Clinical Phenotypes In Drug Allergy 1-6 h of exposure to a drug, and preset flushing, pruritus, urticaria, angioedema), gastrointestinal symptoms, and anaphylaxi Delayed-onset drug allergy Reaction usually occurs than 1 hour, mostly 24 hours or even weeks, after drug intake (21) isolated, single-organ involvement (2) systemic, multi-organ involvement. Cutaneous reactions are the most common with numerous clinical phenotypes (MPE,FDE, urticaria, angloedema) € 200m SCARs which include Steven Johnson ‘Syndrome and Toxic Epidermal Necrolysis Mayorga CC Tat Opens Adar 2018 aa A Currant Prarmacoutel Design 2018 utus-Graca |. Abrgy 2018 ‘Muraro A. Atray 2017Endotypes in Drug Allergy Cee Immediate-onset uc Teel Delayed-onset Asthma, nasalpolyposis, and immediate respiratory reactions to NSAIDs Ce Niioetr re) fori k ce Grr) Abacavir CIP AM ecueUy)| repertoire hypersensitivity fete model HLA- syndrome 57:01, gun Gracia Alorgy 2018 ‘nea A Curent Pharmaceutical Desig 2019 Mur A ergy 2017Diagnostic Biomarkers in IgE mediated reactions ImmunoCAP ategyion | ceases ‘Sensitivity 54% 38% Specificity | 95% 87% Basophil Activation Test * Cut off point 0.35 kUA/I or 0.1 KUA/I?? + False positive with penicillin V New wv + It is recommended for diagnosing BLs, 1M HQ HANDS a Pyatces AROMA NMBAs, chlorhexidine, and cetuximab DHR, Specty BAT is not useful for cross-intolerant reactions to NSAIDs ee eit ee Nofima Hat larg 2015 r/AGe Johanason SO. J Alergy Cn iro! 2013 IARGAA,Cptmoty Part 2014100,00 75,00 50,00 25,00 0,00 T cell mediated reactions LTT ©ELISpot mELISA+Flow a eet , ox 7 | oaeee 42% Abacavir | 100% Piperacilin {64tAllopurinolJoxpurinol m v | ‘SUS-TEN i 20% Allopurinol/Oxpurinol 48% Anticonvulsant Pm {67%Allopurinol/Oxpurinol Mayega Cet nt Male 2017Placing in vitro tests in the diagnosis 19 allergy ert, BHP ImmunoCA? is validated for 8L.and NMBA Time interval from reaction to study is critical for sensitivity It is validated for 8ls and NMBA Time interval from reaction to study is critical for sensitivity Sensitivity depends on the types of reaction and drug Sensitivity decreases in severe skin reactions Analysing a few number of effector cells WASSAY 2+ B BaT 2 8 spor 3c rug provocation wst ¢—— Mayorga Aleray 2018. Mayorga. Alleray 2019,Anaphylaxis iomarkers Inflammatory mediator released by ma * Serum concentration peak (> 10 nmol/L) within 5-10 min after the onset of anaphylaxis, and decrease quickly to baseline (20. Toptase min). « * Immunoassays: serum histamine concentration in the acute * phase. Value always compared with baseline histamine level. ° sein | + Technical Limitations: Short half-life of histamine. Beech ee esa rie wetescaras ‘ma 200, Wile KW. Arg ln Nath en 2035, Mayorga Alergy 2026 Histamine in Urine * Alternative and indirect method is detection N-methylhistamine and N-methylimidazole acetic acid in urine. ‘ * These metabolites appear 30-60 min after the allergic event bein detectable for 24 h yer Wg Md 1989, Stephan Alley Cn rune 1950, ‘rcenberget PA Alergy Asthra Proc. 2012 ROOMAnaphylaxis biomarkers Serum Tryptase Within few minutes after anaphylaxis onset, mature tryptase released from MC/Bo can be detected in serum (level peaks at 60-90 min, remains elevated 5 hours and resolves in 24-48 h) '15 — 180min’ >11.4 ng/mL are indicative of acute MC/Bo activation {flow baseline tryptase Yevels: levels of 2ng/mL+1.2xbaseline are considered significantly increased. * High specificity but low sensitivity + Related with severity ‘Schwartz LB. N Eng! J Med 1087; Abn C. Cin tran! 2007; Snona FE, J Alergy Ci en 2011 ‘4 Masinal lee ofmadator 100: ©. ©. o. 20. Tryptase Histamine Ey 100 20 Tne (ri aa venom change More frequently elevated with drug-induced anaphylaxis compared to food-induced ‘Anaphylactic reactions to intravenous drugs can elicit greater and more persistent increasesAnaphylaxis biomarkers oo Sn es Ns. ne Les Med 2005 ‘Serum chymase and dipeptidy| peptidase | (DPPI) Serum carboxypeptidase A3 Serum Platelet- activating factor (PAF) Serum CCL2 Serum basogranulin * Serine protease stored mainly in granules of MC + Elevated levels (3-380 ng/ml) in anaphylaxis autopsy compared with controls (< 3 ng/ml) * Elevated chymase concentrations in anaphylaxis also correlated with levels of dipeptidyl peptidase | (DPPI), secreted by MC and Bo ‘+ Chymase and DPPI could be diagnostic biomarkers Protease released by MC potential biomarker + Serum concentration increases (> 14 ng/mL) but not in controls, asthma or Ig-E mediated allergic reactions + Increased levels remain longer than total tryptase * Lipid mediator released by MC, Bo and other cells + Essential mediator in human anaphylaxis * Serum concentration of PAF acetylhydrolase are inversely correlated with severity * Chemotactic protein for Bo. + Increased levels that correlates with severity reaction * Secreted by Bo along with histamine * No studies about its usefulness as a biomarker Zhou X. J Allergy Clin immuno! 