Multiple Drug Allergies

I am copying this post from Scalpel or Sword? with my comment as a jumping off point to what I hope will be a constructive and educational discussion on the evaluation of someone presenting with a complaint of multiple drug allergies:

Saturday, June 30, 2007
Allergic to Everything
For some reason, patients with numerous allergies to medications seem to be predominantly female. Are women really more likely to have allergic reactions to medications than men, or are they simply more likely to receive a greater variety of medications over time and thus discover that they are allergic to them? Or are women just more likely to complain about subtle adverse reactions than men? Is guano somehow involved?

I’ve seen plenty of elderly ladies with bewilderingly comprehensive allergy lists, but I always give them the benefit of the doubt. They have lived for all these decades despite their limitations, so they must be doing something right. Anyway, these matriarchs usually have one or two different antibiotic classes they are willing to accept, so I’m happy (relieved, honestly) to throw some Keflex and a prayer at their UTI and bid them farewell.

But what of the 20 year old who claims to be allergic to “every antibiotic known to man?” And who can actually recite many of these drugs from memory, despite the fact that she seems totally healthy and takes no medications? What if she someday develops pyelonephritis, pneumonia, or PID? I guess we’ll cross that bridge when we get there. For the nonspecific febrile illness, all I can offer is Motrin and a pat on the back.

And a good luck wish to the next doc who sees her.

and this post from the last PGR hosted on this site:
I see a number of patients in the psychiatry service state that they have an allergy to haloperidol (Haldol). Our impression has been that what is being called an allergy was actually an adverse reaction or a common side effect such as dystonia or tremors. If so, there might be no contra indication to the use of Haldol with such patients (using low doses and concomitant use of Cogentin).
Is this an appropriate presumption? Also, it is being said by some that the JCAHO requires recording self-report of allergy despite the physician’s judgement about it, and to be guided by this record of allergy. Any comments would be appreciated.

Here is my response:
An allergic reaction or hypersensitivity reaction to drug refers specifically to an IgE mediated immediate reaction involving histamine release, onset of 30 minutes up to 6-12 hours after exposure, and symptoms which include itching, hives, rash, edema, throat closing, abdominal cramps, diarrhea/ vomiting, wheezing, difficulty breathing, and/ or hypotension.

While multiple drug allergies are relatively rare, a physician or any health care practitioner can not just dismiss them offhand, since as you know, this may have serious medical and medico-legal consequences.

The approach I would recommend, which I suggest to anyone who is told by a patient that he/ she is “allergic” to something is:
1. Inquire what kind of reaction the patient had to the drug, how soon after exposure it happened, and how long ago it occurred.
2. If the reaction was itching, hives, rash, wheezing, swelling, throat closing, abdominal sx, or dizziness/ hypotension within 30 minutes to a few hours after exposure, then it is possible that the patient may have had an allergic reaction and I would not give him/ her that medication until further evaluation by an allergist.
Other delayed type hypersensitivity reactions such as serum sickness with hives and joint swelling, and various rashes can occur several days after exposure, but these are not life-threatening.
3. If the reaction is not as described above, or occurs a few days after exposure, it is most likely not an allergic reaction.
4. I would document the patient’s history of allergy, describe the reaction, and the physician’s evaluation of the complaint, regarding whether it is most likely a side effect/ adverse effect of the drug or a true allergy.

I agree that self report of allergy should be documented as this makes for a more complete history. However, it is up to the physician to assess whether the report is a “true” allergy or a side effect, and whether it requires further evaluation. The patient’s self report should be addressed, but it is the physician’s assessment which should be the basis of further treatment, if needed.

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14 thoughts on “Multiple Drug Allergies

  1. Would you be willing to address the growing number of physicians who are willing to dismiss even confirmed reactions? I can hand them the test results and they still don’t pay attention.

    Pax,

    MLO

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  2. Normal scratch and RAST test with 4+++ to certain items with a confirmation from a medical history. One of these items actually sent me to the ER in shock – but the generalists didn’t think that could possibly be it. I only find this with generalists and ER doctors. (Not all of them.) It is something that the entire allergic patient community has had problems with.

