Codeine challenge in chronic urticaria patients

Abstract

Prieto-Lastra et al 1 described three patients who developed adverse reactions after receiving codeine. It is known that codeine can induce direct mast cell degranulation and therefore non-IgE mediated reactions 2. Nonsteroidal anti-inflammatory drugs (NSAIDs) are frequent cause of urticaria and patients with chronic urticaria can present worsening of symptoms with their use. One alternative for these patients is the use of paracetamol, which sometimes is associated with codeine for treatment of more severe pain. We performed 25 controlled oral challenges with 30 mg codeine in patients with chronic urticaria who reported exacerbation with multiple NSAIDs. Neither patient presented adverse reactions. A week later the same patients were submitted to oral challenge with 30 mg codeine associated with 500mg paracetamol. One patient (4 %) developed urticaria 24 hours after drugs intake. Although the present study shows some degree of safety, it is not possible to state that these chronic urticaria patients will not present adverse reactions to codeine in the future. Large and long-term studies are necessary before widespread utilization of codeine in chronic urticaria.

Classification and practical approach to the diagnosis and management of hypersensitivity to nonsteroidal anti‐inflammatory drugs

“…Strict avoidance of NSAIDs does not improve the clinical course of an underlying spontaneous urticaria/angioedema (grade of recommendation D). Oral tolerance tests (preferably placebo‐controlled) should be carried out before prescribing alternative NSAIDs including COX‐2 inhibitors (grade of recommendation D). Selective COX2 inhibitors (coxibs) are tolerated by the majority (75–90%) of NECD patients . Preferential COX‐2 inhibitors, such as nimesulide, or meloxicam or paracetamol (weak inhibitor of COX‐1), may be used as alternative analgesic drug if tolerated on the provocation tests (grade of recommendation D). Similarly, the risk for patients with chronic urticaria to react to opioids is low. However, exceptional cases have been described and if justified a provocation test is advisable (grade of recommendation D). In mild reactions to paracetamol and urgent need for medication, pretreatment of an antihistamine may be an option (grade of recommendation D). Treatment of underlying chronic symptoms of urticaria/angioedema does not differ between patients with NECD or NSAIDs‐tolerant patients (grade of recommendation D).…”

Perioperative Anaphylaxis

“…Some anaphylactic reports involving opioids have been published, including a recent case of anaphylaxis with codeine, with a positive investigation that included SPT (with negative tests in three healthy controls), histamine-release test, and oral challenge test [77]. However, there is data supporting the safe use of codeine in patients presenting chronic urticaria [78].…”

Mast cell degranulation and bradykinin-induced angioedema - searching for the missing link

“…It has also been demonstrated that patients with chronic urticaria have a significantly higher number of MRGPRX2 positive skin mast cells and a higher percentage of MRGPRX2 positive mast cells compared to control subjects ( 101 ). In addition, codeine acts through MRGPRX2 ( 102 ) and response to codeine is accentuated in patients with CSU ( 103 ).…”