Skin and in vitro tes<ng in DRESS, SJS/TEN & AGEP: Possibili<es and limita<ons

Transcription

1 Skin and in vitro tes<ng in DRESS, SJS/TEN & AGEP: Possibili<es and limita<ons Gregor Porebski Jagiellonian University, Faculty of Medicine Krakow, Poland

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3 Skin and in vitro tes<ng in diagnos<c work-up of DHR *Currently available biological tests to diagnose drug allergy lack sensitivity. The clinical tools allowing a definitive diagnosis include a thorough clinical history, standardized skin tests, reliable in vitro tests, and drug provocation tests. Allergo J Int 2015; 24: International Consensus on drug allergy. Allergy 2014; 69:

4 Drug provoca<on tests (systemic) - contraindicated Drug provocation testing in the diagnosis of drug hypersensitivity reactions: general considerations Allergy 2003: 58: supervision of the patient over a sufficient time period where - appropriate, threshold testing with diluted solutions The development of tools for skin testing and biological diagnosis is indeed crucial for those cases where DPT is not possible. International Consensus on drug allergy. Allergy 2014; 69:

5 PATCH TEST - <ming ü A patch test can be performed arer complete skin resolu<on. ü Allergy work-up should be carried out 4 6 weeks arer complete resolu<on of all clinical symptoms ü Op<mally, patch tes<ng should be performed at least 4 6weeks arer complete resolu<on of the CADR ü Tests arer time interval of three weeks, but not arer more than three months, if possible ü Drug skin tests at least 1 month arer the resolu<on of the CADR and during the year following the CADR ü In order to avoid any virus reac<va<on, in DRESS, patch tests at least 6 months arer the disappearance of the ADR Yawalkar et al. Int. J. Mol. Sci. 2016, 17, International Consensus on drug allergy. Allergy 2014; 69: European Society of Contact Dermatitis guideline for diagnostic patch testing recommendations on best practice, Contact Dermatitis 2015 General considerations for skin test procedures in the diagnosis of drug hypersensitivity. Allergy 2002: 57: Barbaud A. Skin Testing and Patch Testing in Non-IgE-Mediated Drug Allergy. Curr Allergy Asthma Rep (2014) 14:442

6 PATCH TESTS - reading ü ARer test applica<on (D0)* and allergen exposure for 2 days, the patch test chambers are removed. The following reading <mes are oren used in prac<ce: D2 and D3 or D4 and around D7 (op<mum)** *drug patch tests can elicit immediate posi<ve reac<ons, especially with betalactam an<bio<cs, these tests need to be read at 20 min **for at least some drugs (cor<costeroids and aminoglycoside an<bio<cs) European Society of Contact Dermatitis guideline for diagnostic patch testing recommendations on best practice, Contact Dermatitis 2015 Guidelines for performing skin tests with drugs in the investigation of cutaneous adverse drug reactions. Contact Dermatitis, 2001, 45,

7 PATCH TESTS - drug concentra<ons ü Concentra<ons should be nonirrita<ng aiming for the highest specificity, if possible exceeding 95% ü Only a few drug allergens commercially available for patch tes<ng, such as some an<bio<cs (5%), NSAIDs, and an<convulsants, usually at 10% in pet. ü Material has to be prepared in-house from the drugs used by the pa<ents, in its commercially available formula<on (pulverized tablet, syrup, solu<on, powder), with each drug diluted up to 30 %. ü The vehicle providing op<mal skin penetra<on for drug patch test has not been formally evaluated. The most common and convenient is petrolatum. ü In severe an<convulsant hypersensi<vity reac<ons the ini<al test concentra<on should be diluted to 1% (0,1%), and, if nega<ve, at higher concentra<ons up to 10% Skin test concentrations for systemically administered drugs an ENDA/EAACI Drug Allergy Interest Group position paper. Allergy 2013; 68: European Society of Contact Dermatitis guideline for diagnostic patch testing recommendations on best practice, Contact Dermatitis 2015 Barbaud A. Skin Testing and Patch Testing in Non-IgE-Mediated Drug Allergy. Curr Allergy Asthma Rep (2014) 14:442

8 PATCH TESTS - DRESS safe and useful method in confirming the culprit drug in DRESS induced by an<epilep<c drugs, whereas it had no value in DRESS induced by allopurinol Santiago F et al. Epicutaneous patch testing in drug hypersensitivity syndrome (DRESS) Contact Dermatitis 2010: 62: 47 53

