Allergy and Immunology Pearls for Clinical Practice No discussion of - PDF document

Nothing to declare Allergy and Immunology Pearls for Clinical Practice No discussion of non ‐ FDA approved medication use Katherine Gundling, MD FACP Professor, Section Chief Allergy and Immunology UCSF Adverse Drug Reactions Adverse Drug Reactions Intermission (with Cool Immunology videos)! Intermission (with Cool Immunology videos)! Hygiene hypothesis update Hygiene hypothesis update EpiPen debacle (and patient instruction video) EpiPen debacle (and patient instruction video)

Adverse Drug Reactions are more common in women than men Ann Allergy Asthma Immunol. 2013 Dec;111(6):452 ‐ 7 The true incidence of Adverse Drug Reactions is unknown: “Adverse drug reaction” (ADR) = any unwanted ADRs: reaction to a medication 3 ‐ 6% of hospital admissions 10 ‐ 15% of hospitalized patients “Drug allergy” = ADR that results from a specific Drug allergy immunologic response to a medication 1 ‐ 2% of hospital admissions 3 ‐ 5% of hospitalized patients Br J Clin Pharmacol 2011; 71:684 ‐ 700

Perioperative Anaphylaxis Perioperative Anaphylaxis Exposure to many agents occurs during a short time period: – Antibiotics Reactions can be severe or fatal – Neuromuscular blocking agents – Propofol – Latex The incidence of perioperative anaphylaxis is the – Chlorhexidine same in boys and girls but more common in – Dyes women than men. – Opioids – Blood transfusions – Benzodiazepines – Others Perioperative Anaphylaxis “3/4 of anaphylactic reactions to neuromuscular blocking agents occur in women, ….. Exposure to many agents occurs during a short time period: suggesting that cross ‐ reactions with ammonium – Antibiotics compounds in makeup and other personal care – Neuromuscular blocking agents products could be responsible.” – Propofol – Latex “Skin testing is unlikely to be useful in selecting the – Chlorhexidine safest alternative for subsequent surgery because of the unknown predictive value.” – Dyes – Opioids – Blood transfusions Anaphylaxis Practice Parameters – Benzodiazepines Lieberman P et al. Ann Allergy Immunol 115 (2015) 341 ‐ 384 – Others

IgE mediated reaction Or….. Non ‐ IgE mediated reaction “ Immediate (Type 1) hypersensitivity ” “Direct Mast Cell Degranulation” Perioperative Anaphylaxis Commercial products that contain chlorhexidine (to name a few): • Exposure to many agents occurs during a short time period: – Antibiotics  Antiseptic mouthwashes – Neuromuscular blocking agents  Antiseptic sore throat lozenges and sprays – Propofol  Antiseptic toothpastes – Latex  Topical eczema creams – Chlorhexidine  Acne creams – Dyes  Antiseptic powders such as athletes foot powder – Opioids  Antiseptic creams – Blood transfusions  Antiseptic wipes

More chlorhexidine containing products More chlorhexidine containing products  Antiseptic dressings  Antiseptic dressings  Skin washes/cleansers  Skin washes/cleansers  Topical disinfectants  Topical disinfectants  Bladder washouts  Bladder washouts  Eye drops  Eye drops  Contact lens solution  Contact lens solution  Anesthetic gels for catheterization  Anesthetic gels for catheterization  Some creams and sprays (such as nasal sprays)  Some creams and sprays (such as nasal sprays) include chlorhexidine as a preservative include chlorhexidine as a preservative  Some sunscreens  Some sunscreens  Central venous catheters  Central venous catheters Chlorhexidine allergy Clinical Pearl If your patient develops a rash upon exposure to No matter what the cause of perioperative chlorhexidine, consider avoiding its use during the anaphylaxis, obtain a serum tryptase level: perioperative period . • within 1 ‐ 2 hours of the event, and • at baseline (a couple of weeks later ok) ****Chlorhexidine is embedded in some central line catheters**** Elevated acute tryptase levels supports mast cell degranulation as a proximate cause of the event The predictive value of skin testing to chlorhexidine is Elevated baseline tryptase supports an underlying unknown mast cell activation disorder

