorithms and compared them against clinician-validated phenotyping algorithms from the Electronic Medical Records and Genomics (eMERGE) network. Results GPT-4 and GPT-3.5 exhibited significantly higher overall expert evaluation scores in instruction following, algorithmic logic, and SQL executability, when compared to Claude 2 and Bard. Although GPT-4 and GPT-3.5 effectively identified relevant clinical concepts, they exhibited immature capability in organizing phenotyping criteria with the proper logic, leading to phenotyping algorithms that were either excessively restrictive (with low recall) or overly broad (with low positive predictive values). Conclusion GPT versions 3.5 and 4 are capable of drafting phenotyping algorithms by identifying relevant clinical criteria aligned with a CDM. However, expertise in informatics and clinical experience is still required to assess and further refine generated algorithms.
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Affiliation(s)
- Chao Yan
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | - Henry H. Ong
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | - Monika E. Grabowska
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | - Matthew S. Krantz
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | - Wu-Chen Su
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | - Alyson L. Dickson
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Josh F. Peterson
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - QiPing Feng
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Dan M. Roden
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | - C. Michael Stein
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - V. Eric Kerchberger
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Bradley A. Malin
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
- Department of Computer Science, Vanderbilt University, Nashville, TN
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Wei-Qi Wei
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
- Department of Computer Science, Vanderbilt University, Nashville, TN
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Gardner J, Hammond S, Jensen R, Gibson A, Krantz MS, Ardern‐Jones M, Phillips EJ, Pirmohamed M, Chadwick AE, Betts C, Naisbitt DJ. Glycolysis: An early marker for vancomycin-specific T-cell activation. Clin Exp Allergy 2024; 54:21-33. [PMID: 38177093 PMCID: PMC10953384 DOI: 10.1111/cea.14423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/13/2023] [Accepted: 11/01/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND Vancomycin, a glycopeptide antibiotic used for Gram-positive bacterial infections, has been linked with drug reaction with eosinophilia and systemic symptoms (DRESS) in HLA-A*32:01-expressing individuals. This is associated with activation of T lymphocytes, for which glycolysis has been isolated as a fuel pathway following antigenic stimulation. However, the metabolic processes that underpin drug-reactive T-cell activation are currently undefined and may shed light on the energetic conditions needed for the elicitation of drug hypersensitivity or tolerogenic pathways. Here, we sought to characterise the immunological and metabolic pathways involved in drug-specific T-cell activation within the context of DRESS pathogenesis using vancomycin as model compound and drug-reactive T-cell clones (TCCs) generated from healthy donors and vancomycin-hypersensitive patients. METHODS CD4+ and CD8+ vancomycin-responsive TCCs were generated by serial dilution. The Seahorse XFe96 Analyzer was used to measure the extracellular acidification rate (ECAR) as an indicator of glycolytic function. Additionally, T-cell proliferation and cytokine release (IFN-γ) assay were utilised to correlate the bioenergetic characteristics of T-cell activation with in vitro assays. RESULTS Model T-cell stimulants induced non-specific T-cell activation, characterised by immediate augmentation of ECAR and rate of ATP production (JATPglyc). There was a dose-dependent and drug-specific glycolytic shift when vancomycin-reactive TCCs were exposed to the drug. Vancomycin-reactive TCCs did not exhibit T-cell cross-reactivity with structurally similar compounds within proliferative and cytokine readouts. However, cross-reactivity was observed when analysing energetic responses; TCCs with prior specificity for vancomycin were also found to exhibit glycolytic switching after exposure to teicoplanin. Glycolytic activation of TCC was HLA restricted, as exposure to HLA blockade attenuated the glycolytic induction. CONCLUSION These studies describe the glycolytic shift of CD4+ and CD8+ T cells following vancomycin exposure. Since similar glycolytic switching is observed with teicoplanin, which did not activate T cells, it is possible the master switch for T-cell activation is located upstream of metabolic signalling.
