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Allergy and Immunology Pearls for Clinical Practice No discussion - - PDF document
Allergy and Immunology Pearls for Clinical Practice No discussion - - PDF document
10/11/17 Nothing to declare Allergy and Immunology Pearls for Clinical Practice No discussion of non-FDA approved medication use 2017 Katherine Gundling, MD FACP Professor, Section Chief Allergy and Immunology UCSF Perioperative
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Clinical Pearls
****Chlorhexidine is embedded in some central line catheters**** If your patient develops a rash upon exposure to chlorhexidine, consider avoiding its use during the perioperative period.
For any severe anaphylactic reaction history, consider obtaining serum tryptase level to help rule out a mast cell disorder.
Clinical Pearls
A patient with a previous allergic reaction to which agent is most likely to experience a drug allergic reaction to furosemide?
- A. Acetazolamide
- B. Atenolol
- C. Penicillin
- D. Trimethoprim-sulfamethoxazole
A patient with a previous allergic reaction to which agent is most likely to experience a drug allergic reaction to furosemide?
- A. Acetazolamide
- B. Atenolol
- C. Penicillin
- D. Trimethoprim-sulfamethoxazole
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Reactions to sulfonamide non-antibiotics are likely due to predispostion to allergic reactions, not due to cross-reactivity with sulfonamide antibiotics!
On the sulfonamide molecule it is the arylamine component that is most allergenic, hence the vast majority of patients who react to arylamine sulfonamides will not react to non-arylamine sulfonamides.
Partial list of sulfonamide medications
Arylamine Sulfonamides – Sulfamethoxazole – Sulfadiazine – Sulfacetamide – Sulfasalazine
- Sulfonamide antiretrovirals
– Amprenavir – Fosampranavir Non-arylamine Sulfonamides Carbonic anhydrase inhibitors Sulfonylureas Loop diuretics Thiazide diuretics Anti-inflammatory Others
From the furosemide package insert, noted in 2017: “patients allergic to sulfonamides may also be allergic to furosemide.” Updated recommendations: “The weight of evidence suggests that withholding non-antibacterial sulfonamides from patients with prior reactions to antibacterial sulfonamides or
- ther non-antibacterial sulfonamides is not
clinically justified.”
N Engl J Med 349;17 Am J Health-Syst Pharm 70:1483-94
The Drug Allergy Practice Parameters from the AAAAI state:
“There is no evidence to suggest allergic cross- reactivity between sulfonamide antibiotics and nonantibiotic sulfonamides.”
AAAAI.org Drug Allergy: An Updated Practice Paramenter
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Clinical Pearls
The term “sulfa” allergy should be dropped! § Endeavor to determine and report the exact medication to which a reaction occurred. § When that information is not available, inquire as to the condition that was being treated, and document the information.
Adverse Drug Reactions Intermission (with 2 Cool Immunology videos)! Hygiene hypothesis update News flash Adverse Drug Reactions Intermission (with 2 Cool Immunology videos)! Hygiene hypothesis update News flash
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 dog
- B. An older brother
- C. Barn animals
- D. Dust mites in the pillow
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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 dog
- B. An older brother
- C. Barn animals
- D. Dust mites in the pillow
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 (is this still true??)
Von Mutius E. Proc Am Thorac Soc 2007; Vol 4 pp 212-216
Farming, Bavarian Style
+ =
Images: Wikipedia dogs
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Image by K. Gundling
Current Opinion Immunology 2016,42:41-47
Hot off the presses…
Environmental exposures and development
- f asthma
Background:
- Environmental exposure in early life appears to play an
important role in the pathogenesis of childhood asthma
- What exposures can be modified to decrease the
likelihood of developing asthma?
- 442 high risk, inner-city children
Evaluated the relationship of prenatal and early-life environmental factors to the occurrence of asthma at 7 years.
J Allergy Clin Immunol; Sept 2017
Higher indoor levels of pet or pest allergens in infancy were associated with lower risk of developing asthma. The abundance of a number of bacterial taxa in house dust was associated with increased or decreased asthma risk. Sampling of the association with taxa:
- Homes without asthma: Kocuria genus more abundant;
produces kocurin, a potent macrolide with activity against Staphylococcus species
- Homes with asthma: potent pathogens such as Staphylococcus,
Haemophilus, Corynebacterium, (others)
- It may not be just about diversity of the microbiome (popular
theory)
- Much work to be done to define cause and effect…..
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Other risk factors for the development of childhood asthma that confirmed previous
- bservations:
Prenatal tobacco smoke exposure (umbilical cord cotinine concentration) Higher maternal stress and depression scores
Prevention of atopic conditions
Clear:
– Infants should be breast fed – New guidelines in 2017 for introduction of peanuts to infants (http://www.annallergy.org/article/S1081- 1206(16)31164-4/fulltext) – Early exposure to animals and a broad variety of proteins is associated with decreased likelihood of developing asthma – 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
JACI 122:114-8
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Adverse Drug Reactions Intermission (with Cool Immunology videos)! Hygiene hypothesis update News flash
News Flash
Dust mite sublingual tablets have just been approved to treat allergic respiratory disease! Consider this type of immunotherapy for patients who:
- have year round allergy symptoms
- who have a limited number of allergic triggers
- who are tired of taking medication
- who don’t have time to dedicate 3-5 years to allergy
shots
Summary of Key Points
- Watch out for sneaky exposures to chlorhexidine,
which can be associated with severe anaphylaxis
- “Sulfa allergy” is a term that should be dropped
- Immune cells at work are truly awe inspiring
- Early life exposures play a key role in training a
healthy immune system
- For those people who already have allergy to dust