Table 5 Similarities and differences between Americans and Europeans in the management of drug hypersensitivity
American perspective | European perspective | |
|---|---|---|
General rules for management | Based on clinical evaluation For immediate reactions, STs are applied first; if they are negative, DPT is performed unless contraindication exists STs are not recommended for non-immediate reactions No allergy tests are recommended in history of severe reactions* Desensitization is recommended in indicated cases | Allergy tests are strongly recommended if there are no contraindications. STs are applied first; if they are negative, DPT is performed unless contraindication exists Selection of STs depends on underlying mechanisms (SPTs/IDTs for immediate reactions, PTs and delayed-reading IDTs for non-immediate reactions) Desensitization is recommended in indicated cases |
Immediate reactions | ||
SPTs/IDTs | Recommended for BLs, other antibiotics, NMBAs, chlorhexidine, chemotherapeutic agents, insulin, heterologous antisera, and streptokinase at non-irritating concentrations | Recommended based on sensitivity and specificity of the tests BLs, pyrazolones, NMBAs, chlorhexidine, LAs, RCM (strong recommendation) Should be performed at non-irritating concentrations |
In vitro tests | Not recommended | Serum specific IgE assays are recommended for BLs, NMBAs, and chlorhexidine BAT is recommended for BLs and NMBAs (complementary to sIgE assays), as well as for pyrazolones, fluoroquinolones, and RCM |
Non-immediate reactions | ||
General rules for management | PTs and IDTs are not recommended routinely | PTs and IDTs are recommended routinely PTs are performed first; if negative, delayed-reading IDTs are performed if no contraindications exist |
PTs | May have a role in delayed DHRs, such as MPE, AGEP, and FDE | Recommended In severe cases, lower drug concentrations are recommended |
Delayed-reading IDTs | Not recommended | In severe cases, such as DRESS, AGEP, and TEN/SJS, can be performed after negative PTs and at higher drug dilutions |
In vitro tests | Pre-screening with certain HLA alleles before introduction of abacavir and carbamazepine Other tests (e.g., LTT and ELISpot) are not recommended | Pre-screening with certain HLA alleles before introduction of abacavir and carbamazepine Other tests (e.g., LTT and ELISpot) arenot recommended |
Non allergic drug hypersensitivity | ||
Skin tests | Not recommended | Not recommended |
In vitro tests | Not recommended | Not recommended |
Drug provocation tests/challenges | ||
Indication | To exclude DHR in non-suggestive histories or provide safe alternatives | To exclude DHR in non-suggestive histories or provide safe alternatives To confirm diagnosis |
Methods | Similar contraindications and precautions | Similar contraindications and precautions |
Comment on a negative test result | “Patients who tolerate a graded challenge are considered to not be allergic to the drug and are not at increased risk for future reactions compared with the general population” | “A negative test does not prove tolerance to the drug in the future, but rather that there is no DHR at the time of the challenge and to the doses challenged” |