Multiple Drug Allergies Research Articles

Special Considerations in the Treatment of Idiopathic Intracranial Hypertension.

To review the management of Idiopathic Intracranial Hypertension (IIH) with co-existing conditions affecting therapy: obesity, sulfa allergy, nephrolithiasis, and pregnancy. The IIH-WT trial showed that bariatric surgery is currently the most effective method for obese patients with IIH to lose weight, leading to normalization of CSF pressure in many cases. Allergy to sulfonamide antibiotics does not preclude the use of acetazolamide; rather, penicillin allergy or multiple drug allergies are the strongest predictor of a hypersensitivity reaction. Carbonic anhydrase inhibitors should be avoided in individuals with a personal history of nephrolithiasis; the risk of renal stones increases with concomitant use of other medications with the potential for nephrolithiasis. Glucagon-like peptide-1 receptor antagonists (GLP-1RA) are promising non-surgical weight loss options although preliminary studies have not demonstrated considerable impact on papilledema, headache or vision. Women with IIH have high rates of pregnancy complications partly related to obesity. Recommendations for weight gain or loss during gestation are controversial. Recent studies show better outcomes in obese women who maintain or lose weight while pregnant including gestational diabetes, pre-eclampsia and emergency caesarian section. Progress continues in the search for the cause and best treatments for IIH. Larger multicenter trials of GLP-1RA are needed to determine their efficacy.

Empowering Pediatricians With Direct Penicillin Challenges: A Promising Delabeling Strategy.

Current literature supports a multidisciplinary approach to penicillin allergy delabeling. Our study aims to review the success rate of penicillin challenges performed at Walter Reed National Military Medical Center Allergy Clinic and assess the reaction rate associated with a direct oral challenge in low-risk patients. We conducted a retrospective review of the outcomes of pediatric penicillin challenges at the Walter Reed National Military Medical Center Allergy and Immunology clinic from June 2019 to May 2023. A total of 74 challenges were included in this study. Patients were initially screened to assess the date of reaction, nature of reaction, if the reaction was life-threatening, and if the patient was hospitalized or sought emergency medical care for the reported reaction. After completion of the screening questionnaire, a direct graded challenge was performed (without skin testing) if a patient's history was deemed low risk. Patients with a recent reaction or a history of multiple drug allergies were more likely to be directed to skin prick testing and intra-dermal testing with Pre-pen and Penicillin-G prior to challenge. All patients passed all challenges. Thus, there was a 100% pass rate for both direct challenges and skin test with oral challenges. Given the low rate of adverse events in this study, expansion of penicillin delabeling in the primary care setting should be considered in patients deemed to be at low risk. It is important for allergists to empower and educate their peers and push forward a movement to create a multidisciplinary approach to penicillin delabeling.

Drug reaction, cyclooxygenase 2, and alteration on lymphatics

Adverse drug reactions, multiple drug allergy syndrome, and multiple drug intolerance syndrome, are common terms used in clinical practice worldwide. Here we present a 61-year-old Caucasian female, who is diabetic and hypertensive, and started receiving doxycycline for an upper respiratory tract infection. Simultaneously, she self-prescribed Advil.®. The patient has had a previous episode of drug intolerance. In this episode, she presented with a skin rash included bullae on her arms, legs and in part of her abdomen along with some systemic symptoms such fever, cough, and upset stomach. Biopsies for hematoxylin and eosin (H&E), direct immunofluorescence (DIF), and immunohistochemistry (IHC) stain analysis were performed. The diagnosis was made based upon interpretation of the histology in the context of drug reaction with alterations on the dermal lymphatics. DIF showed significant deposits of fibrinogen, complement/C3c and IgA around the dermal vessels, and at the endothelial-mesenchymal dermal cell junctions. IHC staining showed lymphangiectases with strong staining of the lymphatic junctions to the adjacent upper dermis using D2-40 marker. In this case, it is possible that the drug reaction could be causing previously unreported damage in lymphatics, including fragmentation and dilatation. These channels are stimulated inhibited, contracted, and relaxed by interactions with multiple receptors and the inflammation could cause dysregulation in those including their shape. Key words: Drug reaction, Lymphatics, D2-40, Cyclooxygenase 2, Direct immunofluorescence, Immunohistochemistry

A Case Report and Pediatric Literature Review: Povidone as a Rare Cause of Anaphylaxis in Children.

