Hypersensitivity Reaction After Inhalation of a Lactose-Containing Dry Powder Inhaler

Abstract

Milk protein allergy–induced reactions from lactose-containing dry powder inhalers (DPIs) have not been widely described in the literature. Lactose is a common inactive ingredient in many pharmaceutical products that is used to enhance the stability of active substances in medicinal products, including asthma medications. Contamination of lactose with milk proteins has been identified in reports of inhaled corticosteroid product lot testing. Serious respiratory sequelae may follow after the inhalation of a DPI corticosteroid in a patient with milk protein allergy because DPIs that contain lactose may be contaminated with milk proteins. Lactose-containing DPIs are contraindicated in patients with milk protein allergy. Although manufacturers identify this contraindication in product package inserts, some drug references may not include this information and health care professionals may lack awareness. Clinicians should consider reviewing multiple medication resources for warnings and contraindications of medications to prevent complications. We describe a refractory asthma exacerbation secondary to a hypersensitivity reaction following administration of a lactose-containing DPI corticosteroid and long-acting β2 agonist combination in a child with a milk protein allergy.

Hazardous Medications in Children with Egg, Red Meat, Gelatin, Fish, and Cow’s Milk Allergy

“…Cow’s milk proteins can contaminate lactose contained in fluticasone/salmeterol or laninamivir dry-powder inhalers (DPI) and rarely elicit anaphylaxis in children with cow’s milk allergy (CMA) [55]. However, patients allergic to milk usually tolerate lactose in DPI [44].…”

Excipients of inhaled medications with potential to cause adverse reactions

“…There is a lack of the enzyme lactase which has a role in metabolizing lactose and as a consequence milder forms of side effects can occur, as well as an anaphylactic reaction. In one case report, a nine year-old African American boy with a history of persistent asthma was hospitalized due to the development of an anaphylactic reaction as a consequence of lactose intolerance after administration of inhalation medicine [18].…”

Hidden and Rare Food Allergens in Pediatric Age

“…Lactose is an inactive ingredient common in many pharmaceutical products that is used, e.g., to improve the stability of active substances in medicines, including drugs to treat allergic conditions such as asthma, even in the acute phase. Although medical grade lactose is usually free of milk protein, it can convey milk protein as described in the case of a nine-year-old boy that developed a refractory asthma exacerbation after the use of lactose-containing dry powder inhalers [ 74 ].…”