Management of Refractory Anaphylaxis: An Overview of Current Guidelines.

In this review, we compare different refractory anaphylaxis (RA) management guidelines focusing on cardiovascular involvement and best practice recommendations, discuss postulated pathogenic mechanisms underlining RA and highlight knowledge gaps and research priorities. There is a paucity of data supporting existing management guidelines. Therapeutic recommendations include the need for the timely administration of appropriate doses of aggressive fluid resuscitation and intravenous (IV) adrenaline in RA. The preferred second-line vasopressor (noradrenaline, vasopressin, metaraminol and dopamine) is unknown. Most guidelines recommend IV glucagon for patients on beta-blockers, despite a lack of evidence. The use of methylene blue or extracorporeal life support (ECLS) is also suggested as rescue therapy. Despite recent advances in understanding the pathogenesis of anaphylaxis, the factors that lead to a lack of response to the initial adrenaline and thus RA are unclear. Genetic factors, such as deficiency in platelet activating factor-acetyl hydrolase or hereditary alpha-tryptasaemia, mastocytosis may modulate reaction severity or response to treatment. Further research into the underlying pathophysiology of RA may help define potential new therapeutic approaches and reduce the morbidity and mortality of anaphylaxis.

Hypersensitivity reactions to biologics in children.

INTRODUCTION: Hypersensitivity reactions (HSRs) have been observed with the use of biologics in children. The management of HSRs in children is mainly based on experiences from the adult population. Recently, data from different centers experienced in managing these reactions, including desensitization in children, have been published, allowing clinicians to have an appropriate global overview and compare results. AREAS COVERED: This review highlights the published data on hypersensitivity reactions to biologics in children and drug desensitization protocols adapted to the pediatric population. EXPERT OPINION: With regard to HSRs to biologics in children, few data are available. Compared with the adult population, there is a lack of knowledge in the endophenotypes, management and the standardization of protocols including premedication regimens in children. An international consensus is needed to provide clinicians with new insight on how to apply personalized management and to perform tailored desensitization protocols in pediatric populations. Various specialists including allergists, pediatricians, oncologists, hematologists, rheumatologists, and pharmacists, should build a multidisciplinary management team to keep pediatric patients on their best treatment options in the safest manner.

Global patterns of drug allergy-induced fatalities: a wake-up call to prevent avoidable deaths.

PURPOSE OF REVIEW: To identify patterns and key issues though a systematic review in order to support prevention strategies and reduce avoidable deaths related to drug-induced anaphylaxis (DAF). RECENT FINDINGS: DAF rate has been estimated by 0.13-0.53/106 population/year. General global trends of DAF are increasing over time, mostly occurring at healthcare settings (62%) with a similar gender distribution and an average age of 53 years. Antibiotics, anaesthetics, radio-contrast media and NSAIDs were the most frequently implicated agents. Main comorbidities were personal history of drug allergy, cardiovascular diseases and asthma. Main manifestations were cardiovascular and respiratory commitments. Use of adrenaline is mentioned in only 29% of the articles. SUMMARY: DAF is increasing worldwide and most cases are iatrogenic. This first systematic review of DAF identified key gaps and served as a wake-up call to prevent avoidable deaths. Phenotype at risk for DAF was represented by patients aged more than 54 years, with personal history of drug allergy/hypersensitivity with no or incomplete allergological work-up, cardiovascular disease and/or asthma with need of hospitalization and/or frequent healthcare assistance. Additional risk for those who need frequent use of intravenous antibiotics and/or undergoing surgery or image investigation with radiocontrast media.

Safety and effectiveness of laparoscopic Y-en-Roux gastric bypass surgery in obese elderly patients.

Purpose To analyze, in aged obese patients, the weight loss, comorbidity control, and safety postoperative complications of bariatric surgery by Roux-en-Y gastric bypass technique. Methods Twenty-seven patients who underwent laparoscopic weight-reducing gastroplasty with Roux-en-Y gastric bypass to treat obesity were included. All patients were ≥ 60 years old at the time of surgery. The Wilcoxon test was used for statistical analysis, and a p-value ≤0.05it was considered significant. Results Ten (90.9%) patients with dyslipidemia were cured (p < 0.001). Nine (81.8%) patients with type 2 diabetes mellitus had total improvement and 2 (18.2%) had partial improvement (p = 0.003). In 23 patients with systemic arterial hypertension, 9 (39.1%) achieved total improvement and 14 (60.9%) partial improvement (p = 0.140). Five (71.4%) patients with obstructive sleep apnea syndrome were cured (p = <0.001). For other comorbidities, no partial improvement or cure was shown. Conclusions Roux-en-Y gastric bypass surgery in obese elderly patients can be performed safely and with low morbidity and mortality rates. The benefits of weight loss and reduced comorbidities are promising and like those of the younger population.

