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Gaudin, Clara; Ryan, Dermot; Demoly, Pascal; Tanno, Luciana Kase
doi: 10.1097/aci.0000000000000924pmid: 37357792
Purpose of reviewThe aim of this study was to review the practice of general practitioners (GPs) in regard to the diagnosis and management of drug hypersensitivity reactions (DHRs) to identify major challenges and to facilitate the development of decision support tools to GPs confronted with DHRs patients.Recent findingsDHRs are still a challenge in the GPs clinical practice, which implies difficulties in clinical decisions and referral to allergy specialists.SummaryDHRs can range from mild to severe and even life-threatening. Drugs are the main cause of anaphylaxis deaths in most countries. Most DHRs are firstly seen by GPs, paediatricians or emergency doctors. However, our systematic review demonstrated difficulties in differentiating DHRs from other drug side effects. Most DHRs epidemiological data are from hospital and emergency departments, which may not reflect the real-life experience in primary care. GPs should be aware of the alert signs of DHRs: the involvement of other systems beyond the skin and/or atypical skin/ mucosal involvement, which mandated immediate referral to an emergency department. Data still stress difficulties in the recognition of DHRs clinical manifestations and highlight the need for decision aids to support their management by GPs. Structured clinical history and clinical examination are key diagnostic tools. Reasons for referring to allergy specialists based on the literature are to investigate cause, to undergo specific procedure, such as desensitization and to identify well tolerated, alternative drugs.
doi: 10.1097/aci.0000000000000914pmid: 37284785
Purpose of review:Recent studies have been clarifying the pathogenesis and early diagnostic markers of Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). Additionally, the efficacy of tumor necrosis factor alpha inhibitors is attracting attention. This review provides) recent evidence for the diagnosis and management of SJS/TEN.Recent findings:Risk factors for the development of SJS/TEN have been identified, particularly the association between HLA and the onset of SJS/TEN with specific drugs, which has been intensively studied. Research on the pathogenesis of keratinocyte cell death in SJS/TEN has also progressed, revealing the involvement of necroptosis, an inflammatory cell death, in addition to apoptosis. Diagnostic biomarkers associated with these studies have also been identified.Summary:The pathogenesis of SJS/TEN remains unclear and effective therapeutic agents have not yet been established. As the involvement of innate immunity, such as monocytes and neutrophils, in addition to T cells, has become clear, a more complex pathogenesis is predicted. Further elucidation of the pathogenesis of SJS/TEN is expected to lead to the development of new diagnostic and therapeutic agents.
Puig, Montserrat; Norcross, Michael A.
doi: 10.1097/aci.0000000000000913pmid: 37284777
Purpose of reviewImmune-mediated drug hypersensitivity reactions (DHRs) can be life-threatening and an impediment to drug development. Mechanism of disease studies are difficult to perform in humans. Here we review human leukocyte antigens class I (HLA-I) transgenic murine models and highlight how these systems have helped to elucidate drug-specific and host immune factors that initiate, propagate and control severe drug toxicities to skin and liver.Recent findingsHLA transgenic mice have been developed and used to study immune-mediated drug reactions in vitro and in vivo. CD8+ T cells from HLA-B∗57:01-expressing mice respond strongly to abacavir (ABC) in vitro but have self-limited responses to drug exposure in vivo. Immune tolerance can be overcome by depleting regulatory T cells (Treg) allowing antigen-presenting dendritic cells to express CD80/86 costimulatory molecules and signal through CD28 on the CD8+ T cell. Depletion of Treg also removes competition for interleukin 2 (IL-2) to allow T cell expansion and differentiation. Fine tuning of responses depends on inhibitory checkpoint molecules such as PD-1. Improved mouse models express only HLA in the absence of PD-1. These models show enhanced liver injury to flucloxacillin (FLX) which depends on drug priming, CD4+ T cell depletion, and lack of PD-1 expression. Drug-specific HLA-restricted cytotoxic CD8+ T cells can infiltrate the liver but are suppressed by Kupffer and liver sinusoidal endothelial cells.SummaryHLA-I transgenic mouse models are now available to study ABC, FLX and carbamazepine-induced adverse reactions. In vivo studies range from characterizing drug-antigen presentation, T cell activation, immune-regulatory molecules and cell-cell interaction pathways that are specifically involved in causing or controlling unwanted DHRs.
Mertes, Paul-Michel; Tacquard, Charles
doi: 10.1097/aci.0000000000000912pmid: 37357801
Purpose of reviewPerioperative anaphylaxis (POA) is rare but is associated with significant morbidity and mortality. Patients are referred to the allergist to identify the mechanism of the reaction, the causative agent and make recommendations regarding subsequent anaesthesia. Despite a well conducted allergological evaluation, the causative agent is not found in 30–60% of these reactions, leaving patients without a well established diagnosis.Recent findingsSeveral mechanisms can induce POA. In addition to the well known IgE-mediated reactions, IgG-mediated reaction, MRGPR-X2-related reaction or nonspecific histamine release may be involved. These situations are not easily assessed by the allergological workup.SummaryWhen the allergological workup is negative, the situation should be reassessed with the team present at the time of the reaction to confirm the reality of the hypersensitivity reaction and to search for a possible differential diagnosis. If POA is confirmed, the allergological evaluation should be repeated, ensuring proper execution according to current guidelines and including the search for hidden allergens. Specific IgE assays or basophil activation tests may be of interest. In case of negative results, a closely monitored drug challenge test, in coordination with the anaesthesia teams, may be useful to avoid the exclusion of any drug injected during the reaction.