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Affiliation(s)
- Joshua Gardner
- Department of Pharmacology and Therapeutics, Centre for Drug Safety ScienceUniversity of LiverpoolLiverpoolUK
| | | | - Rebecca Jensen
- Department of Pharmacology and Therapeutics, Centre for Drug Safety ScienceUniversity of LiverpoolLiverpoolUK
| | - Andrew Gibson
- Murdoch UniversityInstitute for Immunology & Infectious DiseasesPerthWestern AustraliaAustralia
| | - Matthew S. Krantz
- Vanderbilt Institute for Infection, Immunology and InflammationVanderbilt UniversityNashvilleTennesseeUSA
| | - Michael Ardern‐Jones
- Clinical Experimental SciencesUniversity of Southampton Faculty of Medicine, Sir Henry Wellcome Laboratories, Southampton General HospitalSouthamptonUK
| | - Elizabeth J. Phillips
- Vanderbilt Institute for Infection, Immunology and InflammationVanderbilt UniversityNashvilleTennesseeUSA
| | - Munir Pirmohamed
- Department of Pharmacology and Therapeutics, Centre for Drug Safety ScienceUniversity of LiverpoolLiverpoolUK
| | - Amy E. Chadwick
- Department of Pharmacology and Therapeutics, Centre for Drug Safety ScienceUniversity of LiverpoolLiverpoolUK
| | - Catherine Betts
- Clinical Pharmacology & Safety SciencesAstraZeneca R&DCambridgeUK
| | - Dean J. Naisbitt
- Department of Pharmacology and Therapeutics, Centre for Drug Safety ScienceUniversity of LiverpoolLiverpoolUK
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Waldron JL, Rose M, Vogrin S, Krantz MS, Bolotte R, Phillips EJ, Trubiano JA. Development and Validation of a Sulfa Antibiotic Allergy Clinical Decision Rule. JAMA Netw Open 2023; 6:e2316776. [PMID: 37273210 DOI: 10.1001/jamanetworkopen.2023.16776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/06/2023] Open
Affiliation(s)
- Jamie L Waldron
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
| | - Morgan Rose
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
| | - Sara Vogrin
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- Department of Medicine (St Vincent's Health), University of Melbourne, Fitzroy, Victoria, Australia
| | - Matthew S Krantz
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Drug Safety and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ryan Bolotte
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Elizabeth J Phillips
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Center for Drug Safety and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jason A Trubiano
- Centre for Antibiotic Allergy and Research, Department of Infectious Diseases, Austin Health, Heidelberg, Victoria, Australia
- Department of Infectious Diseases, University of Melbourne, Parkville, Victoria, Australia
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Krantz MS, Phillips EJ. Drug Reaction With Eosinophilia and Systemic Symptoms. JAMA Dermatol 2023; 159:348. [PMID: 36630118 DOI: 10.1001/jamadermatol.2022.4519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
This Patient Page describes the symptoms, diagnosis, and treatment of drug reaction with eosinophilia and systemic symptoms.
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Affiliation(s)
- Matthew S Krantz
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Elizabeth J Phillips
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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Gibson A, Deshpande P, Campbell CN, Krantz MS, Mukherjee E, Mockenhaupt M, Pirmohamed M, Palubinsky AM, Phillips EJ. Updates on the immunopathology and genomics of severe cutaneous adverse drug reactions. J Allergy Clin Immunol 2023; 151:289-300.e4. [PMID: 36740326 PMCID: PMC9976545 DOI: 10.1016/j.jaci.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 12/05/2022] [Accepted: 12/06/2022] [Indexed: 02/05/2023]
Abstract
Severe cutaneous adverse reactions (SCARs) such as Stevens-Johnson syndrome, toxic epidermal necrolysis (SJS/TEN), and drug reaction with eosinophilia and systemic symptoms (DRESS)/drug-induced hypersensitivity syndrome (DIHS) cause significant morbidity and mortality and impede new drug development. HLA class I associations with SJS/TEN and drug reaction with eosinophilia and systemic symptoms/drug-induced hypersensitivity syndrome have aided preventive efforts and provided insights into immunopathogenesis. In SJS/TEN, HLA class I-restricted oligoclonal CD8+ T-cell responses occur at the tissue level. However, specific HLA risk allele(s) and antigens driving this response have not been identified for most drugs. HLA risk alleles also have incomplete positive and negative predictive values, making truly comprehensive screening currently challenging. Although, there have been key paradigm shifts in knowledge regarding drug hypersensitivity, there are still many open and unanswered questions about SCAR immunopathogenesis, as well as genetic and environmental risk. In addition to understanding the cellular and molecular basis of SCAR at the single-cell level, identification of the MHC-restricted drug-reactive self- or viral peptides driving the hypersensitivity reaction will also be critical to advancing premarketing strategies to predict risk at an individual and drug level. This will also enable identification of biologic markers for earlier diagnosis and accurate prognosis, as well as drug causality and targeted therapeutics.
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Affiliation(s)
- Andrew Gibson
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Australia
| | - Pooja Deshpande
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Australia
| | - Chelsea N Campbell
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, Tenn
| | - Matthew S Krantz
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tenn
| | - Eric Mukherjee
- Department of Dermatology, Vanderbilt University Medical Center, Nashville; Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tenn
| | - Maja Mockenhaupt
- Dokumentationszentrum schwerer Hautreaktionen Department of Dermatologie, Medical Center and Medical Faculty, University of Freiburg, Freiberg, Germany
| | - Munir Pirmohamed
- Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool, United Kingdom
| | - Amy M Palubinsky
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tenn
| | - Elizabeth J Phillips
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Australia; Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, Tenn; Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tenn; Department of Dermatology, Vanderbilt University Medical Center, Nashville; Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tenn.