9 PATCH TESTS - for SCARs ü Pa<ents referred for AGEP, DRESS, or SJS/TEN within 1 year of their SCAR, in tes<ng all drugs administered in the 2 months prior to and the week following the onset of the SCAR ü Among the 134 pa<ents included, posi<ve DPTs were obtained for 24 different drugs and were posi<ve in 76 of the 134 pa<ents (57.5 %) with SCAR ü For AGEP, PTs seem to be of value, as they were posi<ve in 26 out of 45 cases (58 %) with the most frequent posi<ve results observed in beta-lactams, pris<namycin, RCM ü Pa<ents with SJS posi<ve in 4 of 17 of cases (24 %); posi<ve drugs: lamotrigine, ramipril, tetrazepam, amoxicillin ü Pa<ents with DRESS posi<ve in 46 of 72 of cases (64 %) with the most frequent posi<ve drugs: an<microbials (beta-lactams, vancomycin, pris<namycin, quinolones), carbamazepine (11/13), proton pump inhibitors Barbaud A et al. A multicentre study to determine the value and safety of drug patch tests for the three main classes of severe cutaneous adverse drug reactions. BJD ,

10 PATCH TETS - CBZ CBZ-SJS/TEN pa<ents 10/16 (62.5%) CBZ-DRESS pa<ents 7/10 (70%) Only the HLA-B*1502 genotype was present and strongly associated with the CBZ-SJS TEN, but not with the CBZ-DRESS. Cross-sensi<vity to other aroma<c AEDs was observed in both the CBZ-SJS/TEN and the CBZ- DRESS. Lin YT et al. A patch testing and cross-sensitivity study of carbamazepine-induced severe cutaneous adverse drug reactions. JEADV 2013, 27,

11 PATCH TETS - an<bio<cs Pinho A. et al. Patch testing a valuable tool for investigating nonimmediate cutaneous adverse drug reactions to antibiotics. JEADV 2017, 31,

12 PATCH TESTS other case series Clinical presenta<on Incidence (%) Posi<ve patch tests (%) SJS/TEN 22 (37%) 2 (9%) AGEP 14 (24%) 7 (50%) other CADRs 23 (39%) 6 (26%) Hassoun-Kheir N et al. The use of patch tests in the diagnosis of delayed hypersensitivity drug eruptions. International Journal of Dermatology 2016, 55, Wolkenstein P et al. Patch testing in severe cutaneous adverse drug reactions, including Stevens-Johnson syndrome and toxic epidermal necrolysis. Contact Dermatitis. 1996;35:

13 PATCH TESTS - safety Ø 1/134 DRESS, SJS, AGEP Only one relapse of AGEP requiring scs following posi<ve PTs with pris<namycin. (Barbaud 2013) Ø 0/56 DRESS complica<ons of PT (San<ago 2010) Ø 0/26 DRESS, SJS (Lin 2013) ü Patch tes<ng with CBZ induced an exfolia<ve derma<<s (performed using crushed tablets in pet. where final drug concentra<on could not be adequately controlled) Vaillant L et al. Patch testing with carbamazepine: reinduction of an exfoliative dermatitis. Arch Dermatol 1989: 125: 299. ü A case of acute generalized exanthematous pustulosis (AGEP) provoked by a patch test with acetaminophen Mashiah J at al. A systemic reaction to patch testing for the evaluation of acute generalized exanthematous pustulosis. Arch Dermatol Sep;139(9): ü A generalized AGEP-like reac<on caused by a patch test with dil<azem Nishimura et al. Pustular drug eruption induced by diltiazem HCL. Skin Res. 1991;33, ü An appearance of a diffuse pruri<c erup<on on the neck, abdomen, and patch test area - which resolved in a few days - arer a posi<ve patch test with dil<azem. Vincente-Calleja et al. Acute generalized exanthematous pustulosis due to diltiazem: confirmation by patch testing. Br J Dermatol. 1997;137, ü A posi<ve patch test with dil<azem accompanied by a mild eczematous reac<on on both forearms. Wakelin et al. Diltiazem-induced acute generalized exanthematous pustulosis. Clin Exp Dermatol. 1995;20,

14 PATCH TESTS safety 2 * *most oren: rash, eosinophilia, transamini<s and fever In HIV-infected persons with tuberculosis-associated SCARs patch-tes<ng reac<ons to first-line an<tuberculosis drugs are common and tend to be associated with systemic, but are not life threatening or fatal. Lehloenya RJ et al. Diagnostic patch testing following tuberculosis-associated cutaneous adverse drug reactions induces systemic reactions in HIV-infected persons. British Journal of Dermatology (2016) 175, pp

15 PATCH TESTS - SUMMARY ü ARer time interval of 3 weeks and 3 months or possibly later in DRESS ü Reading: D2 and D3 or D4 and around D7 (op<mum) ü Concentra<ons: an<bio<cs (5%), NSAIDs 10%, an<convulsants 0,1-10% in pet. The others prepared in-house up to 30 %. ü Patch tests more frequently give posi<ve results in pa<ents with DRESS, and AGEP, and less oren in pa<ents with SJS/TEN. ü Patch tes<ng specificity and sensi<vity are drug-dependent. ü Patch testsing is a safe procedure, apart from excep<onal cases.