Background: Povidone, a synthetic polymer commonly used in various products such as antiseptics, cosmetics, and medications, has been associated with allergic reactions, including anaphylaxis. Despite its widespread use, cases of povidone-induced anaphylaxis, especially in children, are under-recognized. This case report aims to highlight the importance of considering povidone allergy in pediatric patients presenting with anaphylaxis. Case Presentation: We describe a 3-year-old boy who experienced anaphylaxis following the application of povidone-iodine antiseptic solution to a leg wound. He presented with generalized urticaria, angioedema, dyspnea, and cough. Prompt diagnosis and management were initiated in the emergency department. He experienced the second anaphylaxis with povidone-containing eye drops prescribed during an ophthalmology visit. Conclusions: Povidone allergy should be considered in pediatric patients presenting with anaphylaxis, especially those with idiopathic reactions or multiple drug allergies. Clinicians should emphasize patient education on label reading and the provision of adrenaline autoinjectors to prevent life-threatening reactions associated with povidone exposure.

Clinical Pharmacology Consultation for Better Patient Care: A Single-Center Audit

Abstract Background: Evaluation of patient referrals, treatments, and satisfaction may help to gain insight into the usefulness of clinical pharmacology consultations in meeting patients’ different healthcare needs. The present study aimed to investigate how clinical pharmacology consultation affects patient care, including its effects on patient outcomes, satisfaction, and the management of treatment-emergent adverse events and the role of clinical pharmacology consultation clinics in modern healthcare. Materials and Methods: This prospective observational study included patients visiting a clinical pharmacology clinic. Data were collected on demographic information, referral sources, reason for consultation, and patient satisfaction survey (PSS) score. Data were statistically analyzed. Results: A total of 224 participants were enrolled. The primary motivation for seeking clinical pharmacology consultations was varied, with the most common reason being the need to address issues related to polypharmacy (21.4%). This was followed by concerns about glycemic fluctuations (11.2%), eligibility for coronavirus disease 2019 vaccination in the context of multiple drug allergies (10.7%), and the evaluation of drug rashes (10.3%). The initial PSS score was 65.38% at baseline, which increased to the overall mean PSS score of 69.42%. However, a weak correlation between follow-up visit latency and PSS change (r = 0.351). One of the most notable findings was the significant clinical improvement observed in 95% of cases. Conclusion: The role of clinical pharmacology is indispensable, particularly in an era where medication regimens are becoming increasingly complex. Our study advocates for policy changes that support the growth of clinical pharmacology through strategic education and training initiatives, ensuring the discipline continues to improve patient care and medication safety.

‘General anesthesia without intravenous agents in a patient with multiple drug allergies’

‘General anesthesia without intravenous agents in a patient with multiple drug allergies’

CHALLENGES OF OCULAR TOXOPLASMOSIS TREATMENT IN MULTIPLE DRUG INTOLERANCE SYNDROME: A CASE REPORT AND LITERATURE REVIEW

We report a literature review and a case of ocular toxoplasmosis in a patient with multiple drug allergies, who was successfully treated with regular intravitreal clindamycin and subconjunctival dexamethasone. A Malay lady in her twenties presented to us with right eye blurring of vision of 2 weeks duration, which she described as a central scotoma. Visual acuity at presentation was hand movements. Examination revealed intense ocular inflammation. The right eye had anterior segment inflammation of 3+ cells with fine keratic precipitates, whilst the posterior segment revealed papillitis, vitritis, retinitis, choroiditis, vasculitis and hyperpigmented chorioretinal scar inferotemporal to fovea. Ocular coherence tomography showed intraretinal fluid and retinal thickening. Fluorescein angiography showed early hypofluorescence of the lesion with progressive hyperfluorescence and leakage from the optic disc. Immunoglobulin G serology of Toxoplasma gondii was raised and immunoglobulin M levels were normal. The patient developed an allergic reaction with classical antibiotic and antifolate therapy. She was successfully treated with regular two-weekly intravitreal clindamycin and subconjunctival dexamethasone and her best corrected visual acuity was 6/18 at the end of her treatment. Intravitreal injection of clindamycin and subconjunctival dexamethasone is a good option in patients of ocular toxoplasmosis who are allergic to oral medications.