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Stone CA, Robinson LB, Li L, Krantz MS, Kwah JH, Ortega G, Mancini C, Wolfson AR, Saff RR, Samarakoon U, Hong DI, Koo G, Chow TG, Gruchalla R, Liao JX, Kuster JK, Price C, Ahola C, Khan DA, Phillips EJ, Banerji A, Blumenthal KG. Clinical Phenotypes of Immediate First-Dose Reactions to mRNA COVID-19: A Multicenter Latent Class Analysis. J Allergy Clin Immunol Pract 2023; 11:458-465.e1. [PMID: 36108922 PMCID: PMC9468049 DOI: 10.1016/j.jaip.2022.08.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 08/10/2022] [Accepted: 08/28/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although immediate potentially allergic reactions have been reported after dose 1 of mRNA coronavirus disease 2019 (COVID-19) vaccines, comprehensively defined subtypes have not been clearly distinguished. OBJECTIVE To define distinct clinical phenotypes of immediate reactions after dose 1 of mRNA COVID-19 vaccination, and to assess the relation of clinical phenotype to mRNA COVID-19 vaccine second dose tolerance. METHODS This retrospective study included patients with 1 or more potentially allergic symptoms or signs within 4 hours of receiving dose 1 of an mRNA COVID-19 vaccine and assessed by allergy/immunology specialists from 5 U.S. academic medical centers (January-June 2021). We used latent class analysis-an unbiased, machine-learning modeling method-to define novel clinical phenotypes. We assessed demographic, clinical, and reaction characteristics associated with phenotype membership. Using log-binomial regression, we assessed the relation between phenotype membership and second dose tolerance, defined as either no symptoms or mild, self-limited symptoms resolving with antihistamines alone. A sensitivity analysis considered second dose tolerance as objective signs only. RESULTS We identified 265 patients with dose-1 immediate reactions with 3 phenotype clusters: (1) Limited or Predominantly Cutaneous, (2) Sensory, and (3) Systemic. A total of 223 patients (84%) received a second dose and 200 (90%) tolerated their second dose. Sensory cluster (all patients had the symptom of numbness or tingling) was associated with a higher likelihood of second dose intolerance, but this finding did not persist when accounting for objective signs. CONCLUSIONS Three novel clinical phenotypes of immediate-onset reactions after dose 1 of mRNA COVID-19 vaccines were identified using latent class analysis: (1) Limited or Predominantly Cutaneous, (2) Sensory, and (3) Systemic. Whereas these clinical phenotypes may indicate differential mechanistic etiologies or associations with subsequent dose tolerance, most individuals proceeding to their second dose tolerated it.
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Affiliation(s)
- Cosby A Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Lacey B Robinson
- Harvard Medical School, Boston, Mass; Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Mongan Institute, Massachusetts General Hospital, Boston, Mass
| | - Lily Li
- Harvard Medical School, Boston, Mass; Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Matthew S Krantz
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Jason H Kwah
- Department of Internal Medicine, Section of Rheumatology, Allergy, and Immunology, Yale School of Medicine, New Haven, Conn
| | - Gilbert Ortega
- Division of Allergy and Immunology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Christian Mancini
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Mongan Institute, Massachusetts General Hospital, Boston, Mass
| | - Anna R Wolfson
- Harvard Medical School, Boston, Mass; Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Rebecca R Saff
- Harvard Medical School, Boston, Mass; Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Upeka Samarakoon
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Mongan Institute, Massachusetts General Hospital, Boston, Mass
| | - David I Hong
- Harvard Medical School, Boston, Mass; Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Grace Koo
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Timothy G Chow
- Division of Allergy and Immunology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Rebecca Gruchalla
- Division of Allergy and Immunology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jane X Liao
- Department of Internal Medicine, Section of Rheumatology, Allergy, and Immunology, Yale School of Medicine, New Haven, Conn
| | - John K Kuster
- Department of Internal Medicine, Section of Rheumatology, Allergy, and Immunology, Yale School of Medicine, New Haven, Conn
| | - Christina Price
- Department of Internal Medicine, Section of Rheumatology, Allergy, and Immunology, Yale School of Medicine, New Haven, Conn
| | - Catherine Ahola
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Mongan Institute, Massachusetts General Hospital, Boston, Mass
| | - David A Khan
- Division of Allergy and Immunology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Elizabeth J Phillips
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn; Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tenn
| | - Aleena Banerji
- Harvard Medical School, Boston, Mass; Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass
| | - Kimberly G Blumenthal
- Harvard Medical School, Boston, Mass; Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston, Mass; Mongan Institute, Massachusetts General Hospital, Boston, Mass; Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital, Boston, Mass.
