Drug provocation tests with hypnotics, opioids, and neuromuscular blocking agents in the diagnosis of suspected perioperative hypersensitivity

Abstract

Editor—Perioperative hypersensitivity reactions constitute a significant health issue with serious consequences of misdiagnosis. 1 Garvey L.H. Ebo D.G. Mertes P.M. et al. An EAACI position paper on the investigation of perioperative immediate hypersensitivity reactions. Allergy. 2019; 74: 1872-1884 Crossref PubMed Scopus (75) Google Scholar Drug provocation tests are considered the reference test in the investigation of drug hypersensitivity 2 Demoly P. Adkinson N.F. Brockow K. et al. International consensus on drug allergy. Allergy. 2014; 69: 420-437 Crossref PubMed Scopus (632) Google Scholar but have not been systematically recommended for perioperative hypersensitivity reactions, mainly because of the pronounced pharmacologic effects of anaesthetic drugs, the absence of validated drug provocation testing protocols, and the necessity to test multiple potential culprits. 3 Garvey L.H. Ebo D.G. Krøigaard M. et al. The use of drug provocation testing in the investigation of suspected immediate perioperative allergic reactions: current status. Br J Anaesth. 2019; 123: e126-e134 Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar ,4 Garvey L.H. Melchiors B.B. Ebo D.G. Mertes P.M. Krøigaard M. Medical algorithms: diagnosis and investigation of perioperative immediate hypersensitivity reactions. Allergy. 2020; 75: 2139-2142 Crossref PubMed Scopus (7) Google Scholar Because of potential double sensitisations (reported in up to 7% of patients) and the fact that conventional tests are not absolutely predictive, some centres perform systematic drug provocation testing for all potential culprits. 3 Garvey L.H. Ebo D.G. Krøigaard M. et al. The use of drug provocation testing in the investigation of suspected immediate perioperative allergic reactions: current status. Br J Anaesth. 2019; 123: e126-e134 Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar Although some studies report high negative predictive value of skin tests, 5 Asserhøj L.L. Mosbech H. Krøigaard M. Garvey L.H. No evidence for contraindications to the use of propofol in adults allergic to egg, soy or peanut. Br J Anaesth. 2016; 116: 77-82 Abstract Full Text Full Text PDF PubMed Scopus (81) Google Scholar , 6 Tornero Molina P. Rojas-Perez-Ezquerra P. Noguerado-Mellado B. et al. Drug challenge tests with general anesthetics: predictive value of skin tests. J Investig Allergol Clin Immunol. 2020; 30: 101-107 Crossref PubMed Scopus (10) Google Scholar , 7 Ramirez L.F. Pereira A. Chiriac A.M. Bonnet-Boyer M.C. Demoly P. Negative predictive value of skin tests to neuromuscular blocking agents. Allergy. 2012; 67: 439-441 Crossref PubMed Scopus (31) Google Scholar , 8 Leysen J. Uyttebroek A. Sabato V. Bridts C.H. De Clerck L.S. Ebo D.G. Predictive value of allergy tests for neuromuscular blocking agents: tackling an unmet need. Clin Exp Allergy. 2014; 44: 1069-1075 Crossref PubMed Scopus (53) Google Scholar robust data on the need and benefit of drug provocation testing in suspected perioperative hypersensitivity reactions remain limited. This study explores the need for drug provocation testing to hypnotics, opioid analgesics, and neuromuscular blocking agents (NMBAs) as a part of an investigation of suspected perioperative hypersensitivity reactions in patients with negative conventional testing.