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Physician Mailbag

AAAAI COVID 19 Website for Practitioners

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The American Academy of Allergy Asthma & Immunology has created a website for practitioners, which can be accessed here. Below is guidance offered in the letter to members.

Asthma
  • There is no data to support the belief that asthma is a risk factor for COVID-19. Available data suggest that the rate of asthma in patients with severe COVID-19 is the same or lower than the general population.
  • Systemic steroids are not recommended for the treatment of COVID-19, but are okay for asthma exacerbation.
  • It is important to continue to manage your asthma patients and asthma exacerbations according to the guidelines. Focus on asthma control to keep our patients well and out of the emergency room (ER) and urgent care, where the risk for infection with COVID-19 is much higher. This would be a good time to ensure that all of your asthma patients are up to date on medications and treatment plans.
  • There is no evidence that the biologics we use in asthma have any adverse effect on COVID-19 cases, and it would be important to continue them based on the need for asthma control.
  • Steroid dependent asthmatics: Remember adjustments for adrenal insufficiency and severe infection, may need to consider stress doses of hydrocortisone even for patients on high dose ICS. See this article.
Food Allergies
  • Additional counseling for food allergy patients regarding the inability to choose more familiar foods or query waitpersons/chefs when getting restaurant take-out was posted in a previous message.
  • The white paper on COVID-19 and the allergist just published in JACI: In Practice recommends adjusting counseling about epinephrine use in the case of a reaction, emphasizing that transportation to the ER was for the allergic reaction itself and not for potential adverse reactions to epinephrine. If the patient has a mild allergic reaction, an ER trip may not be needed even if epinephrine was administered, in order to reduce the risk for COVID-19 infection.

Allergy to Antibiotics

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Q: A child comes in with a rash a few days after AMOXICILLIN is given for an ear infection. It is red, blotchy, and spreads across the body. It appears to be a drug reaction rather than a viral exanthem. Does this mean the child cannot take PENICILLIN in the future? Is the child restricted from trying any other “CILLIN” – DICLOXACILLIN, etc.
— Dr. L

Dear Dr. L,
The majority of side effects observed in AMOXICILLIN clinical trials were of a mild and transient nature and less than 3% of patients discontinued therapy because of drug-related side effects. The most frequently reported adverse effects were diarrhea/loose stools (9%), nausea (3%), skin rashes and urticaria (3%).

This is an “allergic reaction” but it is NOT related to a life threatening one. I think there is little risk if the child takes PENICILLIN in the future and should not be restricted from trying any other “CILLIN”, including DICLOXACILLIN.
Dr. Chiaramonte

Dr. Ehrlich adds:
I would add to this comment by Dr. Larry that there are those children who have Ampicillin reactions in the latter part of treatment, and many of those come from the non-allergic side effect of the drug (or Amoxicillin). Often their parents are told that the children have penicillin allergies, a misconception that they carry into adulthood.

Physicians Mailbag

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Q: Many patients report a SULFA allergy–typically a rash. What is the chance that they will react to a diuretic like HYDROCHLOROTHIAZIDE
which as a sulfa moiety?
–Dr. L

Dear Dr. L
Skin testing to sulfa and many other drugs is not useful. The culprit-antigen is formed in the body when a breakdown product of the sulfa drug combines with a patient’s proteins. So I cheated a little and went to the Mayo Clinic website. This is a Quote:

“There are also a number of other medications related to sulfonamides. Although the medications noted below are probably safe for you to take if you have a sulfa allergy, you should first check with your doctor. Examples include, but are not limited to: Certain ‘water pills’ (diuretics), such as furosemide (Lasix) and hydrochlorothiazide (Microzide).”
So the cheating did not help me. I would like to know how bad the sulfa reaction was. Did the reaction occur with other sulfa drugs? If it did, how much medication was needed to cause a reaction? What was the time interval between taking the drug and having a reaction? This knowledge would help us do a challenge test.
We would give approximately a quarter dose of the DIURETIC and observe the patient twice as long as the time interval between taking the drug and having a reaction. Then we would increase the dose in a stepwise fashion until a full dose was reached without a reaction.
Dr. Chiaramonte

Allergy to One Antibiotic Doesn’t Rule Out the Rest

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Q: A child comes in with a rash a few days after receiving AMOXICILLIN for an ear infection. It is red, blotchy, and spreads across the body. It appears to be a drug reaction rather than a viral exanthem. Does this mean the child cannot take PENICILLIN in the future? Is the child restricted from trying any other “CILLIN” – DICLOXACILLIN, etc.
— Dr. L

Dear Dr. L,
The majority of side effects observed in AMOXICILLIN clinical trials were of a mild and transient nature and less than 3% of patients discontinued therapy because of drug-related side effects. The most frequently reported adverse effects were diarrhea/loose stools (9%), nausea (3%), skin rashes and urticaria (3%).

This is an “allergic reaction” but it is NOT related to a life threatening one. I think there is little risk if the child takes PENICILLIN in the future and should not be restricted from trying any other “CILLIN”, including DICLOXACILLIN.

Anaphylaxis Action Plan

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Q: Can you provide an anaphylaxis action plan similar to the asthma action plans that are in use in schools and in homes?

–Dr. P (pediatrician)

Dear Dr. P,

You can find a link to an food allergy action plan, which includes anaphylaxis, by clicking on “Action Plans” at the top of this page. This one comes to us courtesy of the pioneering organization, Food Allergy and Anaphylaxis Network [FAAN].

Familiarity with this plan will take the guesswork out of anaphylaxis and the emergency it represents. The plan depicted at food allergy.org talks about signs of mild reaction as well as moderate and more severe ones.

It promotes the use of the epinephrine when the time is at hand. Caution dictates that if breathing becomes a problem, whether in the form of a cough or constriction, epinephrine should be used. If you as a pediatrician are in touch with the parent during an episode, you should make treatment decisions based on your knowledge of the patient and the parent according to criteria such as: are they new to the problem?; are they familiar with the different medications and what they do?; do they understand what happens to the body during anaphylaxis? (For a full discussion of anaphylaxis read chapter 5 and elsewhere in Asthma Allergies Children: a parent’s guide.)

Physicians Mailbag

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Q: If a patient in the operating room, intubated, is on or has been given steroids, is it safe to give a drug that the patient is allergic to? What should be done to make it safer?
— Dr. M, surgeon

Dear Dr. M
One first has to establish whether it is antibiotic “x” and none other will do. If that is the case, then the choice is to desensitize the patient giving increasing dosage while monitoring for side effects until the maximum dose is reached. From that point on the recommended therapeutic dosage can be given.

However, if the patient is in the hospital, intubated and pretreated with steroids and an antihistamine (with epinephrine and other meds at the ready) one can be much more aggressive. But be prepared for anaphylaxis and know how to handle it.

Alternatively, if another unrelated antibiotic will do the job, go that route.

Dr. Ehrlich

Shellfish problems and iodinated contrast media (“x-ray dye”)

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(This was written in response to Dr. Ehrlich’s post, “The Relevant Allergist,” which mentioned the persistent myth that shellfish-allergic patients will react to the iodine in dye used during x-rays, by a board-certified radiologist who practices in upstate New York.)

Radiologists years ago considered a patient’s history of an allergic reaction to shellfish as a contraindication to giving contrast for an IVP (kidney study), angiogram, CT (a.k.a. cat scan), or other radiologic studies. I say “years ago” because I have been in practice for 30 years and it was dogma when I started.

Because lots of radiology is about science, later studies were done that showed no connection between a patient’s shrimp “allergy” and the incidence of contrast reactions. The American College of Radiology produces a 98-page contrast manual. Its latest iteration Version 6 was issued in 1998. If you search it for the word “shellfish” you find only one mention on page 13:

The predictive value of specific allergies, such as those to shellfish or dairy products, previously thought to be helpful, is now recognized to be unreliable.

We don’t really understand contrast allergies or if they are even allergies at all. My patients who have broken out in hives with an injection may have no hives the next time. There is no definite connection between the hives and the anaphylactic reactions. Generally patients with lots of allergies are more likely to have reactions to contrast. If the benefit of the injection is very great, I go ahead and inject those with a history of hives. If the patient says his tongue swelled up and he can’t remember what happened before he woke up in the ER, I don’t inject unless the patient has been pre-treated with whatever combination of steroids and antihistamines is in vogue. If the patient has had a really bad contrast reaction, any future study requiring an injection ought to be done not in an outpatient office but in a real hospital with an emergency room.

All this being said, I have seen only 4 serious contrast reactions in my 30 years. They all did well. One did indeed have a shellfish history. Her reaction was not to injected “dye” but to the mixture of water and 2 tablespoons of water soluble contrast given by mouth. Because of the shrimp history we had no intention of injecting her. It did not protect her from the profound diarrhea she experienced.

Dr. A

Childhood Allergy to a Medicine

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Q: What do I do with a patient who reports having had an “allergy” to a medicine as a
child that is unknown or so long ago that no one seems to remember
what it was except that the patient was told “never to take it”. They
don’t recall going to the emergency room, shortness of breath /
hives, or any obvious life-threatening reaction. Typically this
relates to antibiotics.

–Dr. L

Dear Dr. L,
I learned from Dr. Stan Fine who wrote a paper attempting to answer this question. He studied what happened to patients on a second exposure after an immediate, severe systemic reaction to penicillin. The lapsed time from the first reaction WAS EXTREMELY IMPORTANT. In a five-year time interval after the first exposure roughly one half [50%] of patients lost their sensitivity. In a second five year interval another 50% lost their sensitivity, in other words in a ten-year time interval only 25% kept their sensitivity.

This is an area where the physician’s clinical judgment of the risk /benefit ratio is the determining factor. In this situation, severe reaction to a second exposure is highly unlikely, but why take any chance if there are substitute drugs available?

In my role as director of an allergy-immunology training program we received multiple referrals of patients, who clearly had severe immediate systemic reactions to an antibiotic, but who also required its use. We used rush desensitization; starting with an infinitesimally small dose; increasing it by roughly 50% every fifteen minutes if no reaction occurred. After about eight hours at the patient’s bedside we would reach the recommended dose without a reaction. As long as patients continuously had the antibiotic in their systems they could safely receive the therapeutic dose. So in expert hands in the hospital it is possible to give an antibiotic that might have caused a severe, immediate, systemic reaction. Rush desensitization is like major surgery; not used lightly.
–Dr. Chiaramonte

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