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Greenhawt M, Shaker M, Golden DBK, Abrams EM, Blumenthal KG, Wolfson AR, Stone CA, Krantz MS, Chu DK, Dwamena BA. Diagnostic accuracy of vaccine and vaccine excipient testing in the setting of allergic reactions to COVID-19 vaccines: A systematic review and meta-analysis. Allergy 2023; 78:71-83. [PMID: 36321821 PMCID: PMC9878056 DOI: 10.1111/all.15571] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 09/14/2022] [Accepted: 10/04/2022] [Indexed: 11/05/2022]
Abstract
For persons with immediate allergic reactions to mRNA COVID-19 vaccines, skin testing (ST) to the vaccine/excipients (polyethylene glycol[PEG] and polysorbate 80 [PS]) has been recommended, but has unknown accuracy. To assess vaccine/excipient ST accuracy in predicting all-severity immediate allergic reactions upon re-vaccination, systematic review was performed searching Medline, EMBASE, Web of Science, and the WHO global coronavirus database (inception-Oct 4, 2021) for studies addressing immediate (≤4 h post-vaccination) all-severity allergic reactions to 2nd mRNA COVID-19 vaccination in persons with 1st dose immediate allergic reactions. Cases evaluating delayed reactions, change of vaccine platform, or revaccination without vaccine/excipient ST were excluded. Meta-analysis of diagnostic testing accuracy was performed using Bayesian methods. The GRADE approach evaluated certainty of the evidence, and QUADAS-2 assessed risk of bias. Among 20 studies of mRNA COVID-19 first dose vaccine reactions, 317 individuals underwent 578 ST to any one or combination of vaccine, PEG, or PS, and were re-vaccinated with the same vaccine. Test sensitivity for either mRNA vaccine was 0.2 (95%CrI 0.01-0.52) and specificity 0.97 (95%CrI 0.9-1). PEG test sensitivity was 0.02 (95%CrI 0.00-0.07) and specificity 0.99 (95%CrI 0.96-1). PS test sensitivity was 0.03 (95%CrI 0.00-0.0.11) and specificity 0.97 (95%CrI 0.91-1). Combined for use of any of the 3 testing agents, sensitivity was 0.03 (95%CrI 0.00-0.08) and specificity was 0.98 (95%CrI 0.95-1.00). Certainty of evidence was moderate. ST has low sensitivity but high specificity in predicting all-severity repeat immediate allergic reactions to the same agent, among persons with 1st dose immediate allergic reactions to mRNA COVID-19 vaccines. mRNA COVID-19 vaccine or excipient ST has limited risk assessment utility.
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Affiliation(s)
- Matthew Greenhawt
- Section of Allergy and Clinical Immunology, Children's Hospital ColoradoUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Marcus Shaker
- Dartmouth‐Hitchcock Medical Center, Section of Allergy and ImmunologyLebanonNew HampshireUSA,Dartmouth Geisel School of MedicineHanoverNew HampshireUSA
| | - David B. K. Golden
- Division of Allergy and Clinical ImmunologyJohns Hopkins University School of MedicineBaltimoreMarylandUSA
| | - Elissa M. Abrams
- Department of Pediatrics and Child Health, Section of Allergy and ImmunologyThe University of ManitobaWinnipegManitobaCanada
| | - Kimberly G. Blumenthal
- Division of Rheumatology, Allergy, and ImmunologyDepartment of Medicine, Massachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Anna R. Wolfson
- Division of Rheumatology, Allergy, and ImmunologyDepartment of Medicine, Massachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Cosby A. Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of MedicineVanderbilt University School of MedicineNashvilleTennesseeUSA
| | - Matthew S. Krantz
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of MedicineVanderbilt University School of MedicineNashvilleTennesseeUSA
| | - Derek K. Chu
- Department of MedicineMcMaster UniversityHamiltonOntarioCanada,Department of Health Research Methods, Evidence & ImpactMcMaster UniversityHamiltonOntarioCanada,The Research Institute of St. Joe's HamiltonHamiltonOntarioCanada,Evidence in Allergy GroupHamiltonOntarioCanada
| | - Ben A. Dwamena
- Division of Nuclear Medicine, Department of Radiology, Michigan MedicineUniversity of Michigan Medical SchoolAnn ArborMichiganUSA
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Krantz MS, Kerchberger VE, Wei WQ. Novel Analysis Methods to Mine Immune-Mediated Phenotypes and Find Genetic Variation Within the Electronic Health Record (Roadmap for Phenotype to Genotype: Immunogenomics). J Allergy Clin Immunol Pract 2022; 10:1757-1762. [PMID: 35487368 PMCID: PMC9624141 DOI: 10.1016/j.jaip.2022.04.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 04/13/2022] [Accepted: 04/18/2022] [Indexed: 06/14/2023]
Abstract
The field of immunogenomics has the opportunity for accelerated genetic discovery aided by the maturation of electronic health records (EHRs) linked to DNA biobanks. Novel analysis methods in deep phenotyping of EHR data allow the full realization of the paired and increasingly dense genetic/phenotypic information available. This enables researchers to uncover genetic risk factors for the prevention and optimal treatment of immune-mediated diseases and immune-mediated adverse drug reactions. This article reviews the background of EHRs linked to DNA biobanks, potential applications to immunogenomic discovery, and current and emerging techniques in EHR-based deep phenotyping.
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Affiliation(s)
- Matthew S Krantz
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn.
| | - V Eric Kerchberger
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn; Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tenn
| | - Wei-Qi Wei
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tenn
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Krantz MS, Phillips EJ. COVID-19 mRNA vaccine safety during the first 6 months of roll-out in the USA. Lancet Infect Dis 2022; 22:747-748. [PMID: 35271806 PMCID: PMC8901182 DOI: 10.1016/s1473-3099(22)00123-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 02/10/2022] [Indexed: 12/17/2022]
Affiliation(s)
- Matthew S Krantz
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Elizabeth J Phillips
- Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, TN, USA; Department of Pathology, Microbiology, and Immunology, Vanderbilt University School of Medicine, Nashville, TN, USA; Institute for Immunology & Infectious Diseases, Murdoch University, Murdoch, WA, Australia.
