MEDICINE 2

F.24A ANAPHYLAXIS, HYPERSENSITIVITY AND ADVERSE

DRUG REACTIONS (Part 1)
Dr. Dominguez (2019 lecture) | May 7, 2019

I. OUTLINE
I. OUTLINE
II. CASE
III. ANAPHYLAXIS
a. Clinical Criteria
b. Risk Factors
c. Diagnosis
d. Treatment
i. First line treatment
ii. Second line treatment
iii. Long term management
e. Prevention
f. Adverse Drug Reactions

Outcome: Diagnose and develop management plan

*All are secreted by mast cell (Central to the development of
anaphylaxis)
II. CASE
• 25 year old female RISK FACTORS
• Sudden dyspnea and wheezing after • Atopy → recurrent pruritus and lesions on elbows, neck,
intake of Ibuprofen popliteal area, and other areas with skin folds, allergy to latex,
• BP: 70/40 dermatographism
• Severe respiratory distress • Older age
• Beta blockers→can cause bronchoconstriction
• Preexisting asthma→asthma attacks that has been intermittent
• Always ask these in history

CLASSIFICATION OF ALLERGENS (BY WORLD RANK)

• By skin contact:
o Poison plant - No
poison ivy in the
Philipppines
o Animal scratches
• Swelling of mucosal surfaces- Angioedema o Pollen, mold and
• Hives are demarcated and elevated mildew: common
• Diagnosis: Anaphylactic shock because of the blood pressure here specially if
season is
III. ANAPHYLAXIS changing from
CLINICAL CRITERIA cold to summer.
1. Acute onset of skin &/or mucosal lesions + respiratory symptoms or o Latex gloves
reduced BP/end-organ dysfunction • Injection:
• Acute: Occurs within minutes to few hours after exposure to o Bee sting
suspected allergen • Ingestion:
• Skin and mucosal: Urticarial, wheals, hives, angioedema o Medications: any medication could cause anaphylaxis
• Respiratory symptoms: wheezing, stridor (indicative of ▪ MC: Ibuprofen, penicillin, Radiocontrast media
upper respiratory tract obstruction/ laryngeal area) even ▪ A negative skin test is not 100% reliable
hypoxemia, or possible respiratory distress, increased RR, o Nuts and shellfish
poor air entry • Inhalation:
• End organ-damage: Sometimes with neurologic symptoms o Pollen, dusts
(loss of consciousness), syncope with/without o Mold and mildew
incontinence o Animal dander: are there pets inside the house?

2. ≥2 after exposure to likely allergen: skin, respiratory symptoms,

MECHANISM TRIGGERS
hypotension, GI symptoms
• Can present with uterine contractions in pregnant women Immunologic Food, venoms, drugs, NRL, aero allergens,
• GI: abdominal pain, vomiting and diarrhea. This is because (IgE dependent) seminal fluid
the intestines are also swollen

3. Hypotension after exposure to known allergen

Non-immunologic RCM, narcotics, NSAIDs, ASA, dextrans,
• The allergen has already been established on the patient.
(Direct mast cell exercise, cold, heat, sunlight, ethanol,
Confirmed and documented allergy
activation) sulfiting agents
• Hypotension as a result of widespread vasodilation due to
histamine
• Histamine→ widespread vasodilation→ increased vascular NRL – natural rubber latex
permeability → increased bronchial constriction RCM – radiocontrast media
• Has undergone skin test before Food: most common trigger for anaphylaxis in children and young
• Anaphylactic shock- if patient is already hypotensive; adults
will change the management entirely Drugs and bee stings: most common in elderly and adults

