Produção Nacional
Revisado por pares
Drug-induced anaphylaxis in children: Nonsteroidal anti-inflammatory drugs and drug provocation test
2014; Elsevier BV; Volume: 2; Issue: 6 Linguagem: Inglês
10.1016/j.jaip.2014.08.016
ISSN2213-2201
AutoresLuís Felipe Ensina, Alex Eustáquio de Lacerda, Djanira Andrade, Ligia Maria Oliveira Machado, Inês Cristina Camelo‐Nunes, Dirceu Solé,
Tópico(s)Asthma and respiratory diseases
ResumoIn a recent publication, Aun et al1Aun M.V. Blanca M. Garro L.S. Ribeiro M.R. Kalil J. Motta A.A. et al.Nonsteroidal anti-inflammatory drugs are major causes of drug-induced anaphylaxis.J Allergy and Clin Immunol Pract. 2014; 2: 414-420Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar demonstrated that 14.5% of drug hypersensitivity reactions (DHR) are anaphylactic in nature, and nonsteroidal anti-inflammatory drugs (NSAID) account for nearly half of these cases. In our practice, we observed a higher frequency of anaphylactic reactions in pediatric patients with DHR, which also highlights the importance of NSAIDs in this population. From June 2011 to May 2014, we evaluated 104 children (mean age, 10.4 years) with a history of DHR, from which 26 had anaphylaxis symptoms. Unlike adults, there was a predominance of male patients (n = 16). Most reactions were classified as moderate (85%), with dyspnea (n = 18), urticaria associated with angioedema (n = 16), and angioedema alone (n = 8) being the most frequent clinical manifestations.2Rawlins M.D. Thomson J.W. Hartwig S.C. Siegel J. Schneider P.J. Preventability and severity assessment in reporting adverse drug reactions.Am J Hosp Pharm. 1992; 49: 2229-2232PubMed Google Scholar All the patients were seen in the emergency department, except one, who had not received medical attention. However, only 5 received epinephrine, whereas most received antihistamines (n = 12) or corticosteroid injections (n = 11). Twenty patients presented fever and/or viral infection symptoms at the time of reaction.NSAIDs were the main drug class involved in anaphylactic reactions (70.6%). Sixteen patients associated the reactions exclusively to NSAIDs, whereas 4 had used other drugs in combination (amoxicillin [2], azithromycin, and metoclopramide). Among those who presented reactions to NSAIDs alone, 12 reported 2 or more episodes with drugs of different chemical groups, with dipyrone being associated to all cases, followed by ibuprofen (75%) and paracetamol (acetaminophen) (50%). The other 4 patients reported only 1 episode of reaction (3 with dipyrone and 1 with paracetamol) (Table I). Eleven patients had atopy symptoms, and only 3 had a familial history of drug hypersensitivity.Table INSAIDs and DPT in children with anaphylaxisPatient no.SexAge(y)Drugs involved∗Drugs involved in the reaction that was evaluated and prior reactions: a, aspirin; dic, diclofenac; dip, dipyrone; i, ibuprofen; pa, paracetamol.DPT1M9dip, pa, ipa neg2M9dip, pa, ipa neg3F13pa, dip4M12dip, i5M2dip6M11dip, i7M11papa pos8F11dip, pa, i, dicpa neg, e neg9F18dica pos10F16pa, dip, dic, n11F12a, dip, dic12M8dip, ia pos13M9dip14M10dip, ipa neg15M15dip, i, pa, n16M14dip, ne, etoricoxib; neg, negative; pos, positive.∗ Drugs involved in the reaction that was evaluated and prior reactions: a, aspirin; dic, diclofenac; dip, dipyrone; i, ibuprofen; pa, paracetamol. Open table in a new tab In our department, we prescribe the drug provocation test (DPT) with paracetamol for all patients with a suspected reaction to this drug because paracetamol is a weak inhibitor of COX and rarely triggers symptoms in subjects with nonselective hypersensitivity reaction to NSAIDs. In 5 patients tested, only 1 had a reaction. During the study, this patient took ibuprofen and dipyrone on his own, without the occurrence of symptoms, which characterized a selective hypersensitivity reaction to paracetamol, with a positive skin test (by using paracetamol drops at 50 mg/mL concentration and negative in 10 controls), suggesting an IgE-mediated mechanism. The DPT also is indicated in cases in which the patient had a single episode in an attempt to characterize it as a selective or nonselective NSAID reactor. We also performed DPT with acetylsalicylic acid with 2 patients who presented a single episode of anaphylaxis associated with dipyrone, both with positive results. Finally, 1 patient was challenged with etoricoxib. The test result was negative, and the drug was offered as a safe therapeutic option. We concluded that NSAIDs are the most important cause of DHR-related anaphylaxis also in children, with most reactions being related to dipyrone. We also emphasize the importance of the DPT, mainly to exclude paracetamol as a cause of anaphylaxis because this is one of the few safe options for these patients. In a recent publication, Aun et al1Aun M.V. Blanca M. Garro L.S. Ribeiro M.R. Kalil J. Motta A.A. et al.Nonsteroidal anti-inflammatory drugs are major causes of drug-induced anaphylaxis.J Allergy and Clin Immunol Pract. 