The use of drug provocation testing in the investigation of suspected immediate perioperative allergic reactions: current status

Abstract

Suspected perioperative allergic reactions are often severe. To avoid potentially life-threatening re-exposure to the culprit drug, establishing a firm diagnosis and identifying the culprit is crucial. Drug provocation tests are considered the gold standard in drug allergy investigation but have not been recommended in the investigation of perioperative allergy, mainly because of the pharmacological effects of drugs such as induction agents and neuromuscular blocking agents. Some specialised centres have reported benefits of provocation testing in perioperative allergy investigation, but the literature on the subject is limited. Here we provide a status update on the use of drug provocation testing in perioperative allergy, including its use in specific drug groups. This review is based on a literature search and experiences of the authors comprising anaesthesiologists and allergists with experience in perioperative allergy investigation. In addition, 19 participating centres in the International Suspected Perioperative Allergic Reaction Group were surveyed on the use of provocation testing in perioperative allergy investigation. A response was received from 13 centres in eight European countries, New Zealand, and the USA. Also, 21 centres from the Australian and New Zealand Anaesthetic Allergy Group were surveyed. Two centres performed provocation routinely and seven centres performed no provocations at all. Nearly half of the centres reported performing provocations with induction agents and neuromuscular blocking agents. Drug provocation testing is being used in perioperative allergy investigation in specialised centres, but collaborations between relevant specialties and multicentre studies are necessary to determine indications and establish common testing protocols.

Management of suspected immediate perioperative allergic reactions: an international overview and consensus recommendations

“…108,109 DPT has only recently been recommended in perioperative allergy investigation, and very limited literature is available. 7,8,43,110 When involving drugs specific to anaesthesia, it should only be undertaken in specialised centres after ensuring informed consent. 7,8,43,110 In most centres where DPT is not routinely used, conclusions must be based on other tests.…”

“…7,8,43,110 When involving drugs specific to anaesthesia, it should only be undertaken in specialised centres after ensuring informed consent. 7,8,43,110 In most centres where DPT is not routinely used, conclusions must be based on other tests. Results of single tests should always be interpreted in the context of relevant clinical information and serum tryptase results from the time of reaction and a later baseline sample.…”

Medical algorithms: Diagnosis and investigation of perioperative immediate hypersensitivity reactions

“…Once it has been decided that an allergic mechanism is likely or cannot be ruled out, a The presented algorithms are a truncated version of recommendations made in the 2019 EAACI position paper 1 and other recent international publications. [2][3][4][5][6][7] Work in this field was initiated in France 8 and Australia, 6 and is now expanding rapidly with increasing international collaborations. This publication provides an overview only, and more detailed information can be found in the referenced guidelines and articles.…”

“…The presented algorithms are a truncated version of recommendations made in the 2019 EAACI position paper and other recent international publications . Work in this field was initiated in France and Australia, and is now expanding rapidly with increasing international collaborations.…”

“…For some drug groups such as neuromuscular-blocking agents, antibiotics and local anaesthetics potential cross-reactivity should be assessed, and a safe alternative identified.When no obvious culprit is found, or there is a suspicion that test results are false positives, the case should be re-evaluated with regard to identifying overlooked culprits, re-evaluating the tests and considering an underlying clonal mast cell disorder 6. Drug provocation testing is increasingly used in cases where skin testing is suspected to be either false negative or false positive 7.…”