16 IN VITRO tes<ng potentailly possible endpoints Kay AB et al. (ed.) Allergy and Allergic Diseases. Blackwell Publishing, 2008 Time course of T-cell ac<va<on

17 IN VITRO tes<ng - Lymphocyte transforma<on test Prolifera<on of drug-specific T cells upon the s<mula<on with the suspected drug(s) is measured by the incorpora<on of tri<um [3H] or carboxyfluorescein diacetate succinimidyl ester (CFSE) content using flow cytometry. ü Sensi<vity of lymphocyte transforma<on test is higher than that of patch tests ü Sensi<vity highly variable, from 27% to 88.8% depend on - the clinical manifesta<ons, being higher in AGEP and DRESS but of liple value in SJS/TEN - the culprit drug, being higher for betalactams and an<convulsants Rozieres A et al. Detection and quantification of drug-specific T cells in penicillin allergy. Allergy 2009;64: Kano Y Utility of the lymphocyte transformation test in the diagnosis of drug sensitivity: dependence on its timing and the type of drug eruption. Allergy 2007 Polak ME et al. In vitro diagnostic assays are effective during the acute phase of delayed-type drug hypersensitivity reactions. Br J Dermatol 2013;168: Thong BY et al. A world allergy organization international survey on diagnostic procedures and therapies in drug allergy/hypersensitivity. World Allergy Organ J 2011 Porebski G et al. In vitro drug causality assessment in Stevens-Johnson syndrome alternatives for lymphocyte transformation test. Clin Exp Allergy In vitro tests for drug hypersensitivity reactions: an ENDA/EAACI Drug Allergy Interest Group position paper. Allergy Aug;71: Nyfeler B, Pichler WJ. The lymphocyte transformation test for the diagnosis of drug allergy: sensitivity and specificity. Clin Exp Allergy 1997;27: Luque I et al. In vitro T-cell responses to beta-lactam drugs in immediate and nonimmediate allergic reactions. Allergy 2001;56:

18 IN VITRO tes<ng - Lymphocyte transforma<on test ü Op<mal phase of the reac<on to perform LTT: for SJS/TEN: higher sensi<vity has been found in the acute phase and for DRESS in the resolu<on phase, while other studies found no differences ü Modifica<ons can increase sensi<vity by: - the use of professional an<gen-presen<ng cells - the inclusion of drug metabolites - the deple<on of FoxP3+ regulatory T cells Antunez C et al. Recognition of iodixanol by dendritic cells increases the cellular response in delayed allergic reactions to contrast media. Clin Exp Allergy 2011 Gomez ECJ et al. Effect of metabolising cell system in lymphocyte transformation test to evaluate non immediate reactions to anticonvulsivants. EAACI Istanbul: Srinoulprasert Y, Pichler WJ. Enhancement of Drug-Specific Lymphocyte Proliferation Using CD25-Depleted CD3 Effector Cells. Int Arch Allergy Immunol 2014 Kano Y Utility of the lymphocyte transformation test in the diagnosis of drug sensitivity: dependence on its timing and the type of drug eruption. Allergy 2007 Polak ME et al. In vitro diagnostic assays are effective during the acute phase of delayed-type drug hypersensitivity reactions. Br J Dermatol 2013;168:

19 IN VITRO tes<ng Enzyme-linked immunosorbent spot assay (ELISpot) ELISpot determines the number of cells that release relevant cytokines and cytotoxic markers arer their ac<va<on by the culprit drug - two or more cytokines determina<on can be used - able to detect <25 secre<ng cells per million peripheral blood mononuclear cells - drug-reac<ve T cells detectable several years arer the reac<on ELISpot has been mostly used to diagnose T cell-mediated allergy - to beta-lactams (IFNg) - involving cytotoxic mechanisms (granzyme B and granulysin) Polak ME et al. In vitro diagnostic assays are effective during the acute phase of delayed-type drug hypersensitivity reactions. Br J Dermatol 2013;168: Beeler A et al. Long-lasting reactivity and high frequency of drug-specific T cells after severe systemic drug hypersensitivity reactions. JACI 2006 Fu M et al. Recovered patients with Stevens-Johson syndrome TEN maintain long-lived IFNgamma and sfasl memory response. PLoS One 2012

