Mara Morelo Rocha Felix

Drug-Induced Anaphylaxis in Latin American Countries

BACKGROUND Information regarding the clinical features and management of drug-induced anaphylaxis (DIA) in Latin America is lacking. OBJECTIVE The objective of this study was to assess implicated medications, demographics, and treatments received for DIA in Latin American patients referred to national specialty centers for evaluation. METHOD A database previously used to compile information on drug-induced allergic reactions in 11 Latin American countries was used to identify and characterize patients presenting specifically with a clinical diagnosis of DIA. Information regarding clinical presentation, causative agent(s), diagnostic studies performed, treatment, and contributing factors associated with increased reaction severity was analyzed. RESULTS There were 1005 patients evaluated for possible drug hypersensitivity reactions during the study interval, and 264 (26.3%) met criteria for DIA. DIA was more frequent in adults and in elderly females (N = 129 [76.6%] and N = 30 [75%], respectively) compared with children and/or adolescents (N = 21 [42.9%], P < .01). Severe DIA was less frequent with underlying asthma (N = 22 vs 35 [38.6% vs 61.4%], P < .05) or atopy (N = 62 vs 71 [43% vs 59% ], P < .01). Nonsteroidal anti-inflammatory drugs (NSAIDs) (N = 178 [57.8%]), beta-lactam antibiotics (N = 44 [14.3%]), and other antibiotics (N = 16 [5.2%]) were the most frequently implicated drug classes. Anaphylaxis was rated as severe in N = 133 (50.4%) and anaphylactic shock (AS) was present in N = 90 (34.1%). Epinephrine was only used in N = 73 (27.6%) overall, but in N = 70 (77.8%) of patients with AS. CONCLUSION In Latin American patients referred for evaluation of DIA, NSAIDs and antibiotics were implicated in approximately 80% of cases. Most of these reactions were treated in the emergency department. Epinephrine was administered in only 27.6% of all cases, although more frequently for anaphylactic shock. Dissemination of anaphylaxis guidelines among emergency department physicians should be encouraged to improve management of DIA.

ERICA: prevalence of asthma in Brazilian adolescents

ABSTRACT OBJECTIVE To describe the prevalence of asthma and physician-diagnosed asthma in Brazilian adolescents. METHODS Cross-sectional, national, school-based study with adolescents from 12 to 17 years old, participants in the Study of Cardiovascular Risks in Adolescents (ERICA). The study stratified the sample by region and grouped according to schools and classes with representativeness to the set of cities with more than 100,000 inhabitants of the Country, macro-regions, capitals, and Federal District. A questionnaire collected data through a self-filled in method. We calculated the prevalences and their confidence intervals of 95% (95%CI) according to sex, age group, type of school and skin color. RESULTS Between 2013 and 2014, 74,589 adolescents were evaluated, 55.3% of the female sex. The total prevalence of active asthma was of 13.1% (95%CI 12.1-13.9), being higher in girls (14.8%; 95%CI 13.7-16.0) when compared to boys (11.2%; 95%CI 10.3-12.2) in all geographical strata examined. It was also higher between students of private schools (15.9%; 95%CI 14.2-17.7) when compared to public ones (12.4%; 95%CI 11.4-13.4). It was higher in the Southeast region (14.5%; 95%CI 12.9-16.1), and in the city of Sao Paulo (16.7%; 95%CI 14.7-18.7). The lowest prevalence was observed in North region (9.7%; 95%CI 9.7-10.5), and in Teresina (6.3%; 95%CI 4.9-7.7). The prevalence of physician-diagnosed asthma was of 8.7% (95%CI 8.2-9.1); higher in the North region (13.5%; 95%CI 12.7-14.2), and in Porto Alegre (19.8%; 95%CI 17.5-22.3). It was lower in the Midwest (6.9%; 95%CI 6.0-7.8), and in Cuiaba (4.8%; 95%CI 3.8-5.9). We found no significant difference in the expression of this rate between the sexes, as well as in other variables evaluated by the study. CONCLUSIONS The prevalence of asthma in Brazilian adolescents is high. Rates of active asthma and physician-diagnosed asthma vary widely in different regions and capitals evaluated by the ERICA. These results may assist in the preparation of preventive programs and policies on health and a better understanding of the factors associated with asthma in this age group.