Measles epidemiological profile in Brasil from 2013 to 2018

SUMMARY BACKGROUND To determine the epidemiological profile of measles in Brasil from 2013 to 2018, and to evaluate the possible association between increased number of cases and vaccination coverage. METHODS This is an observational, descriptive, cross-sectional, retrospective study with quantitative approach, carried out through analysis of secondary data collected through the Notifiable Diseases Information System (SINAN), in the National Immunization Program (PNI). RESULTS The total number of reported cases was 10,886, with the year 2018 having the highest number (10,185). In the North macro-region (93.4%), male (55.53%), autochthonous cases from the city of residence (94.42%) and laboratory confirmation (99.09%) predominated. Regarding the age group, it was observed that in the period from 2013 to 2015 the highest prevalence occurred in <1 year, with 44.5%, 40.6% and 29.0%, respectively, while in 2018, the highest rate was in the 20-29 age group with 24.2%. Vaccination coverage was below 95%, except for SCR - D1 (first dose of triple viral) in the years 2013 to 2016. Regarding the outcome, there was a limited number of deaths secondary to measles (0.12%). CONCLUSIONS There was an exponential growth in the number of measles cases in Brasil in 2018, which represents a public health problem. In view of this, it is necessary to implement measures such as broad vaccination coverage and sanitary control at the borders, in order to reduce the incidence of this disease and, consequently, the number of deaths.

RESUMO OBJETIVO Determinar o perfil epidemiológico do sarampo no Brasil no período de 2013 a 2018, além da possível correlação entre incidência de casos e cobertura vacinal. MÉTODO Trata-se uma pesquisa observacional, com delineamento descritivo, transversal, retrospectivo e com abordagem quantitativa, feita por meio de análises de dados secundários coletados no Sistema Nacional de Agravos de Notificação (Sinan), no Programa Nacional de Imunizações (PNI). RESULTADOS O total de casos confirmados foi 10.886, sendo o ano de 2018 com o maior número (10.185). Predominou a macrorregião Norte (93,4%), sexo masculino (55,53%), casos autóctones do município de residência (94,42%) e confirmação laboratorial (99,09%). Com relação à faixa etária, observou-se que, no período de 2013 a 2015, a maior prevalência ocorreu em <1 ano, com 44,5%, 40,6% e 29,0%, respectivamente, enquanto que, em 2018, o maior índice foi na faixa de 20-29 anos, com 24,2%. A cobertura vacinal ficou abaixo de 95%, exceto a SCR - D1 (primeira dose da tríplice viral) nos anos de 2013 a 2016. Quanto ao desfecho, houve limitado número de óbitos secundários ao sarampo (0,12%). CONCLUSÃO Verifica-se um crescimento exponencial no número de casos de sarampo no Brasil em 2018, o que representa um problema de saúde pública. Diante disso, carece que medidas como ampla cobertura vacinal e controle sanitário, nas fronteiras, sejam implementadas, a fim de reduzir a incidência dessa enfermidade e, consequentemente, o número de óbitos.

Safety and effectiveness of laparoscopic Y-en-Roux gastric bypass surgery in obese elderly patients

Abstract Purpose To analyze, in aged obese patients, the weight loss, comorbidity control, and safety postoperative complications of bariatric surgery by Roux-en-Y gastric bypass technique. Methods Twenty-seven patients who underwent laparoscopic weight-reducing gastroplasty with Roux-en-Y gastric bypass to treat obesity were included. All patients were ≥ 60 years old at the time of surgery. The Wilcoxon test was used for statistical analysis, and a p-value ≤0.05it was considered significant. Results Ten (90.9%) patients with dyslipidemia were cured (p < 0.001). Nine (81.8%) patients with type 2 diabetes mellitus had total improvement and 2 (18.2%) had partial improvement (p = 0.003). In 23 patients with systemic arterial hypertension, 9 (39.1%) achieved total improvement and 14 (60.9%) partial improvement (p = 0.140). Five (71.4%) patients with obstructive sleep apnea syndrome were cured (p = <0.001). For other comorbidities, no partial improvement or cure was shown. Conclusions Roux-en-Y gastric bypass surgery in obese elderly patients can be performed safely and with low morbidity and mortality rates. The benefits of weight loss and reduced comorbidities are promising and like those of the younger population.