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11
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Chu DK, Abrams EM, Golden DBK, Blumenthal KG, Wolfson AR, Stone CA, Krantz MS, Shaker M, Greenhawt M. Risk of Second Allergic Reaction to SARS-CoV-2 Vaccines: A Systematic Review and Meta-analysis. JAMA Intern Med 2022; 182:376-385. [PMID: 35188528 PMCID: PMC8861900 DOI: 10.1001/jamainternmed.2021.8515] [Citation(s) in RCA: 59] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 12/26/2021] [Indexed: 12/12/2022]
Abstract
IMPORTANCE Vaccination against SARS-CoV-2 is a highly effective strategy to prevent infection and severe COVID-19 outcomes. The best strategy for a second dose of vaccine among persons who had an immediate allergic reaction to their first SARS CoV-2 vaccination is unclear. OBJECTIVE To assess the risk of severe immediate allergic reactions (eg, anaphylaxis) to a second dose of SARS-CoV-2 mRNA vaccine among persons with immediate allergic reactions to their first vaccine dose. DATA SOURCES MEDLINE, Embase, Web of Science, and the World Health Organization Global Coronavirus database were searched from inception through October 4, 2021. STUDY SELECTION Included studies addressed immediate allergic reactions of any severity to a second SARS-CoV-2 vaccine dose in persons with a known or suspected immediate allergic reaction (<4 hours after vaccination) after their first SARS-CoV-2 vaccine dose. Studies describing a second vaccine dose among persons reporting delayed reactions (>4 hours after vaccination) were excluded. DATA EXTRACTION AND SYNTHESIS Paired reviewers independently selected studies, extracted data, and assessed risk of bias. Random-effects models were used for meta-analysis. The GRADE (Grading of Recommendation, Assessment, Development, and Evaluation) approach evaluated certainty of the evidence. MAIN OUTCOMES AND MEASURES Risk of severe immediate allergic reaction and repeated severe immediate allergic reactions with a second vaccine dose. Reaction severity was defined by the reporting investigator, using Brighton Collaboration Criteria, Ring and Messmer criteria, World Allergy Organization criteria, or National Institute of Allergy and Infectious Diseases criteria. RESULTS Among 22 studies of SARS-CoV-2 mRNA vaccines, 1366 individuals (87.8% women; mean age, 46.1 years) had immediate allergic reactions to their first vaccination. Analysis using the pooled random-effects model found that 6 patients developed severe immediate allergic reactions after their second vaccination (absolute risk, 0.16% [95% CI, 0.01%-2.94%]), 232 developed mild symptoms (13.65% [95% CI, 7.76%-22.9%]), and, conversely, 1360 tolerated the dose (99.84% [95% CI, 97.09%-99.99%]). Among 78 persons with severe immediate allergic reactions to their first SARS-CoV-2 mRNA vaccination, 4 people (4.94% [95% CI, 0.93%-22.28%]) had a second severe immediate reaction, and 15 had nonsevere symptoms (9.54% [95% CI, 2.18%-33.34%]). There were no deaths. Graded vaccine dosing, skin testing, and premedication as risk-stratification strategies did not alter the findings. Certainty of evidence was moderate for those with any allergic reaction to the first dose and low for those with severe allergic reactions to the first dose. CONCLUSIONS AND RELEVANCE In this systematic review and meta-analysis of case studies and case reports, the risk of immediate allergic reactions and severe immediate reactions or anaphylaxis associated with a second dose of an SARS-CoV-2 mRNA vaccine was low among persons who experienced an immediate allergic reaction to their first dose. These findings suggest that revaccination of individuals with an immediate allergic reaction to a first SARS-CoV-2 mRNA vaccine dose in a supervised setting equipped to manage severe allergic reactions can be safe.
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Affiliation(s)
- Derek K. Chu
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
- The Research Institute of St Joe’s Hamilton, Hamilton, Ontario, Canada
- Evidence in Allergy Group, Hamilton, Ontario, Canada
| | - Elissa M. Abrams
- Section of Allergy and Immunology, Department of Pediatrics and Child Health, The University of Manitoba, Winnipeg, Manitoba, Canada
| | - David B. K. Golden
- Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kimberly G. Blumenthal
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Anna R. Wolfson
- Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Cosby A. Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Matthew S. Krantz
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Marcus Shaker
- Section of Allergy and Immunology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
- Dartmouth Geisel School of Medicine, Hanover, New Hampshire
| | - Matthew Greenhawt
- Food Challenge and Research Unit, Section of Allergy and Clinical Immunology, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora
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12
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Frush BW, Richardson TL, Krantz MS. The Admission Checklist: The key steps and responsibilities for the admitting resident. Ann Med Surg (Lond) 2022; 75:103388. [PMID: 35386761 PMCID: PMC8978045 DOI: 10.1016/j.amsu.2022.103388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 02/20/2022] [Indexed: 12/02/2022] Open
Abstract
The process of admitting patients from the emergency department to the general medicine floor is foundational to the medical training process and medical practice more generally. Yet this process is rife with potential error if not approached systematically, and residents rarely receive explicit teaching in this area. The creation of an “Admission Checklist” proposed by the authors could serve the function of reducing error and enhancing inter-provider communication throughout this process. Such a checklist could improve trainee experience and education, and ultimately allow for improved outcomes for patients during transitions of care.
