741 Trends in Offending Medications in Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis in a Large Academic Burn Center

Abstract

Abstract Introduction Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (SJS/TEN) is a rare, severe mucocutaneous eruption caused by medications and resulting in diffuse epidermal detachment. Patients are often referred to burn units for specialized care. This study assesses trends in precipitating medications over 10 years at our Burn Center. Methods We performed a single-site, retrospective review at our burn center using the institutional burn registry and patient charts. Patients admitted from January 1, 2009 to December 31, 2018 identified as having SJS/TEN were eligible for inclusion. Demographics, comorbidities, diagnosis, treatment, inciting agents, and severity-of-illness score for TEN (SCORTEN) were evaluated. Statistical analysis was performed using the Mann Whitney U test using SAS version 9.4 (SAS Inc., Cary, NC). Results Biopsy-proven SJS, SJS/TEN overlap, or TEN was confirmed in 168 patients. Of these, 103 had a single identified offending drug. Of these patients, 36% had been exposed to sulfamethoxazole-trimethoprim (SMX-TMP), 11% to allopurinol, and 10% to lamotrigine. Trends in culprit drug by year are shown in Figure 1. The majority of SMX-TMP and penicillin cases occurred early in the period of study; lamotrigine and pembrolizumab cases occurred more recently. Patients exposed to allopurinol presented with higher SCORTENs than patients exposed to SMX-TMP, 2.9 vs 1.9, respectively (p< 0.035). Conclusions SMX-TMP once accounted for a large portion of SJS and TEN cases at our center. In recent years, lamotrigine has become a more common offending drug, prescribed in our cohort for psychiatric indications. Also notable, in the past year we have treated three patients with TEN due to immunotherapy (pembrolizumab) for metastatic or unresectable cancer. Paralleling the increasing use of immunotherapy has been a rise of immune-related adverse events, including severe skin toxicities. Further study is warranted to determine what can be done to prevent SJS/TEN from occurring in patients treated with these drugs. Applicability of Research to Practice Understanding emerging trends in causative agents of SJS/TEN will allow the burn community to focus education efforts for providers who prescribe these medications frequently. The psychiatric and oncology communities may benefit from increased awareness of the risk of SJS/TEN in patients receiving lamotrigine and immunotherapy, respectively.