Use of dupilumab on the treatment of moderate-to-severe asthma: a systematic review

SUMMARY OBJECTIVE The objective of this article was to conduct a systematic review of the treatment of moderate-to-severe asthma by administrating Dupilumab. METHODS A search on the online databases EBSCO, Scielo, PubMed, Medline Bireme, Lilacs, and The New England Journal of Medicine was conducted, publications from 2010 to 2018 were selected. The inclusion criteria were articles which contained control groups, tested the validity of Dupilumab, and verified the response of patients through controlled tests. For the search of such articles, the following keywords were used: "Dupilumab", "asthma", "Bronchial Asthma" AND "Asthma, Bronchial" AND their correspondent in Portuguese "asma", "Asma brônquica" and "Asma brônquica". The exclusion criteria were literature reviews, news, articles without control groups, articles on different subjects, Dupilumab studies on other diseases, articles concerning asthma without the use of Dupilumab, and repeated articles on the databases were discarded. RESULTS The literature considers that the medication shows a good response for the treatment of moderate-to-severe asthma and assists in the improvement of lung function, aside from resulting in few side effects. It presents good efficacy, safety, and tolerance by patients. CONCLUSIONS Dupilumab is promising for the treatment of asthma, whereas conventional therapy is deemed to be insufficient. More additional studies are needed to confirm the long-term safety and effectiveness.

RESUMO OBJETIVO Este artigo teve como objetivo fazer uma revisão sistemática sobre o tratamento da asma moderada a grave, administrando Dupilumabe. MÉTODOS Foi realizada uma busca nas plataformas on-line Ebsco, SciELO, PubMed, Medline Bireme, Lilacs e New England Journal of Medicine. Foram selecionadas publicações de 2010 a 2018 referentes a artigos que continham grupos controle, que testaram a validade de Dupilumabe e verificaram a resposta dos pacientes por meio de testes controlados. Para a busca desses artigos, foram utilizadas as seguintes palavras-chave: "Dupilumab", "asthma", "Bronchial Asthma" and "Asthma, Bronchial". E o correspondente em português: "asma", "Asma brônquica" and "Asma brônquica". Os critérios de exclusão, revisões de literatura, notícias, artigos sem grupos de controle, artigos sobre diferentes assuntos, estudos de Dupilumabe sobre outras doenças, artigos sobre asma sem uso de Dupilumabe e artigos repetidos em plataformas de busca foram descartados. RESULTADOS A literatura aponta que a medicação apresenta boa resposta no tratamento da asma moderada a grave e auxilia na melhora da função pulmonar, além de resultar em poucos efeitos colaterais. Apresenta boa eficácia, segurança e tolerância pelos pacientes. CONCLUSÕES Dupilumabe é promissor para o tratamento da asma em que a terapia convencional se revela insuficiente. Maiores estudos adicionais são necessários para confirmar a segurança e a eficácia em longo prazo.

Shared Genetic Risk Factors Across Carbamazepine-Induced Hypersensitivity Reactions.

Carbamazepine (CBZ) causes life-threating T-cell-mediated hypersensitivity reactions, including serious cutaneous adverse reactions (SCARs) and drug-induced liver injury (CBZ-DILI). In order to evaluate shared or phenotype-specific genetic predisposing factors for CBZ hypersensitivity reactions, we performed a meta-analysis of two genomewide association studies (GWAS) on a total of 43 well-phenotyped Northern and Southern European CBZ-SCAR cases and 10,701 population controls and a GWAS on 12 CBZ-DILI cases and 8,438 ethnically matched population controls. HLA-A*31:01 was identified as the strongest genetic predisposing factor for both CBZ-SCAR (odds ratio (OR) = 8.0; 95% CI 4.10-15.80; P = 1.2 × 10-9 ) and CBZ-DILI (OR = 7.3; 95% CI 2.47-23.67; P = 0.0004) in European populations. The association with HLA-A*31:01 in patients with SCAR was mainly driven by hypersensitivity syndrome (OR = 12.9; P = 2.1 × 10-9 ) rather than by Stevens-Johnson syndrome/toxic epidermal necrolysis cases, which showed an association with HLA-B*57:01. We also identified a novel risk locus mapping to ALK only for CBZ-SCAR cases, which needs replication in additional cohorts and functional evaluation.

