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Aspirin Allergy in a VA Population: Is There Potential Benefit for Evaluation in the Allergy Clinic?
Abstracts AB167
J ALLERGY CLIN IMMUNOL VOLUME 131, NUMBER 2
DAP: New Products for Skin Tests Diagnosis of Penicillin Allergy F. Javier Fernandez, MD, PhD1, Marıa Jose Torres, MD, PhD2, Julian Campos, Biologist3, Francisca Arribas-Poves, Pharmacist3, Miguel Blanca, MD, PhD2, Angel Vallverdu, MD3; 1UMH Alicante G.University Hospital - Allergy Sect., Alicante, Spain, 2Allergy Service, Carlos Haya Hospital, Malaga, Spain, 3Diater Laboratory, Madrid, Spain. RATIONALE: Allergy to penicillin is the most common drug hypersensitivity reported. Skin testing with the major determinant of benzylpenicillin, the penicilloyl determinant (PPL) and the minor determinants (MDM) consisting of BP, benzylpenicilloic and benzylpenilloic, has been used for diagnosis. Objective: To synthesize and evaluate the diagnostic capacity of two new benzylpenicillin reagents, benzylpenicilloyl octa-Llysine (BP-OL) and benzylpenilloate (Penilloate), in patients with immediate hypersensitivity reactions to betalactams. METHODS: Prospective and multicentre clinical trial performed in 18 Spanish centers. The efficacy was assessed by detection of positive skin tests in an allergic population and negative skin test in non-allergic drug exposed population. Sensitivity, specificity, negative and positive predictive values were determined. RESULTS: Ninety-four allergic patients were included: 31 (35.23%) anaphylaxis, 4 (4.55%) anaphylactic shock, 51 (58.04%) urticaria and 2 (2.27%) not determined. The culprit betalactams were: amoxicillin in 63 (71.60%) cases, non-identified in 6 (6.82%), cefalosporins in 2 (2.27%), and others in 3 (3,42%). Forty-six (52.3%) patients were positive to BP-OL and 33 (37.5%) to DM. Considering both reagents the sensitivity reaches 61.36% with a specificity of 100%. Skin testing to DM was significantly more often negative when the interval between the reaction and the study was longer. CONCLUSIONS: The sensitivity of BP-OL and penilloate was 61%, and considering that amoxicillin was the culprit drug in 71% of reactions, these results indicate that most patients were allergic to the whole group of penicillins. These data support the need of using BP determinants for BL diagnosis.
592
Aspirin Allergy in a VA Population: Is There Potential Benefit for Evaluation in the Allergy Clinic? Bhavisha Patel, MD1,2, Peter Mason, MD, MPH1,2, Sujani Kakumanu, MD1,2, Sameer K. Mathur, MD, PhD, FAAAAI1,2; 1University of Wisconsin School of Medicine and Public Health, Madison, WI, 2 William S. Middleton Veterans Hospital, Madison, WI. RATIONALE: The prevalence of aspirin hypersensitivity reactions, including aspirin exacerbated respiratory disease (AERD), aspirin induced urticaria or angioedema, and anaphylaxis is between 0.2 to 0.9% of the general population. Aspirin is important for prophylaxis and treatment of atherosclerotic cardiovascular disease in adults but is often avoided due to reported aspirin allergies. We hypothesize that a significant proportion of reported aspirin allergic patients are candidates for aspirin desensitization or challenge. Our goal was to analyze the reported aspirin allergy in a VA population to identify the proportion of patients that could be potential candidates for aspirin desensitization. METHODS: Data were obtained from Middleton Veterans Hospital in Madison, Wisconsin. All entries of aspirin or NSAID allergies documented from November 2009 to August 2012 were evaluated. RESULTS: Of the preliminary 193 documented reactions, 44 had no further detail listed. Of the remaining 149 reactions, 37 (24.8%) were due to urticaria/angioedema, 10 (6.7%) were due to AERD, 8 (5.4%) were due to anaphylaxis, 11 (7.4%) were classified as ‘‘rash’’, 45 (30.2%) were due to bleeding or gastrointestinal ulcers, 25 (16.8%) were due to nausea/vomiting, 3 (2.0%) were due to GERD or esophagitis, and 10 (6.7%) were grouped as ‘‘other’’. CONCLUSIONS: Based on these results, at least 55 out of a 149 documented reactions (36.9%) are likely due to true hypersensitivity reactions amenable to aspirin desensitization. Evaluation in the Allergy clinic could allow these patients to receive aspirin therapy for primary prevention, secondary prevention or treatment to improve cardiovascular outcomes.
