Προσεγγίζοντας τον ασθενή με πολυφαρμακευτική αλλεργία

Khan DA.

Treating patients with multiple drug allergies.

Ann Allergy Asthma Immunol. 2013 Jan;110(1):2-6.

Απόσπασμα από την εισαγωγή:

« It is well recognized that some patients report multiple allergies to medications. One of the first descriptions using the term multiple drug allergy syndrome was in 1989 in an abstract by Sullivan et al, who reported that 21% of 312 penicillin allergic patients reported allergies to other drugs compared with only 1% of 349 adults with no penicillin allergy history. In contrast, a study by Khoury and Warrington found the incidence of reactions to non–β-lactam drugs to be similar between patients with penicillin allergy with positive penicillin skin test results, patients with penicillin allergy with negative penicillin skin test results, and patients with vasomotor rhinitis without a history of penicillin allergy. The term multiple drug allergy is controversial because a criterion standard for confirming allergy (ie, skin testing or drug challenge) is typically lacking, there is no clear immunologic explanation, and prospective studies are not available. Subsequently, another term has been introduced to explain patients with reactions to multiple drugs: multiple drug intolerance syndrome (MDIS).»

Πολλοί ασθενείς οι οποίοι προσέρχονται στα αλλεργιολογικά τμήματα για διερεύνηση φαρμακευτικής αλλεργίας αναφέρουν μία ποικιλία από αντιδράσεις, σε πολλαπλές φαρμακευτικές ουσίες, συνήθως πτωχά τεκμηριωμένες από τους ιατρούς οι οποίοι αντιμετώπισαν σε επείγουσα βάση το επεισόδιο. Επιπλέον οι ακριβείς συνθήκες του επεισοδίου δεν είναι εύκολα ανακλήσιμες από τον ασθενή με αποτέλεσμα το ιστορικό να είναι ελλιπές και αμφίβολο. Η αδυναμία διαχωρισμού των ανεπιθύμητων αντιδράσεων των φαρμάκων από τις ανοσολογικά μεσολαβούμενες ανεπιθύμητες ενέργειες περιπλέκει ακόμη περισσότερο τόσο τον ασθενή, όσο και τον κλινικό ιατρό. Η έννοιες της «πολλαπλής φαρμακευτικής αλλεργίας» και του «συνδρόμου της πολυφαρμακευτικής δυσανεξίας» αναφέρονται σε αυτούς τους ασθενείς πολλές φορές από κοινού, αν και αποτελούν δύο διαφορετικές διατυπώσεις του ίδιου προβλήματος.

http://www.annallergy.org/article/S1081-1206%2812%2900855-1/abstract

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ΕΠΙΠΛΕΟΝ ΒΙΒΛΙΟΓΡΑΦΙΑ:

Atanasković-Marković M, Gaeta F, Gavrović-Jankulović M, Cirković Veličković T,

Valluzzi RL, Romano A.

Diagnosing multiple drug hypersensitivity in children.

Pediatr Allergy Immunol. 2012 Dec;23(8):785-91.

Abstract

BACKGROUND:

Multiple drug hypersensitivity (MDH) has been defined as a hypersensitivity to two or more chemically different drugs. Two types of MDH have been reported: the first one, which develops to different drugs administered simultaneously and the second type, in which sensitizations develop sequentially. In children, studies which diagnose MDH on the basis of positive allergologic tests to 2 or more chemically different drugs are lacking.

METHODS:

We conducted a prospective study evaluating children with histories of MDH by skin tests, patch tests, serum-specific IgE assays, and drug provocation tests.

RESULTS:

A MDH was diagnosed in 7 (2.5%) of the 279 children evaluated who completed the study. The responsible drugs were β-lactams (penicillins and cephalosporins) in 5 episodes, ibuprofen and anticonvulsants in 3, and erythromycin, fentanyl, methylprednisolone, and cotrimoxazole in 1. Sensitivity to 2 chemically different drugs was diagnosed in 6 children and to 3 drugs in 1 child. Two of the 7 children presented the first type of MDH, whereas 5 displayed the second one.

CONCLUSIONS:

MDH can occur in children, even to drugs other than antibiotics. It is crucial to evaluate children with histories of MDH using both in vivo and in vitro allergologic tests, including challenges. In fact, such approach allows the physician to confirm the diagnosis of MDH in a small percentage of children with histories of MDH, as well as to rule it out in the great majority of them.

http://onlinelibrary.wiley.com/doi/10.1111/pai.12020/abstract

Macy E, Ho NJ.

Multiple drug intolerance syndrome: prevalence, clinical characteristics, and management.

Ann Allergy Asthma Immunol. 2012 Feb;108(2):88-93.

Abstract

BACKGROUND:

Population-based data on the demographics and clinical characteristics of patients with multiple unrelated drug class intolerances noted in their medical records are lacking.

OBJECTIVES:

To provide population-based drug “allergy” incidence rates and prevalence, and to identify individuals with multiple drug intolerance syndrome (MDIS) defined by 3 or more unrelated drug class “allergies,” and to provide demographic and clinical information on MDIS cases.

METHODS:

Electronic medical record data from 2,375,424 Kaiser Permanente Southern California health plan members who had a health care visit and at least 11 months of health care coverage during 2009 were reviewed. Population-based drug “allergy” incidence rates and prevalence were determined for 23 unrelated medication classes.

RESULTS:

On January 1, 2009, 478,283 (20.1%) health plan members had at least one reported “allergy.” Individuals with a history of at least 1 “allergy” and females, in general, reported higher population-based new “allergy” incidence rates. Multiple drug intolerance syndrome was present in 49,582 (2.1%). The MDIS cases were significantly older, 62.4 ± 16.1 years; heavier, body mass index 29.3 ± 7.1; and likely to be female, 84.9%, compared with average health plan members. They had high rates of health care utilization, medication usage, and new drug “allergy” incidence. They sought medical attention for common nonmorbid conditions.

CONCLUSIONS:

Multiple drug intolerance syndrome is in part iatrogenic. It is associated with overweight elderly women who have high rates of health care and medication usage. Urticarial syndromes only explain a small fraction of MDIS cases. Multiple drug intolerance syndrome is associated with anxiety, but not predominately with immunoglobulin E (IgE)-mediated allergy or life-threatening illness. Multiple drug intolerance syndrome can be managed by medication avoidance and judicious rechallenge.

http://www.annallergy.org/article/S1081-1206%2811%2900901-X/abstract

Dioun AF.

Management of multiple drug allergies in children.

Curr Allergy Asthma Rep. 2012 Feb;12(1):79-84.

Abstract

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.

http://link.springer.com/article/10.1007/s11882-011-0239-y/fulltext.html