Rapid drug desensitization for immediate hypersensitivity reactions
- Mariana C Castells, MD, PhD
Mariana C Castells, MD, PhD
- Associate Professor of Medicine
- Harvard Medical School
- Roland Solensky, MD
Roland Solensky, MD
- Oregon State University/Oregon Health and Science University College of Pharmacy
Desensitization is a procedure that alters the immune response to the drug and results in TEMPORARY tolerance, allowing the patient with a drug hypersensitivity reaction to receive an uninterrupted course of the medication safely. Once the medication is discontinued, or if treatment is interrupted for a sufficient period of time, the patient's hypersensitivity to the medication returns. Desensitization is only safe and effective for certain types of drug allergy. The terms drug hypersensitivity and drug allergy are used synonymously in this topic review.
Techniques for drug desensitization in patients with immediate hypersensitivity reactions and the proposed mechanisms underlying these techniques will be reviewed here. Desensitizations for reactions to nonsteroidal antiinflammatory drugs (NSAIDs) are NOT included in this discussion, but are discussed elsewhere. (See "Diagnostic challenge and desensitization protocols for NSAID reactions" and "Aspirin-exacerbated respiratory disease: NSAID challenge and desensitization".)
IMMEDIATE DRUG REACTIONS
The World Allergy Organization (WAO) has recommended dividing drug hypersensitivity reactions into two general types :
●Immediate reactions – Reactions that begin within one hour of exposure to the culprit drug.
●Delayed reactions – Reactions that begin later than one hour after exposure to the culprit drug.
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- IMMEDIATE DRUG REACTIONS
- Types of immediate reactions
- - IgE-mediated
- - Non IgE-mediated
- POSSIBLE MECHANISMS OF DESENSITIZATION
- INDICATIONS AND PATIENT SELECTION
- Identifying appropriate patients
- Risk stratification
- Setting and staffing
- - Incidence of breakthrough symptoms
- - Rare immunologic complications
- Informed consent
- TECHNICAL ASPECTS OF DESENSITIZATION
- Overview of the technique
- Route of administration
- Dose increase and time interval for each step
- Patient preparation
- - For IgE-mediated reactions
- - For non IgE-mediated reactions
- Oral protocols
- Standardized intravenous protocol
- Protocol for patients with past severe reactions
- Time required
- Administering the protocol
- - Management of symptoms during desensitization
- - When to abort a desensitization
- - Adjusting the protocol
- Maintaining the desensitized state
- Counseling the patient to continue avoidance
- Controversial areas
- APPLICATION TO OTHER TYPES OF DRUG ALLERGY
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS