Multiple Drug Allergies Research Articles

Acupressure only as pain relief for patient with multiple drug allergies undergoing oocyte retrieval

In vitro fertilization (IVF) is associated with significant stress, which can affect the general wellbeing of the couple as well as the outcome of treatment. Oocyte retrieval (OR) is the fundamental step in the IVF/intracytoplasmic sperm injection (ICSI) cycle. Transvaginal ultrasound-guided OR (TVOR) is the most common method used in assisted reproductive technology (ART). However, even though TVOR is a short and minimally invasive procedure, it is stressful and undoubtedly painful [1]. Such pain is due to the passage of a double-bore needle through the vaginal wall and ovarian capsule followed by mechanical stimulation within the ovary during the procedure.

A multiple drug allergy syndrome, multiple drug intolerance syndrome and/or allergic drug reaction with multiple immune reactants

A multiple drug allergy syndrome, multiple drug intolerance syndrome and/or allergic drug reaction with multiple immune reactants

Could aluminum be a new hidden allergen in type 1 hypersensitivity reactions when used as a drug additive?

Medications usually contain numerous additives and preservatives. Some of these agents have been reported as causative factors in adverse drug reactions, including asthma attacks, urticaria and/or angioedema, and even severe systemic anaphylaxis. Moreover, allergens such as additives and preservatives may be hidden as they are not easily identified during etiological investigations.

Ceftaroline desensitization procedure in a pregnant patient with multiple drug allergies.

Validated skin testing is lacking for many drugs, including ceftaroline. The cross-reactivity between ceftaroline and other β-lactam antibiotics is unknown. We report a case of a pregnant patient with cystic fibrosis and multiple drug allergies who required ceftaroline for methicillin-resistant Staphylococcus aureus pneumonia and underwent an uncomplicated empiric desensitization procedure.

General anesthesia in a patient with multiple drug allergy

General anesthesia in a patient with multiple drug allergy

Hypersensitivity reactions to intravenous iron: guidance for risk minimization and management.

Intravenous iron is widely used for the treatment of iron deficiency anemia when oral iron is inappropriate, ineffective or poorly tolerated. Acute hypersensitivity reactions during iron infusions are very rare but can be life-threatening. This paper reviews their frequency, pathogenesis and risk factors, and provides recommendations about their management and prevention. Complement activation-related pseudo-allergy triggered by iron nanoparticles is probably a more frequent pathogenetic mechanism in acute reactions to current formulations of intravenous iron than is an immunological IgE-mediated response. Major risk factors for hypersensitivity reactions include a previous reaction to an iron infusion, a fast iron infusion rate, multiple drug allergies, severe atopy, and possibly systemic inflammatory diseases. Early pregnancy is a contraindication to iron infusions, while old age and serious co-morbidity may worsen the impact of acute reactions if they occur. 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.

Comparison of basophil activation test and lymphocyte transformation test as diagnostic assays for drug hypersensitivity

Lymphocyte transformation test (LTT) is a widely used assay to detect drug-specific T cell reaction, but its relatively low sensitivity renders risk for pseudo-negativity. Basophil activation test (BAT) is an emerging assay initially used to diagnose food allergy, but its application to drug hypersensitivity as been reported anecdotally. Although a promising assay, the clinical settings or a particular class of drugs in which BAT is useful has not been well characterized. Herein, we performed a side-by-side comparison of BAT and LTT in detecting culprit drugs in several types of drug hypersensitivities. 248 patients who visited our department from October 2011 to December 2013 were enrolled in this study. Peripheral blood cells drawn from patients were co-cultured with or without relevant drugs. LTT was performed according to a standard protocol with 3H-thymidine uptake and stimulation index of 1.8 and above (CPM value with drug divided by CPM without drug) were defined positive. For BAT, whole blood cells were exposed to drugs for 24hrs and were assessed via flow cytometry for the proportion of cells that had upregulated CD203c (activated state) among total basophils. 9.0% and above were defined positive, based on values from healthy controls (mean value + 5SD). Overall, 14.7% and 28.8% of culprit drugs tested yielded positive results by BAT and LTT, respectively. Analysis of disease phenotype of patients revealed that BAT yielded positive results not only in immediate-type, but also delayed-type hypersensitivity such as drug-induced hypersensitivity syndrome and Stevens-Johnson syndrome. Of note, samples that yielded positive for LTT and BAT did not overlap, suggesting that the two analyses might compensate each other for pseudo-negativity. Furthermore, analysis focusing on the class of antibiotics showed that macrolides were frequently obtained positive via BAT, whereas that for -lactams tended to be positive via LTT. Utilizing both BAT and LTT, we screened antibiotics and NSAIDs for selection of drugs that could be used for challenge tests in patients with histories of multiple drug allergy. The negative indicative value was 96.4%, suggesting the usefulness of these assays in safely identifying drugs for future use. Taken together, different spectrum of drugs can be covered by performing both BAT and LTT, allowing identification of culprit drugs with higher sensitivity than by performing a single assay.

