A.M. Chiriac

Reasons for prescribing second generation antihistamines to treat allergic rhinitis in real-life conditions and patient response

BackgroundSecond generation H1 antihistamines (H1A) are currently recommended as first choice medications for allergic rhinitis and rhinoconjunctivitis. However, little is known about what influences the choice of prescription of one second generation (H1A) as opposed to another in real-life conditions.ObjectiveThe aim of the study was to identify the main criteria determining the choice of a second generation H1A by allergy specialists in mainland France.MethodsConsecutive patients suffering from allergic rhinitis or rhinoconjunctivitis were included and followed prospectively for 30xa0days from the prescription of a second generation H1A in monotherapy. Patients were asked to fill in auto-questionnaires at baseline, daily during the first 10xa0days of the new treatment, and at the end of follow-up. Data on efficacy, tolerance, safety, rate and type of response to treatment, as well as patient satisfaction were recorded and analyzed.Results1,080 patients were included between March 2011 and October 2012, mostly suffering from moderate to severe rhinitis (82.0%). The most frequently cited reason for choosing a specific H1A was the expected efficacy (85.3%). The mean time to nasal and ocular recovery was 6xa0days and 78.2% of patients responded to treatment within this interval. The presence of conjunctivitis was significantly associated with a more rapid response. At the end of follow-up, the satisfaction rate was higher for patients who were switched from a previous treatment (87.5%), compared to those receiving their first treatment (78.8%).Conclusion and clinical relevanceThe main reason for choosing a specific second generation H1A was its expected efficacy. Concomitant conjunctivitis is associated with a more rapid response to treatment. Symptom recovery necessitates a mean of 6xa0days.

Prevalence of uncontrolled allergic rhinitis in Wuhan, China: a prospective cohort study.

Background Allergic rhinitis (AR) is a highly prevalent disease that affects the quality of life, especially in the “severe chronic upper airway disease” (SCUAD) group of patients who still have severe symptoms after adequate treatment. This study investigated the prevalence of uncontrolled AR and SCUAD consulting in the Allergy Department of Tongji Hospital, Wuhan, China. Methods In this prospective cohort study, all patients consulting for AR were prospectively assessed using visual analog scale (VAS) and Allergic Rhinitis Control Test (ARCT) and put on standardized treatment based on the Allergic Rhinitis and Its Impact on Asthma (ARIA) guidelines. After 15 days, they were reevaluated by a telephone interview using a numerical scale (NS) and ARCT. A score of ARCT of <20 defined uncontrolled AR and a score of NS of ≥5 at day 15 defined SCUAD patients. Results A total of 252 patients were included. Moderate/severe AR (VAS ≥ 5) was diagnosed in 82.9 of the patients which had an impact on sleep (86.9%), work life (84.9%), social activities (81%), and physical activities (90.1%). Patients with uncontrolled AR (27.7%) at day 15 more frequently presented a higher weight (p = 0.042), history of ear, nose, and throat (ENT) infection or antibiotics intake for respiratory infection in the last 12 months (62.3% versus 45.6%; p = 0.018), smoking (15.9% versus 6.7%; p = 0.024), and smell disturbance (26.1% versus 11.7%; p = 0.005). Patients with SCUAD (24.5%) more frequently presented a history of ENT infection or antibiotics intake for respiratory infection in the last 12 months (63.9% versus 45.7%; p = 0.014) and smell disturbance (27.9% versus 11.7%; p = 0.003), and less commonly had atopic dermatitis (13.1% versus 28.2%; p = 0.017). Conclusion Uncontrolled AR and SCUAD patients are numerous. VAS and ARCT are simple and quantitative methods and self-completion questionnaires that can be used for a global evaluation of the severity and control of AR.