Implementation gaps for asthma prevention and control.

Asthma and allergic diseases can start in childhood and persist throughout life, but could also be manifested later, at any time for still misunderstood reasons. They are major chronic multifactorial respiratory diseases, for which prevention, early diagnosis and treatment is recognized as a priority for the Europe's public health policy and the United Nations. Given that allergy triggers (including infections, rapid urbanization leading to loss in biodiversity, pollution and climate changes) are not expected to change in a foreseeable future, it is imperative that steps are taken to develop, strengthen and optimize preventive and treatment strategies. Currently there are good treatments for asthma, several risk factors are known (e.g., allergies, rhinitis, tobacco smoke) and tools to control the disease have been developed. However, we are still uncertain how to prevent patients from developing asthma and allergic diseases. In this paper, we list the positive and negative experiences in this field as well as analyze the missing links in the process. This critical analysis will be the basis of setting-up an effective program for prevention and making, a process labeled as "implementation gaps".

Mast Cell Clonal Disorders: Classification, Diagnosis and Management.

Mast cell clonal disorders are characterized by the clonal proliferation of pathological mast cells as a result of somatic mutations in the KIT gene, most commonly the D816V mutation. Accumulation and degranulation of these cells causes a wide variety of symptoms. Mast cell clonal disorders can be divided into mastocytosis and monoclonal mast cell activation syndrome, depending of the level of clonality. The severity of mastocytosis varies from an indolent variant with a good prognosis, to an aggressive condition with short life expectancy. Diagnosis is based on demonstration of clonality and accumulation in the skin and in extracutaneous tissues. Treatment is highly individualized, and is based on the severity of the condition. Treatment of patients with indolent systemic mastocytosis is aimed at reducing symptoms, using histamine H1 and H2 receptor antagonists as a starting point. In addition, associated conditions such as osteoporosis must be treated. Treatment of advanced systemic mastocytosis is aimed at reducing mast cell load through cytoreductive therapy. The choice of such therapy depends on the KIT mutational status. Though currently there is no curative treatment available, promising new therapies such as midostaurin are emerging that have demonstrated success in reducing symptoms and improving quality of life.

Respiratory exercise program for elderly individuals with asthma

INTRODUCTION: Asthma in older adults is frequently underdiagnosed, as reflected by approximately 60 percent of asthma deaths occurring in people older than age 65. OBJECTIVE: The present study evaluates the effects of a respiratory exercise program tailored for elderly individuals with asthma. We are not aware of any other reports examining breathing exercises in this population. METHODS: Fourteen patients concluded the 16-week respiratory exercise program. All the patients were evaluated with regard to lung function, respiratory muscle strength, aerobic capacity, quality of life and clinical presentation. RESULTS: After 16 weeks of this open-trial intervention, significant increases in maximum inspiratory pressure and maximum expiratory pressure (27.6 percent and 20.54 percent, respectively) were demonstrated. Considerable improvement in quality of life was also observed. The clinical evaluations and daily recorded-symptoms diary also indicated significant improvements and fewer respiratory symptoms. A month after the exercises were discontinued, however, detraining was observed. DISCUSSION: In conclusion, a respiratory exercise program increased muscle strength and was associated with a positive effect on patient health and quality of life. Therefore, a respiratory training program could be included in the therapeutic approach in older adults with asthma.

Alergia a anestésicos locales y generales y a otros medicamentos durante procedimientos quirúrgicos / Allergy to local and general anesthetics and to other drugs during surgical procedures

Las reacciones de choque e hipersensibilidad a los anestésicos locales y generales y a otros medicamentos utilizados durante los procedimientos quirúrgicos, continúan siendo un reto en la práctica clínica. Las reacciones de hipersensibilidad alérgica pueden variar en su presentación e intensidad, y pueden producir desde síntomas leves en la piel hasta la muerte.

Shock and hypersensitivity reactions to local and general anesthetics and to other drugs used during surgical procedures continue being a challenge in clinical practice. Allergic hypersensitivity can vary in presentation and intensity and might manifest itself from mild cutaneous symptoms to death.

