Article

Early presentation with angioedema and urticaria in cross-reactive hypersensitivity to nonsteroidal antiinflammatory drugs among young, Asian, atopic children

Department of Pediatric Medicine, Kendang Kerbau Children's Hospital, 229899, Singapore.
PEDIATRICS (Impact Factor: 5.47). 12/2005; 116(5):e675-80. DOI: 10.1542/peds.2005-0969
Source: PubMed

ABSTRACT

Nonsteroidal antiinflammatory drugs (NSAIDs), mainly ibuprofen, are used extensively among children as analgesic and antipyretic agents. Our initial survey in the Kendang Kerbau Children's Hospital in Singapore showed NSAIDs to be the second most common adverse drug reaction-causing medications among children of Asian descent. We attempted to characterize the clinical and epidemiologic profile of NSAID reactions in this group of patients.
A retrospective case series from a hospital-based pediatric drug allergy clinic was studied. A diagnosis of NSAID hypersensitivity was made with a modified oral provocation test. Atopy was evaluated clinically and tested with a standard panel of skin-prick tests. We excluded from analysis patients with any unprovoked episodes of urticaria and/or angioedema, patients < 1 year of age, and patients who refused a diagnostic challenge test.
Between March 1, 2003, and February 28, 2004, 24 patients, including 14 male patients (58%) and 18 Chinese patients (75%), with a mean age of 7.4 years (range: 1.4-14.4 years), were diagnosed as having cross-reactive NSAID hypersensitivity. A family history consistent with NSAID hypersensitivity was elicited for 17% of patients. None of the patients reported any episodes of angioedema/urticaria unrelated to NSAIDs. The median cumulative reaction-eliciting dose was 7.1 mg/kg. Facial angioedema developed for all patients (100%) and generalized urticaria for 38% of challenged patients, irrespective of age. There was no circulatory compromise, but respiratory symptoms of tachypnea, wheezing, and/or cough were documented for 42% of patients. A cross-reactive hypersensitivity response to acetaminophen was documented for 46% of our patients through their history and for 25% through diagnostic challenge. Compared with patients with suspected adverse drug reactions to antibiotics, patients in the NSAID group were older (7.4 vs 4.8 years) and more likely to have a diagnosis of asthma (odds ratio: 7.5; 95% confidence interval: 3.1-19).
Early presentations of facial angioedema and urticaria are key features of dose- and potency-dependent, cross-reactive reactions to NSAIDs in a subpopulation of young, Asian, atopic children. Significant overlap with acetaminophen hypersensitivity, especially among very young patients, for whom the use of a cyclooxygenase-2-specific medication may not be feasible, severely limits options for medical antipyretic treatment.

