The Role of the Allergist in Coronavirus Disease 2019 Vaccine Allergy Safety

Chiang, Valerie; Saha, Chinmoy; Yim, Jackie S. H.; Au, Elaine; Kan, Andy Ka Chun; Hui, Harris K. S.; Li, Tin Sum; Lo, Wing Lam Whitney; Hong, Yuh Dong; Ye, Jiaxi; Ng, Carmen; Ko, Welchie W K; Ho, Carmen Tk; Lau, Chak Sing; Quan, Jianchao; Li, Philip H.

doi:10.1016/j.anai.2022.05.011

Cited by 20 publications

(8 citation statements)

References 17 publications

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“…22,[31][32][33] Despite the severe lack of allergists in the Asia-Pacific region, previous multi-disciplinary initiatives have shown much promise in tackling drug allergies. 10,34,35 For example, a nurseled penicillin allergy delabelling initiative demonstrated superior outcomes compared to traditional allergist evaluation in Hong Kong and similar strategies employing trained pharmacists are underway. 10 Further research on wider applications of similar multidisciplinary drug allergy initiatives is warranted.…”

Section: Discussionmentioning

confidence: 99%

Disproportionate drug allergy labelling among middle-aged patients and barriers to excipient allergy testing from the Hong Kong Comprehensive Excipient and Drug Allergy Registry (CEDAR)

Chiang

Kan

Chinmoy

et al. 2023

Preprint

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Background: Longitudinal whole-population studies can explore new dimensions in drug allergy research. Excipient allergy testing remains a barrier to allergy evaluation in countries without legislations mandating ingredient disclosure in registered drugs. The Comprehensive Excipient and Drug Allergy Registry (CEDAR) was established to investigate Hong Kong’s drug allergy landscape and potential role of excipient registries. Methods: Drug allergy data from over 7,337,778 individuals between 2016-2021 was analyzed. Excipient lists were gathered from all formulations of the top 50 reported drug allergies and checked for the presence of polyethylene glycol (PEG). Results: The absolute-prevalence and -incidence of reported drug allergy was 5.61% and 277/100,000 population in 2021, respectively. Annual incidence of newly reported drug allergy was stable between 2016-2019, until a significant drop in 2020 (-16.3%, p=0.037). The most common implicated drugs were anti-infectives (245,832 [44.5%]), NSAIDs (106,843 [19.3%]), and nervous system drugs (45,802 [8.3%]). There was significant higher incidence among individuals aged >40, contributing to the majority of newly reported allergies (377,004, 68.2%). Beta-lactams and nervous system drugs were the most common reported culprits of anaphylaxis and Stevens-Johnson syndrome. CEDAR was unable to confirm presence or absence of PEG in any of the top reported culprits due to insufficient excipient information. Conclusion: We report the detailed drug allergy landscape of the Hong Kong population. Excipient registries are ineffective in countries without mandatory excipient listings . Contrary to traditional doagma, we identified a disproportionately higher incident drug allergy among middle-aged and older patients. Findings need to be confirmed by region-specific big data studies.

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Section: Discussionmentioning

confidence: 99%

Disproportionate drug allergy labelling among middle-aged patients and barriers to excipient allergy testing from the Hong Kong Comprehensive Excipient and Drug Allergy Registry (CEDAR)

Chiang

Kan

Chinmoy

et al. 2023

Preprint

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“…Although recommendations for direct DPT have also been published, this algorithm focuses on the AP region and empowers nonallergists working in hospital settings to independently delabel patients without the need for hospitalization [ 27 ]. Building upon the experience of one successful hub and spoke model in the AP, we recommend a multidisciplinary collaboration between allergists and nonallergists in triaging low-risk patients for direct DPT [ 28 , 29 ]. The simulation run of the algorithm on a cohort of genuine patients referred for penicillin allergy evaluation clearly demonstrates the potential of this strategy in mitigating the need for specialists or unnecessary skin testing, as well as the safety of direct DPT after risk stratification.…”

Section: Discussionmentioning

confidence: 99%

APAAACI clinical pathway on direct provocation testing for penicillin allergy delabeling

