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Practical Management of Patients with a History of Immediate Hypersensitivity to Common non-Beta-Lactam Drugs

  • Anaphylaxis and Drug Allergy (DA Khan and M Castells, Section Editors)
  • Published:
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Abstract

Immediate hypersensitivity reactions to medications are among the most feared adverse drug reactions, because of their close association with anaphylaxis. This review discusses a practical management approach for patients with a history of an immediate hypersensitivity to a non-beta-lactam medication, where reexposure to the implicated, or similar, medication is clinically necessary. Mechanisms associated with severe immediate hypersensitivity reactions include IgE-mediated mast cell activation, complement-mediated mast cell activation, and direct mast cell activation. Immediate hypersensitivity reactions may also be mediated by vasodilators, other pharmacologic mechanisms, or be secondary to underlying patient-specific biochemical abnormalities such as endocrine tumors or chronic spontaneous urticaria. The key features in the reaction history and the biochemistry of the implicated medication are discussed. Most individuals with a history of immediate hypersensitivity to a medication, who require reuse of that drug, can be safely retreated with a therapeutic course of the implicated drug after a full-dose challenge, graded challenge, or desensitization, with or without premedication and/or any preliminary diagnostic testing, depending on the specific situation.

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Abbreviations

ACE:

Angiotensin converting enzyme

AERD:

Aspirin exacerbated respiratory disease

BSA:

Bovine serum albumin

GBCA:

Gadolinium-based contrast agent

IV:

Intravenous

MCAS:

Mast cell activation syndrome

NMBA:

Neuromuscular blocking agent

NERD:

Non-steroidal anti-inflammatory drug exacerbated respiratory disease

NSAID:

Non-steroidal anti-inflammatory drug

PPV:

Positive predictive value

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Authors and Affiliations

  1. Kaiser Permanente, Department of Allergy, 7060 Clairemont Mesa Blvd, San Diego, CA, 92111, USA

    Eric Macy

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  1. Eric Macy
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Correspondence to Eric Macy.

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Conflict of Interest

The author is a partner of the Southern California Permanente Medical Group (SCPMG). SCPMG provided the majority of the funding for the work reviewed here in which the author participated. Eric Macy is a previous chair of the Adverse Reactions to Drugs and Biologics Committee of the American Academy of Allergy Asthma and Immunology (AAAAI). He has received research grants from the United States Food and Drug Administration (FDA) and ALK Abello, Inc. to study adverse drug reactions. He is a member of clinical trial safety and monitoring committees for BioMarin Pharmaceutical, Inc., Tufts University, and Ultragenyx, and has done consulting for KaloBios. The commentary presented here is the opinion of the author and does not reflect the policy of the AAAAI.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

This article will restrict the word “allergy” to mean a confirmed clinically significant IgE-mediated immediate hypersensitivity. When “allergy” is used, it will refer to what is noted in a medical record pertaining to an adverse reaction or intolerance associated with the previous use of a specific medication or medication class that has not been confirmed to be IgE-mediated. The term “immediate hypersensitivity” will be restricted to reactions that start within 6 h of exposure to the implicated drug (1).

This article is part of the Topical Collection on Anaphylaxis and Drug Allergy

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Macy, E. Practical Management of Patients with a History of Immediate Hypersensitivity to Common non-Beta-Lactam Drugs. Curr Allergy Asthma Rep 16, 4 (2016). https://doi.org/10.1007/s11882-015-0584-3

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  • DOI: https://doi.org/10.1007/s11882-015-0584-3

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