593
Rapid Outpatient Aspirin Desensitization/Challenge for Urticaria/Angioedema and AERD Johnson T. Wong, MD, FAAAAI; Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA; Newton-Wellesley Hospital, Newton, MA. RATIONALE: A rapid outpatient oral desensitization/challenge protocol (ROD) for patients with Aspirin/NSAID sensitivity offers substantial advantages c/w traditional protracted inpatient protocols. METHODS: ROD starting at aspirin 0.1mg ending at 81-650mg over 8-10 steps over 2-4hr modified from our previous inpatient protocol. AERD patients with severe history were capped at 81mg first day, maintained the dose at home, and then desensitized further on a subsequent visit. For Aspirin/NSAID induced urticaria/angioedema patients (AIUA), H1blocker was used as pretreatment whereas montelukast and H1- blocker were used for AERD patients. RESULTS: In addition to the original 10 AIUA inpatients, we extended the protocol to an additional 21 AIUA patients. 18 patients tolerated the protocol without problem. 1 patient developed mild lip angioedema at 36hr while on narcotic but tolerated off narcotic. 2 patients with chronic urticaria/angioedema (CUA) developed late onset urticaria/angioedema (UA) hrs after finishing the protocol. 1 early AERD patients received 650mg total dose the first day developed asthma/sinus/otorrhea 4-6hr after the start. Another early AERD received 162mg total dose and developed rhinitis at 4.5hr and UA by 48hr. Subsequent patients with severe AERD history was capped at 81mg the first day, maintained same dose at home, and advanced on a separate visit. 4 out of 5 AERD patients tolerated the modified protocol. 1 developed asthma flares post protocol but tolerated years later after started on Xolair. CONCLUSIONS: ROD may be utilized on AIUA patients if they do not have CUA. AERD patients may utilize a modified capped protocol. Xolair may offer additional safety protection.
594
Food Allergy Is Not A Risk Factor in Cross-Intolerance to Nsaids for Induction of Symptoms Francisca Gomez, MD PhD1, Inmaculada Do~na, MD, PhD2, Natalia Blanca-Lopez, MD, PhD3, Maria J. Torres, MD, PhD2, Maria Salas, MD, PhD4, Carmen Rondon, MD, PhD5, Paloma Campo, MD, PhD5, Teresa Posadas2, Maria Auxiliadora Guerrero4, Gabriela Canto, MD, PhD6, Miguel Blanca, MD, PhD2; 1IMABIS Foundation, Malaga, Spain, 2Allergy Service, Carlos Haya Hospital, Malaga, Spain, 3 Allergy Service, Infanta Leonor Hospital, Madrid, Spain, 4Allergy Service, Carlos Haya Hospital, Spain, 5Allergy Service, Carlos Haya Hospital, Malaga, Spain, 6Allergy Service, Infanta Leonor Hospital. RATIONALE: An increased prevalence of atopy has been observed in patients with cross-intolerance to NSAIDs. This association has been observed between inhalant allergens (house dust mites) and different clinical manifestations of cross-intolerance to NSAIDs (i.e. acute urticaria/ angioedema). Whether an association exists with food allergens has not been assessed. The aim of this study was to investigate sensitization to a wide panel of food allergens in patients diagnosed as acute urticaria/ angioedema induced by cross-intolerance to NSAIDs (AUA). _2 episodes with at METHODS: Patients with confirmed history of AUA (> least 2 different NSAIDs or positive drug provocation test), selective responders to NSAIDs (SR) and controls who tolerated NSAIDs were included. Skin prick tests were performed with a battery of 31 common food allergens that included animal, fruit and vegetable allergens. Specific IgE was determined in serum by ImmunoCAP, considering positive a value higher than 0,35 IU/mL. RESULTS: A total of 120 patients with confirmed history of AUA, 100 SR and 152 controls were studied. The 62.5% were females with a mean age 42.54614.76 years. Positive skin tests and specific IgE in serum were detected in 4 (3,33%) patients AUA and in 7 (4,6%) controls (p>0,05). None of SR had positive tests. No differences were found in the allergens tested in both AUA and control groups. CONCLUSIONS: Food allergy is not a risk factor for developing AUA. Further studies are needed to confirm this finding.
