Drug Eruptions: Allergic Reactions?
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Drug I n f o m t i o n Journal, Vol. 31. pp. 1311-1316. 1997 Printed in the USA. All rights reserved.
DRUG ERUPTIONS: ALLERGIC REACTIONS? DERKP.BRUYNZEEL, MD Dennato-allergology/OccupationalDermatology, Academic Hospital Free University, Amsterdam. The Netherlands
Drugs often cause adverse reactions, many of which involve the skin. Life-threatening skin reactions such as toxic epidermal necrolysis are rare, just like anaphylactic shock. Less severe but still worrisome eruptions are abundant but may develop into serious reactions. Only a part (20%) of these eruptions are evoked by an allergic mechanism. Usually one does not know i f the drug or a metabolite is the antigen. As a consequence, tests in vitro and in vivo will be rather unreliable. Negative tests are not helpful and not decisive as the test could be false negative. It might be necessary to carry out a provocation test, the gold standard. A provocation test is not without dangers and does not discriminate between allergic and nonallergic reactions. More clinically reliable skin and laboratory tests should be developed to identify allergic reactions and to detect the allergenicify of new drugs. Key Words: Adverse drug reactions; Allergic reactions; Test methods; Intracutaneous tests; Epicutaneous tests
INTRODUCTION THE EXACT INCIDENCE of adverse reactions is not known. From the available figures it is estimated that 10-25% of hospitalized patients have an adverse drug reaction. The skin, together with the gastrointestinal tract and the central nervous system, are the organs most often affected in drug reactions. Depending on the source about 16% are skin reactions (1,2,3). This means that 2-3% of all
Presented at the DIA Workshop “Immunotoxicity of Pharmaceuticals: Current Knowledge, Testing Strategies, Risk Evaluation & Consequences for Human Health,’’ October 2 4 , 1996. Montreux, Switzerland. Reprint address: Prof. dr. D. P. Bruynzeel, Dept. of Dermato-allergy and Occupational Dermatology, Free University, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands.
hospitalized patients suffer from a cutaneous adverse reaction. Information on outpatients is far less reliable. Several mechanisms can be involved. True allergic reactions are estimated to occur in approximately 20% (1040%) of all adverse skin reactions. Adverse reactions tend to increase if several drugs are used, with increasing age, and in immune compromised persons (those with AIDS). Drugs most often involved in adverse skin reactions are (4): Anti-infectious drugs: p-lactam antibiotics, and mmethoprim-sulfamethoxazole, Blood products, 0 NSAIDs: acetylsalicylic acid, pyrazolon derivatives, arylproprionic acid derivatives, 0 CNS affecting drugs: anti-epileptics, carbamazepine,
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Derk P. Bruynzeel
Cardiovascular drugs: P-blockers, diuretics, and 0 Antitumor agents.
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There are regional differences due to differences in drug availability, usage, and prescription practices.
THE CLINICAL PICTURE Adver
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