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Available from: Mona Iancovici Kidon, Feb 09, 2015
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    • "Physician diagnosed food allergy was almost none of the patients followed up in this cohort. Presence of antipyretics such as ibuprofen and paracetamol allergy in children in our local population is prevalent[23,24]. In some cases, intolerance to nonsteroidal anti-inflammatory drugs is reported to precede by years the onset of chronic urticarial[18]. "
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    ABSTRACT: Background: There is limited literature in the management of chronic urticaria in children. Treatment algorithms are generally extrapolated from adult studies. Objective: Utility of a weight and age-based algorithm for antihistamines in management of chronic spontaneous urticaria (CSU) in childhood. To document associated factors that predict for step of control of CSU and time taken to attain control of symptoms in children. Methods: A workgroup comprising of allergists, nurses, and pharmacists convened to develop a stepwise treatment algorithm in management of children with CSU. Sequential patients presenting to the paediatric allergy service with CSU were included in this observational, prospective study. Results: Ninety-eight patients were recruited from September 2012 to September 2013. Majority were male, Chinese with median age 4 years 7 months. A third of patients with CSU had a family history of acute urticaria. Ten point two percent had previously resolved CSU, 25.5% had associated angioedema, and 53.1% had a history of atopy. A total of 96.9% of patients achieved control of symptoms, of which 91.8% achieved control with cetirizine. Fifty percent of all the patients were controlled on step 2 or higher. Forty-seven point eight percent of those on step 2 or higher were between 2 to 6 years of age compared to 32.6% and 19.6% who were 6 years and older and lesser than 2 years of age respectively. Eighty percent of those with previously resolved CSU required an increase to step 2 and above to achieve chronic urticaria control. Conclusion: We propose a weight- and age-based titration algorithm for different antihistamines for CSU in children using a stepwise approach to achieve control. This algorithm may improve the management and safety profile for paediatric CSU patients and allow for review in a more systematic manner for physicians dealing with CSU in children.
    Full-text · Article · Feb 2016
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    • "L'urticaire peut être associée à un angiooedème , soit localisé (extrémités des membres, paupières, visage) ou généralisé. Un oedème facial est fréquent chez les enfants atteints d'HS allergique ou non-allergique aux AINS [10]. Dans l'urticaire « hémorragique », un purpura résiduel peut persister pendant plusieurs jours, et faire évoquer à tort des lésions « en cocarde » d'EP [22]. "
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    ABSTRACT: Suspected allergic reactions to drugs and biological substances (anti-infectious drugs and non-opioid analgesics, antipyretics and non-steroidal anti-inflammatory drugs especially) are reported in 5 to 12% of children. Most frequent reactions are morbilliform/maculopapular and unidentified rashes (60-80%), and urticaria and/or angioedema (20-30%). Other cutaneous and respiratory reactions, and severe anaphylaxis, are rare. The results of studies based on allergological tests and/or microbiological/serological tests clearly show that, except for a few types of reactions, especially anaphylactic and/or immediate reactions, and potentially harmful toxidermas, most reactions to commonly used drugs and biological substances in children do not result from drug hypersensitivity, but are rather a consequence of the febrile, infectious and/or inflammatory diseases for which the drugs have been prescribed, and/or from a promoting effect of drugs on viral replication. Thus, allergological work-up based on a detailed analysis of clinical history, skin tests (if validated), biological tests (if available and validated), and challenge/provocation tests (if indicated), is primarily indicated in children reporting anaphylactic and/or immediate reactions and (potentially) severe non-immediate skin reactions. In the other children, challenge/provocation tests (1-several days), performed in hospital settings or at home with the suspected drugs, will rule out the suspected diagnosis of drug hypersensitivity in most cases.
    Full-text · Article · Apr 2013 · Revue Française d Allergologie
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    • "L'urticaire peut être associée à un angiooedème , soit localisé (extrémités des membres, paupières, visage) ou généralisé. Un oedème facial est fréquent chez les enfants atteints d'HS allergique ou non-allergique aux AINS [10]. Dans l'urticaire « hémorragique », un purpura résiduel peut persister pendant plusieurs jours, et faire évoquer à tort des lésions « en cocarde » d'EP [22]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Suspected allergic reactions to drugs and biological substances (anti-infectious drugs and non-opioid analgesics, antipyretics and non-steroidal anti-inflammatory drugs especially) are reported in 5 to 12% of children. Most frequent reactions are morbilliform/maculopapular and unidentified rashes (60–80%), and urticaria and/or angioedema (20–30%). Other cutaneous and respiratory reactions, and severe anaphylaxis, are rare. The results of studies based on allergological tests and/or microbiological/serological tests clearly show that, except for a few types of reactions, especially anaphylactic and/or immediate reactions, and potentially harmful toxidermas, most reactions to commonly used drugs and biological substances in children do not result from drug hypersensitivity, but are rather a consequence of the febrile, infectious and/or inflammatory diseases for which the drugs have been prescribed, and/or from a promoting effect of drugs on viral replication. Thus, allergological work-up based on a detailed analysis of clinical history, skin tests (if validated), biological tests (if available and validated), and challenge/provocation tests (if indicated), is primarily indicated in children reporting anaphylactic and/or immediate reactions and (potentially) severe non-immediate skin reactions. In the other children, challenge/provocation tests (1-several days), performed in hospital settings or at home with the suspected drugs, will rule out the suspected diagnosis of drug hypersensitivity in most cases.
    Full-text · Article · Apr 2013 · Revue Française d'Allergologie
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