Evaluation and management of a patient with multiple drug allergies.

Multiple drug allergy syndrome (MDAS) is a clinical diagnosis made in patients with adverse reactions to two or more structurally unrelated drugs with an underlying immune-mediated mechanism causing the reaction. The evaluation of a patient with MDAS begins with a comprehensive drug allergy history and consideration of the underlying immune mechanism for each reaction. Skin testing is a useful diagnostic tool; however, the only validated immediate hypersensitivity skin testing is for penicillin where the antigenic determinants have been identified. Skin testing to most other drugs, although not validated, can be considered using a nonirritating concentration (NIC). In general, skin test positivity using an NIC suggests that the drug should be avoided, but a negative result does not rule out an IgE-mediated allergy. A test dose, also called a drug provocation test, graded oral challenge, or incremental challenge, should be performed when there is a low likelihood of an IgE-mediated mechanism for the reaction. In patients with a recent IgE-mediated hypersensitivity reaction or positive skin testing with no reasonable alternative treatment options, desensitization protocols can be used to allow the patient to safely receive a necessary drug. The evaluation of patients with MDAS is both challenging and time-consuming for the practicing allergist, who must systematically evaluate each reaction to help determine which drugs can be safely used again in the future. The molecular mechanisms and risk factors for this condition remain poorly understood, but research to further understand this condition is ongoing.

Indications, Protocols, and Outcomes of Drug Desensitizations for Chemotherapy and Monoclonal Antibodies in Adults and Children

Advances in the understanding of various malignancies and chronic inflammatory diseases has led to the development of better treatment options for prolonging patient survival and minimizing morbidity. The recognition of "first-line" chemotherapy and monoclonal agents for these conditions has given more urgency to the need to re-administer these drugs in cases of drug hypersensitivity reactions. Therefore, in these cases, not only is desensitization considered when there is no alternative therapy available but also when alternative treatments are considered therapeutically inferior and/or more toxic. In this article, we describe the steps involved in the evaluation of these patients, factors to consider before making a decision to desensitize, the implementation of desensitization protocols, and the outcomes of such procedures.

Anaesthesia in a patient with multiple drug allergies

Anaphylactic reaction occurring during anaesthesia remains a major cause of concern for anaesthetists. It can have various causes because patients can be exposed to a large number of drugs and other substances over a relatively short period of time. Latex allergy should always be considered as a potential cause of perioperative anaphylaxis. Hypotension, cyanosis and bronchospasm are the most common manifestations of intraoperative anaphylaxis. Management includes initial supportive therapy and follow-up management, including detailed documentation and thorough investigation to identify the predisposing factor(s). It is the anaesthetist's responsibility to ensure that any suspected anaphylactic reaction is thoroughly investigated using immediate and post-operative testing; failure to do so may lead to wrong diagnosis and other life-threatening events on repeated exposure. There are two pillars for safe perioperative management: an active policy of high-risk identification during preoperative assessment and specialized allergists to provide expert advice throughout the perioperative period.

Anesthesia Management in a Patient Diagnosed with Kounis-Zavras Syndrome and Who has Brittle Asthma and Samter Triad

In Kounis-Zavras syndrome, vasospastic mediators released from mast cells as response to allergic stimulus lead to coronary vasospasm and result in acute coronary syndrome or angina pectoris. In this case report, anesthesia management in a 35 year old female patient with Kounis-Zavras syndrome who had Samter triad and multiple drug allergy and had arrest previously due to drug allergy and hence who has implantable cardioverter defibrillator is presented.

Pediatric Patients with a History of Penicillin Allergy and a Positive Penicillin Skin Test May Not Be at an Increased Risk for Multiple Drug Allergies

Pediatric Patients with a History of Penicillin Allergy and a Positive Penicillin Skin Test May Not Be at an Increased Risk for Multiple Drug Allergies

Management of Multiple Drug Allergies in Children

Children with multiple drug allergies are likely to require treatment with one or more of the drugs to which they may have had a reaction, when there is no alternate effective drug available. Detailed review of their history and/or use of appropriate diagnostic studies will help determine the potential safety of readministering the desired drug as well as the method for its readministration, most likely in the form of a drug challenge or desensitization. A practical approach to the diagnosis and treatment of children with multiple drug allergies is described in this review.