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13
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Bruusgaard-Mouritsen MA, Koo G, Heinrichsen AS, Melchiors BB, Krantz MS, Plager JH, Boxer M, Phillips EJ, Stone CA, Garvey LH. Janssen COVID-19 vaccine tolerated in 10 patients with confirmed polyethylene glycol allergy. J Allergy Clin Immunol Pract 2022; 10:859-862. [PMID: 34979336 PMCID: PMC8719916 DOI: 10.1016/j.jaip.2021.12.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 12/13/2021] [Accepted: 12/16/2021] [Indexed: 11/15/2022]
Affiliation(s)
- Maria A Bruusgaard-Mouritsen
- Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - Grace Koo
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Anne Sophie Heinrichsen
- Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - Birgitte Bech Melchiors
- Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark
| | - Matthew S Krantz
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Jessica H Plager
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Mitchell Boxer
- Department of Allergy & Immunology, Zucker School of Medicine at Hofstra/Northwell, New York, NY
| | - Elizabeth J Phillips
- Center for Drug Safety and Immunology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn; Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, WA, Australia
| | - Cosby A Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn; Center for Drug Safety and Immunology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Lene H Garvey
- Allergy Clinic, Department of Dermatology and Allergy, Copenhagen University Hospital-Herlev and Gentofte, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
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14
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Frush BW, Blythe JA, Krantz MS, Zaidi D. Ethical Considerations for the Just Utilization of House Staff During the COVID-19 Pandemic. Am J Bioeth 2022; 22:6-8. [PMID: 35258419 DOI: 10.1080/15265161.2022.2030590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- Benjamin W Frush
- Vanderbilt University Medical Center
- Monroe Carrell Junior Children's Hospital at Vanderbilt
| | | | | | - Danish Zaidi
- Yale University School of Medicine
- Yale New Haven Hospital
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15
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Krantz MS, Kwah JH, Stone CA, Phillips EJ, Ortega G, Banerji A, Blumenthal KG. Safety Evaluation of the Second Dose of Messenger RNA COVID-19 Vaccines in Patients With Immediate Reactions to the First Dose. JAMA Intern Med 2021; 181:1530-1533. [PMID: 34309623 PMCID: PMC8314170 DOI: 10.1001/jamainternmed.2021.3779] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
This case series study examines the safety of second doses of messenger RNA COVID-19 vaccines after first-dose allergic reactions.
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Affiliation(s)
- Matthew S Krantz
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jason H Kwah
- Yale School of Medicine, Section of Rheumatology, Allergy, and Immunology, Department of Internal Medicine, New Haven, Connecticut
| | - Cosby A Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Elizabeth J Phillips
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Gilbert Ortega
- Division of Allergy and Immunology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Aleena Banerji
- Harvard Medical School, Boston, Massachusetts.,Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston
| | - Kimberly G Blumenthal
- Harvard Medical School, Boston, Massachusetts.,Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Boston.,Mongan Institute, Massachusetts General Hospital.,Edward P. Lawrence Center for Quality and Safety, Massachusetts General Hospital, Boston
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16
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Krantz MS, Stone CA, Abreo A, Phillips EJ. Reply to ''The safety and efficacy of direct oral challenge in trimethoprim-sulfamethoxazole antibiotic allergy". J Allergy Clin Immunol Pract 2021; 9:3849-3850. [PMID: 34627544 DOI: 10.1016/j.jaip.2021.07.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 07/11/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Matthew S Krantz
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tenn
| | - Cosby A Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tenn
| | - Andrew Abreo
- Department of Pediatrics, Louisiana State University Health Sciences Center, New Orleans, La
| | - Elizabeth J Phillips
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn; Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tenn; Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, Tenn; Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Perth, Western Australia.
