Results of Drug Provocation Tests in Patients with a History of Drug Hypersensitivity Reaction
Keywords:
Drug allergy, skin test, drug provocation test, skin rashAbstract
Background : The diagnosis of drug hypersensitivity is often based upon history without further diagnostic evaluation. However, several studies indicated that history alone is unreliable. Although drug provocation testing (DPT) is the gold standard for a diagnosis there are very few reports of DPTs in Thailand. The purpose of this study was to present the results of DPT in patients with suspected drug hypersensitivity.
Objective : To evaluate drug hypersensivity in patient who had history of any drug hypersensitivity reactions
Methods : Retrospective chart review of patients with suspected drug hypersensitivity between November 2017 and September 2020 at the Pediatric Allergy Clinic of Maharaj Nakhon Si Thammarat Hospital. All patients were interviewed for demographic data and a detailed clinical history of any drug hypersensitivity reactions. Performed skin testing using well-established concentrations. DPTs were administered when skin tests were negative or not validated with culprit drugs using age/weight-adjusted drug doses.
Results : We performed 27 skin tests and 43 DPTs in 44 patients (27 females, 17 males). The mean age was 10 years. Drug hypersensitivity was excluded in 39 of 44 patients(88.6%) by tolerated challenge tests. Five children (11.4%) were confirmed to have true drug hypersensitivity. One (20%) of them was confirmed by an intradermal test, based on a positive response to ceftriaxone. Four (80%) cases were confirmed by a drug provocation test. There was no systemic reaction occurring after the skin prick test and intradermal tests. Four patients were diagnosed as drug hypersensitivity, based on positive provocation test confirmed NSAID hypersensitivity (n=1) and cefotaxime (n=1) with and induced urticarial rash, a positive provocation test confirmed omeprazole hypersensitivity (n=1) with fixed drug eruption. Anaphylaxis occurred in only one patient who had a positive provocation
test confirmed L-Asparaginase hypersensitivity (n=1) and he responded well to treatments that included intramuscular epinephrine and intravenous antihistamine.
Conclusion : After complete evaluation few patients(11.4%) have true drug hypersensitivity. Allergologic testing and DPT procedure in patients with a history of suspected drug hypersensitivity are of importance both to establish a correct diagnosis and to improve
unjustified withholding of a drug.
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References
Boguniewicz M, Leung DYM. Adverse reactions to drugs. In: Kliegman RM, Behrman RE, Jenson HB, Stand BF, editors. Nelson textbook of pediatrics. 18th ed. Philadelphia: Saunders Inc.: 2007:990-3.
Demoly P, Pichler W, Pirmohamed M, Romano A. Important questions in Allergy: 1-drug allergy/hypersensitivity. Allergy. 2008; 63:616-9.
DesWarte RD, Patterson R. Drug allergy. In: Patterson R, Grammer LC, GreenbErger PA, editors. Allergic Diseases. 5th ed. Philadelphia: Lippincott-Raven; 1997:317-412.
Ceilic G, Pichler WJ, Adkinson NF Jr. Drug allergy. In:Adkinson NF Jr, Bochner BS, Busse WW, Holgate ST, Lemanske RF Jr, Simons FER, editors. Middleton’s allergy, principles & practice. 7th ed. China: Elsevier Inc.; 2009:1205-26.
Gomes E, Cardoso MF, Praca F, et al. Selfreported drug allergy in a general adult Portuguese population. Clin Exp Allergy2004; 34:1597-601
Solensky R. Drug hypersensitivity. Med Clin North Am 2006; 90: 233–60
Gandhi TK, Weingart SN, Borus J, et al. Adverse drug events in ambulatory care. N Engl J Med 2003; 348:1556-664.
Lazarou J, Pomeranz BH, Corey PN. Incidence of adverse drug reactions in hospitalized patients: a meta-analysis of prospective studies.JAMA1998; 279:1200-5.
Porter J, Jick H. Drug-related deaths among medicalimpatients.JAMA. 1977; 237:879-81.
