2014 Midyear Clinical Meeting No Hives About It: An Evidence-Based Approach to Managing Patients with a History of Drug Allergies

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1 Conflict of Interest No Hives About It: An Evidence Based Approach to Managing Patients with a History of Drug Allergies Bryan D. Hayes, PharmD, DABAT, FAACT Clinical Pharmacy pecialist, EM & Toxicology Neither presenter has (nor does any immediate family member have) a vested interest in or affiliation with a corporate organization offering financial support or grant monies for this continuing education activity, or any affiliation with an organization whose philosophy could potentially bias the presentation. John Patka, PharmD, BCP Clinical pecialist, Emergency Medicine Objectives Design an antimicrobial plan to include cephalosporins, given a patient with a documented penicillin allergy Evaluate the risk of prescribing a sulfa based, non antimicrobial medication, given a patient with a listed sulfa antibiotic allergy Evaluate the risk of prescribing an opiate or opioid medication, given a patient with a reported history of opiate allergy Evaluate the risk of prescribing contrast media and alternative treatments, given a patient with a contrast media or iodine allergy The Engagement is Off! Busting the Beta Lactam ing and Other Antimicrobial Cross eactivity Myths Bryan D. Hayes, PharmD, DABAT, FAACT Clinical Pharmacy pecialist, EM & Toxicology University of Maryland Medical Center Baltimore, MD 53 y/o E. Coli The patient is allergic to penicillin. What antibiotic should you recommend? Ciprofloxacin Levofloxacin TMP MX Cefuroxime Cefazolin I Nitrofurantoin Cefpodoxime Gentamicin Ciprofloxacin Levofloxacin TMP MX Cefuroxime Cefazolin I 2014 American ociety of Health-ystem Pharmacists 1

2 71 y/o T 38.9 o C 68/46 mmhg The patient is allergic to penicillin. Vancomycin PLU??? Piperacillin/tazobactam Ceftazidime/Cefepime Aztreonam PCN Allergy History Longer stay C. difficile ABX C. difficile, VE, MA prevalence <a href=" via <a href=" <a href=" nc nd/2.0/">cc</a> Macy E, et al. J Allergy Clin Immunol 2014;133(3); isk of Anaphylaxis Penicillins: % 10% Cephalosporins: % β lactam ring Pichichero ME, et al. Ann Allergy Asthma Immunol 2014;112: Idsoe O, et al. Bull World Health Organ 1968;38: Kelkar P, et al. N Engl J Med 2001;345: <a href=" Clear Communication People</a> via <a href=" <a href=" nc nd/2.0/">cc</a> 2014 American ociety of Health-ystem Pharmacists 2

3 Contamination Allergy Definition Campagna JD, et al. J Emerg Med 2012;42(5): Pichichero ME, et al. Ann Allergy Asthma Immunol 2014;112: Penicillin Amoxicillin Cephalosporins to Avoid Cephalexin Cefaclor Cefadroxil Cefprozil 1 st gen, (+) PCN anaphylaxis 1 st gen, similar side chain 1 st gen, ( ) anaphylaxis, different side chain +/ Campagna JD, et al. J Emerg Med 2012;42(5): Campagna JD, et al. J Emerg Med 2012;42(5): Pichichero ME. Diagn Microbiol Infect Dis 2007;57(3 suppl):13s 18s. 2nd gen, similar side chain 2nd gen, different side chain Cephalosporin cross reactivity 3 rd, 4 th, 5 th gen Campagna JD, et al. J Emerg Med 2012;42(5): Atanaskovic Markovic M, et al. Pediatr Allergy Immunol 2005;16: omano A, et al. Clin Exp Allergy 2005;35: American ociety of Health-ystem Pharmacists 3

4 53 y/o E. Coli The patient is allergic to penicillin. What antibiotic should you recommend? Ciprofloxacin Levofloxacin TMP MX Cefuroxime Cefazolin I Nitrofurantoin Cefpodoxime Gentamicin Ciprofloxacin Levofloxacin TMP MX Cefuroxime Cefazolin I The patient is allergic to penicillin. What antibiotic should you recommend? PCN in Cephalosporinallergic patient? Nitrofurantoin Cefpodoxime Gentamicin Ciprofloxacin Levofloxacin TMP MX Cefuroxime Cefazolin I ~ 5% ide chain _No_U_Turn.svg omano A, et al. J Allergy Clin Immunol 2010;126(5): Macy E. J Allergy Clin Immunol2011;127(6): Carbapenems 71 y/o T 38.9 o C 68/46 mmhg J Allergy Clin Immunol 2009;124: % Allergy 2008;63: % Ann Intern Med 0.9% 2007;146(4): N Engl J Med 2006;354: % Wall GC, et al. J Chemother 2014;26(3): Kula B, et al. Clin Infect Dis 2014 Jul 21. [Epub ahead of print] Frumin J, et al. Ann Pharmacother 2009;43(2): American ociety of Health-ystem Pharmacists 4