Li,

Thong,

Pawankar

et al. 2023

Asia Pacific Allergy

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Background: Allergy to penicillin is commonly reported in many countries and is an overwhelming global public health concern. Penicillin allergy labels can lead to the use of less effective antibiotics and can be associated with antimicrobial resistance. Appropriate assessment of suspected penicillin allergy (often including skin testing, followed by drug provocation testing [DPT] performed by allergists) can prevent the unnecessary restriction of penicillin or delabelling. Many countries in the Asia Pacific (AP) have very limited access to allergy services, and there are significant disparities in the methods of evaluating penicillin allergy. Therefore, a clinical pathway for the management of penicillin allergy is essential. Objectives: To develop a risk-stratified clinical pathway for delabeling penicillin allergy, taking into account the distinct epidemiology, patient/sensitization profiles, and disparities of allergy services or facilities within the AP. Methods: A risk-stratified penicillin allergy delabeling clinical pathway was formulated by the Drug Allergy Committee of the Asia Pacific Association of Allergy, Asthma and Clinical Immunology. and members of the Penicillin Allergy Disparities survey in AP each representing one country/region of the AP. The clinical pathway was tested based on a database of anonymized patients who were sequentially referred for and completed penicillin allergy evaluation in Hong Kong. Results: The clinical pathway was piloted employing a “hub-and-spoke” approach to foster multidisciplinary collaboration between allergists and nonallergists. A simulation run of the algorithm on a retrospective Hong Kong cohort of 439 patients was performed. Overall, 367 (84%) of patients were suitable for direct DPT and reduced the need for skin testing or specialist’s care for 357 (97%) skin test-negative individuals. Out of the skin test-negative patients, 345 (94%) patients had a negative DPT. Conclusions: This risk-stratification strategy for direct oral DPT can reduce the need for unnecessary skin testing in patients with low-risk penicillin allergy histories. The hub and spoke model of care may be considered for further piloting and validation in other AP populations that lack adequately trained allergists.

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“…Another model comprising evaluation of low risk penicillin allergy cases by non-allergists at spoke clinics within hospital departments of medicine, with training and support of an allergist-led hub has also been described ( 16 ). Such models have also been successful for other multi-disciplinary allergy initiatives ( 43 , 44 ). These models of care may potentially be adapted for use in allergy/immunology services for patients with multiple antibiotic allergy where the number of provocation tests and patients who need to be tested far exceed the number of trained specialists in allergy/immunology.…”

Section: Healthcare Resource Prioritisation In Delabellingmentioning

confidence: 99%

Delabelling multiple antibiotic allergy: Practical issues

Thong

2023

Front. Allergy

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With the growing incidence of multi-drug resistant organisms, delabelling incorrect antibiotic allergies has become an integral part of antimicrobial stewardship worldwide. For example, around 90% of penicillin allergy labels are found to be inaccurate following a full allergy work-up, which deprive patients the use of effective first-line penicillin antibiotics and increase the risk of antimicrobial resistance with the use of other extended spectrum non-penicillin antimicrobials. Significant numbers of adult and paediatric patients over time are labelled with multiple penicillin and non-penicillin antibiotic allergies often during inappropriate antimicrobial use, resulting in a label of “multiple antibiotic allergy”. In contrast to delabelling penicillin allergy where oral direct provocation tests can be used for low-risk, mild reactions, and sensitivity/specificity/positive and negative predictive values of skin tests have been demonstrated, diagnostic tests for multiple antibiotic allergy often require the use of a combination of in-vivo and in-vitro tests across different antimicrobial classes for evaluation. Shared decision making with patients and informed consent are also needed when prioritising which drugs to delabel first, balancing the risks, benefits of testing vs. interim use of alternative antibiotics. Similar to delabelling penicillin allergy, the cost-effectiveness of delabelling multiple drug allergies is unknown.

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The Role of the Allergist in Coronavirus Disease 2019 Vaccine Allergy Safety

Cited by 20 publications

References 17 publications

Disproportionate drug allergy labelling among middle-aged patients and barriers to excipient allergy testing from the Hong Kong Comprehensive Excipient and Drug Allergy Registry (CEDAR)

Disproportionate drug allergy labelling among middle-aged patients and barriers to excipient allergy testing from the Hong Kong Comprehensive Excipient and Drug Allergy Registry (CEDAR)

APAAACI clinical pathway on direct provocation testing for penicillin allergy delabeling

Delabelling multiple antibiotic allergy: Practical issues

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