Autumn Guyer

Evaluation and management of hypersensitivity to proton pump inhibitors

OBJECTIVE Proton pump inhibitors (PPIs) are widely used for the treatment of gastroesophageal reflux disease and peptic ulcer disease. PPIs are well tolerated, but they can cause hypersensitivity reactions (HSRs). Although simply avoiding a PPI after an HSR is appropriate for most patients, there are clinical scenarios that require treatment with a PPI. DATA SOURCES A comprehensive literature review was performed to propose an evidence-based approach to the evaluation and management of HSRs to PPIs. STUDY SELECTIONS Articles from June 1986 through September 2012 on PPI hypersensitivity were reviewed. Thirty-nine studies that met the search criteria were included in the review. HSRs to PPIs and skin testing protocols used to evaluate HSRs were analyzed from the 39 identified publications. For each case, the culprit drug and dose, the age and sex of the patient, and the symptoms and timing of the HSR were recorded. HSRs were classified into immune- or nonimmune-mediated categories. RESULTS A total of 118 cases of immune-mediated HSRs to 5 PPIs were identified, most of which were suspected IgE-mediated HSRs. Omeprazole was the culprit PPI most frequently associated with HSRs. The most common clinical manifestations of PPI HSRs were cutaneous reactions. Nonirritating concentrations for skin prick and intradermal testing were identified. Skin testing showed variable cross-reactivity patterns among the different PPIs. CONCLUSION The HSRs to PPIs should be formally investigated, especially when reasonable alternative therapies do not exist. The reviewers propose an evidence-based algorithm for evaluating and managing patients with an HSR to a PPI.

Antibiotics Are the Most Commonly Identified Cause of Perioperative Hypersensitivity Reactions.

BACKGROUND Hypersensitivity reactions (HSRs) during the perioperative period are unpredictable and can be life threatening. Prospective studies for the evaluation of perioperative HSRs are lacking, and data on causative agents vary between different studies. OBJECTIVE The objective of this study was to prospectively determine the success of a comprehensive allergy evaluation plan for patients with HSRs during anesthesia, including identification of a causative agent and outcomes during subsequent anesthesia exposure. METHODS All patients referred for a perioperative HSR between November 2013 and March 2015, from a Boston teaching hospital, were evaluated using a standardized protocol with skin testing (ST) within 6 months of HSR. Comprehensive allergy evaluation included collection of patient information, including characteristics of HSR during anesthesia. We reviewed the results of ST and/or test doses for all potential causative medications Event-related tryptase levels were reviewed when available. RESULTS Over 17 months, 25 patients completed the comprehensive allergy evaluation. Fifty-two percent (13 of 25) were female with a median age of 52 (interquartile range 43-66) years. The most frequently observed HSR systems were cutaneous (68%), cardiovascular (64%), and pulmonary (24%). A culprit drug, defined as a positive ST, was identified in 36% (9 of 25) of patients. The most common agent identified was cefazolin (6 of 9). After our comprehensive evaluation and management plan, 7 (7 of 8, 88%) patients tolerated subsequent anesthesia. CONCLUSIONS Cefazolin was the most commonly identified cause of a perioperative HSR in our study population. Skin testing patients within 6 months of a perioperative HSR may improve the odds of finding a positive result. Tolerance of subsequent anesthesia is generally achieved in patients undergoing our comprehensive evaluation.

Current characteristics associated with hereditary angioedema attacks and treatment: the home infusion based patient experience.

This article presents a current perspective on the characteristics of hereditary angioedema (HAE) attacks and treatment as captured by a home infusion service. Retrospective data on 158 HAE patients who were enrolled in this acute treatment program were analyzed for factors surrounding an attack. The majority of patients had a high level of disease severity at baseline (88%), with a higher than expected likelihood of having a positive family history (87.8%). The most likely times for patients to call for home treatment were just before and during working hours (6:00 A.M.-5:00 P.M.). Eighty-three percent had more than one alternate mode of medication. Factors associated with a severe attack included an overall severe rating of HAE attacks in the previous year, an abdominal attack alone or a combination of peripheral and abdominal attacks versus a peripheral attack alone, and the use of two doses rather than one for treatment of the current attack. Average time to relief onset was 43.5 minutes. One dose of ecallantide was sufficient to treat the majority of attacks, and a second dose was needed in 23.6% of patients experiencing a severe attack. However, patients who reported both a severe attack rating during the previous year and experiencing only a peripheral current attack were more likely to experience a severe current attack. Acute treatment paradigms for HAE remain diverse. Understanding factors driving these decisions could help alleviate the overall burden of this disease and help overcome some of the challenges faced by the patients and their caretakers and improve their quality of life. Enhanced capture and analysis of prodromal factors in future studies should help us further alleviate the burden of this disease.

IgE-mediated hypersensitivity to ondansetron and safe use of palonosetron

TO THE EDITOR: Selective 5-HT3 receptor antagonists (5-HT3-RAs) are the cornerstone for the prevention and treatment of chemotherapyinduced nausea and vomiting. Therapeutic options are limited in patients with 5-HT3-RA hypersensitivity because there is a concern for cross-reactivity between different 5-HT3-RAs. Palonosetron is the newest 5-HT3-RA, and its chemical structure is different from the other 5-HT3-RAs (tropisetron, ondansetron, granisetron, and ondansetron). We describe a patient with ondansetron hypersensitivity who tolerated palonosetron. A 38-year-old woman was undergoing chemotherapy for advanced lung cancer. Seven days after she received her second cycle of Alimta/cisplatin, she noted periorbital and hand swelling, as well as urticaria on her upper and lower extremities, 20