Testes de provocação com drogas: positividade e segurança / Drug Provocation Tests: positivity and safety

O teste de provocação com droga (TPD) é o padrão-ouro para diagnóstico das reações adversas a drogas (RAD). Analisamos resultados de TPD e discutimos os riscos de reações sistêmicas.Método: Estudo retrospectivo e descritivo no qual foram avaliados os prontuários de 500 pacientes com história de RAD no período de janeiro de 2005 a abril de 2009 e selecionados aqueles submetidos a TPD simples cego placebo controlado. Foram realizados TPD com antibióticos (ATB), anti-inflamatórios não esteroidais (AINE), anestésicos locais (A L) e outros. Caracterizamos esta população quanto ao sexo, idade, testes positivos e ocorrência de reações graves. Resultados: Foram realizados 243 TPD em 198 pacientes, 80,8% mulheres e a média de idade de 39,9 anos. Dentre os TPD, realizamos 19 testes com ATB, 26 com AINE seletivos da COX2, 7 com dipirona, 4 com ácido acetil salicílico, 44 com paracetamol, 93 com AL e 17 com outras medicações. Ocorreram 10 TPD positivos (4,1%) e 4 (1,6%) duvidosos. Os testes positivos ocorreram com ATB (2/19), AINE seletivos da COX 2 (2/26), paracetamol (3/44), AL (3/93). Ocorreram 2 reações graves, sendo 1 choque anafilático por cefalexina e 1 anafilaxia sem choque por bupivacaína. Em 4 pacientes (1,6%) houve positividade para o placebo antes da administração da droga ativa.Conclusões: Testes de provocação com drogas são seguros para realização na prática clínica. Os testes devem ser controlados com placebo e supervisionados por um alergista experiente em provocações com drogas.

Drug provocation test (DPT) is considered the gold standard to establish the diagnosis of adverse drug reactions (ADR). We analyzed DPTs results and we discuss severe systemic reactions to them.Methods: A retrospective analysis was conducted on medicai record of 500 patients with ADR history between January of 2005 and April of 2009. Provocation tests, which were single-blind placebo controlled, are reported. There were DPTs with antibiotics, local anesthetics, non¬steroldal antiinflammatory drugs, among other drugs. Patient's features, DPT positivity and its severe adverse reactions were analyzed. Results: The study sample included 243 DPTs in 198 patients (80.8% women) and the mean age was 39.9 years. Ninety-three DPTs were done with local anesthetics, 19 with antibiotics, 44 with acetaminophen, 26 with COX 2 inhibitors, 7 with dipyrone, 4 with aspirin and 17 with other drugs. There were 10 (4.1%) positive and 4 (1,6%) inconclusive tests. The positive tests were due to antibiotics (2/19), COX 2 inhibitors (2/26), acetaminophen (3/44) and local anesthetics (3/93). Two reactions were severe: one anaphylactic shock due to cephalexin and one anaphylaxis without shock due to bupivacaine. Four patients (1,6%) had placebo reaction, before drug administration.Conclusions: Drug provocation tests are safe to be performed in clinicai practice. They should be placebo controlled and done under allergist supervisiono.

Uso a longo prazo de alternativas terapêuticas aos anti-inflamatórios não-esteroidais / Long term use of therapeutic alternatives for non-steroidal anti-inflammatory drugs

A benzidamina e o etoricoxibe são drogas que podem ser utilizadas como alternativa terapêutica em pacientes com hipersensibilidade aos anti-inflamatórios não-esteroidais (AINEs). O objetivo do estudo foi avaliar a utilização destas medicações a longo prazo em pacientes com teste de provocação negativo. Métodos: Pacientes com hipersensibilidade aos AINEs que apresentaram teste de provocação negativo foram contactados por telefone e questionados sobre a utilização posterior da drogatestada. Os pacientes que responderam que não voltaram a utilizar a droga foram questionados sobre os motivos pelo qualnão usaram. Resultados: Dos 53 pacientes testados, 50 apresentaram teste de provocação negativo. Destes, 36 foram contactados por telefone e 18 haviam utilizado novamente a droga sem qualquer reação. Dentre os que não foram expostos novamente aos medicamentos, metade não o fez porque não julgou necessário, e a outra metade por receio de uma nova reação. Conclusões: O teste de provocação oral é seguro para a determinação de alternativas terapêuticas, mas a eficácia do mesmo está diretamente relacionada ao entendimento do paciente quanto a possibilidade de novas reações. Além disso, as indicações para o teste também devem ser revistas.

