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DRUG & FOOD ALLERGY General Considerations
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Some drugs are clearly more immunogenic than others, and this can be reflected in the incidence of drug hypersensitivity A partial list of drugs frequently implicated in drug reactions includes -lactam antibiotics, sulfonamides, phenytoin, carbamazepine, allopurinol, muscle relaxants used for general anesthesia, nonsteroidal anti-inflammatory drugs, antisera, and antiarrhythmic agents Many drugs can be associated with recognizable known toxicities, drug interactions, or idiosyncratic reactions that are not immune-mediated These must be distinguished from true hypersensitivity reactions because the prognosis and management differ Some estimate that only 10% or less of adverse reactions to drugs are true hypersensitivity reactions Patients with multidrug hypersensitivity are quite rare, and those reporting allergies to more than three distinct classes of drugs should be carefully evaluated since intolerance to many of these drug classes may not be immunologic Four foods account for 90% of food allergy in adults: peanuts, tree nuts, fish, and shellfish Food hypersensitivity must be distinguished from food intolerance, which is more common and more variable in terms of underlying mechanism An example of food intolerance would be lactose intolerance, which is due to an enzyme deficiency rather than an IgE-mediated hypersensitivity
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B Laboratory Findings
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1 Allergy testing Allergy skin testing is only available for a limited number of drugs (penicillin, insulin, streptokinase, chymopapain, heterologous serum), since patients may react to the native drug as well as any metabolite that covalently binds to native protein and becomes immunoreactive Skin testing is available for patients with suspected immediate hypersensitivity to penicillin or -lactam antibiotics (see 30) The degree of cross-reactivity between the
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The development of symptoms and the nature of the adverse drug reaction can suggest whether an immunologic process is responsible for symptoms Factors to consider include type of symptoms, history of previous drug exposure, time of onset
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cephalosporin antibiotics and penicillins is uncertain The incidence of IgE-mediated hypersensitivity appears to be less than 5% There appears to be no allergic cross-reactivity between the monobactam antibiotics (aztreonam) and penicillin or other -lactam antibiotics A high degree of crossreactivity exists between penicillin and the carbapenem, imipenem, so this drug should be given to the penicillin-allergic patient with the same degree of caution as if the patient were to receive penicillin If the likelihood of immunologic reaction is low based on the history and the assessment of likely offending agents and if no allergy testing is available, judicious test dose challenges may be considered in a monitored setting If the likelihood of IgE-mediated reaction is significant, these challenges are risky and rapid drug desensitization is indicated The gold standard for allergy food testing is skin-prick testing with actual food items, but due to the inconvenience and potential risk for systemic reactions, this form of testing is usually preceded by IgE RAST testing or skin prick testing with commercially available extracts or both Food allergy testing must be interpreted within the context of the clinical picture, since false-positive tests can occur 2 Provocation tests Occasionally, direct allergen challenge of the target organ or tissue under controlled conditions is required for definitive diagnosis Such challenges may be bronchial, nasal, conjunctival, oral, or cutaneous A positive test confirms that the test substance can cause the reaction, but it does not prove that an immunologic mechanism is responsible In most cases of suspected allergy to a food or drug, placebo-controlled oral challenge is the definitive test To be considered a positive result, the reported clinical findings must be reproduced during provocation testing A blinded provocation test may be preceded by an open challenge (no placebo control), which, if negative, negates the necessity for logistically difficult blinded challenge Freeze-dried foods in large opaque capsules provide a sufficient dose of allergen for testing This should not be done in patients with suspected food- or drug-induced anaphylaxis
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