MONDAY
591
J ALLERGY CLIN IMMUNOL VOLUME 131, NUMBER 2
DAP: New Products for Skin Tests Diagnosis of Penicillin Allergy F. Javier Fernandez, MD, PhD1, Marıa Jose Torres, MD, PhD2, Julian Campos, Biologist3, Francisca Arribas-Poves, Pharmacist3, Miguel Blanca, MD, PhD2, Angel Vallverdu, MD3; 1UMH Alicante G.University Hospital - Allergy Sect., Alicante, Spain, 2Allergy Service, Carlos Haya Hospital, Malaga, Spain, 3Diater Laboratory, Madrid, Spain. RATIONALE: Allergy to penicillin is the most common drug hypersensitivity reported. Skin testing with the major determinant of benzylpenicillin, the penicilloyl determinant (PPL) and the minor determinants (MDM) consisting of BP, benzylpenicilloic and benzylpenilloic, has been used for diagnosis. Objective: To synthesize and evaluate the diagnostic capacity of two new benzylpenicillin reagents, benzylpenicilloyl octa-Llysine (BP-OL) and benzylpenilloate (Penilloate), in patients with immediate hypersensitivity reactions to betalactams. METHODS: Prospective and multicentre clinical trial performed in 18 Spanish centers. The efficacy was assessed by detection of positive skin tests in an allergic population and negative skin test in non-allergic drug exposed population. Sensitivity, specificity, negative and positive predictive values were determined. RESULTS: Ninety-four allergic patients were included: 31 (35.23%) anaphylaxis, 4 (4.55%) anaphylactic shock, 51 (58.04%) urticaria and 2 (2.27%) not determined. The culprit betalactams were: amoxicillin in 63 (71.60%) cases, non-identified in 6 (6.82%), cefalosporins in 2 (2.27%), and others in 3 (3,42%). Forty-six (52.3%) patients were positive to BP-OL and 33 (37.5%) to DM. Considering both reagents the sensitivity reaches 61.36% with a specificity of 100%. Skin testing to DM was significantly more often negative when the interval between the reaction and the study was longer. CONCLUSIONS: The sensitivity of BP-OL and penilloate was 61%, and considering that amoxicillin was the culprit drug in 71% of reactions, these results indicate that most patients were allergic to the whole group of penicillins. These data support the need of using BP determinants for BL diagnosis.
592
Aspirin Allergy in a VA Population: Is There Potential Benefit for Evaluation in the Allergy Clinic? Bhavisha Patel, MD1,2, Peter Mason, MD, MPH1,2, Sujani Kakumanu, MD1,2, Sameer K. Mathur, MD, PhD, FAAAAI1,2; 1University of Wisconsin School of Medicine and Public Health, Madison, WI, 2 William S. Middleton Veterans Hospital, Madison, WI. RATIONALE: The prevalence of aspirin hypersensitivity reactions, including aspirin exacerbated respiratory disease (AERD), aspirin induced urticaria or angioedema, and anaphylaxis is between 0.2 to 0.9% of the general population. Aspirin is important for prophylaxis and treatment of atherosclerotic cardiovascular disease in adults but is often avoided due to reported aspirin allergies. We hypothesize that a significant proportion of reported aspirin allergic patients are candidates for aspirin desensitization or challenge. Our goal was to analyze the reported aspirin allergy in a VA population to identify the proportion of patients that could be potential candidates for aspirin desensitization. METHODS: Data were obtained from Middleton Veterans Hospital in Madison, Wisconsin. All entries of aspirin or NSAID allergies documented from November 2009 to August 2012 were evaluated. RESULTS: Of the preliminary 193 documented reactions, 44 had no further detail listed. Of the remaining 149 reactions, 37 (24.8%) were due to urticaria/angioedema, 10 (6.7%) were due to AERD, 8 (5.4%) were due to anaphylaxis, 11 (7.4%) were classified as ‘‘rash’’, 45 (30.2%) were due to bleeding or gastrointestinal ulcers, 25 (16.8%) were due to nausea/vomiting, 3 (2.0%) were due to GERD or esophagitis, and 10 (6.7%) were grouped as ‘‘other’’. CONCLUSIONS: Based on these results, at least 55 out of a 149 documented reactions (36.9%) are likely due to true hypersensitivity reactions amenable to aspirin desensitization. Evaluation in the Allergy clinic could allow these patients to receive aspirin therapy for primary prevention, secondary prevention or treatment to improve cardiovascular outcomes.