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17
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Krantz MS, Bruusgaard‐Mouritsen MA, Koo G, Phillips EJ, Stone CA, Garvey LH. Anaphylaxis to the first dose of mRNA SARS-CoV-2 vaccines: Don't give up on the second dose! Allergy 2021; 76:2916-2920. [PMID: 34028041 PMCID: PMC8222898 DOI: 10.1111/all.14958] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 05/11/2021] [Accepted: 05/18/2021] [Indexed: 01/14/2023]
Affiliation(s)
- Matthew S. Krantz
- Division of Allergy, Pulmonary and Critical Care Medicine Department of Medicine Vanderbilt University School of Medicine Nashville TN USA
| | - Maria A. Bruusgaard‐Mouritsen
- Department of Dermatology and Allergy Allergy Clinic Copenhagen University Hospital – Herlev and Gentofte Copenhagen Denmark
| | - Grace Koo
- Division of Allergy, Pulmonary and Critical Care Medicine Department of Medicine Vanderbilt University School of Medicine Nashville TN USA
| | - Elizabeth J. Phillips
- Division of Infectious Diseases Department of Medicine Vanderbilt University Medical Center Nashville TN USA
| | - Cosby A. Stone
- Division of Allergy, Pulmonary and Critical Care Medicine Department of Medicine Vanderbilt University School of Medicine Nashville TN USA
| | - Lene H. Garvey
- Department of Dermatology and Allergy Allergy Clinic Copenhagen University Hospital – Herlev and Gentofte Copenhagen Denmark
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18
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Caballero ML, Krantz MS, Quirce S, Phillips EJ, Stone CA. Hidden Dangers: Recognizing Excipients as Potential Causes of Drug and Vaccine Hypersensitivity Reactions. J Allergy Clin Immunol Pract 2021; 9:2968-2982. [PMID: 33737254 PMCID: PMC8355062 DOI: 10.1016/j.jaip.2021.03.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 02/22/2021] [Accepted: 03/03/2021] [Indexed: 12/18/2022]
Abstract
Excipients are necessary as a support to the active ingredients in drugs, vaccines, and other products, and they contribute to their stability, preservation, pharmacokinetics, bioavailability, appearance, and acceptability. For both drugs and vaccines, these are rare reactions; however, for vaccines, they are the primary cause of immediate hypersensitivity. Suspicion for these "hidden dangers" should be high, in particular, when anaphylaxis has occurred in association with multiple chemically distinct drugs. Common excipients implicated include gelatin, carboxymethylcellulose, polyethylene glycols, and products related to polyethylene glycols in immediate hypersensitivity reactions and propylene glycol in delayed hypersensitivity reactions. Complete evaluation of a suspected excipient reaction requires detailed information from the product monograph and package insert to identify all ingredients that are present and to understand the function and structure for these chemicals. This knowledge helps develop a management plan that may include allergy testing to identify the implicated component and to give patients detailed information for future avoidance of relevant foods, drugs, and vaccines. Excipient reactions should be particularly considered for specific classes of drugs where they have been commonly found to be the culprit (eg, corticosteroids, injectable hormones, immunotherapies, monoclonal antibodies, and vaccines). We provide a review of the evidence-based literature outlining epidemiology and mechanisms of excipient reactions and provide strategies for heightened recognition and allergy testing.
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Affiliation(s)
| | - Matthew S Krantz
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Santiago Quirce
- Department of Allergy, La Paz University Hospital, IdiPAZ, Madrid, Spain; Department of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Elizabeth J Phillips
- Division of Infectious Disease, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn; Department of Pharmacology, Vanderbilt School of Medicine, Nashville, Tenn; Institute of Immunology and Infectious Diseases, Murdoch University, Murdoch, Australia
| | - Cosby A Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn.
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19
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Krantz MS, Stone CA, Rolando LA, Nobis AE, Koo G, Corey KB, Bluestein SB, Staso PJ, Campbell EM, Phillips EJ. An academic hospital experience screening mRNA COVID-19 vaccine risk using patient allergy history. J Allergy Clin Immunol Pract 2021; 9:3807-3810. [PMID: 34293499 PMCID: PMC8288228 DOI: 10.1016/j.jaip.2021.07.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 06/22/2021] [Accepted: 07/02/2021] [Indexed: 11/16/2022]
Affiliation(s)
- Matthew S Krantz
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Cosby A Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Lori A Rolando
- Vanderbilt Occupational Health Clinic, Vanderbilt Health & Wellness, Vanderbilt University Medical Center, Nashville, Tenn; Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Ana E Nobis
- Vanderbilt Occupational Health Clinic, Vanderbilt Health & Wellness, Vanderbilt University Medical Center, Nashville, Tenn; Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Grace Koo
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Kristen B Corey
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Sara B Bluestein
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Patrick J Staso
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Emily M Campbell
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Elizabeth J Phillips
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn.
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20
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Affiliation(s)
- Matthew S. Krantz
- Division of Allergy, Pulmonary and Critical Care Medicine Department of Medicine Vanderbilt University Medical Center Nashville TN USA
| | - Yiwei Liu
- Pharmaceutical Sciences Department St. Jude Children's Research Hospital Memphis TN USA
| | - Elizabeth J. Phillips
- Division of Infectious Diseases Department of Medicine Vanderbilt University Medical Center Nashville TN USA
- Department of Pharmacology Vanderbilt University School of Medicine Nashville TN USA
| | - Cosby A. Stone
- Division of Allergy, Pulmonary and Critical Care Medicine Department of Medicine Vanderbilt University Medical Center Nashville TN USA
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21
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Yu RJ, Krantz MS, Phillips EJ, Stone CA. Emerging Causes of Drug-Induced Anaphylaxis: A Review of Anaphylaxis-Associated Reports in the FDA Adverse Event Reporting System (FAERS). J Allergy Clin Immunol Pract 2020; 9:819-829.e2. [PMID: 32992044 DOI: 10.1016/j.jaip.2020.09.021] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 09/09/2020] [Accepted: 09/13/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Drug-induced anaphylaxis is a well-known adverse drug reaction for some drug classes, but emerging drug causes of anaphylaxis and novel mechanisms may contribute in unrecognized ways. OBJECTIVE We sought to determine the top drugs reported in association with anaphylaxis and anaphylaxis followed by death in the Food and Drug Administration Adverse Event Reporting System (FAERS). METHODS We reviewed the publicly available FAERS database from 1999 to 2019. Using search terms "anaphylactic shock" or "anaphylactic reaction" and sorting cases by generic drug names, we counted and trended reports to FAERS in which a drug was associated with anaphylaxis or anaphylaxis followed by death. RESULTS From 1999 to 2019, there were 17,506,002 adverse drug events reported in FAERS, of which 47,496 (0.27%) were reported as anaphylaxis. Excluding patients without age, sex, or country data, respectively, the median age of patients in reports of anaphylaxis was 52 (interquartile range: 28), 62.71% were female, and 13,899 of 34,381 (40.43%) reports were from the United States. There were 2984 of 47,496 (6.28%) reports of anaphylaxis followed by death. Top drug classes associated with anaphylaxis in FAERS were antibiotics, monoclonal antibodies (mAbs), nonsteroidal anti-inflammatory drugs, and acetaminophen. Top drug classes associated with anaphylaxis deaths were antibiotics, radiocontrast agents, and intraoperative agents. Linear regression demonstrated reports of anaphylaxis to mAbs increasing at an average rate of 0.77% of total anaphylaxis reports per year (95% confidence interval: 0.65, 0.88) from 2.00% in 1999 to 17.37% in 2019, faster than any other drug class. CONCLUSION Antibiotics were highly reported for anaphylaxis overall and anaphylaxis followed by death. Increasing reports were noted for anaphylaxis to mAb therapies.