Etiology of chronic urticaria: the Ecuadorian experience

BackgroundThe purpose of this study was to identify chronic urticaria (CU) etiologies and treatment modalities in Ecuador. We propose that the sample distribution fits the expected one, and that there is an association between the etiology and its treatment.MethodsWe performed a retrospective study involving 112 patients diagnosed with CU using a Checklist for a complete chronic urticaria medical history. Demographic and clinical variables were collected. The etiology of CU was classified using the EAACI/GA2LEN/EDF/WAO guideline. Descriptive analyses were performed for demographical and clinical variables. Chi square tests were applied to analyze the fit of distribution and the independence of variables. P values less than 0.05 were considered significant.ResultsAmong all the patients, 76.8% were diagnosed with chronic spontaneous urticaria (CSU), of which 22.3% had a known etiology or possible exacerbating condition. Food allergy was identified as the most common accompanying condition in patients with CSU (10.7%) (p < 0.01).. On the other hand, 23.2% inducible urticarias (CIndU) were indentified; dermographism was the most common (10.7%) (p < 0.01).Regarding treatment regimens, sg-H1-antihistamines alone represented the highest proportion (44.6%). The combination of any H1-antihistamine plus other drug was a close second (42.0%) (p < 0.01). Almost 48% of CSUs of unknown etiology were treated with any antihistamine plus another drug. In patients with known etiology, sg-antihistamines alone (44.0%) was the most common management. In addition, 53.8% of CIndUs were treated with sg-antihistamines alone. Though, these associations were not statistically significant.ConclusionCSU is the most frequent subtype of CU. Modern non-sedating antihistamines in licensed doses are the drug of choice. Nevertheless, a great proportion of patients require the addition of another type of medication.

Drug-Induced Anaphylaxis: Clinical Scope, Management, and Prevention

Opinion statementDrug-induced anaphylaxis (DIA) is a severe, life-threatening reaction occurring after drug exposure. It is an important cause of anaphylaxis and accounts for up to one third of drug hypersensitivity reactions. As in other anaphylaxis reactions, immunoglobulin E (IgE) has an important role in its mechanism, but other non-immunological reactions may also occur in DIA. Cutaneous and respiratory symptoms are present in a majority of patients, and cardiovascular events are more common in elderly patients. A complete work up is recommended not just to offer safe alternatives, but also to avoid incorrect labeling of patients as allergic to drugs. The investigation includes in vitro tests when available, followed by skin prick and intradermal tests. Although provocation tests are still considered the “gold standard” for the diagnosis of drug allergy, in DIA, the risk versus benefit ratio must be analyzed. Non-steroid anti-inflammatory drugs and antibiotics are the drug classes more frequently involved. Neuromuscular blocking agents, chemotherapeutic drugs, and biologics are commonly related to reactions in a hospital setting. Prevention measures include an individualized education plan, with recommendations to avoid the culprit drug and potential cross-reactive medications. In selected patients, desensitization can induce a temporary state of tolerance. Protocols are available and can be adapted for drugs used in different situations, from cancer treatment to enzyme replacement therapy.