593
Rapid Outpatient Aspirin Desensitization/Challenge for Urticaria/Angioedema and AERD Johnson T. Wong, MD, FAAAAI; Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA; Newton-Wellesley Hospital, Newton, MA. RATIONALE: A rapid outpatient oral desensitization/challenge protocol (ROD) for patients with Aspirin/NSAID sensitivity offers substantial advantages c/w traditional protracted inpatient protocols. METHODS: ROD starting at aspirin 0.1mg ending at 81-650mg over 8-10 steps over 2-4hr modified from our previous inpatient protocol. AERD patients with severe history were capped at 81mg first day, maintained the dose at home, and then desensitized further on a subsequent visit. For Aspirin/NSAID induced urticaria/angioedema patients (AIUA), H1blocker was used as pretreatment whereas montelukast and H1- blocker were used for AERD patients. RESULTS: In addition to the original 10 AIUA inpatients, we extended the protocol to an additional 21 AIUA patients. 18 patients tolerated the protocol without problem. 1 patient developed mild lip angioedema at 36hr while on narcotic but tolerated off narcotic. 2 patients with chronic urticaria/angioedema (CUA) developed late onset urticaria/angioedema (UA) hrs after finishing the protocol. 1 early AERD patients received 650mg total dose the first day developed asthma/sinus/otorrhea 4-6hr after the start. Another early AERD received 162mg total dose and developed rhinitis at 4.5hr and UA by 48hr. Subsequent patients with severe AERD history was capped at 81mg the first day, maintained same dose at home, and advanced on a separate visit. 4 out of 5 AERD patients tolerated the modified protocol. 1 developed asthma flares post protocol but tolerated years later after started on Xolair. CONCLUSIONS: ROD may be utilized on AIUA patients if they do not have CUA. AERD patients may utilize a modified capped protocol. Xolair may offer additional safety protection.
594
Food Allergy Is Not A Risk Factor in Cross-Intolerance to Nsaids for Induction of Symptoms Francisca Gomez, MD PhD1, Inmaculada Do~na, MD, PhD2, Natalia Blanca-Lopez, MD, PhD3, Maria J. Torres, MD, PhD2, Maria Salas, MD, PhD4, Carmen Rondon, MD, PhD5, Paloma Campo, MD, PhD5, Teresa Posadas2, Maria Auxiliadora Guerrero4, Gabriela Canto, MD, PhD6, Miguel Blanca, MD, PhD2; 1IMABIS Foundation, Malaga, Spain, 2Allergy Service, Carlos Haya Hospital, Malaga, Spain, 3 Allergy Service, Infanta Leonor Hospital, Madrid, Spain, 4Allergy Service, Carlos Haya Hospital, Spain, 5Allergy Service, Carlos Haya Hospital, Malaga, Spain, 6Allergy Service, Infanta Leonor Hospital. RATIONALE: An increased prevalence of atopy has been observed in patients with cross-intolerance to NSAIDs. This association has been observed between inhalant allergens (house dust mites) and different clinical manifestations of cross-intolerance to NSAIDs (i.e. acute urticaria/ angioedema). Whether an association exists with food allergens has not been assessed. The aim of this study was to investigate sensitization to a wide panel of food allergens in patients diagnosed as acute urticaria/ angioedema induced by cross-intolerance to NSAIDs (AUA). _2 episodes with at METHODS: Patients with confirmed history of AUA (> least 2 different NSAIDs or positive drug provocation test), selective responders to NSAIDs (SR) and controls who tolerated NSAIDs were included. Skin prick tests were performed with a battery of 31 common food allergens that included animal, fruit and vegetable allergens. Specific IgE was determined in serum by ImmunoCAP, considering positive a value higher than 0,35 IU/mL. RESULTS: A total of 120 patients with confirmed history of AUA, 100 SR and 152 controls were studied. The 62.5% were females with a mean age 42.54614.76 years. Positive skin tests and specific IgE in serum were detected in 4 (3,33%) patients AUA and in 7 (4,6%) controls (p>0,05). None of SR had positive tests. No differences were found in the allergens tested in both AUA and control groups. CONCLUSIONS: Food allergy is not a risk factor for developing AUA. Further studies are needed to confirm this finding.
MONDAY
591