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Allergy and Immunology - UCSF · PDF fileAllergy and Immunology Pearls for Clinical Practice ... mast cell activation disorder ... Summary of Key Points

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  • 6/12/2017

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    AllergyandImmunologyPearlsforClinicalPractice

    2017KatherineGundling,MDFACP

    Professor,SectionChiefAllergyandImmunology

    UCSF

    Nothingtodeclare

    NodiscussionofnonFDAapprovedmedicationuse

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    AdverseDrugReactionsIntermission(with2CoolImmunologyvideos)!

    HygienehypothesisupdateNewsflash

    Adversedrugreaction(ADR)=anyunwantedreactiontoamedication

    Drugallergy =ADR thatresultsfromaspecificimmunologicresponsetoamedication

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    ThetrueincidenceofDrugAllergyisunknown:

    Estimated12%ofhospitaladmissions35%ofhospitalizedpatients

    VarietyofimmunologicreactionsAnaphylaxisSerumsicknessSJS/TENOthers

    BrJClin Pharmacol 2011;71:684700

    ThetrueincidenceofDrugAllergyisunknown:

    Estimated12%ofhospitaladmissions35%ofhospitalizedpatients

    VarietyofimmunologicreactionsAnaphylaxisSerumsicknessSJS/TENOthers

    BrJClin Pharmacol 2011;71:684700

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    PerioperativeAnaphylaxis

    Reactionscanbesevereorfatal

    PerioperativeAnaphylaxis

    Exposuretomanyagentsoccursduringashorttimeperiod:

    Antibiotics Neuromuscularblockingagents Propofol Latex Chlorhexidine Dyes Opioids Bloodtransfusions Benzodiazepines Others

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    PerioperativeAnaphylaxis

    Exposuretomanyagentsoccursduringashorttimeperiod:

    Antibiotics Neuromuscularblockingagents Propofol Latex Chlorhexidine Dyes Opioids Bloodtransfusions Benzodiazepines Others

    Theincidenceofperioperativeanaphylaxisisthesameinboysandgirlsbutmorecommoninwomenthanmen.

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    3/4ofanaphylacticreactionstoneuromuscularblockingagentsoccurinwomen,..

    suggestingthatcrossreactionswithammoniumcompoundsinmakeupandotherpersonalcareproductscouldberesponsible.

    AnaphylaxisPracticeParametersLiebermanPetal.AnnAllergyImmunol 115(2015)341384

    PerioperativeAnaphylaxis

    Exposuretomanyagentsoccursduringashorttimeperiod:

    Antibiotics Neuromuscularblockingagents Propofol Latex Chlorhexidine Dyes Opioids Bloodtransfusions Benzodiazepines Others

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    Commercial products that contain chlorhexidine (to name a few):

    Antiseptic mouthwashes Antiseptic sore throat lozenges and sprays Antiseptic toothpastes Topical eczema creams Acne creams Antiseptic powders such as athletes foot powder Antiseptic creams Antiseptic wipes

    Morechlorhexidine containingproducts

    Antiseptic dressings Skin washes/cleansers Topical disinfectants Bladder washouts Eye drops Contact lens solution Anesthetic gels for catheterization Some creams and sprays (such as nasal sprays)

    include chlorhexidine as a preservative Some sunscreens Central venous catheters

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    ClinicalPearls

    Ifyourpatientdevelopsarashuponexposuretochlorhexidine,consideravoidingitsuseduringtheperioperativeperiod.

    ****Chlorhexidine isembeddedinsomecentrallinecatheters****

    Aserumtryptase levelcanhelpdistinguishanaphylaxisfromothercausesofsimilarsymptoms: within12hoursoftheevent,and atbaseline(acoupleofweekslaterok)

    Elevatedacutetryptase levelssupportsmastcelldegranulationasaproximatecauseoftheeventElevatedbaselinetryptase supportsanunderlyingmastcellactivationdisorder

    ClinicalPearls

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    Apatientwithapreviousallergicreactiontowhichagentismostlikelytoexperienceadrugallergicreactiontofurosemide?

    A.AcetazolamideB.AtenololC.PenicillinD.Trimethoprimsulfamethoxazole

    Reactionstosulfonamidenonantibioticsarelikelyduetopredispostion toallergicreactions,notduetocrossreactivitywithsulfonamideantibiotics!