Designing Predictive Models for Beta-Lactam Allergy Using the Drug Allergy and Hypersensitivity Database

BACKGROUNDnBeta-lactam antibiotics represent the main cause of allergic reactions to drugs, inducing both immediate and nonimmediate allergies. The diagnosis is well established, usually based on skin tests and drug provocation tests, but cumbersome.nnnOBJECTIVESnTo design predictive models for the diagnosis of beta-lactam allergy, based on the clinical history of patients with suspicions of allergic reactions to beta-lactams.nnnMETHODSnThe study included a retrospective phase, in which records of patients explored for a suspicion of beta-lactam allergy (in the Allergy Unit of the University Hospital of Montpellier between September 1996 and September 2012) were used to construct predictive models based on a logistic regression and decision tree method; a prospective phase, in which we performed an external validation of the chosen models in patients with suspicion of beta-lactam allergy recruited from 3 allergy centers (Montpellier, Nîmes, Narbonne) between March and November 2013. Data related to clinical history and allergy evaluation results were retrieved and analyzed.nnnRESULTSnThe retrospective and prospective phases included 1991 and 200 patients, respectively, with a different prevalence of confirmed beta-lactam allergy (23.6% vs 31%, Pxa0= .02). For the logistic regression method, performances of the models were similar in both samples: sensitivity was 51% (vs 60%), specificity 75% (vs 80%), positive predictive value 40% (vs 57%), and negative predictive value 83% (vs 82%). The decision tree method reached a sensitivity of 29.5% (vs 43.5%), specificity of 96.4% (vs 94.9%), positive predictive value of 71.6% (vs 79.4%), and negative predictive value of 81.6% (vs 81.3%).nnnCONCLUSIONSnTwo different independent methods using clinical history predictors were unable to accurately predict beta-lactam allergy and replace a conventional allergy evaluation for suspected beta-lactam allergy.

Patient versus allergy specialist interpretation of a negative workup for suspected iodinated contrast media allergy

Drug allergy workup aspires to validate or invalidate assumed allergies, identify potential cross-reacting drugs, and provide safe alternatives. However, the results obtained and information given by the allergist is not always perceived as such by the patient. Therefore, the label of “allergy” often persists for patients despite a negative workup and can result in unnecessary avoidance or unnecessary use of second-line alternatives. In the management of iodinated contrast media (ICM) hypersensitivity reactions (HRs), skin testing can be used to identify the subset of truly ICM-allergic patients and to provide safe skin-testenegative ICMs for potential reexposure. Recently, we contacted 597 patients who underwent skin testing for a potential drug hypersensitivity reaction after exposure to ICM. Using a standardized questionnaire, patients were contacted and questioned whether subsequent exposure to ICM occurred and if this was tolerated. Sixteen of 233 (6.9%) patients who were reexposed experienced reactions, with mostly milder or identical symptoms compared with the initial reaction. No patient with 1 or more positive skin test result reacted to an identified skin-testenegative alternative and a stepwise approach was proposed for future evaluation and care for patients with a potential ICM HR. In this work, we evaluated how the result of the allergy workup was perceived by patients and if this was concordant or not with the view of the allergist. Therefore, at the end of the questionnaire, patients were asked whether they considered themselves as allergic to ICM or not. Only physically contacted patients were included (n 1⁄4 387) and patients with positive skin test results (n 1⁄4 57) or reactions upon reexposure despite negative skin test results (n 1⁄4 13), or incomplete data (n 1⁄4 18) were excluded, because they could be perceived as allergic, although this would not always corroborate the opinion of the allergist. The study was approved by the local ethical committee. In 299 patients with all negative skin test results, 121 (40.4%) were reexposed, all uneventfully, and 178 (59.5%) were not reexposed (Table I). Patients who were reexposed (with tolerance) reported “not to be allergic” in 92 of 121 (76.0%) cases, “allergic” in 11 of 121 (9.1%), and “uncertain” in 18 of 121 (14.9%). Those who were not reexposed reported “not to be allergic” in 57 of 178 (32.0%) cases, “allergic” in 43 of 178 (24.2%), and “uncertain” in 78 of 178 (43.8%). The proportion of patients reporting “not to be allergic” was higher in the reexposed group versus the not reexposed group (76.0% vs 32.0%; P < .0001 c test). This might reflect a change in perception after a tolerated reexposure although a lower threshold for reexposure in this subgroup of patients cannot be excluded. The proportion of patients reporting “uncertain” was lower in the reexposed group versus the not reexposed group (14.9% vs 43.8%; P < .01 c test). However, in total still 54 of 299 (18.1%) questioned patients were convinced to be “allergic” despite a negative allergy workup and 96 of 299 (32.1%) remained “uncertain.” Although skin testing can identify safe alternative(s) for ICM reexposure and potentially discriminate between allergic and nonallergic ICM HRs, the allergist and patient interpretation is often not well aligned. It is unclear whether more solid information on the negative predictive value of skin testing in ICM HR at the time of the allergy workup in this study would have reduced the number of patients continuing to perceive themselves as “allergic” or “uncertain.” However, our study indicates the need for better dissemination of information of the allergy workup toward patients and health care workers. Similar work in penicillin allergy indicates that the allergy label often persists despite a negative workup and that many patients and/or physicians remain reluctant to readminister penicillins despite a negative evaluation. In a survey in patients who underwent a penicillin allergy workup, Gerace and Philips observed that 12 of 49 (41%) patients with negative skin test results continued to avoid penicillins because of either personal (42%) or the primary care physician’s (58%) concerns. Picard et al observed that the parents of 24 of 170 (18%) children who had negative penicillin skin and provocation testing refused readministration of penicillins in their children because of fear for a reaction, similar to the 9% of patients considering themselves as allergic despite negative skin test results and a tolerated rechallenge in our work. To our knowledge, this is the first study to evaluate patient interpretation of an ICM drug allergy workup and we would suggest that this be implemented in future work to better evaluate the impact and limitations of the allergy specialist advice.

