Drug allergy expertise improves care in other specialties
Using Drug Allergy Expertise to Improve Patient Care in Other Specialties
Symposium presented Sunday, February 26, 2023
Moderators
Jason Kwah, MD
Assistant Professor of Medicine, Section of Rheumatology, Allergy and Immunology, Department of Medicine, Yale School of Medicine.
Iris M. Otani, MD
Associate Professor, UCSF School of Medicine
Presenters
Anna R. Wolfson, MD
Assistant Professor of Medicine at Harvard Medical School
Evaluation and Management of Penicillin Allergy in Pregnancy
Tanya M. Laidlaw, MD
Allergist, Brigham and Women's Hospital
When Office Challenges to Acetylsalicylic Acid (ASA)/Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) are Important to Patient Care Outcomes
Aleena Banerji, MD
Associate Professor, Harvard Medical School
Expand the Scope of Practice and Improve Patient Outcomes by Incorporating the Evaluation of Chemotherapy HSRs into Your Practice
Summary:
Drug allergies impact patient care across most specialties.
Patient-reported drug allergies are indications for nuanced decisions on testing in patients who are pregnant or who report sensitivity to aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs). For patients undergoing chemotherapy who report hypersensitivity, allergists can offer safe options that will support the oncologist’s therapeutic plan
Penicillin allergy in pregnancy: confirm with testing
In a common clinical scenario, a pregnant patient is referred to an allergist because of a history of allergy to penicillin from childhood.
“The details may be vague,” said Anna R. Wolfson, MD, “such as ‘my mom says I had a rash.’” About 8% of patients who are pregnant self-report a penicillin allergy, but, as in other patient populations, more than 90% do not have a verified penicillin allergy, noted Dr. Wolfson.
There are several potential indications for penicillin in obstetric patients. During pregnancy, there may be a need to treat bacteriuria or syphilis. Labor and delivery may be complicated by group B Streptococcus, cesarean delivery, chorioamnionitis, or endometritis. Mastitis or cesarean delivery might complicate the postpartum period.
Dr. Wolfson, assistant professor of Medicine at Harvard Medical School, outlined the Massachusetts General Hospital allergy department’s approach to assessing potential penicillin allergy during pregnancy, which starts with an e-consult to triage patients using the history gathered by the obstetrician. The patient is then scheduled to receive penicillin allergy testing when she is at least 30 weeks pregnant. After skin testing, a 1-step oral challenge with amoxicillin 500 mg is administered with 60 minutes of observation.
The American College of Obstetricians and Gynecologists supports penicillin testing in pregnant patients and has issued a Committee Opinion on this practice. Unverified penicillin allergy leads to increased hospitalizations in obstetric patients. Dr. Wolfson outlined future goals, including the need for more data on the role of test dosing without skin testing and for improved access to testing.
When to consider office challenges to aspirin or NSAIDs
Since 80% of patients with a reported aspirin or NSAID allergy do not have a reaction consistent with hypersensitivity, it is important to know when office-based drug challenge tests are needed, said Tanya M. Laidlaw, MD. Most reactions are due to pharmacologic inhibition of COX-1. Many reported allergies to aspirin or NSAIDs are in fact side effects such as headache, dizziness, gastrointestinal upset, or adverse reactions like gastrointestinal bleeds or tinnitus.
Referencing the aspirin/NSAID hypersensitivity pathway used at Massachusetts General and Brigham and Women’s Hospitals, Dr. Laidlaw noted that gastrointestinal upset is the most often reported side effect. Whether testing is appropriate depends on the patient’s history, why they need an NSAID, and consideration of continuing its use in a lower dose or in combination with a proton pump inhibitor. As for respiratory reactions, patients who are wheezing usually have rhinitis, she said, and many have polyps. Aspirin-induced asthma can occur, however, and can be exacerbated by NSAID use. For the rare patient who has an isolated respiratory reaction to an NSAID, she recommends using a cyclooxygenase-2 inhibitor.
Dr. Laidlaw, who practices allergy at Brigham and Women's Hospital, noted a recent retrospective cohort study by Li et al showing that 2-step NSAID challenge protocols can be performed safely in an outpatient setting. In the study, more than 85% of patients had no reaction, 11% had an immediate reaction, and 2.9% had a delayed reaction hours later.