    Onthesulfonamidemoleculeitisthearylaminecomponentthatismostallergenic,hencethevastmajorityofpatientswhoreacttoarylaminesulfonamideswillnotreacttononarylaminesulfonamides.

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    Partiallistofsulfonamidemedications

    Arylamine Sulfonamides Sulfamethoxazole Sulfadiazine Sulfacetamide Sulfasalazine

    Sulfonamideantiretrovirals Amprenavir Fosampranavir

    Nonarylamine Sulfonamides

    CarbonicanhydraseinhibitorsSulfonylureasLoopdiureticsThiazidediureticsAntiinflammatoryOthers

    Fromthefurosemidepackageinsert,notedin2017:patientsallergictosulfonamidesmayalsobeallergictofurosemide.

    Updatedrecommendations:Theweightofevidencesuggeststhatwithholdingnonantibacterialsulfonamidesfrompatientswithpriorreactionstoantibacterialsulfonamidesorothernonantibacterialsulfonamidesisnotclinicallyjustified.

    NEngl JMed349;17AmJHealthSyst Pharm70:148394

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    TheDrugAllergyPracticeParametersfromtheAAAAIstate:

    Thereisnoevidencetosuggestallergiccrossreactivitybetweensulfonamideantibioticsandnonantibiotic sulfonamides.

    AAAAI.org DrugAllergy:AnUpdatedPracticeParamenter

    ClinicalPearls

    Thetermsulfaallergyshouldbedropped!

    Endeavortodetermineandreporttheexactmedicationtowhichareactionoccurred.

    Whenthatinformationisnotavailable,inquireastotheconditionthatwasbeingtreated,anddocumenttheinformation.

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    AdverseDrugReactionsIntermission(with2CoolImmunologyvideos)!

    HygienehypothesisupdateNewsflash

    Howcanoneboosttheimmunesystem?

    EverythingGrandmatoldyouistrue.GetagoodnightssleepEatavarietyoffoods,includingfruitsandvegetablesModerate(notsevereorcouchpotatotype)exerciseLaughwithyourfriendsListentosomegoodmusic

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    AdverseDrugReactionsIntermission(with2CoolImmunologyvideos)!

    HygienehypothesisupdateNewsflash

    Early life exposure to which of the following is most associated with the prevention of atopic disease (atopic dermatitis, food allergy, allergic rhinitis, asthma)?

    A. A household dogB. An older brotherC. Barn animalsD. Dust mites in the pillow

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    Answer: Barn animals

    Early exposure to barn animals is strongly associated with less atopy

    Exposure to pets from infancy might also be helpful, as are older siblings

    Exposure to dust mites is associated with increased atopic conditions

    Von Mutius E. Proc Am Thorac Soc 2007; Vol 4 pp 212-216

    Farming,BavarianStyle

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    + =

    Images: Wikipedia dogs

    Image by K. Gundling

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    CurrentOpinionImmunology2016,42:4147

    Prevention of atopic conditionsClear:

    -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 asthmaGathering data: Influence of food/microbiome of the gut and airways Role of early exposures to pollution, infections,

    medications Whether/when an at risk infant should be exposed to

    small amounts of common food allergens (New guidelines in 2017 for introduction of peanuts to infants)

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    JACI122:1148

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    AdverseDrugReactionsIntermission(withCoolImmunologyvideos)!

    HygienehypothesisupdateNewsflash

    NewsFlash

    Dustmitesublingualtablets havejustbeenapprovedtotreatallergicrespiratorydisease!

    Considerthistypeofimmunotherapyforpatientswho:haveyearroundallergysymptomswhohavealimitednumberofallergictriggerswhoaretiredoftakingmedicationwhodonthavetimetodedicate35yearstoallergyshots

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    SummaryofKeyPoints

    Multipleagentscancausesevereanaphylaxisintheperioperativeperiod

    Sulfaallergyisatermthatshouldbedropped Immunecellsatworkaretrulyaweinspiring Earlylifeexposuresplayakeyroleintrainingahealthyimmunesystem

    Forthosepeoplewhoalreadyhaveallergytodustmites,immunotherapytabletsareanewoptiontoretraintheimmunesystem