Benzydamine and etoricoxib are drugs that can be used as an alternative therapy in patients with hypersensitivity to thenon-steroidal anti-inflammatory drugs (NSAIDs). The aim of the study was to evaluate the long-term use of these drugs inpatients with a negative drug provocation test. Methods: Patients with NSAIDs hypersensitivity that presented a negative drug provocation test were contacted by telephone and questioned about the subsequent use of the tested drug. The patients who answered that they had not used the drug again were questioned on the reasons for not using it. Results: Of the 53 patients tested, 50 presented a negative drug provocation test. Of these, 36 were contacted by telephone and 18 had used the drug again without any reaction. Among the ones that were not exposed again to the drugs, halfof them had not used because they didn't judge necessary, andt he other half were afraid of a new reaction. Conclusions: The drug provocation test is safe for the determination of an alternative therapy, but the effectiveness oft he test is directly related to the patient's understanding about the possibility of new reactions. Besides, the indications for the test should also be reviewed.

Reações de hipersensibilidade à insulina / Insulin hypersensitivity reactions

As reações de hipersensibilidade à insulina têm diminuído significativamente após a introdução da preparação de insulina humana. No entanto, alguns casos continuam sendo observados na prática clínica. Revisamos os principais aspectos relacionados à fisiopatologia, às manifestações clínicas, ao diagnóstico e ao tratamento das reações de hipersensibilidade a insulina. As reações à insulina podem estar relacionadas a qualquerum dos quatro mecanismos de Gell e Coombs. As manifestações clínicas surgem geralmente nas quatro primeiras semanas de tratamento e incluem mais frequentemente reações locais, mas também urticária, angioedema e anafilaxia. A sensibilização à insulina pode ser avaliada pelo teste cutâneo de leitura imediata, pesquisa de IgE sérica específica, teste intradérmico e pesquisa de IgG específica. O tratamento envolve o uso deadrenalina, anti-histamínicos e corticosteróides, dependendo do tipo e gravidade da reação. Em alguns casos a dessensibilização deve ser considerada.

Hypersensitivity reactions to the insulin have been decreesing significantly after the introduction of the preparation of human insulin. However, some cases continue being observed in clinical practice. We revised the main aspects related to the physiopathology, clinical manifestations, diagnosis and treatmentof the insulin hypersensitivity reactions. Insulin reactions can be related with any one of the four mechanisms of Gell and Coombs. Clinical manifestations usually appear in the first 4 weeks of treatment and they more frequently include local reactions, but also urticaria, angioedema and anaphylaxis. Insulin sensitization can be evaluated by the prick test, serum specific IgE, intradermal test and serum specific IgG.

Teste de provocação em indivíduos com suspeita de hipersensibilidade a anestésicos locais - Proposta de uma abordagem prática / Provocatíon test in patíents wíth suspected local anesthetícs hypersensítívíty - A practícal proposal approach

Objetivo: Os anestésicos locais (AL) podem desencadear grande variedade de eventos adversos, mas raramente são responsáveis por hipersensibilidade alérgica IgE mediada. Ainda são causa de grande preocupação para profissionais de saúde e para pacientes. O teste de provocação com a droga (TPD) constitui método de escolha para prover alternativa se¬gura para estes pacientes. Outras causas de hipersensibilidade alérgica, como a alergia ao látex, podem mimetizar as reações aos AL e devem ser investigadas. Propomos uma abordagem prática para a realização do TPD diante da suspeita de hiper¬sensibilidade alérgica aos AL. Pacientes e Métodos: Foram estudados 33 pacientes com suspeita de hipersensibilidade a AL, submetidos a TPD. Estes pacientes foram atendidos em nosso serviço entre julho de 2003 e julho de 2006. Os TPD foram indicados e realizados de acordo com as orientações da European Network for Orug Allergy (ENDA) e a droga testada foi escolhida a partir da his¬tória clínica. Todos os pacientes foram avaliados (história clí¬nica e testes in vivo e vitro) para se verificar alergia ao látex previamente à realização do TPD. Foi procedido contato telefó¬nico com estes pacientes em abril de 2007 a fim de verificar se a droga disponibilizada havia sido utilizada e se houve intercor¬rências com a sua utilização. Resultados: Foram realizadas 33 provocações em pacien¬tes com suspeita de reação a AL (18 com Bupivacaína e 15 com Lidocaína), todos negativos. Dois desses pacientes tive¬ram avaliação para látex positiva. Foi verificado por contato telefónico que todos os pacientes utilizaram sem intercorrên¬cias o AL testado...