Bladder Pain Syndrome/Interstitial Cystitis in Twin Sisters

We determined the genetic contribution of and associated factors for bladder pain syndrome using an identical twin model. Multiple questionnaires were administered to adult identical twin sister pairs. The O'Leary-Sant Interstitial Cystitis Symptom and Problem Index was administered to identify individuals at risk for bladder pain syndrome. Potential associated factors were modeled against the bladder pain syndrome score with the twin pair as a random effect of the factor on the bladder pain syndrome score. Variables that showed a significant relationship with the bladder pain syndrome score were entered into a multivariable model. In this study 246 identical twin sister pairs (total 492) participated with a mean age (± SD) of 40.3 ± 17 years. Of these women 45 (9%) were identified as having a moderate or high risk of bladder pain syndrome (index score greater than 13). There were 5 twin sets (2%) in which both twins met the criteria. Correlation of bladder pain syndrome scores within twin pairs was estimated at 0.35, suggesting a genetic contribution to bladder pain syndrome. Multivariable analysis revealed that increasing age (estimate 0.46 [95% CI 0.2, 0.7]), irritable bowel syndrome (1.8 [0.6, 3.7]), physical abuse (2.5 [0.5, 4.1]), frequent headaches (1.6 [0.6, 2.8]), multiple drug allergies (1.5 [0.5, 2.7]) and number of self-reported urinary tract infections in the last year (8.2 [4.7, 10.9]) were significantly associated with bladder pain syndrome. Bladder pain syndrome scores within twin pairs were moderately correlated, implying some genetic component. Increasing age, irritable bowel syndrome, frequent headaches, drug allergies, self-reported urinary tract infections and physical abuse were factors associated with higher bladder pain syndrome scores.

Disseminated Nocardia farcinica infection in a patient with myasthenia gravis successfully treated by linezolid: a case report and literature review

Nocardiosis is increasingly being diagnosed because of a growing population of immunocompromised hosts and improvements in the detection of Nocardia species in clinical laboratories. Historically, sulphonamides have been the first-line therapy for the treatment of nocardiosis, but sulphonamides tend to have a high rate of drug allergy in clinical settings. In this report, we described a disseminated Nocardia farcinica infection that occurred in a patient with myasthenia gravis who suffered from multiple drug allergies and was successfully treated using linezolid. We undertook a review of the literature of previously reported cases of nocardiosis treated with linezolid. To date, only 15 cases of nocardiosis treated with linezolid have been published. All cases exhibited long-term tolerance of linezolid, and 14 of 15 cases showed either an improvement in or complete clearance of the infection. According to the literature review, linezolid is an attractive alternative to trimethoprim-sulfamethoxazole for the treatment of disseminated nocardiosis, despite limited clinical evidence to support this claim.

Macrogol hypersensitivity in multiple drug allergy

Polyethylene glycols (macrogols) are condensation products of glycols with ethylene oxide and are widely used as excipients in food, cosmetics, and topical and systemic drugs because of their stabilizing properties. Although macrogols are used frequently and extensively, only a few immediate hypersensitivity reactions have been reported, probably because they are poorly absorbed by the gastrointestinal tract. Immediate hypersensitivity reactions have been reported after parenteral and oral administration of products containing macrogols, such as corticosteroids,1,2 laxative oral solutions,3 and tablets.

Safety and efficacy of rapidly administered (one hour) one gram of low molecular weight iron dextran (INFeD) for the treatment of iron deficient anemia

Safety and efficacy of rapidly administered (one hour) one gram of low molecular weight iron dextran (INFeD) for the treatment of iron deficient anemia

Sequential development of eczematous type “multiple drug allergy” to unrelated drugs

To the Editor: A 48-year-old nonatopic Turkish man developed an eczematous eruption on his trunk and extremities in 2003 after oral intake of cetirizine. The eruption worsened after switch to hydroxyzine. Histopathology confirmed an eczematous eruption. Similar attacks occurred with amoxicillin, erythromycin, tetracycline, lansoprazole, and pseudoephedrine during a 2-year follow-up. In 2005, Hodgkin lymphoma was diagnosed and treated with surgical excision and radiotherapy. Later, new attacks of eczematous eruption occurred with sultamicillin and iohexol (Table I).

Anesthesia in the patient with multiple drug allergies: are all allergies the same?

