Drug Allergy

A Guide to Diagnosis and Management

(Version 1 – April 2015)

Author:
Jed Hewitt – Chief Pharmacist, Governance & Professional Practice

Date of Preparation:
April 2015
Date for next full Review: April 2018

Approved by the Trust Drugs & Therapeutics Group in April 2015

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Information sources for drug allergy status include:       Medical notes Medical letters from specialist centres GP patient summaries Summary Care Records The patient The patient’s carers / relatives 2. This guidance defines drug allergy as any reaction caused by a drug with clinical features compatible with an immunological mechanism. Other reactions are idiosyncratic. pseudo-allergic or caused by drug intolerance. If this cannot be ascertained at the time of first writing up the chart the prescriber must complete the second section of the allergy box (inpatient chart) stating the allergy status ‘is not yet ascertained’. 1. The British Society for Allergy and Clinical Immunology (BSACI) defines drug allergy as an adverse drug reaction with an established immunological mechanism. in reality less than 1% are truly allergic. 2. also known as 'adverse drug reactions'. 1.1 Prevention of drug allergy is achieved by avoiding exposure to drugs for which the patient has known allergy or sensitivity and to those for which crosssensitivity is possible. drug allergies are not as common as often believed.2 The commonest drug allergies are in response to antibiotics. allergy status should be confirmed before the first drug chart is completed on admission. great care must be taken to avoid prescribing drugs for which there is known patient allergy. Prevention.2 When prescribing.4 Allergy status or sensitivities to medication must be recorded on the drug chart. However. 1. Introduction. This applies to prescribed medication and for those purchased without prescription. The medical team is ultimately responsible for completing the allergy status box as . but not all of these are allergic in nature.4 Drug allergy to psychotropic drugs is rare but is more commonly seen in response to anticonvulsant drugs. ideally by the prescriber when first writing up the chart. 1. The mechanism at presentation may not be apparent from the clinical history and it cannot always be established whether a drug reaction is allergic or non-allergic without investigation.1. 2. (in particular peniciliins and cephalosporins) and non-steroidal anti-inflammatory drugs (NSAIDs) including aspirin.3 Ideally. Whilst 10% of the general population claim to have a penicillin allergy.3 Allergic reactions to NSAIDs are much more common in those with asthma. (inpatient and/or community long-acting injection chart). 2. 2.1 All drugs have the potential to cause side effects.

if a penicillin has been prescribed for a patient whose allergy status is not recorded. including their designation e. the following signed and dated entries must be made in the patient’s notes and on all drug charts:  Generic name(s) of medicine(s). pharmacist. If allergy status is not recorded every attempt should be made to ascertain and record this prior to administration. (The following boxes can be used as a guide when deciding whether to suspect drug allergy). especially in relation to newly prescribed medication.6 If there is a known allergy. Glossary – see section 11. urticaria or angioedema and  hypotension and/or bronchospasm Urticaria or angioedema without systemic features Exacerbation of asthma (eg. 2. with NSAIDs). but another healthcare clinician involved in the medicines management process may ascertain the status and sign instead of the prescriber. take a history and undertake a clinical examination. Assessment – Signs & allergic patterns of suspected allergy 3. 3.5 When rewriting drug charts. 2. rapidly evolving reactions: Anaphylaxis – a severe multi-system reaction characterised by:  erythema. 2.7.soon as possible.g. 2. allergies or sensitivities must be carried forward.7 When administering medication it is vital that the allergy status of the patient be checked on every occasion. unless otherwise recommended by the BNF  Nature of reaction(s) – to ensure a true allergy is being described.1 When assessing a person presenting with a possible drug allergy. . administration should not take place until the relevant information has been obtained and recorded.8 Further to point 2. Box 1 – Immediate. (Previous exposure not always confirmed). Onset is usually within an hour of drug exposure.

.  painful rash and fever  mucosal or cutaneous erosions  vesicles. eczema hepatitis nephritis vasculitis photosensitivity Glossary – see section 11. rarely. papules or erythroderma  fever  lymphadenopathy  liver dysfunction  eosinophilia Toxic epidermal necrolysis or Stevens. blistering or epidermal detachment  red purpuric macules or erythema multiforme Acute generalised exanthematous pustulosis ( AGEP) characterised by:    widespread pustules fever neutrophilia Common disorders caused.  widespread red macules. by drug allergy:      Onset usually 3 to 5 days after first exposure.Box 2 – Non-immediate reactions without systemic involvement: Widespread red macules or papules (exanthema-like) Fixed drug eruption (localised inflamed skin) Onset usually 6 to 10 days after first drug exposure or within 3 days of second exposure.Onset usually 7 to 14 days after first Johnson syndrome characterised by: drug exposure or within 3 days of second exposure. Variable time of onset. Box 3 – Non-immediate reactions with systemic involvement: Drug reaction with eosinophilia and systemic symptoms (DRESS) or drug hypersensitivity syndrome (DHS) characterised by: Onset usually 2 to 6 weeks after first drug exposure or within 3 days of second exposure.