Objective: Although local anesthetic (LA) drugs can elicit variety of adverse reactions, but true allergic hypersensitivi' reactions are uncommon. It still constitutes a concern fi health professionals and for patients. The drug provocation te (DPT) is a determinant method to provide a safe alternative these patients. Other allergic hypersensitive causes (eg. lats allergy) can mimic LA reactions and must be investigated. VI suggest a practical approach based on DPT to be used when LA allergic hypersensitivity is suspected. Pacients and Methods: We stud ied 33 patients with SUSI: cion of local anesthetic hypersensitivity evaluated in our clin between July 2003 and July 2006. Ali of them underwent DP which was performed based on European Network for OrL Allergy (EN DA) orientations and the choice of the drug to t tested was based on the clinical history. Ali patients we avallied (clinical history and in vivo and in vitro tests) in ord to investigate latex allergy before the drug provocation. VI proceeded phone contact to ali these patients in April 2007 order to check if the medication we tested was used and if thr had reactions with it. Results: We proceeded 33 drug provocation tests in pai ents with suggestive history of local anesthetic reaction (: with Bupivacaine and 15 with Lidocaine), ali negative. Two these patients, who underwent DPT with Bupivacaine and wi Lidocaine, had positive evaluation to latex allergy. We conta ted ali patients and verified that the tested drug was used I ali of them with no problems. Conclusion: We demonstrated that DPT is an importa method to provide a safe alternative drug to patients with su picion of allergic hypersensitivity to LA and latex allergy Inve tigation has always to be proceeded. Therefore, the practic approach we use helps us to provide a correct, safe and inc vidualized orientation to each patient.

Teste de provocação em indivíduos com hipersensibilidade aos antiinflamatórios não-esteroidais - Proposta de uma abordagem prática / Drug provocation test in non-steroid anti-inflamatory drug (NSAID) hypersensitivity patients - suggestion of a practical approach

As reações de hipersensibilidade aos AINE são comuns. O teste de provocação com droga (TPD) é o método de escolha para determinar alternativas terapêuticas seguras nestes pa¬cientes. Sugerimos uma abordagem prática para a realização do TPD. Métodos: Avaliamos 52 pacientes com suspeita de reação imediata (urticária, angioedema, broncoespasmo e anafilaxia) aos AIN Es em nosso serviço durante 2006. Os pacientes foram testados com diferentes drogas, de acordo com sua história clínica e gravidade da reação. O TPD foi realizado de acordo com os protocolos sugeridos pela ENDA. Resultados: Realizamos 33 provocações (14 com viminol, sete com paracetamol, sete com etoricoxibe, quatro com ben¬zidamina e uma com tramadol), todas com resultados negati¬vos, exceto uma com etoricoxibe. Um paciente provocado com viminol apresentou reação duvidosa confirmada como negativa após uma segunda provocação. Conclusão: Demonstramos que o teste de provocação com AINEs é um procedimento simples e seguro, que permite me¬lhorar a qualidade de vida do paciente, proporcionando drogas alternativas para o uso.

Rational: Non-allergic hypersensitivity reaction to NSAID are common. The drug provocation test (DPT) is the procedure of choice to determine safety alternative drugs to these pati¬ents. We suggest a practical approach to be used in the DPT. Methods: We evaluated 52 patients with suspicion of im¬mediate reaction (urticaria, angioedema, bronchoconstriction and/or anaphylaxis) to NSAID in our c1inic during 2006. The patients were challenged with different drugs, according to their clinical history and severity of the reaction. The DPT was performed following the ENDA protocols. Results: We performed 33 challenges (14 with viminol, 07 with paracetamol, 07with etoricoxib, 04 with benzidamine and 01 with tramadol), ali of them with negative results, except one with etoricoxib. Another patient challenged with viminol had a doubtful event, confirmed as negative after a second challenge. Conclusion: We demonstrated that the DPT is a practical and safety method that helps us to improve the quality of life of our patients, giving them the possibility to use alternative drugs.