ERICA: smoking is associated with more severe asthma in Brazilian adolescents

OBJECTIVE To investigate the association between smoking and asthma, and possible associated factors in Brazilian adolescents. METHODS A cross-sectional, national, school-based study with adolescents aged 12-17 years, participants in the Study of Cardiovascular Risks in Adolescents (Estudo de Riscos Cardiovasculares em Adolescentes - ERICA). A total of 66,394 participants answered a self-administered questionnaire with questions about asthma, smoking, lifestyle and sociodemographic variables. Bivariate analysis between Current Asthma (CA) and Severe Asthma (SA) and the other study variables were performed using Chi-squared. Then, the crude and adjusted Prevalence Ratios (PR), and respective 95% Confidence Intervals (95% CI) of current asthma/severe asthma and smoking variables, corrected for sociodemographic and lifestyle variables, were estimated using generalized linear models with Poisson regression, logit link, and robust variance. RESULTS The prevalence of current asthma and severe asthma were significantly higher in adolescents who were exposed to: experimentation (current asthma: PR=1.78, 95% CI: 1.51-2.09; severe asthma: PR=2.01; 95% CI: 1.35-2.98); current smoking (current asthma: PR=2.08, 95% CI: 1.65-2.64; severe asthma: PR=2.29; 95% CI: 1.38-3.82); regular smoking (current asthma: PR=2.25, 95% CI: 1.64-3.07; severe asthma: PR: 2.41; 95% CI: 1.23-4.73); and passive smoking (current asthma: PR=1.47, 95% CI: 1.27-1.67; severe asthma: PR=1.66; 95% CI: 1.19-2.32); these associations remained significant after adjustment. CONCLUSIONS Asthma and smoking were significantly associated in Brazilian adolescents, regardless of the sociodemographic and lifestyle factors, notably in those with more severe disease.

What kind of information and communication technologies do patients with COPD prefer to use? A cross-sectional study in Latin America

The aim of the present study was to assess the frequency of uses and preferences of information and communication technologies (ICTs) among Latin American chronic obstructive pulmonary disease (COPD) patients. We conducted an anonymous cross-sectional survey study on Latin American COPD patients. The adapted version of the Michigan questionnaire was employed in eligible outpatients in different cities of Latin America. We categorized age and educational levels into three groups. The time passed since COPD diagnosis was categorized as ≤5 years and >5 years. χ 2 and crude and adjusted logistic regressions were performed. A total of 256 patients were enrolled with a mean age of 68.7 years old. The most recurrently used ICTs were short message service (SMS; 47.1%) and WhatsApp (30.7%) for receiving COPD information. Moreover, SMS (85.8%) and Facebook (36.1%) were rated as useful for asking physicians information about COPD. Regression analysis showed that the best predictor for patients using ICTs, for any purpose, was higher education (undergraduate or graduate school). Understanding the preferences of ICTs among COPD patients could help improve patient’s outcomes through developing applications in response to specific requirements of each patient.

Drug hypersensitivity in children in Brazil

Results Ninety patients were evaluated, 54 male, with a median age of 6 years. Personal history of atopy was reported in 65 and previous DHR in 9. Cutaneous manifestations were observed in 86 – urticaria and/or angioedema in 71 and macular or maculopapular exanthema in 15. Other symptoms reported were: respiratory (25), gastrointestinal (8), cardiovascular (5). The interval between dose and reaction was less than 1 hour in 38 subjects. Mild reaction was observed in 32 patients and moderate in 55. Fever and/or viral infection were present in 61 patients during or just before the reaction. The majority of subjects were treated in emergency units (79). More than one drug was suspected as a trigger in 50 children (NSAIDs in 50%, beta-lactam antibiotics in 31% and other antibiotics in 8.5%). Sixteen skin tests (prick and intradermal) were performed and were all negative but one with amoxicilin. Drug provocation tests were positive in 4 of 51 tests NSAIDs 29 (4 positive), beta-lactam antibiotics 20 and others 4. Sixty-one reactions were possible or probable related with the suspected drug, but in 25 this relation was unlikely.

Successful desensitization in a patient with Von Willebrand´s disease and anaphylaxis to factor VIII/VW

Background Von Willebrand s disease (VWD) is the most common congenital disorder of hemostasis, characterized by deficient or defective von Willebrand factor. Patients are treated by intravenous replacement of factor VIII/VW (FVIII/ VW) when needed, for prophylaxis before surgical procedures. Anaphylactic reactions to FVIII/VW are rare and desmopressin (DDAVP) can be used as an alternative.