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Affiliation(s)
- Roger J Yu
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Matthew S Krantz
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Elizabeth J Phillips
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Cosby A Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn.
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Krantz MS, Stone CA, Yu R, Adams SN, Phillips EJ. Criteria for intradermal skin testing and oral challenge in patients labeled as fluoroquinolone allergic. J Allergy Clin Immunol Pract 2020; 9:1024-1028.e3. [PMID: 32980582 DOI: 10.1016/j.jaip.2020.09.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 09/10/2020] [Accepted: 09/11/2020] [Indexed: 11/16/2022]
Affiliation(s)
- Matthew S Krantz
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tenn
| | - Cosby A Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tenn
| | - Roger Yu
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tenn
| | - Sarah N Adams
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tenn
| | - Elizabeth J Phillips
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tenn; Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn; Department of Pharmacology, Vanderbilt University School of Medicine, Nashville, Tenn; Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, Tenn; Institute for Immunology & Infectious Diseases, Murdoch University, Murdoch, WA, Australia.
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23
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Krantz MS. Web Exclusive. Annals Graphic Medicine - The Physical Exam. Ann Intern Med 2020; 173:W84-W85. [PMID: 32833490 DOI: 10.7326/g20-0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Matthew S Krantz
- Vanderbilt University Medical Center, Nashville, Tennessee (M.S.K.)
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Krantz MS. Web Exclusive. Annals Graphic Medicine - Masked Facies. Ann Intern Med 2020; 173:W12-W13. [PMID: 32479167 DOI: 10.7326/g20-0052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Matthew S Krantz
- Vanderbilt University Medical Center, Nashville, Tennessee (M.S.K.)
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Krantz MS. Web Exclusive. Annals Graphic Medicine - Comparing Resident Noon Conference Attendance by Quality of Speaker Versus Quality of Food. Ann Intern Med 2020; 172:W155-W156. [PMID: 32539519 DOI: 10.7326/g19-0071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Matthew S Krantz
- Vanderbilt University Medical Center, Nashville, Tennessee (M.S.K.)
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Krantz MS, Stone CA, Abreo A, Phillips EJ. Oral Challenge with Trimethoprim-Sulfamethoxazole in Patients with “Sulfa” Antibiotic Allergy Referred to an Outpatient Drug Allergy Clinic. J Allergy Clin Immunol 2019. [DOI: 10.1016/j.jaci.2018.12.637] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Krantz MS, Stone CA, Connelly JA, Norton AE, Khan YW. The effect of delayed and early diagnosis in siblings, and importance of newborn screening for SCID. Ann Allergy Asthma Immunol 2018; 122:211-213. [PMID: 30439467 DOI: 10.1016/j.anai.2018.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 10/31/2018] [Accepted: 11/05/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Matthew S Krantz
- Departments of Medicine and Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Cosby A Stone
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - James A Connelly
- Division of Hematology-Oncology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Allison E Norton
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Yasmin W Khan
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
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28
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Krantz MS, Berg JS. Crowdsourcing to define the clinical actionability of incidental findings of genetic testing. N C Med J 2013; 74:501-502. [PMID: 24316777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Affiliation(s)
- Matthew S Krantz
- Corresponding author: Jonathan S. Berg, Department of Genetics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA.
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29
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Lindenberg CS, Solorzano RM, Krantz MS, Galvis C, Baroni G, Strickland O. Risk and resilience: building protective factors. An intervention for preventing substance abuse and sexual risk-taking and for promoting strength and protection among young, low-income Hispanic women. MCN Am J Matern Child Nurs 1998; 23:99-104. [PMID: 9529873 DOI: 10.1097/00005721-199803000-00008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- C S Lindenberg
- Emory University, School of Nursing, Atlanta, GA 30322, USA.
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