5 The patient is allergic to penicillin. Vancomycin PLU??? The patient is allergic to penicillin. Vancomycin PLU??? Piperacillin/tazobactam Ceftazidime/Cefepime Aztreonam Piperacillin/tazobactam Ceftazidime/Cefepime Aztreonam 66 y/o po 2 84% 228/136 mmhg hould furosemide be avoided in this patient based on history of sulfa allergy to an unknown antibiotic? Yes No Am J Health yst Pharm 2013;70: Wulf N, et al. Am J Health yst Pharm 2013;70: American ociety of Health-ystem Pharmacists 5

6 Data N Engl J Med 2003;349: Am J Ophthalmol 2004;138: Pharmacother 2006;26(4): cases! etrospective cohort etrospective case series Prospective observational ulfonamide nonantibiotic in sulfa allergic patient Wulf N, et al. Am J Health yst Pharm 2013;70: Johnson KK, et al. Ann Pharmacother 2005;39: y/o po 2 84% 228/136 mmhg hould furosemide be avoided in this patient based on history of sulfa allergy to an unknown antibiotic? Yes No hould furosemide be avoided in this patient based on history of sulfa allergy to an unknown antibiotic? Yes No Cephalosporins: Avoid similar side chains ulfonamide nonantibacterials ok in patients with sulfonamide antibacterial allergies 2014 American ociety of Health-ystem Pharmacists 6

7 I m Allergic to Everything but Dilaudid and Allergic to Iodine but I m Not an Alien John Patka, PharmD, BCP Clinical pecialist, Emergency Medicine Grady Health ystem Atlanta, GA Allergy History Often inaccurate Use of second line treatments Increased cost Confusion between allergy and adverse drug reaction (AD) I m allergic to Bactrim because my aunt has an allergy to Bactrim My mom said I cannot take (that drug) (37 year old man) Int Arch Allergy Immunol 2012;158: Pharmacotherapy 2008;28(11): OPIATE ALLEGY Incidence of Opiate Allergy Allergy & anaphylaxis rare Common: urticaria, pruritus, sneezing, asthma exacerbation Natural & derivatives Morphine, codeine emi synthetic Hydrocodone, oxycodone ynthetic opiates Fentanyl, meperidine, methadone (Opioid analgesics cross allergenicity). In: DUGDEX ystem (electronic version). Truven Health Analytics, Greenwood Village, Colorado, UA. Available at: (cited: 08/26/2014) Opiate Adverse eaction vs. Allergy Histamine release (AD, non IgE) Hypotension, rash, pruritus, tachycardia Maculopapular rash IgE mediated (Allergy) Angioedema Urticaria How to Treat Anaphylaxis Airway, Breathing, Circulation Epinephrine IM Adult 0.3 to 0.5 mg (adult) Pediatric 0.01 mg/kg (0.3 mg max) Do not give antihistamine Do not delay ID # American ociety of Health-ystem Pharmacists 7

8 Intramuscular vs. Q Epinephrine oute 8 ±2 34 ± Time to C max (minutes) imons: J Allergy Clin Immunol 2004;113:837 IM Q Opiate Allergy and Cross eactivity are Not well defined Case reports Inconsistent skin test results Antibody testing preferred C 6 hydroxyl & N methyl group implicated Clin ev Allergy Fall Winter;9(3 4): (Opioid analgesics cross allergenicity). In: DUGDEX ystem (electronic version). Truven Health Analytics, Greenwood Village, Colorado, UA. Available at: (cited: 08/26/2014) tructure elationship No hydroxyl Opiate Cross eaction Literature 2004 case series (N=30) with reported opioid allergy N=6 classified high probability of allergic reaction 4 patients prescribed opioids without adverse effects eports with synthetic agents (fentanyl) Positive skin testing Lack of morphine cross reaction? Morphine.html J Oncol Pharm Practice. 2004;10: J Emerg Trauma hock Jul;5(3): Clin ev Allergy Fall Winter;9(3 4): How to Mitigate Opiate Allergy elect non opiate analgesic Choose agent from different opiate class Natural & derivatives Morphine, codeine emi synthetic Hydrocodone, oxycodone ynthetic opiates Fentanyl, meperidine, methadone CONTAT ALLEGY (Opioid analgesics cross allergenicity). In: DUGDEX ystem (electronic version). Truven Health Analytics, Greenwood Village, Colorado, UA. Available at: (cited: 08/26/2014) American ociety of Health-ystem Pharmacists 8