Delabelling multiple antibiotic allergy: Practical issues.

With the growing incidence of multi-drug resistant organisms, delabelling incorrect antibiotic allergies has become an integral part of antimicrobial stewardship worldwide. For example, around 90% of penicillin allergy labels are found to be inaccurate following a full allergy work-up, which deprive patients the use of effective first-line penicillin antibiotics and increase the risk of antimicrobial resistance with the use of other extended spectrum non-penicillin antimicrobials. Significant numbers of adult and paediatric patients over time are labelled with multiple penicillin and non-penicillin antibiotic allergies often during inappropriate antimicrobial use, resulting in a label of "multiple antibiotic allergy". In contrast to delabelling penicillin allergy where oral direct provocation tests can be used for low-risk, mild reactions, and sensitivity/specificity/positive and negative predictive values of skin tests have been demonstrated, diagnostic tests for multiple antibiotic allergy often require the use of a combination of in-vivo and in-vitro tests across different antimicrobial classes for evaluation. Shared decision making with patients and informed consent are also needed when prioritising which drugs to delabel first, balancing the risks, benefits of testing vs. interim use of alternative antibiotics. Similar to delabelling penicillin allergy, the cost-effectiveness of delabelling multiple drug allergies is unknown.

Pediatric multiple drug allergy syndrome including penicillin allergy: epidemiology and association with anxiety and depression

Multiple drug allergy syndrome (MDAS) is well described in the adult population and is associated with a higher rate of depression. MDAS in the setting of penicillin allergy is poorly described in in pediatric patients.

AN ADOLESCENT CASE OF HAE-NL-C1INH (WHO WAS) MISDIAGNOSED WITH WHEAT ALLERGY AND MULTIPLE DRUG ALLERGIES

Hereditary angioedema (HAE) is frequently misdiagnosed as drug allergy. It is essential to differentiate HAE from allergy. Diagnosing HAE-normal-C1INH (conventional HAE type III), presenting normal C1-INH, is even more difficult. Here, we report a case of a 17-year-old female diagnosed with HAE and having labeled wheat and multiple drug allergies. She had been suffering from skin edema and abdominal symptoms since childhood. After taking wheat at 13 years old, she had multiple episodes of the same symptoms. Wheat allergy was suspected, and she started eliminating wheat. Multiple attacks were observed after several drug use, and drug allergy was labeled. However, her attacks did not improve after eliminating wheat and the suspected drugs. Her C4 and C1-INH activity was normal, but we diagnosed her with HAE-normal-C1INH based on her family history, multiple attacks after dental procedures, ineffective antihistamines, and significant efficacy of C1-INH infusion. A double-blind, placebo-controlled wheat challenge test at our hospital was negative, and wheat removal was lifted. Drugs could be de-labeled by allergic tests and history. Repeated attacks of unexplained edema and abdominal pain should be differentiated from HAE and lead to an appropriate diagnosis.

TOLERABILITY OF GRADED CORONAVIRUS DISEASE 2019 MRNA VACCINE DOSING

<h3>Introduction</h3> The rapid development of novel coronavirus disease 2019 (COVID-19) mRNA vaccines and their widespread use has raised concerns that they may cause allergic reactions at rates greater than conventional vaccines. Vaccine administration strategies in cases of prior COVID-19 vaccine reaction or patient hesitancy include full dose administration with close observation and graded dosing protocols. <h3>Methods</h3> Retrospective chart review of patients who were referred to an allergy clinic for observed COVID-19 vaccine administration with emphasis on demographic characteristics, atopic co-morbidities, prior vaccine reactions, and outcome of challenge. <h3>Results</h3> Data were available for 83 patients comprising 102 total COVID-19 vaccine challenges. All (n=102) challenges were successful; 21 experienced symptoms and 81 did not. The most reported symptoms were pruritus (n=5), headache (n=5), and chest tightness (n=3). No patient experienced vital sign changes during the protocol and there were no cases of anaphylaxis. The most common dosing protocols were either one-step (n=38) or two-step (n=36). The most common reasons for undergoing challenge were previous COVID-19 vaccine reaction (n=55) and concern for multiple drug allergies (n=21). <h3>Conclusion</h3> This review demonstrates that COVID-19 vaccine graded dosing protocols were highly tolerated and successful regardless of prior COVID-19 vaccine reactions or drug allergies. The presence of symptoms during the challenge did not preclude successful outcome, and no patients experienced anaphylaxis. Given the ongoing nature of the COVID-19 pandemic, it is important to recognize that graded challenge or full dose administration with observation may provide a safe means for patients who are hesitant to pursue COVID-19 vaccination.