2014; 2: 414-420Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar demonstrated that 14.5% of drug hypersensitivity reactions (DHR) are anaphylactic in nature, and nonsteroidal anti-inflammatory drugs (NSAID) account for nearly half of these cases. In our practice, we observed a higher frequency of anaphylactic reactions in pediatric patients with DHR, which also highlights the importance of NSAIDs in this population. From June 2011 to May 2014, we evaluated 104 children (mean age, 10.4 years) with a history of DHR, from which 26 had anaphylaxis symptoms. Unlike adults, there was a predominance of male patients (n = 16). Most reactions were classified as moderate (85%), with dyspnea (n = 18), urticaria associated with angioedema (n = 16), and angioedema alone (n = 8) being the most frequent clinical manifestations.2Rawlins M.D. Thomson J.W. Hartwig S.C. Siegel J. Schneider P.J. Preventability and severity assessment in reporting adverse drug reactions.Am J Hosp Pharm. 1992; 49: 2229-2232PubMed Google Scholar All the patients were seen in the emergency department, except one, who had not received medical attention. However, only 5 received epinephrine, whereas most received antihistamines (n = 12) or corticosteroid injections (n = 11). Twenty patients presented fever and/or viral infection symptoms at the time of reaction. NSAIDs were the main drug class involved in anaphylactic reactions (70.6%). Sixteen patients associated the reactions exclusively to NSAIDs, whereas 4 had used other drugs in combination (amoxicillin [2], azithromycin, and metoclopramide). Among those who presented reactions to NSAIDs alone, 12 reported 2 or more episodes with drugs of different chemical groups, with dipyrone being associated to all cases, followed by ibuprofen (75%) and paracetamol (acetaminophen) (50%). The other 4 patients reported only 1 episode of reaction (3 with dipyrone and 1 with paracetamol) (Table I). Eleven patients had atopy symptoms, and only 3 had a familial history of drug hypersensitivity. e, etoricoxib; neg, negative; pos, positive. In our department, we prescribe the drug provocation test (DPT) with paracetamol for all patients with a suspected reaction to this drug because paracetamol is a weak inhibitor of COX and rarely triggers symptoms in subjects with nonselective hypersensitivity reaction to NSAIDs. In 5 patients tested, only 1 had a reaction. During the study, this patient took ibuprofen and dipyrone on his own, without the occurrence of symptoms, which characterized a selective hypersensitivity reaction to paracetamol, with a positive skin test (by using paracetamol drops at 50 mg/mL concentration and negative in 10 controls), suggesting an IgE-mediated mechanism. The DPT also is indicated in cases in which the patient had a single episode in an attempt to characterize it as a selective or nonselective NSAID reactor. We also performed DPT with acetylsalicylic acid with 2 patients who presented a single episode of anaphylaxis associated with dipyrone, both with positive results. Finally, 1 patient was challenged with etoricoxib. The test result was negative, and the drug was offered as a safe therapeutic option. We concluded that NSAIDs are the most important cause of DHR-related anaphylaxis also in children, with most reactions being related to dipyrone. We also emphasize the importance of the DPT, mainly to exclude paracetamol as a cause of anaphylaxis because this is one of the few safe options for these patients. Nonsteroidal Anti-Inflammatory Drugs are Major Causes of Drug-Induced AnaphylaxisThe Journal of Allergy and Clinical Immunology: In PracticeVol. 2Issue 4PreviewDrugs are responsible for 40% to 60% of anaphylactic reactions treated in the emergency department. A global research agenda to address uncertainties in anaphylaxis includes studies that identify factors associated with morbidity and mortality. Full-Text PDF ReplyThe Journal of Allergy and Clinical Immunology: In PracticeVol. 2Issue 6PreviewWe recently published a study that indicated that nonsteroidal anti-inflammatory drugs (NSAID) are a major cause of drug-induced anaphylaxis.1 The medications implicated in drug-induced anaphylaxis may vary in different geographic regions and depend on patient's genetic factors and on several drug-associated factors: chemical structure, pattern and frequency of prescription, and route of administration (Table I). The prevalence of drugs involved in anaphylaxis is modified as new compounds are developed and released to be used, which can be illustrated by the increasing number of hypersensitivity reactions to new mAbs and chemotherapeutic agents. Full-Text PDF
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