9 adio contrast media (CM) Monomeric Dimeric Ionic Nonionic High osmolality contrast (HOCM) Low osmolality contrast media (LOCM) Mechanism of CM Allergy 1. IgE mediated, immediate hypersensitivity 2. Membrane effect related to osmolarity Compliment Bradykinin formation Neither mechanism is well demonstrated J Emerg Med Nov;39(5):701 7 Curr Opin Allergy Clin Immunol : Mechanism of CM Anaphylaxis IgE mediated, immediate hypersensitivity T cell mediated, delayed hypersensitivity Not well demonstrated CM Anaphylactoid eaction Membrane effect related to osmolarity Compliment Bradykinin formation Neither mechanism is well demonstrated Office for Emergency Management. Office of War Information. Domestic Operations Branch. Bureau of pecial ervices. (03/09/ /15/1945) isk for CM Allergy isk Factors Older age Atopy, asthma Prior CM exposure Female gender Use of nonionic or HOCM Cardiovascular disease Critically ill Allergy 2013; 68: PLo One Jun 16;9(6):e doi: /journal.pone Testing for CM Allergy Incidence of positive skin testing 90 Patients with suspected immediatehypersensitivity 8 (8.9%) confirmed with skin testing 51 patients with CM associated anaphylaxis 33 (64.7%) confirmed with skin testing to at least one CM Allergy 2013; 68: PLo One Jun 16;9(6):e doi: /journal.pone American ociety of Health-ystem Pharmacists 9

10 tudy Design CM N eaction, N (%) Kim 2014 Case series LOCM %* Bedolla Barajas 2013 Observational case series LOCM 99 Ho 2014 Case series LOCM 29, % mild 6.1% moderate 2% severe 0.11% mild 0.037% moderate 0.01% severe All, 1470 (2%) Kopp ,717 Post marketing evere, 14 (0.02%) LOCM Prior reaction registry 1569 All (7.4%) + Atopy 7696 All (4.1%) Valls 2003 Case series 19,554 Low risk HOCM 13,670 High isk LOCM 5884 * anaphylaxis + hypotension + p< compared to all reactions All, 338 (1.7%) evere, 13 (0.06%) All, 304 (2.2%) evere, 11(0.08%) All, 34 (0.6%) evere, 3 (0.05%) Premedication with CM Treatments controversial Corticosteroids H1 & H2 receptor antagonists Immunosuppressant (cyclosporine) Breakthrough reactions possible Immunol Allergy Clin N Am 2014; 34: Allergy 2005;60(2):150 8 eaction to CM: isk Factors & Premedication (N=19,402) 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% isk Factor Without isk Factor Premedication Adapted from: Acta adiol Oct;49(8): Without Premedication evere Moderate Mild Contrast Media & Iodine Allergy Literature eview Iodine allergy vs. intolerance The risk of reaction in patients with a seafood allergy is similar (0.2 17%) to other food allergies or asthma Without iodine in the body, a person cannot survive J Emerg Med Nov;39(5):701 7 Curr Opin Allergy Clin Immunol : CM & hellfish Allergy Injections (n) All cases 112,003 eafood Allergy Other food allergy Contrast All reactions 5546(5%) evere reactions 38 (0.003%) Deaths 8 (0.007%) (15%) 1 (0.5%) HOCM 41 (13%) 0 0 Asthma (11%) 0 0 Prior contrast reaction (17%) Not reported History of any allergy 2.2 x more likely to have a reaction no allergy history Primary allergy: seafood allergy J Emerg Med Nov;39(5):701 7 Ther Nucl Med 1975;124: Not reported World J Cardiol 2014;6(3): American ociety of Health-ystem Pharmacists 10

11 Dispel the Myth! Identify false risk factors hellfish/iodine allergy in patient (or other family member) efrain from seeking iodine allergy during history emove reference to seafood and iodine allergy from consent forms and questionnaires Patient Cases Audience election American College of Asthma, Allergy, and Immunology Drug and Anaphylaxis Committee 2009 Key Takeaways Perform a thorough allergy history before changing therapy If suspect true opiate allergy select nonopiate, or different opiate class eafood allergy does not increase risk of reaction to CM Humans cannot be allergic to iodine Bryan D. Hayes, PharmD, DABAT, FAACT E mail: bhayes@umem.org ALiEM.com John Patka, PharmD, BCP E mail: jpatka@gmh.edu 2014 American ociety of Health-ystem Pharmacists 11