A patient with a previous allergic reaction to Reactions to sulfonamide non ‐ antibiotics are likely which agent is most likely to experience a drug due to predispostion to allergic reactions , not due allergic reaction to furosemide? to cross ‐ reactivity with sulfonamide antibiotics! On the sulfonamide molecule it is the arylamine A. Acetazolamide component that is most allergenic, hence the vast B. Atenolol majority of patients who react to arylamine sulfonamides will not react to non ‐ arylamine C. Penicillin sulfonamides. D. Trimethoprim ‐ sulfamethoxazole From the package insert for furosemide, noted Partial list of sulfonamide medications 11/1/16: “patients allergic to sulfonamides may also be allergic to furosemide.” Arylamine Sulfonamides Non ‐ arylamine Sulfonamides – Sulfamethoxazole Carbonic anhydrase inhibitors Updated recommendations: – Sulfadiazine Sulfonylureas “The weight of evidence suggests that withholding – Sulfacetamide Loop diuretics non ‐ antibacterial sulfonamides from patients with – Sulfasalazine Thiazide diuretics prior reactions to antibacterial sulfonamides or • Sulfonamide antiretrovirals Anti ‐ inflammatory other non ‐ antibacterial sulfonamides is not – Amprenavir Others clinically justified.” – Fosampranavir N Engl J Med 349;17 Am J Health ‐ Syst Pharm 70:1483 ‐ 94

The Drug Allergy Practice Parameters from Clinical Pearls the AAAAI state: The term “sulfa” allergy should be dropped! “There is no evidence to suggest allergic cross ‐ reactivity between sulfonamide antibiotics and  Endeavor to determine and report the exact medication nonantibiotic sulfonamides.” to which a reaction occurred.  When that information is not available, inquire as to the condition that was being treated, and document the information. AAAAI.org Drug Allergy: An Updated Practice Paramenter Hot off the presses… Intermission The risk of adverse pregnancy outcomes after first trimester exposure to H1 antihistamines: A systematic review and meta ‐ analysis. 2 cool videos of the immune system in action! Offers reassurance about the use of H1 antihistamines during early pregnancy. Etwel F, Faught L et al. Drug Safety Nov 2016

NIH video Cytotoxic T cells on Patrol How can one “boost” the immune system? Adverse Drug Reactions Intermission (with Cool Immunology videos)! Everything Grandma told you is true…. Hygiene hypothesis update Get a good night’s sleep Eat a variety of foods, including fruits and vegetables EpiPen debacle (and patient instruction video) Moderate (not severe or couch potato type) exercise Laugh with your friends Listen to some good music

Answer: A Barn animals Which of the following early exposures is most associated with the prevention of atopic Early exposure to barn animals is strongly disease (atopic dermatitis, food allergy, associated with less atopy allergic rhinitis, asthma)? Exposure to pets from infancy might also A. Barn animals be helpful, as are older siblings B. An older brother C. A household dog Exposure to dust mites is associated with D. Dust mites in the pillow increased atopic conditions Von Mutius E. Proc Am Thorac Soc 2007; Vol 4 pp 212-216 Farming, Bavarian Style Current Opinion Immunology 2016,42:41 ‐ 47

Prevention of atopic conditions Clear: -Infants should be breast fed -Early exposure to animals (especially barn animals) and older siblings is preventative -Allergen immunotherapy can prevent the development of new sensitization and asthma Gathering data: – Influence of food/microbiome of the gut and airways – Role of early exposures to pollution, infections, medications – Whether an “at risk” infant should be exposed to small amounts of common food allergens (will have better answers next year…) Adverse Drug Reactions Intermission (with Cool Immunology videos)! Hygiene hypothesis EpiPen debacle (and patient instruction video) https://www. youtube .com/watch?v=i6K2_kVmr3E JACI 122:114 ‐ 8