Drug allergy desensitization is not a unique recipe

Abstract

Purpose of reviewDrug desensitization is the only therapeutic option for patients with drug allergies who need to receive the drugs they are allergic to, and it is especially critical in patients with an urgent need for chemotherapy, biologics, or antibiotics, where equally effective alternatives might not be available. However, drug desensitization is not a cookbook where anyone with no experience or specific training can find a general recipe. This review article will approach the singularities that make personalized and highly specialized care essential in this field.Recent findingsDrug desensitization needs to be personalized for each individual patient bearing in mind countless factors. Recent articles have tried to define the optimal resources and the most important factors to account for in personalization. However, drug desensitization is only a tool within the wider management pathway, and we will discuss recent findings in allergy delabelling in chemotherapy, biologics, and antibiotics.SummaryRisk-assessment, delabelling, and desensitization protocols, as a part of wider management pathways, can be adapted locally along with comprehensive and multifactorial risk-management strategies. These high-complexity and high-risk procedures, such as drug desensitization, need to be managed by expert allergists who can provide personalization, innovation, continuous improvement, research, and teaching in expert centres.

Standards for practical intravenous rapid drug desensitization & delabeling: A WAO committee statement

“…2 As for the temporary nature of RDD, these findings are compatible with real-life experience, where chemotherapy-allergic patients receiving chemotherapy every 2-3 weeks need desensitization for every administration. 2,298 In contrast, antibiotic-allergic patients will usually receive continuous exposure to an antibiotic for a continuous course and, generally, will only need desensitization for the first dose of the course. 2,67,298 The exact duration of the desensitized state is unknown and might be influenced by multiple factors.…”

“…2,298 In contrast, antibiotic-allergic patients will usually receive continuous exposure to an antibiotic for a continuous course and, generally, will only need desensitization for the first dose of the course. 2,67,298 The exact duration of the desensitized state is unknown and might be influenced by multiple factors. Shalit et al found that desensitized mast cells can be activated after 24 hours 72,73 Sancho-Serra et al found that the desensitized state lasted at least 4 hours, but the authors could not test this beyond 4 hours due to technical difficulties.…”

“…19,67 RDD has been successfully used for countless drugs, in patients of all ages with different conditions, in patients presenting with severe reactions like anaphylaxis, pregnant women and patients with underlying conditions such as mastocytosis. 2,8,10,12,19,55,56,67 Nonetheless, as we will explore in Section 2, similarly to other highly specialized procedures in medicine, RDD is far more than using an administration protocol or a recipe that anyone can follow 298 . Indeed, RDD reaches its optimal efficacy and safety outcomes in combination with sophisticated risk management strategies and when in the hands of multidisciplinary teams led by expert allergists with access to dedicated spaces and the necessary resources.…”

“…RDD protocols alone do not suffice for a successful RDD strategy. 2,4,5,56,298 "RDD is not only a protocol for drug administration, but it is a complex and multidisciplinary system". 2 For example, this multidisciplinary approach to RDD should involve not only the right protocols, but also validated diagnostic pathways, dedicated spaces, trained and experienced staff, and even institutional preventative measures for early detection of reactive patients and expedited referral to the allergy department, thus preventing suboptimal management.…”

“…2 For example, this multidisciplinary approach to RDD should involve not only the right protocols, but also validated diagnostic pathways, dedicated spaces, trained and experienced staff, and even institutional preventative measures for early detection of reactive patients and expedited referral to the allergy department, thus preventing suboptimal management. 4,5,298 The indiscriminate use of allergy-specific techniques (such as DPT and RDD) by non-allergists is frequently recommended against, as it can negatively impact patients in the form of misdiagnosis, unnecessary risks (including death), or surprisingly low rates of successful RDDs. 2,5,21,56 For example, failure to refer patients to an allergy department after a reaction can incur false labels of allergy to the chemotherapeutic drug by overlooking other culprit drugs, as explained by Urena-Tavera et al 10 Studies from Massachusetts General Hospital (MGH) have observed how DPT (or drug challenges) to chemotherapy and biologics conducted by non-allergists expose patients to unnecessary risks.…”