Diagnosis and management of drug‐induced anaphylaxis in children: An EAACI position paper

Abstract

Drug hypersensitivity reactions (DHR) constitute a major and common public health problem, particularly in children. One of the most severe manifestations of DHR is anaphylaxis, which might be associated with a life‐threatening risk. During those past decades, anaphylaxis has received particularly a lot of attention and international consensus guidelines have been recently published. Whilst drug‐induced anaphylaxis is more commonly reported in adulthood, less is known about the role of drugs in pediatric anaphylaxis. Betalactam antibiotics and non‐steroidal anti‐inflammatory drugs are the most commonly involved drugs, probably related to high prescription rates. Diagnosis relies on the recognition of symptoms pattern and is based on complete allergic workup, particularly including skin tests and/or specific IgE. However, the real diagnostic value of those tests to diagnose immediate reactions in children remains not well defined for a significant number of the drugs. Generally, a drug provocation test is discussed to confirm or exclude an immediate‐onset drug‐induced hypersensitivity. Although avoidance of the incriminated drug (and related drug) is the rule, rapid desensitization is useful in selected subgroups of patients. There is a need for large, multicentric studies, to evaluate the real diagnostic value of the currently available skin tests. Moreover there is also a need to develop new diagnostic tests in the future to improve the management of these children.

Recent developments and highlights in drug hypersensitivity

“…However, in a retrospective study, STs have demonstrated a PPV of 99.4%, indicating their usefulness, before DPT . Large multicentre studies, to evaluate the real diagnostic predictive values of ST, are needed …”

“…85 Large multicentre studies, to evaluate the real diagnostic predictive values of ST, are needed. 86 In the case of NIR, due to the potential risk of triggering a severe reaction, the diagnostic procedure starts with a patch test and if negative, IDTs, although recent studies suggest the performance of IDTs with no need of a previous patch testing. 87,88 Unfortunately, the real diagnostic value of STs for SCARs is unknown, as confirmatory DPTs cannot be performed for ethical reasons due to the risk of inducing a severe reaction when reintroducing the culprit drug.…”

“…184 Moreover, long premedication protocols increase costs, side effects and length of hospital stay. 185 In general, desensitization has been shown to be useful to maintain the first election treatment in multiple groups of drugs, 67 including anticonvulsants, 13 antituberculosis medication, 186,187 antibiotics, [188][189][190] NSAIDs 96,183,191,192 and others, 193,194 in both IR 96,174,178,188,191,194 and NIR, 96,186,187,190,193 and even in paediatric population 86,188,192 and patients with multiple autoimmune disorders. 189…”

Local rhinitis needs allergen‐challenges for diagnosis, late infancy supplementation of probiotics prevents eczema, and milk oral immunotherapy is effective in the long term

“…1 Also often presenting with a skin rash, drug allergy is the theme of the second review: Marina Atanaskovic-Markovic et al have in the frame of an EAACI task force reviewed the diagnosis and management of drug-induced anaphylaxis. 2 The topic of the third review relates to another major focus of the journal, primary immunodeficiencies, with Parisa Amirifar et al 3 reviewing ataxia-telangiectasia.…”

“…Educational publications open the issue: In the first, Hagen Ott reviews the various clinical conditions related to erythroderma in neonates and infants; allergists are used to linking this clinical sign to atopic dermatitis, but nevertheless should be well aware of other, less frequent diagnosis . Also often presenting with a skin rash, drug allergy is the theme of the second review: Marina Atanaskovic‐Markovic et al have in the frame of an EAACI task force reviewed the diagnosis and management of drug‐induced anaphylaxis . The topic of the third review relates to another major focus of the journal, primary immunodeficiencies, with Parisa Amirifar et al reviewing ataxia‐telangiectasia.…”