During the preoperative evaluation, patients frequently indicate 'multiple drug allergies', most of which have not been validated. Potential allergic cross-reactivity between drugs and foods is frequently considered as a risk factor for perioperative hypersensitivity. The aim of this review is to facilitate the recognition of risk factors for perioperative anaphylaxis and help the management of patients with 'multiple drug allergies' during the perioperative period. Neuromuscular blocking agents (NMBAs) and antibiotics are the most common drugs triggering perioperative anaphylaxis. Quaternary ammonium ions have been suggested to be the allergenic determinant of NMBAs. Even though the 'pholcodine hypothesis' has been suggested to explain the occurrence of NMBA-induced allergy, this concept remains unclear. Although many practitioners believe that certain food allergies present an issue with the use of propofol, there is no role to contraindicate propofol in egg-allergic, soy-allergic or peanut-allergic patients. IgE-mediated hypersensitivity has been reported with seafood and iodinated drugs, IgE-mediated hypersensitivity has been reported with seafood and iodinated drugs, but there is no cross-reactivity between them. The allergenic determinants have been characterized for fish, shellfish and povidone iodine and remain unknown for contrast agents. There are many false assumptions regarding drug allergies. The main goal of this article is to review the potential cross-reactivity among specific families of drugs and foods in order to facilitate the anesthetic management of patients with 'multiple drug allergies'.

Management of anaemia in CKD-the relative importance of erythropoietin and iron.

During an industry-sponsored symposium at the ERA–EDTA meeting in Munich 2010, four experts gathered to debate and provide an update on the treatment of anaemia in chronic kidney disease (CKD) patients, especially the relative contributions of erythropoiesis-stimulating agents (ESAs) and iron in its management. I chaired this symposium and invited these experts in collaboration with the sponsor to summarize their opinions. As the results of the largest of the ESA trial, TREAT, were available, many presenters focused on those results. The expert opinions were partly supported by available data, and there were, on occasions, differences in opinion between the experts on the interpretation of the data. For example, Dr Coyne’s statement that stroke risk is independent of ESA hyporesponsiveness is not a view that I share. I believe that the analysis of Solomon et al. in which Dr Coyne’s statement was based was simply not sufficiently powered to detect this relationship. Dr Locatelli states that the TREAT study was not a ‘placebo’ randomized controlled trial because the placebo group experienced an increase in haemoglobin (Hgb) over time. I disagree. The Hgb levels increased over time because the placebo group had a rescue feature which allowed administration of darbepoietin should Hgb fall below 9 g/dL. Dr Bhandari states that the profile of the ideal iron preparation should be capable of delivering sufficient quantities of intravenous iron to correct iron deficiency rapidly, with minimal potential side effects including low catalytic/labile iron release and negligible immunogenicity (risk of anaphylaxis). Yes, but I believe that the long-term safety of intravenous iron is the most important attribute which needs to be evaluated; long-term toxicity would trump any convenience afforded by the drug. Dr Kalra states that the drug should have reduced immunogenic potential and reduced risk for free iron toxicity. Although these claims may be true, they remain to be validated in larger safety studies especially among patients with multiple drug allergies. Below are opinions provided by the experts. There are several statements where consensus was not achieved. However, the experts do have a right to their opinions, and I present them below as they were presented to me, even when I am in disagreement. The highlights of this symposium, as I see it, are as follows: Normalizing Hbg among people with CKD is associated with cardiovascular and thrombotic risk. These risks can only be partially managed by correcting anaemia. Hyporesponsiveness to ESAs is associated with increased cardiovascular risk. Whether it is the dose of ESAs, poor response to ESA dose, a combination of the two or some other traits that confer this increased risk is unknown. Therefore, it should not be taken as a foregone conclusion that the dose of ESA is toxic. However, it is prudent to limit the dose of ESA to the minimum required to achieve a satisfactory Hbg response. The upper limit of ESA dose is unknown. Iron deficiency remains an important cause of ESA hyporesponsiveness. The diagnosis of iron deficiency among patients with CKD remains difficult. The pitfalls in making a diagnosis of iron deficiency anaemia are discussed. No gold standard is established. Therefore, when in doubt, a therapeutic trial of intravenous iron may be useful to establish a firm diagnosis. Among haemodialysis patients, the preferred route of iron administration is intravenous. However, it must be noted that patients with CKD who are not on haemodialysis can receive iron either orally or intravenously; there is no preference. The various parenteral irons, which are currently marketed, and their risks and benefits are discussed. Normalizing Hbg with ESAs in patients with CKD increases cardiovascular risk, whereas hyporesponsiveness to ESAs is associated with increased risk. Thus, it is logical to hypothesize that the cardiovascular risk of ESA use in patients with CKD may be mitigated with iron administration. Whether iron administration reduces ESA hyporesponsiveness or decreases or increases cardiovascular risk is currently unknown. The risk–benefit ratio of iron administration in CKD patients needs to be evaluated in well-designed prospective randomized controlled trials with cardiovascular and renal outcomes. Iron isomaltoside 1000 may be an attractive intravenous iron that may allow rapid repletion and theoretically a better safety profile.