Recurrent Immediate Type Hypersensitivity Reaction Induced by Macrogol in a 3-Year-Old Boy

Towards the best approach to PEG allergy

“…followed the case of a patient who reacted to polysorbate and polyethoxylated castor oils, quite similar to the one reported by Bibera et alia 3 . Again, Wenande with Garvey in their subsequent brilliant review 4 collected reports about individuals reacting to both PEG and other PEG derivatives, such as polyethylene glycol stearate, 5,6 cetomacrogol 6–8 and even to hydroxyethyl starch 9 ; the following years’ literature told us of clinically relevant reactivity to both PEG and polyoxyethylated castor oils 10 and to both PEG and polidocanol 11…”

“…2 followed the case of a patient who reacted to polysorbate and polyethoxylated castor oils, quite similar to the one reported by Bibera et alia. 3 Again, Wenande with Garvey in their subsequent brilliant review 4 collected reports about individuals reacting to both PEG and other PEG derivatives, such as polyethylene glycol stearate, 5,6 cetomacrogol [6][7][8] and even to hydroxyethyl starch 9 ; the following years' literature told us of clinically relevant reactivity to both PEG and polyoxyethylated castor oils 10 and to both PEG and polidocanol. 11 Since PEGs are obtained from polymerization of ethylene oxide, their chemical structure has to be considered practically identical with the only difference of the chain length, which influences both skin test reactivity and clinical reactivity probably by increasing the likelihood of IgE capping as the chain length enlarges.…”

“…We do agree on the extreme caution to observe while performing skin tests with PEG epitope carrying products, especially in people who withstood severe reactions; but we also encourage intradermal testing when SPTs give negative results. As already proposed, 4 end-point IDT concentrations (about 10 mg/ml for PEGs with MW 3,350-4,000 14,15 and about 0.04 mg/ml for polysorbate 80 are not irritating [15][16][17] ) must be reached gradually -and the same prudence has to be applied also to SPTs (end-point 60-250 mg/ ml for PEG 4,000-6,000-20,000 and 0.4 mg/ml for polysorbate 80 10,[18][19][20] ) -testing one product a time and keeping in mind that there are reports of slightly delayed cutaneous reactions with systemic symptoms (anaphylaxis). 13 A final safety recommendation could be to observe for at least two hours those with a personal history of severe reactions to PEG or PEG derivatives when testing very high molecular weight PEGs.…”

Diagnostic Value of Oral Provocation Tests in Drug Hypersensitivity Reactions Induced by Nonsteroidal Anti-Inflammatory Drugs and Paracetamol

“…Usually, after a negative DPT, the patient receives information that he can use the active substance, but, in his daily life, he can buy and take many generic drugs containing different excipients ( Tables S1–S4 ). Many of them have allergenic potential and can cause hypersensitivity reactions, as shown in Table 4 [ 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 ]. An excellent illustration of this is the case series by Cox et al [ 81 ].…”

“…In our group A2, symptoms reported after reexposure to ASA despite negative challenge were urticaria (5 persons), urticaria and erythema (1 person), angioedema (2 persons), dyspnea (1 person). In fact, many excipients in ASA generics ( Table S1 ) can trigger such reactions: carmine [ 34 ], citric acid [ 38 ], cochineal red [ 39 ], glycine [ 44 ], hypromellose [ 48 ], macrogol [ 50 ], mannitol [ 52 , 53 , 54 , 55 ], polysorbate 80 [ 56 , 57 ], potato starch [ 63 ], and povidone [ 60 , 61 , 62 ]. Another patient developed urticaria after reexposure to MEL.…”