Comprehensive hospital drug monitoring (CHDM): adverse skin reactions, a 20‐year survey

Abstract

Studies on the epidemiology of common adverse cutaneous drug reactions have rarely been reported, since they can only be successfully conducted in clinics of internal medicine employing consultant dermatologists and having a comprehensive or intensive system of monitoring. Between 1974 and 1993, the adverse skin reactions occurring in divisions of general internal medicine of three different hospitals were monitored by a computerized comprehensive system. The "drug-monitoring patient" was defined as the recipient of at least one drug during hospitalization. The relationship of the skin reactions to drug causality in these patients had to be either definite (proven by re-exposure) or probable (drug relation greater than that of nondrug causality). The skin reactions were classified into four diagnostic groups. Maculopapular exanthema, urticaria, and vasculitis were the three main groups. The fourth group comprised cases of nonhomogeneous but clinically well-defined special exanthema. For selected drugs and years of observation, special emphasis was placed on the study of time patterns (reaction time, exposure time). A total of 1317 definite or probable drug-induced skin reactions occurred during the hospitalization of 48,005 consecutively admitted "drug-monitoring patients": 1201 cases of maculopapular exanthema, 78 cases of urticaria, 18 cases of cutaneous vasculitis, and 20 cases of special exanthema (five of erythema multiforme minor, six of fixed eruption, one of photosensitivity reaction, and eight of acneiform eruption). The main drugs involved did not differ for the three main types of skin reactions, penicillins ranking in the first place, followed by sulfonamides--most often combined with trimethoprim--and in the third place nonsteroidal anti-inflammatory drugs. The reaction time (time from last drug exposure to first skin manifestation) for urticaria showed a relevant proportion of the acute type (within 1 h) and most of the subacute type (1-24 h). For maculopapular exanthema, the subacute or, rarely, the latent type (1-8 days, exceptionally more than 8 days) predominated. For aminopenicillins, the rate of occurrence of skin reactions increased with increasing exposure time up to 12 days, and then markedly diminished. Possibly due to the tendency to withdraw suspected drugs even in the case of minor (e.g., maculopapular) skin reactions, no severe events such as erythema multiforme major/Stevens-Johnson syndrome or toxic epidermal necrolysis occurred.

Treatment of adverse drug reactions in a dermatology department

“…Due to polypharmacy in 17.4% of the studied patients the ADR received a lower level of probability by the Naranjo scale, and this finding is in line with the results of Fiszenson et al, who confirm the difficulties to attest the imputability of a drug especially when there is concomitant use of multiple drugs [11]. The high proportion of "type B" reactions may also be the reason for this considerably low level of probability of drug causation because the algorithms used for establishing drug causality are adjusted for pharmacologically dependent ADRs [12] and cannot replace allergy testing in hypersensitivity reactions [13]. Drug provocation tests were not performed for ethical reasons and this resulted in a rather low proportion of "definite" ADRs.…”

“…Antianemic preparations included vitamin B 12 and folic acid and were used for the management of drugexacerbated psoriasis vulgaris. The ATC group "R06 Antihistamines for systemic use" corresponds to the …”

Skin manifestations of drug allergy

“…Skin manifestations are the commonest presentation of drug allergy [1,2] and they may range from mild (two-thirds) to severe or life threatening (one-third) in a hospital setting [3]. Distinguishing these two outcomes is clearly the most important task for any clinician engaged in the management of individuals with a drug allergy.…”

Avaliação diagnóstica do exantema máculo-papular e urticária tardia induzidos por antibióticos beta-lactâmicos

“…Estima-se que 5 a 10% dos pacientes desenvolvam reações adversas a alguma medicação durante o curso do tratamento (Weiss, 1998). Cerca de 30% dos pacientes hospitalizados experimentam ao menos uma reaçãoo adversa a droga (Hunziker, 1997) . Aproximadamente 3% de todas as admissões em serviços médicos de emergência e 0,3% de todas as admissões hospitalares são atribuídas a reações adversas a medicações (Hunziker, 1997 (Bachot, 2003;Bibby, 2001;Adkinson, 1998;Romano, 2004).…”

“…Cerca de 30% dos pacientes hospitalizados experimentam ao menos uma reaçãoo adversa a droga (Hunziker, 1997) . Aproximadamente 3% de todas as admissões em serviços médicos de emergência e 0,3% de todas as admissões hospitalares são atribuídas a reações adversas a medicações (Hunziker, 1997 (Bachot, 2003;Bibby, 2001;Adkinson, 1998;Romano, 2004). Os antibióticos do grupo das penicilinas são os medicamentos mais comumente relacionados a estas reações (44 a 54%) (Adkinson, 1984;Fiszenson-Albala, 2003;Hunziker, 1997;Rademarker, 1995 também para a ativação de células T Weltzien, 1998 .…”