Beruflich Dokumente
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CLINICAL PRACTICE
Anaesthetists responses to patients self-reported drug allergies
R. D. MacPherson1 *, C. Willcox2, C. Chow2 and A. Wang1
1
Department of Anaesthesia and Pain Management and 2Department of Pharmacy,
Royal North Shore Hospital, Pacific Highway, St Leonards, NSW 2065, Australia
*Corresponding author. E-mail: RMacpher@nsccahs.health.nsw.gov.au
Background. Patients with drug allergies are commonplace in anaesthetic practice. We inves-
tigated the incidence and nature of drug allergies reported by surgical patients attending a
hospital pre-admission clinic, and went on to ascertain to what degree drug allergies recorded
in the records influenced drug prescribing during the patients hospital stay and determine
whether any adverse events occurred in relation to drug prescribing in this population.
Taking a drug history is an integral part of any medical events were likely to be true drug allergy as opposed to a
admission, and within that history it is important to elicit simple adverse drug effect. Then, by examination of patient
from the patient reports of previous adverse drugs effects or medical records, to ascertain to what degree patient reported
drug allergies, as these details will obviously influence drug allergy had influenced prescribing and whether any adverse
selection and therapeutic decision making. Unfortunately, events occurred because of inappropriate prescribing.
the reliability and details of such self-reported allergies are
often questionable, and furthermore these details are often
recorded in a perfunctory manner. Methods
The aims of the present study were 3-fold. First, to exam- After approval from the Hospital Ethics Committee, as part
ine in detail self-reported drug allergies in a surgical patient of their routine admission, all patients attending the Pre-
population, and to determine the extent to which these Admission Clinic at this hospital were questioned by an
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Anaesthesia and drug allergies
attending pharmacist (C. W. or C. C.) using a formatted breathing/oedema categories, only patients who specific-
questionnaire as to whether they had any drug allergies to ally stated anaphylaxis as their type of reaction were
report. If the response was positive, patient characteristic included in the former category. Of this group, the most
data were recorded, and the exact nature of the reaction and common drugs implicated again were antibiotics with 31
how long ago the reaction occurred. These patient allergies reports [penicillins (n=14); sulphonamides (n=12), other
were recorded in the usual manner on the Patient Medication antibiotics (n=5)], non-steroidal anti-inflammatory drugs
Chart. After discharge from hospital, the medical records of (n=8) and opioids (n=3). There were 38 cases in which
these patients were examined to ascertain what drugs were the patient stated they had suffered an adverse reaction to
administered during their admission and whether any of a particular drug, but had forgotten details of the event and
these medications might conflict with those reported as could offer no further information.
allergies from the patient allergy list. Table 2 shows the most common drugs implicated in
these reactions with antibiotics (n=272) and opioid anal-
Results gesics (n=118) being the most common. Of importance to
anaesthetists, other common agents to which allergy was
During the 30 week period, a total of 1260 patients attended
reported included NSAIDs (62), phenothiazines (13) and
the Hospital PAC for assessment before surgery. Of these
tramadol (12). Of six patients who claimed to be allergic
431 (29.1%) claimed to have at least one drug allergy and
to general anaesthesia, all in fact were reporting postoper-
underwent further assessment by a pharmacist. Eleven
ative nausea and vomiting. The time course of these reac-
patients were excluded. In nine patients this was because
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MacPherson et al.
Table 3 The left column (Stated allergy) lists drugs to which patients had other descriptors have been used to describe these events
claimed a previous adverse reaction. The middle column shows drugs of similar including idiosyncratic reactions (uncharacteristic reactions
pharmacological activity administered to these patients. The right column lists
number of instances that are not explicable in terms of a drugs pharmacological
action) and allergic or hypersensitivity reactions.5 Recently,
Stated allergy Drug given n
the whole question as to what criteria should be present to
Penicillin Cephazolin 73 constitute an allergic reaction has been re-examined. Expert
Penicillin Cefotetan 7 groups6 7 have suggested that the term drug hypersensitiv-
Penicillin Ceftriaxone 4
Prochlorperazine Metoclopramide 2
ity should be used as an umbrella term to cover the gamut of
Pethidine Morphine 2 reactions, especially those involving the skin and mucous
Atropine Hyoscine 1 membranes. The term allergy should be used only to
Atropine Glycopyrrolate 1
describe reactions that have been demonstrated to be
Antibiotics Gentamicin 1
Anaesthetics GA 6 immunologically mediated, with all other events referred
Codeine Tramadol 1 to as non allergic hypersensitivity.
Omeprazole Esomprazole 1
There is no doubt that analysis of ADRs and hence com-
Indomethacin Rofecoxib 1
Indomethacin Diclofenac 1 parisons between studies have become more difficult. This is
because of what one author8 has called a Tower of Babel
terminology, where over time definitions and terms have
the use of cephalosporins in patients who self-reported a pre- changed, with some categories (e.g. pseudo-allergy) being
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Anaesthesia and drug allergies
generally minor with dermatological and gastrointestinal patients (mean age 61.7), reflecting changes in prescribing
reactions being the most common. patterns. While occasional dermatological reactions such as
Others have found conflicting results. In one study15 the StevensJohnson syndrome can be potentially life threaten-
investigators examined more than 1800 patients and found ing, most common skin and gastrointestinal complaints to
that 28% claimed to have one or more allergies. There was a this drug group are generally minor. There is some disagree-
clear female preponderance (60.3%). Commonly implicated ment concerning the incidence of cross-sensitivity between
drugs were antibiotics (50%), opioids (27%) and NSAIDs sulphonamides and other agents with structural similarities.
(10%). The rate of probably true allergic (Type B) reaction While it is known that the para-amino benzoic acid moiety
was higher than most at 50%. In another large prospective found in sulphonamides is also found in a range of other
study of hospital admissions 366 cases of suspected drug drugs such as COX-2 inhibitors, thiazide diuretics, sulph-
allergy were reported during a 2 yr period16 and found onylurea oral hypoglycaemic agents and diazoxide, it has
the majority (57.4%) to be true allergic reactions, 19.7% been suggested that the risk of cross-reactivity would seem
idiosyncratic and 19.1% coincidental reactions. to be more of a theoretical rather than a clinical considera-
Despite changes in prescribing patterns over time, the tion.30 This is because the sulphonamide antibiotics contain
most commonly reported drugs in our study are common an aromatic amine on the N4 position, necessary both for the
to other earlier studies and include antibiotics and analgesics drugs antimicrobial activity and allergenic propensity, a side
including opioids and NSAIDs,12 with the most common chain that is lacking in these other drugs.31
reactions being dermatological, another finding common to NSAIDS are common producers mainly of gastrointest-
previous studies.14 16 17
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MacPherson et al.
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