Journal List > Asia Pac Allergy > v.10(1) > 1142170

Thong, Lucas, Kang, Chang, Li, Tang, Yun, Fok, Kim, Nagao, Rengganis, Tsai, Chung, Yamaguchi, Rerkpattanapipat, Kamchaisatian, Leung, Yoon, Zhang, Latiff, Fujisawa, Thien, Castells, Demoly, Wang, and Pawankar: Drug hypersensitivity reactions in Asia: regional issues and challenges

Abstract

There are geographical, regional, and ethnic differences in the phenotypes and endotypes of patients with drug hypersensitivity reactions (DHRs) in different parts of the world. In Asia, aspects of drug hypersensitivity of regional importance include IgE-mediated allergies and T-cell-mediated reactions, including severe cutaneous adverse reactions (SCARs), to beta-lactam antibiotics, antituberculous drugs, nonsteroidal anti-inflammatory drugs (NSAIDs) and radiocontrast agents. Delabeling of low-risk penicillin allergy using direct oral provocation tests without skin tests have been found to be useful where the drug plausibility of the index reaction is low. Genetic risk associations of relevance to Asia include human leucocyte antigen (HLA)-B*1502 with carbamazepine SCAR, and HLA-B*5801 with allopurinol SCAR in some Asian ethnic groups. There remains a lack of safe and accurate diagnostic tests for antituberculous drug allergy, other than relatively high-risk desensitization regimes to first-line antituberculous therapy. NSAID hypersensitivity is common among both adults and children in Asia, with regional differences in phenotype especially among adults. Low dose aspirin desensitization is an important therapeutic modality in individuals with cross-reactive NSAID hypersensitivity and coronary artery disease following percutaneous coronary intervention. Skin testing allows patients with radiocontrast media hypersensitivity to confirm the suspected agent and test for alternatives, especially when contrasted scans are needed for future monitoring of disease relapse or progression, especially cancers.

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Summary Table
Beta-lactam allergy
  · Risk stratification of the likelihood of penicillin allergy based on history and non–IgE-mediated type of clinical manifestations of the index adverse drug reaction, form the basis of safe direct oral amoxicillin/penicillin challenge for low-risk patients without the need for skin tests.
  · Delabeling and de-escalation encourage appropriate narrow-spectrum antimicrobial use, preventing the
  · Delabeling and de-escalation encourage appropriate narrow-spectrum antimicrobial use, preventing the increasing incidence of antimicrobial resistance.
Severe cutaneous adverse reactions
  · The most commonly implicated drugs in Asia are antiepileptic drugs (carbamazepine, phenytoin, lamotrigine), allopurinol and antimicrobials.
  · Although HLA-B*1502 (carbamazepine), HLA-B*5801 (allopurinol) and HLA-B*5701 (abacavir) testing prior to drug initiation may reduce the risk of severe cutaneous adverse reaction (SCAR), a recent Cochrane review found no eligible evidence on genetic testing for severe drug-induced skin rash in relation to different drugs and classes of drugs.
Antituberculous drug allergy
  · Many antituberculous drug hypersensivity reactions are SCARs.
  · Desensitization or any re-exposure is of much higher risk. Desensitization protocols involving sequential re-introduction of antituberculous drugs are commonly used given the paucity of well-validated in vitro and in vivo tests to identify the causative drug to restart during induction combination therapy.
Nonsteroidal anti-inflammatory drug hypersensitivity
  · The phenotype in children and adolescents tends to have overlapping features, with a much lower prevalence of nonsteroidal anti-inflammatory (NSAID) exacerbated respiratory disease compared to adults.
  · Low-dose aspirin desensitization (up to 100 mg/day) for coronary artery disease has been found to be effective and safe in patients with NSAID hypersensitivity.
Radiocontrast media hypersensitivity
  · Radiocontrast media (RCM) drug hypersensitivity reactions (DHR) may be allergic or nonallergic, immediate or non-immediate (delayed); nonionic and hyperosmolar agents are associated with higher risks of DHR.
  · Skin tests are increasingly useful in the management of patients with RCM DHR, especially those who may require repeat contrasted imaging.
  · Negative intradermal tests are used to select alternative RCM to prevent recurrent DHR. International guidelines suggest changing RCM within the same class of low-osmolar RCM.
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