Hypersensitivity to Intravenous Iron Preparations.

Intravenous iron is widely used for the treatment of iron deficiency anemia when adherence to oral iron replacement is poor. Acute hypersensitivity reactions during iron infusions are very rare but can be life threatening. Major risk factors for hypersensitivity reactions include a previous reaction to an iron infusion, a fast iron infusion rate, multiple drug allergies, atopic diseases, high serum tryptase levels, asthma, and urticaria. The management of iron infusions requires meticulous observation, and, in the event of an adverse reaction, prompt recognition and severity-related interventions by well-trained medical and nursing staff. Avoidance of IV iron products in patients with iron hypersensitivity reactions may not be considered as a standard practice.

Allergic Reactions to COVID-19 Vaccination in High-Risk Allergic Patients: The Experience of Trieste University Hospital (North-Eastern Italy).

Background. Allergic patients may develop reactions following COVID-19 vaccination more frequently than non-allergic individuals. The aim of our study was to assess the risk of reactions in high-risk allergic patients vaccinated for COVID-19 at the University Health Agency Giuliano-Isontina (ASUGI) of Trieste (northeastern Italy). Methods. Patients were considered at high risk for allergic reactions in case of: prior anaphylactic reaction to any drug/vaccine; multiple drug allergy; intolerance to polyethylene glycol (PEG) or polysorbate 80 (PS80) containing drugs; and mast cell disorders. High-risk allergic patients were immunized in hospital by a dedicated allergy team supported by resuscitation staff. Patients were interviewed over the phone one month after vaccination to complete a structured questionnaire investigating signs and symptoms developed after immunization. Results. From March 2021 to February 2022, 269 patients with a history of severe allergic reactions were assessed, of whom 208 (77.3%) eventually received COVID-19 vaccination, 50 (18.6%) refused to be immunized, 10 (3.7%) were deferred for medical reasons and one was declared exempted due to testing positive for PS80. Mild reactions (urticaria, angioedema, rhinitis, erythema) to COVID-19 vaccines were reported by 30.3% of patients, 8.7% within 4 h and 21.6% > 4 h after immunization. No anaphylactic events were observed. Although they were 80 times (3.8%) more prevalent than in COVID-19 vaccinees from the general population (0.047%), vaccine allergic reactions in high-risk patients were mainly mild and late, more likely affecting women (OR = 3.05; 95% CI 1.22–7.65). Conclusions. High-risk allergic patients with urticaria and angioedema may experience mild flare-ups of mast cell activation-like symptoms following COVID-19 vaccination, supporting antihistamine premedication before vaccination and to be continued for one week afterwards.

Characterization, epidemiology and risk factors of multiple drug allergy syndrome and multiple drug intolerance syndrome: A systematic review.

BackgroundMultiple drug allergy and multiple drug intolerance syndrome (MDAS/MDIS) labels are an impediment to clinical care and knowledge regarding these conditions is limited. This systematic review investigated the characterization, epidemiology, risk factors, clinical impact and pharmaco‐economics of MDAS and MDIS.MethodsSystematic literature search across 11 databases (01 January 2000–06 November 2020) for MDIS, MDAS and related terminology. Studies were reviewed for quality of evidence and risk of bias by employing Critical Appraisal Skills Programme cohort study checklist. A narrative synthesis approach facilitated by systematic textual descriptions, tabulation and thematic analysis was adopted.ResultsThere was heterogeneity in terminology and methodology. Few studies applied standard drug allergy diagnostic methods. There is some evidence to suggest that multiple drug hypersensitivity syndrome (MDHS; i.e., confirmed allergies in MDAS) is a distinct clinical entity. Prevalence of MDIS and MDAS labels in unselected & selected populations varied between 2.1%–6.4% & 4.9%–90% and 1.2% & 0%–36% respectively. Reported risk factors included female gender, increasing age, body mass index, anxiety, depression, co‐morbidities, concurrent allergies and increased healthcare utilization. Drugs commonly implicated were antibiotics and non‐steroidal anti‐inflammatory drugs. No studies relating to clinical impact and pharmaco‐economics were found.ConclusionThere is considerable burden of MDAS and MDIS labels. Data needs cautious interpretation as majority of studies described involved unverified labels. Despite this limitation and heterogeneity of studies, there is some evidence to suggest that MDHS is a distinct clinical entity. Well‐designed multi‐centre studies applying standardized terminology and diagnostic methodology are needed to gain further insight into these conditions.