2035, {Guo 0. World| Gastroenterol 2035, Buckley MG. J Allergy Clin immunol 2008 Zhou XY. Allergy Cin immuno} 2008 ‘Brown $6. 1 Alley Clin immuno! 2033, VVadas P. N Engl) Med 2008; ‘Vadas 81 Allergy Clin Immunol 2013 Korosee P.1Allergy Cin mmunol 2017, ‘Vantur R. Allergy 2018 Beck SC. Front immuno} 2019Basophil activation markers CD63/CD203c Two different mechanisms of degranulation ‘BAT POSITIVE MOX ALLERGIC PATIENTS Anaphylactic, characterised by the fusion of the granules to the plasma membrane to expel their contents, leading to the exposition of CD63. Piecemeal, when small vesicles are formed from the histamine-containing granules and gradually | shuttled to the plasma membrane. This is associated with the upregulation of CD203c. de) cp203¢ * constitutively expressed and increases in expression after activation ei specific to basophils CD63 + expressed only after activation with iO bimodal expression, easier to measure Sneek on + expressed in basophil nd pl Femmandt TO ta. ean 2016Biomarkers for non-immune mediated reactions Cross-intolerance to NSAIDs (mainly for AERD) [ Mostly unvalidated research tools E> | Lipid mediators Arachidonic acid metabolites (LT/PG) Other lipids [urinary tre /Serum TE, ‘Serum sphingosine-1-phosphate Serum LTE,/PGF2a Other platelet-derived mediators Urinary 9a, 118-PGF2 8-iso-PGE2 (breath condensate) oe Ay 2017 vet, Ate ln re 2018 Monn, ogy on man Pat 2017 #f00% San ogy 219Severe cutaneous adverse drug reactions: DIHS/DRESS + Eosinophilia can be observed in 60-95% at the early stage of the illness. + Massive elevations of eosinophil- associated cytokines like IL-4, IL5 and IL-3, responsible rane iam a for eosinophil maturation and differentiation. ae | + Thymus and activation-regulated chemokine (TARC CCL17), was also found to be upregulated when reactivation of HHV-6 occurred. + Carbamazepine induced HS is associated with reactivation of HHV-6, transient hypogammaglobulinemia, increased serum levels of inflammatory cytokines and activated eosinophils. it Day 29 Day 39 Day 5: pe mi! 397 0 pemi! 41 0 pe ml? 9 0 pe ml 23 0 0 pe ml! 0 0 oo) pa mi! 0 0 0 pe ml 935; 127 o | mele! sit " a (opmwa K otal 8 Domate 2018 ‘AnaraYot 8. Darra! 2003severe cutaneous adverse drug reactions: AGEP Skin biopsies Revjeau JC. Toxcolagy 2008 Padi MA. J Dermat 2004 T-cell clones * Drug:specific T cells infiltrate the epithelium, induce blistering through * perforin/granzyme B and Fas ligand to induce apoptosis. + Also express IL attracting neutrophil which form pustules. A leucocytosis, typically a neutrophilia may be present. 6 Shae. J eran 2008Biomarkers for SCARs to drugs ‘SUS and TEN ‘ Key cells + CDB* cytoxic Tells NK cells # CDi*and CD14" # CD1q* and CD16 Key molecules + Fas-Fas ligand + Perforin-granzyme B + TRAIL + TWEAK * Granulysin otLas Identification of specific HLA-drug association DRESS syndrome Key cells + CDB* cytoxic T cells + Thzcells + Eosinophils, Key molecules +iLs Ibs +L +IENY “TNFa + HHV family reactivation Identification of specific HLA-drug association AGEP Key cells + CDB* cytoxic T cells + Neutrophils Key molecules © CxCL8 +18 “tL + 1L22 + GM-CSFPharmacogenomics as a useful Tool for precision medicine in drug allergy Genomic biomarkers Polymorphisms in Haplotypes of HLA-B, Copy number] | Genetic variants Identity reactors to variations in of PLAZGLA, abacavir or ‘Atoxsand |} puces, var, sv, carbamazepine PIGERL TNFRSLIA Tangamornsuksan, JAMA Dermatol! 2013 Leckbond, Cin Pharmacol Ther 2013 Px Seon Phamacogee erm 206 BSS, Parmacopenet Seno 203 Validated for the clinical practice Perkins, Pharmacogenomics 12019 ‘Amo, Front Pharmocol 2016Take Home Messages There are several identified unmet needs: * Standardisation of in vitro diagnostic biomarkers especially | for most common drugs and phenotypes/endotypes * Given the rarity of severe reactions, large collaborative networks are needed. * Knowledge of immunopathogenesis of these reactions might answer many key questions and will drive strategies for improved prevention, diagnosis, treatment, and identification of biomarkers