Risk-based pathway for outpatient penicillin allergy evaluations

Blumenthal, Kimberly G.; Huebner, Emily M.; Fu, Xiaoqing; Yu, Li; Bhattacharya, Gita; Levin, Amy S.; Mancini, Christian; Slawski, Benjamin R.; Banerji, Aleena

doi:10.1016/j.jaip.2019.04.006

Cited by 50 publications

(29 citation statements)

References 9 publications

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“…Consistently, we observed that more than three‐quarters of reported severe reactions consisted of anaphylaxis, highlighting the need for prompt recognition and treatment of anaphylactic reactions. A detailed characterization of the index reaction may also identify those low‐risk patients who may undergo a direct DPT, in whom our results did not identify an increased risk of severe reactions 136,137 . Testing the suspected culprit drug did not associate with clear increased risk of severe reactions, and therefore should be encouraged 138 …”

Section: Discussionmentioning

confidence: 78%

“…A detailed characterization of the index reaction may also identify those low-risk patients who may undergo a direct DPT, in whom our results did not identify an increased risk of severe reactions. 136,137 Testing the suspected culprit drug did not associate with clear increased risk of severe reactions, and therefore should be encouraged. 138 To the best of our knowledge, this is the first systematic review with meta-analysis assessing the frequency of severe reactions following DPTs.…”

Section: Risk Of Bias Of Individual Studiesmentioning

confidence: 99%

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Frequency of severe reactions following penicillin drug provocation tests: A Bayesian meta‐analysis

Cardoso-Fernandes

Blumenthal

Chiriac

et al. 2021

Clinical & Translational All

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Background Patients with a penicillin allergy label tend to have worse clinical outcomes and increased healthcare use. Drug provocation tests (DPT) are the gold‐standard in the diagnostic workup of penicillin allergy, but safety concerns may hinder their performance. We aimed to assess the frequency of severe reactions following a DPT in patients with reported allergy to penicillins or other β‐lactams. Methods We performed a systematic review, searching MEDLINE, Scopus, and Web of Science. We included primary studies assessing participants with a penicillin allergy label who underwent a DPT. We performed a Bayesian meta‐analysis to estimate the pooled frequency of severe reactions to penicillin DPTs. Sources of heterogeneity were explored by subgroup and metaregression analyses. Results We included 112 primary studies which included a total of 26,595 participants. The pooled frequency of severe reactions was estimated at 0.06% (95% credible interval [95% CrI] = 0.01%–0.13%; I2 = 57.9%). Most severe reactions (80/93; 86.0%) consisted of anaphylaxis. Compared to studies where the index reaction was immediate, we observed a lower frequency of severe reactions for studies assessing non‐immediate index reactions (OR = 0.05; 95% CrI = 0‐0.31). Patients reporting anaphylaxis as their index reaction were found to be at increased risk of developing severe reactions (OR = 13.5; 95% CrI = 7.7–21.5; I2 = 0.3%). Performance of direct DPTs in low‐risk patients or testing with the suspected culprit drug were not associated with clinically relevant increased risk of severe reactions. Conclusions In patients with a penicillin allergy label, severe reactions resulting from DPTs are rare. Therefore, except for patients with potentially life‐threatening index reactions or patients with positive skin tests—who were mostly not assessed in this analysis ‐, the safety of DPTs supports their performance in the diagnostic assessment of penicillin allergy.

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Section: Discussionmentioning

confidence: 78%

Section: Risk Of Bias Of Individual Studiesmentioning

confidence: 99%

Frequency of severe reactions following penicillin drug provocation tests: A Bayesian meta‐analysis

Cardoso-Fernandes

Blumenthal

Chiriac

et al. 2021

Clinical & Translational All

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“…In some, patients with symptoms suggestive of IgE-mediated reactions were considered suitable for direct DPT providing the reaction occurred more than 5 yr ago. 20 In others, IgE-mediated symptoms that developed >1 h after the first dose were deemed suitable. 2 More commonly, only symptoms suggestive of minor side-effects are considered low risk.…”

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confidence: 99%

DALES, Drug Allergy Labels in Elective Surgical patients: a prospective multicentre cross-sectional study of incidence, risks, and attitudes in penicillin de-labelling strategies

Savic

Thomas

Fallaha

et al. 2020

British Journal of Anaesthesia

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“…60 Formal decision aids can streamline the process of SDM SMART communication (ie, specific, measurable, achievable, realistic, and time-sensitive). 12,14 To date, patient decision aids have been developed for AIT, severe asthma, and atopic dermatitis, 12 but additional areas in which decision aids could be successfully leveraged include eosinophilic esophagitis management, 48 food allergy screening and prevention, [42][43][44] drug allergy skin testing vs direct oral challenge, 32,33 and postanaphylaxis management. 5,8 More work is needed to better understand how decision aids can be incorporated into a busy allergy clinic, where they are stored, and how to ensure decision aids are kept up to date.…”

Section: Patient Decision Aidsmentioning

confidence: 99%

Engaging patient partners in state-of-the-art allergy care

Shaker

Blatman

Abrams

2020

Annals of Allergy, Asthma & Immunology

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Shared decision making improves health care quality, but risk communication can pose a challenge to efficient implementation.Patient and practitioner risk perception can be influenced by recency bias, professional training, numeracy, and geography.Tools to improve risk communication include providing numeric (not just descriptive) likelihoods of risk and benefits, using absolute (not just relative) risks, incorporating pictograms, reducing cognitive overload, and keeping risk in perspective of everyday hazards.Variation of patient preferences for nonallergic health states measured under conditions of risk is not well characterized but can significantly affect the health and economic outcomes of many allergy therapies.Challenges to incorporating shared decision making into practice include the need to develop, validate, maintain, index, and update patient decision aids as well as understand how to efficiently use these tools in clinical practice.

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Risk-based pathway for outpatient penicillin allergy evaluations

Cited by 50 publications

References 9 publications

Frequency of severe reactions following penicillin drug provocation tests: A Bayesian meta‐analysis

Frequency of severe reactions following penicillin drug provocation tests: A Bayesian meta‐analysis

DALES, Drug Allergy Labels in Elective Surgical patients: a prospective multicentre cross-sectional study of incidence, risks, and attitudes in penicillin de-labelling strategies

Engaging patient partners in state-of-the-art allergy care

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