No skin testing is available for diagnosis of aspirin or NSAID hypersensitivity. Drug provocation challenge remains the gold standard for diagnosis of aspirin or NSAID allergy.
Expand scope of practice to support patients on chemotherapy
Hypersensitivity reactions to commonly used chemotherapeutic agents are not unusual, and when a patient reports a reaction to their oncologist, said Aleena Banerji, MD, the likely result is a switch to another drug and a worse cancer treatment outcome. Dr. Banerji, associate professor at Harvard Medical School, encourages allergists to build relationships with oncologists so they can keep their patients on chemotherapy.
“Allergists have tools and options that can keep the patient on their primary drug,” she said. For example, the 3-bag desensitization protocol, which requires special pharmaceutical services, access to an infusion center, and a daylong treatment is difficult for most community practitioners. The novel 1-bag desensitization protocol has good safety data, is successful in patients who do not have respiratory or blood pressure alteration, and can return them to their preferred chemotherapy regimen.
A certain percentage of reactive patients might not be truly allergic and therefore not need desensitization, said Dr. Banerji. Risk stratification and delabeling are essential tools.
A recent study by Vázquez-Revuelta et al reviews a safe and effective way to use drug challenges with chemotherapy in combination with risk stratification to assess mild and moderate immediate reactions and potentially reduce the number of drug desensitizations.
Selected references
Brennan PJ, Rodriguez Bouza T, Hsu FI, et al. Hypersensitivity reactions to mAbs: 105 desensitizations in 23 patients, from evaluation to treatment. J Allergy Clin Immunol 2009;124(6):1259-1266. doi: 10.1016/j.jaci.2009.09.009
DeGregorio GA, Singer J, Cahill KN, Laidlaw T. A 1-day, 90-minute aspirin challenge and desensitization protocol in aspirin-exacerbated respiratory disease. J Allergy Clin Immunol Pract 2019;7(4):1174-1180. doi: 10.1016/j.jaip.2018.10.032
Desai SH, Kaplan MS, Chen Q, Macy EM. Morbidity in pregnant women associated with unverified penicillin allergies, antibiotic use, and group B Streptococcus infections. Perm J 2017;21:16-080. doi: 10.7812/TPP/16-080. Epub 2017 Jan 6.
Desravines N, Waldron J, Venkatesh KK, et al. Outpatient penicillin allergy testing in pregnant women who report an allergy. Obstet Gynecol 2021;137(1):56. doi: 10.1097/AOG.0000000000004213
Laidlaw TM, Cahill KN. Current knowledge and management of hypersensitivity to aspirin and NSAIDs. J Allergy Clin Immunol Pract 2017;5(3):537-545. doi: 10.1016/j.jaip.2016.10.021
Lee RU, White AA, Ding D, et al. Use of intranasal ketorolac and modified oral aspirin challenge for desensitization of aspirin-exacerbated respiratory disease. Ann Allergy Asthma Immunol 2010;105(2):130-135. doi: 10.1016/j.anai.2010.05.020
Li L, Bensko J, Buchheit K, et al. Safety, outcomes, and recommendations for two-step outpatient nonsteroidal anti-inflammatory drug challenges. J Allergy Clin Immunol Pract. 2022 May;10(5):1286-1292.e2. doi: 10.1016/j.jaip.2021.11.006. Epub 2021 Nov 17.
Otani IM, Lax T, Long AA, et al. Utility of risk stratification for paclitaxel hypersensitivity reactions. J Allergy Clin Immunol Pract 2018;6(4):1266-1273.e2. doi: 10.1016/j.jaip.2017.08.025
Vázquez-Revuelta P, Martí-Garrido J, Molina-Mata K, et al. Delabeling patients from chemotherapy and biologics allergy: implementing drug provocation testing. J Allergy Clin Immunol Pract 2021;9(4):1742-1745. doi: 10.1016/j.jaip.2020.11.021
Disclosures
Dr. Laidlaw: Regeneron, GSK
Other faculty have no relevant disclosures.