Klingebiel, Caroline; Belhocine, Wahib; Vitte, Joana
doi: 10.1097/aci.0000000000000916pmid: 37357783
Purpose of reviewSerum tryptase, a mast cell marker, provides clues for the mechanism, severity, and management of drug hypersensitivity induced by immunoglobulin E dependent or independent mast cell activation.Recent findingsThe interpretation of serum tryptase levels has been challenged during the last 2 years by major advances in tryptase genetics and their rapid incorporation into clinical practice. On the contrary, new pathophysiological insight into nonmast cell-dependent immediate hypersensitivity has been gained.SummaryThis review provides up-to-date information on the pathophysiology and recommended use and interpretation of tryptase in the context of drug hypersensitivity reactions as a function of their endotype.
Sáenz de Santa María, Rocío; Labella, Marina; Bogas, Gádor; Doña, Inmaculada; Torres, María José
doi: 10.1097/aci.0000000000000911pmid: 37357781
Purpose of reviewThe use of contrast media is increasing in recent decades. Although gadolinium-based contrast agents (GBCAs) are generally well tolerated, adverse reactions, including hypersensitivity reactions (HSRs), although infrequent, may occur. It is important to perform a thorough allergological evaluation in patients with suspected GBCA-HSRs to avoid potentially serious reactions in subsequent exposures.Recent findingsData on GBCA-HSRs are scarce. Most published articles dealing with skin tests and drug provocation tests (DPTs) with GBCAs are case series and small cohorts. Controversies exist about the role of premedication for preventing HSRs on subsequent exposures. Selection of well tolerated alternatives is based on potential cross-reactivity among GBCAs; however, the extent of cross-reactivity among them remains unclear.SummaryAs premedication is not useful because breakthrough reactions are frequent in patients with GBCA-HSRs in subsequent exposures, an allergological evaluation is required. Available data suggest a high negative predictive value of skin tests, being crucial for guiding the selection of an alternative GBCA. However, DPTs are still necessary to confirm or exclude the diagnosis or find alternative GBCAs. Cross-reactivity is high among GBCAs belonging from the same group, mainly among macrocyclic compounds, so this must be taken into account for selecting alternatives.
Ferri, Sebastian; Paoletti, Giovanni; Pelaia, Corrado; Heffler, Enrico; Canonica, Giorgio Walter; Puggioni, Francesca
doi: 10.1097/aci.0000000000000920pmid: 37357768
Purpose of reviewChronic Obstructive Pulmonary Disease (COPD) is a common, heterogeneous disease associated with abnormal inflammatory response of the lung to noxious particles and gases. The progression of disease leads to respiratory failure, disability and premature death. Although recent progress in reducing the global burden of many chronic disease, such as heart disease and cancer, mortality and morbidity due to COPD continue to increase despite of cigarette smoking worldwide policy. Additionally, diagnostic and therapeutic options have not changed in decades. While patients affected by other respiratory disease may benefit with a personalized precision medicine, thanks to the new biological treatment, to date, there is no biological treatment available for COPD. COPD is generally a neutrophils-predominant disease but approximately 40% of patients with COPD had also an eosinophilic airway inflammation.Recent findingsdifferent Phase III trials have been recently performed to evaluate the efficacy and safety of several biological treatments, mostly against eosinophilic inflammation and, to date, some of this trial, still ongoing have promising results.SummaryThis review resumes the rationale, the attempts of biological treatment in COPD and latest promising results.
Castagnoli, Riccardo; Brambilla, Ilaria; Giovannini, Mattia; Marseglia, Gian Luigi; Licari, Amelia
doi: 10.1097/aci.0000000000000922pmid: 37357774
Purpose of reviewThis review aims to summarize the most recent advances in asthma management, focusing on novel approaches to pediatric asthma.Recent findingsIn recent years, the therapeutic tools for pediatric asthma have expanded significantly for both the nonsevere and severe forms. The use of anti-inflammatory treatment, even for the mildest cases, and the withdrawal of symptomatic bronchodilation as monotherapy have been included in the most recent guidelines. Also, different biological therapies have revolutionized the therapeutical approach for severe uncontrolled asthma in children and adolescents.SummaryWith the expanding landscape of novel therapeutic approaches for pediatric asthma, further evidence is needed to help clinicians choose the best option for patients, particularly those with severe asthma. The identification of novel predictive biomarkers may also help pediatricians in selecting children and adolescents for innovative therapies.
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