    If you hand someone your specialist’s diagnosis and they reject it, it seems to me something is wrong. Obviously, in a PCP situation I move on, but in an ER situation, what can someone do? At times it had the allergist’s letterhead, it just seems inconceivable to me that someone with a confirmed diagnosis is being dismissed because a generalist can’t quite believe the allergy could exist.

    Pax,

    MLO

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  3. Do you know the First-aid treatment for the following condition. Peanuts are nuts people all over the world love eating. Though predominantly used in the manufacture of peanut butter, peanuts are today one of the most allergenic foods available. They are today found in lots of food products directly or indirectly. Food labels labeled with ‘hydrolyzed vegetable protein’ or ‘groundnuts’ usually contain peanuts which can prove to be life threatening to those having allergic reactions to peanuts.

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  4. Hi, im veo 23 yrs old male from philippines i was diagnose with multiple drug allergies 5 years ago, after a tooth extraction i had an allergy attack with lidocaine, then afterwards with several medicines like Mefenamic Acid, Antibiotics and Paracetamol. I even have allergy attack with the Anti-Hepa B Vaccine, my allergologist was at my side when they administer the vaccine and i have an allergy attact on it. is there any treatment available? other doctors said i should try plasmapheresis maybe it could lower the senstivity to medicines..

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    1. Plasmapheresis will not address your problem since it does not remove the specific IgE in your system if indeed you are allergic to all these medications. While allergic reactions to antibiotics and mefenamic acid may be more frequent in the general population, reactions to paracetamol, lidocaine, and hepatitis B vaccine are rare and should be investigated further. I would suggest seeing an allergy specialist at one of the academic medical centers such as the University of the Philippines or the University of Sto. Tomas for further evaluation.

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  5. I have had reactions to most antibiotics,most blood pressure meds, and my
    nerulgia meds. I have been on 8 differant blood pressure meds,9
    differant antibiotics and 5 differant nerulgia meds, etc.I am reacting to every med I take. The cant keep my blood pressure down and I have face pain serverly and have had mutiple sinus in fections. I have tried even taking the meds with Benydryl and that doesnt work. My symptoms are the same with all the meds,Swelling of the throat,runny nose or bad congestion, stomach pain,heavyness in my chest and breathing,etc. And all the doctors tell me the same thing. It is imposible to have reations to all meds. Well funny because I do.Ask my dripping nose because i cant quit taking my blood pressure med even though I get all those reactions from it. Any I deas what I can do????

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    1. Consult with an allergy specialist. They can determine if you are having a true allergic reaction to a drug or experiencing side effects from the drug, which is an important difference. What is the time frame for your “reactions”? A true allergic reaction has a specific time frame for occurring after exposure to medications. If you really want to find out if you are allergic, see an allergist instead of trying to diagnose yourself.

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      1. This simply isn’t true. Anaphalaxis has a specific timeframe. Allergic reactions can develop over time. You could take a full course of antibiotics and have no reaction, but break out in hives a week into your second course.

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      2. And again yiur use of quotations shows you are not taking peoples’ reactions seriously. Unfortunately this is becoming the default assumption of many doctors, to the point of ignoring reports from allergists.

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  6. With all due respect your response is highly misleading. People often devlop allergies several days to weeks after their initial dose. I see too many doctors these days dismiss allergic reactions because they occur a few days into taking the medication. This is very common with certain antibiotics. The fact that you use quotations around the word allergy shows you begin from a dismissive stance. I urge readers to question the writer’s judgement on this one.

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    1. The definition of the term “Allergy” means an IMMEDIATE hypersensitivity reaction occurring within 30 minutes to 6-12 hours after exposure to a specific allergen. Reactions usually consist of itching, hives, swelling, difficulty breathing, or hypotension/ dizziness. You can also have “delayed type hypersensitivity reactions”, which are not strictly “allergic” since they are not immediate reactions, which occur over 3-7 days, and are usually cutaneous or skin reactions. Hypersensitivity reactions can persist over several weeks if not treated appropriately.
      I would again suggest you consult with an allergist for further information on any specific problems. FYI, I am never dismissive of true allergic “reactions”.

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