Ephedrine-induced erythrodermia: Clinical diagnostic procedure and cross-sensitivity

Hospital Sírio Libanês, São Paulo, Brazil Division of Allergy, Département de Pneumologie et Addictologie, University Hospital of Montpellier, Montpellier, France Sorbonne Université, INSERM, Institut Pierre Louis dEpidémiologie et de Santé Publique, Paris, France Centre Hospitalier Emile Durkheim, Epinal, France Correspondence Luciana K. Tanno, Division of Allergy, Département de Pneumologie et Addictologie, Hôpital Arnaud de Villeneuve, University Hospital of Montpellier, 371, av. du Doyen Gaston Giraud Montpellier 34295, France. Email: luciana.tanno@gmail.com Funding information Pascal Demoly and Luciana K. Tanno received Novartis Pharma and Meda/Mylan Pharma grants throught the CHRUM administration

Anaphylaxis case report to trimethylphloroglucinol (Spasfon

Phloroglucinol (P) and its methylated derivative (TMP) are both phenol derivative antispasmodic agents (Fig. 1) acting on smooth muscle and prescribed to treat acute spasmodic abdominal pain, acute painful disorders of the urinary tract, and acute pain in gyne-cology. It has been showed that P and TMP act by reducing glycerol-induced abdominal pain and by inhibiting colonic phasic contractions. 1 Exceptionally, P and TMP are associated with muco-cutaneous manifestations and allergic reactions. It has been reported, in the French National pharmacovigilance database, 21 cases of anaphy-laxis to phloroglucinol, including 16 cases of anaphylactic shock and 5 cases of allergic skin reaction (unpublished data). We report a case of anaphylaxis to phloroglucinol confirmed by skin testing. Case report We report the case of a 23 year old female patient, who has a medical history of mildly active ulcerative colitis treated with mesalamine (Pentasa ®). She had no relevant past surgical history. The patient was evaluated in allergy consultation for a recent generalized facial maculo-papular exanthema associated with dysphonia, dysphagia and mild dyspnea that occurred 6 months ago. In fact, this systemic reaction appeared half an hour after taking Spasfon ® , paracetamol, loperamide and a cough syrup containing codeine (Polery ®), during an influenza-like illness with gastroenteritis. She then presented to the emergency department where she was given intravenous H1 antihistamine plus a single intravenous corticosteroid dose (methylprednisolone 1 mg/kg). Dysphonia, dysphagia and dyspnea improved successfully and she was discharged on oral antihistamine and corticosteroid for 5 days. The facial skin eruption disappeared slowly over 3e4 days. All drugs that have been taken are known to cause allergic reactions as side effects. Also, children and adult can commonly develop urticaria as a result of viral respiratory infections. 2 As this systemic reaction can evoke an immunological IgE mediated mechanism, we decided to test all drugs that were taken on that day. An allergic food reaction is unlikely, given the absence of food intake for at least 6 h before the reaction, and the absence of ingestion of unusual foods within the 24 h before the reaction. Fig. 1. From left to right, and up to down: phloroglucinol, trimebutine, mebeverine, pinaverium.