Graded coronavirus disease 2019 vaccine administration: A safe alternative to vaccine avoidance

Graded coronavirus disease 2019 vaccine administration: A safe alternative to vaccine avoidance

Low-risk penicillin allergy delabeling through a direct oral challenge in immunocompromised and/or multiple drug allergy labeled patients in a critical care setting

Approximately 10% of critically ill patients have a penicillin allergy label (PAL) in their chart at the time of a medical intensive care unit (MICU) admission.1 We previously tested a direct oral challenge with amoxicillin as a safe and effective delabeling strategy in a population of MICU patients with histories of low-risk penicillin allergy.2 Patients hospitalized in an MICU frequently have chronic illnesses that predisposes to infections, which increases their need and utilization of antibiotics.

M021 MULTIPLE CHEMOTHERAPY MEDICATION ALLERGY IN A PATIENT WITH RECURRENT OVARIAN CANCER

Drug allergy is an adverse immunological response to medications that cause symptoms ranging from mild cutaneous findings to life-threatening anaphylaxis. Many chemotherapy agents are known to cause adverse and allergic reactions. We present a patient with recurrent ovarian cancer complicated by multiple chemotherapy drug allergy to Bevacizumab, Taxol, Carboplatin, Oxaliplatin, Cisplatin, and Gemcitabine.

The Association of Multiple Drug Allergies and Vocal Cord Dysfunction Assessed by the Pittsburgh VCD Index

Vocal cord dysfunction (VCD) is a functional disorder of the upper airway that can mimic allergic reactions. The Pittsburgh VCD Index (PVCDI) is a validated questionnaire with high sensitivity and specificity that can help distinguish VCD from asthma. We hypothesized that patients with multiple drug allergies would score higher on the PVCDI as compared to patients with no or few drug allergies.

Multiple drug allergies as a risk factor for IgE mediated penicillin drug allergy in a pediatric population

Risk factors for underlying IgE mediated penicillin drug allergy is poorly described in the pediatric population. We reviewed electronic medical records to further characterize the risk of multiple reported drug allergies on patients with a listed penicillin drug allergy.

Factors Associated with Self-Reported Drug Allergies in a Large Chronic Spontaneous Urticaria Cohort

Chronic spontaneous urticaria (CSU) is characterized by recurrent hives without a known trigger. While certain drugs are associated with urticaria exacerbations, the overall drug allergy incidence in CSU is unknown. We hypothesized that the incidence of drug allergy in CSU would be greater than the general population and that there would be distinguishing clinical features of drug-allergic CSU patients. 362 adult CSU patients seen over a 10-year period at a University Allergy/Asthma clinic were identified. Patients reported no drug allergies or any drug allergy. Multiple drug allergies were defined as allergies to ≥ 2 chemically unrelated drugs. Using Chi-square or Wilcoxon analysis, we compared demographic features of CSU with and without drug allergy and with multiple vs. single drug allergy. Overall, 202 CSU patients (56%) reported drug allergy. Drug allergic CSU patients were older, with a greater proportion of whites and higher BMI vs. CSU without drug allergy (p=0.002, p=0.047, p=0.004, respectively). Penicillin was the most common drug allergy, with urticaria the most frequently reported reaction. Female sex, white race, older age at the visit, and co-existing asthma were more common in multiple drug allergy (n=115) vs. single drug allergy (p=0.002, p=0.02, p=0.03, p=0.0002, respectively). In CSU, the prevalence of self-reported drug allergies was higher than the general population. Drug allergy is associated with older age, white race and higher BMI, while multiple drug allergy was also associated with asthma. These CSU sub-populations should be studied to avoid the potential for morbidity associated with less efficacious and more costly drugs.