Transcribers: DE VERA E, BONIFACIO, GERVERO Page 1 of 2

 MEDICINE 2
DIAGNOSIS o Methylprednisolone: the best to give
• History and PE (mainly clinical) o Hydrocortisone
• Prausnitz-Kustner reaction o May take several hours to be effective
(old, not done in practice
anymore) LONG TERM MANAGEMENT
o Employs injecting sera • Epinephrine autoinjectors/kit
containing IgE; after few o Contains 1 ampule
hours, inject antigen and epinephrine, 1 syringe and
see if there are anti-histamine tablets
development of wheals • Anaphylaxis alert tags
urticaria, etc. • Confirm anaphylaxis triggers
o Like passive immunity test. o Allergen-specific serum IgE
o Problem: danger of transmitting blood-borne levels to particular allergen
infection so this is just a historical test. o Skin tests
▪ Refer to allergologist
▪ Not done on admission of the anaphylactic episode
• Immunoassays → Introduce a known panel of antigens and • Avoidance
measure IgE levels o Avoid known triggers - If patient developed anaphylaxis due
• Intracutaneous skin testing → Done to confirm to what to drugs, avoid drugs for 5 years; if allergic to high protein
allergen the patient has been reactive to. Done after 3-4 foods, avoid for 5 years also (like nuts or foods from trees) ;
weeks after the anaphylactic reaction to make sure that it’s other types of food, avoid for at least 6 months
not due to the previous response; bread and butter of allergologist. o Allergy to excipients - take in drugs that are white in color;
• Serum Tryptase level →Tryptase is elevated in anaphylaxis avoid highly colored medications. Patient did not develop
but has very short half life; golden period is 4 hours from onset of allergy to the drugs but to the excipients
anaphylaxis. Not very effective in allergic reactions to food; • Medication desensitization
tryptase will not rise. o Patient needs the drug BUT is allergic to it, (-) alternative
medication
TREATMENT o Done within 24hours
1st LINE TREATMENT o Start with minimum dose → full dosed is reached → patient
• Epinephrine becomes desensitized → then drug is given by allergologist
o Mechanism of action: Vasoconstriction (to reduce hives and o May have anaphylactic shock anytime
swelling) and bronchodilation.
PREVENTION
o Dose: 0.3 to 0.5 ml at 1:1,000 dilution.
• For drug allergies
o Can be IM, IV or SubQ, maximum of 3 doses.
o Select structurally unrelated agent → Avoid giving 1st gen
o Can be with those with cardiac disease. Can feel numbness or
cephalosporins to penicillin-allergic patients because these
coldness of injection site.
drugs have the same nucleus; you may give 3rd gen
cephalosporins
Other Management for Shock
• Skin testing
• Fluid resuscitation
o Do scratch test first. Control is always on the left arm. Active
o If you have to fast drip with 1 L, then do it
drug is always on the right arm in skin tests.
o No actual loss of fluid but there is just relative fluid loss due
▪ Control (+) and Drug (+) →Repeat test
to excessive vasodilation → thus fill up the veins with fluid →
▪ Control (-) and Drug (+) →Positive result
goal is to increase blood pressure
▪ Control (-) and Drug (-) →Negative result
o Best: Isotonic Solution (PNSS, LRS, RS)
o If scratch test is negative, go to intradermal
o Rate is same with other kinds of shock
o If negative on both scratch and intradermal test, you are sure
o Replacement: less aggressive
that patient is really negative
o Age is not a contraindication
o Skin test for antibiotics is no longer recommended.
o Rate: 10-20 cc/kg to run for 1 hour
• Desensitization → (filling up IgEs with antigens).
• IV epinephrine vasopressors o Give first half of the computed dose as an infusion,
o Epinephrine IV 1:10,000 of 2.5 ml epinephrine or 1:100,000 watch out for reaction within 15 minutes;
dilution or other vasopressors o if no reaction, give ¼; if no reaction again, give the remaining
o Let it run for 5-10 minutes ¼ dose. If no reaction you may give the next dose in
o May use dobutamine or dopamine as an alternative full
• Oxygen inhalation/intubation ADVERSE DRUG REACTIONS
o When patient is in respiratory distress→intubate the patient Patient injury caused by a medicine taken in therapeutic doses
o Problem: Severe laryngeal swelling → difficult to intubate the
patient (done by anesthesiologist) Call the experts! Exaggerated pharmacological response
TYPE A
o Tracheostomy is done if intubation is not possible (develops bronchospasm from beta-blockers)
Nonpharmacological, often allergic response
TYPE B
SECOND LINE MANAGEMENT (all hypersensitivity reactions)
• Antihistamines Continuous or long term (time related)
Diphenhydramine is the best to give 50-100 mg IM or IV TYPE C
o (osteoporosis related to the use of steroids)
every 6 hrs; side effect: drowsiness Delayed (lag time)
o 2nd Gen (Loratadine, Cetirizine) TYPE D
(teratogenic effects of the drugs)
o 1st Generation (Diphenhydramine, Chlorphenamine) → Given Ending of use (withdrawal)
when patient is already stable TYPE E (when you suddenly withdraw clonidine then develops
• Beta-2-adrenergic agonists, aminophylline hypertension)
o To address the bronchospasm – causes bronchodilation Failure of efficacy (no response)
o Salbutamol, Albuterol, Terbutaline TYPE F
(resistance to antibiotics)
• IV glucocorticoids

Transcribers: DE VERA E, BONIFACIO, GERVERO Page 2 of 2