20 IN VITRO tes<ng Cell markers and cytokine release ARer in vitro drug s<mula<on, T cells express or up-regulate a number of surface molecules and produce different inflammatory mediators that can be detected by flow cytometry and ELISA. ü CD69 up-regulated early (arer 48 72h), correlates with LTT results for betalactams, sulphamethoxazole and carbamazepine ü Combina<on of IL-5/IL-10/IFNgamma measurements by flow ü Timing of sample collec<on is cri<cal because the mediators can be secreted in transitory peaks and cytokines can be degraded by proteases Niwa Y et al. Evidence for degradation of cytokines in the serum of patients with atopic dermatitis by calcium-dependent protease. Arch Dermatol Res 2000 Martin M et al. In vitro detection and characterization of drug hypersensitivity using flow cytometry. Allergy 2010;65: Beeler A et al. CD69 upregulation on T cells as an in vitro marker for delayed-type drug hypersensitivity. Allergy 2008;63:

21 IN VITRO tes<ng Combina<ons of tests & following dis<nct mechanisms in SJS/TEN Pathways of cell-mediated cytotoxicity & key mediators Patients, n = 15 Drug-exposed controls, n = 18 male/ female 8 (53%)/ 7 (47%) 9 (50%)/ 9 (50%) tested drugs (n) carbamazepine 6 8 sulfonamides* 4 4 lamotrigine 3 12 allopurinol and oxipurinol 1 5 mefenamic acid 1 5 Porebski G et al. Clinical & Experimental Allergy, 2011 (41) Porebski G et al. In vitro drug causality assessment in Stevens-Johnson syndrome alternatives for lymphocyte transformation test. Clin Exp Allergy 2013.

22 IN VITRO tes<ng Combina<ons of tests & following dis<nct mechanisms in SJS/TEN patient culprit drug LTT (SI) % Granulysin + cells GrB cytokines (pg/ml) NKp46 + CD8 + CD4 + ELISpot IFNγ IL-5 IL-2 (sfc/well) 1. SPD 5,2 1,8-5,5 2,4 0, CBZ 2,9 34,8 2,3 0,3 29, ALP 1,7-5,7 0,3 4 21,5 28,2 0-0,2 4. CBZ 0,8 2,4-0, ,3 0,3-1,5 5. CBZ 0,7-0,4-2,2-1,3-2,5-0,2-0,2-0,2 6. SPD 1,4 1,7 0, nd 0 nd 7. SDX 1,2 5,9-0,1 0,3 2 2,6 3,4-4,7 8. LTG 1,5 3,1-0,6 0,2 0,7 0-0,2-0,7 9. MA 2,02 3,5 2,3 1,1 0-0,2-0,2 3,4 10. SDX 0,9-0,30-0,2-0,3 1,5 nd nd nd 11. CBZ 1,9 14,1 0,2 0,65-6,5 18,7 1 2,9 12. CBZ 1,1 19,6-0, ,7 13,2 6,2 13. CBZ 1,8 30,0 0,8 0,7 5 22,9 11,8 14,5 14. LTG 1,1 26,2 2,7 1,8-9 nd 13,9 41,2 15. LTG 2,3 26,0 *8,7 4,4 59,5 nd 22, sensitivity % specificity % SPD, sulfapyridine; CBZ, carbamazepine; ALP, allopurinol; SDX, sulfadoxine; MA, mefenamic acid; LTG, lamotrigine; nd not done Set of three endpoints: Granulysin in CD4 + Granzyme B ELISpot IFNγ secre<on in cell SN enhance the assay sensi<vity ü Combining different assays may be a valuable progress in the diagnosis of the relevant drug in SJS/TEN ü A sensi<ve tool for iden<fica<on of a causa<ve agent in individual pa<ent, for detec<ng new alerts for pharmaceu<cal companies or regulatory agencies Porebski G et al. In vitro drug causality assessment in Stevens-Johnson syndrome alternatives for lymphocyte transformation test. Clin Exp Allergy 2013.

23 A gene<c associa<ons between the expression of a par<cular HLA allele and the suscep<bility to specific forms of DHRs International Consensus on drug allergy. Allergy 2014; 69: ü HLA-B*5701 screening reduces the risk of DHR to abacavir and is mandatory before starfng treatment ü The same for the drug carbamazepine in Han Chinese and the allele B*1502

24 IN VITRO tes<ng SUMMARY1 Lab assays to detect delayed drug hypersensi<vi<es Porebski G et al. Clinical & Experimental Allergy, 2011 (41)

25 IN VITRO tes<ng SUMMARY2 ü Par<cularly in the case of nega<ve skin tests or severe life-threatening reac<ons, laboratory inves<ga<ons can be helpful, most notably when provoca<on tes<ng is not possible or where the skin test itself poses a risk. ü In vitro test results can only be interpreted in conjunc<on with pa<ent history/ clinical findings and possibly in vivo tests. ü Combina<on assays show increased sensi<vity over one assay alone ü The use of in vitro tests by clinicians will be determined by the availability of the relevant assays in specialist laboratories.