Jirapongsananuruk O, Bunsawansong W, Piyphanee N, Visitsunthorn N, Thongngarm T, Vichyanond P. Features of patients with
anaphylaxis admitted to a university hospital. Ann Allergy Asthma Immunol. 2007; 98:157-62.
Picard M, Begin P, Bouchard H, et al. Treatment of patients with a history of penicillin allergy in a large tertiary care academic hospital. J Allergy Clin Immunol: In practice 2013; 1:252-7.
MacLaughlin EJ, Saseen JJ, Malone DC. Costs of betalactam allergies selection and costs of antibiotics for patients with a reported betalactam allergy. Arch Fam Med 2009; 9:722-6.
Sade K, HoltzerI,LevoY, et al.The economic burden of antibiotic treatment of penicillin allergic patients in internal medicine wards
of general tertiary care hospital. Clin Exp Allergy 2003; 33:501-6.
Caubet CJ, Kaiser L, Lemaıˆtre B, Fellay B, Gervaix A, Eigenmann AP. The role of penicillin in benign skin rashes in childhood:Aprospective study based on drug rechallenge.J Allergy Clin Immunol 2011;127:218-22.
Hershkovich J, Broides A, Kirjner L, et al. Betalactam allergy and resensitization in children with suspected betalactam allergy.
ClinicalExperimentalAllergy2009;39:726-30.
Park MA, LiJT. Diagnosis and management of penicillin allergy. Mayo Clin Proc. 2005;80:405-10.
Executive summary of disease management of drug hypersensitivity: a practice parameter. Joint Task Force on Practice Parameters, the
American Academy of Allergy, Asthma and Immunology, and the Joint Council of Allergy, Asthma and Immunology. Ann Allergy Immunol 2010; 105:1-78.
Demoly P, Kropf R, Bircher A, et al. Drug hypersensitivity: questionnaire. Allergy 1999; 54: 999-1003.
Sagar PS and Katelaris CH. Utility of penicillin allergy testing in patients presenting with a history of penicillin allergy. Asia Pac Allergy 2013; 3:115-9.
Caubet CJ, Kaiser L, Lemaıˆtre B, Fellay B, Gervaix A, Eigenmann AP. The role of penicillin in benign skin rashes in childhood:Aprospective study based on drug rechallenge.J Allergy Clin Immunol 2011;127:218-22.
Aberer W, Bircher A, Romano A, et al. Drug provocation testing in the diagnosis of drug hypersensitivity reactions: general
considerations. Allergy 2003; 58:85-63.
Bousquet P-J, Gaeta F, Bousquet-Rouanet L, et al. Provocation tests in diagnosing drug hypersensitivity. Curr Pharm Des 2008;
:2792-802.
Romano A, Blanca M, Torres MJ, et al. Diagnosis of nonimmediate reactionsto betalactam antibiotics.Allergy 2004; 59:1153-60.
Blanca M, RomanoA, Torres MJ, Demoly P, DeWeck A. Continued need of appropriate betalactam-derived skin test reagentsfor the
management of allergy to betalactams. Clin Exp Allergy. 2007; 37:166-7.
Brockow K, Romano A. Skin tests in the diagnosis of drug hypersensitivity reactions. Curr Pharm Des 2008; 14:2778-91.
RomanoA,CaubetJC.Antibiotic allergiesin children and adults: from clinical symptom so skin testing diagnosis. J Allergy Clin Immunol Pract. 2014; 2:3-12.
Bousquet PJ, Pipet A, Bousquet-Rouanet L,Demoly P. Oral challenges are needed in the diagnosis of beta-lactam hypersensitivity.
Clin Exp Allergy. 2008; 38:185-90.
ManuyakornW, Singvijarn P, Benjaponpitak S, et al. Skin testing with β-lactam antibiotics for diagnosis of β-lactam hypersensitivity in
children.Asian Pac JAllergy Immunol 2016;34:242-7.
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