4.1 Drug allergy status should be documented separately from adverse drug reaction information so that it remains clearly visible to all prescribers. formulation and route of the drug  a description of the reaction – see section 3  the diagnosis / illness the drug was being taken for  the date and time of the reaction  the number of doses taken or the number of days on the drug before the onset of the reaction 5.2 Patients’ drug allergy status must also be recorded on the front of their drug chart(s) using the dedicated “allergy box”. .3.3 Clinicians should be aware that a reaction is less likely to be caused by drug allergy if:  there is a possible non-drug cause for the patient’s symptoms – eg. 6. 4.2 The patient’s GP should be consulted / informed at the earliest opportunity. the reaction must be clearly recorded in the medical notes – including:  the generic (and proprietary) name of the drug suspected of causing the reaction  the strength. This must be recorded on each chart in use and always carried forward when new charts are started.1 Patients’ drug allergy status must be clearly recorded in their medical record.2 Clinicians should be aware that a reaction is more likely to be caused by drug allergy if it occurs during or after use of the drug and:   the drug is known to cause that type of reaction the patient has previously had a similar reaction to the same drug or to another drug in the same class 3.1 When a patient presents with a suspected drug allergy.or  the patient only has gastrointestinal symptoms. 4. Documenting new suspected drug reactions 5. Documenting and sharing information. Maintaining and sharing drug allergy information 6.3 If there is a drug allergy the following minimum information must be recorded:  the (generic) drug name  the signs. symptoms and severity of the reaction  the date when the reaction first occurred (if known) 5. they have had similar symptoms when not taking the drug . 4.

Alternative information sources such as Summary Care Records and GP Summaries should also be used routinely. 6.3 Following an anaphylactic reaction. specialist referral letters and GP referral letters.4 Information about allergy status must be kept updated and must be included in all hospital discharge letters. dentist.1 Clinicians must ensure patients (and their carers) are aware of the drugs or drug classes that they need to avoid. nurse. by ambulance if necessary. GP. 8. pharmacist.6. Stevens-Johnson syndrome or epidermal necrosis. They should be advised to check with the pharmacist before taking any over-the-counter medicines.  Send patients with a severe reaction to the nearest casualty department. This should also occur following any severe non-immediate cutaneous reaction – eg. Non-specialist management and referral to specialist services 8. 8.  When appropriate. hospital doctor. treat the symptoms of the acute reaction if not severe. .  Fully document the incident in the patient’s medical notes – see section 5. provide the patient (and their carers) with the information. 8. 7. 7. even if the reaction appears to have been successfully treated by administering adrenaline injection.2 If a patient has an anaphylactic reaction they should still be immediately referred to the nearest casualty department (dial 999). Trust services should follow up with acute hospital services to ensure the patient receives a referral to a specialist drug allergy service. patients’ drug allergy status should be confirmed with the patient or with their carers before prescribing or administering any drug.  Where possible. Providing information and support to patients 7. 6.1 If a drug allergy is suspected:  Consider stopping the drug(s) suspected to have caused it and advise the patient that they should avoid that drug in the future.2 Where possible.2 Clinicians should advise patients (and their carers) to carry information about their drug allergy with them at all times and to share this with any healthcare professional that is treating them. eg.3 Confirmation of drug allergy status must be considered a routine part of medicines reconciliation at the time of admission to any inpatient unit.

consideration can be given to using a selective COX-II inhibitor as these carry a lower risk of allergy.9. Beta-lactam antibiotics – eg. Cross reference: Trust Medicines Code (2014/15) – Section 4.1 Patients with a suspected drug allergy to a beta-lactam antibiotic should be referred to a specialist drug allergy service if:  they need treatment for an illness that can only be treated by beta-lactam antibiotic. However. Non-steroidal anti-inflammatory drugs (NSAIDs) 9.1 If patients have had a mild allergic reaction to a NSAID but still need an antiinflammatory. . cephalosporins 10. Glossary Angioedema Epidermal necrolysis Eosinophilia Erythema Erythroderma Exanthema Lymphadenopathy Macules Nephritis Papules Pustules Urticaria Vasculitis Swelling of skin and/or mucous membranes Potentially life-threatening separation of skin layers Raised eosinophil count (>450µL) Redness of skin and/or mucous membranes Widespread inflammation of the skin Widespread rash Swollen lymph glands (or other abnormality) Flat discoloured areas of skin Inflammation of the kidneys Raised discoloured areas of skin Small. so a low starting dose should be used and administration should only be once daily. those prescribing and administering must remain aware that there is still some risk of cross sensitivity. 10. fluid-filled skin eruptions Raised itchy rash Inflammation of blood vessels Reference: NICE Clinical Guideline 183 (September 2014): Drug allergy – diagnosis and management in adults. children and young people. penicillins. 11. and/or  they are likely to need a beta-lactam antibiotic frequently in the future.