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PATIENT CARE PROCESS

Patient Care Process for the Management of Drug Allergy

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Collect

  • Patient characteristics (e.g., age, race, sex, pregnant)

  • Medication history (e.g., prescription, OTC, and complementary medications such as herbals)

  • Allergy history (e.g., medications, foods, environmental exposures with descriptions of each reaction)

  • Subjective findings of the allergic reaction (e.g., shortness of breath, itching, feeling of flushing, lip tingling, nausea, lightheadedness)

  • Objective data

    • BP, HR, RR

    • Labs (e.g., serum electrolytes, Scr, BUN, LFTs)

    • Observation of the rash, if applicable (e.g., type of lesion(s), distribution of lesions, presence or absence of oral or genital ulcerations, presence or absence of bullae)

Assess

  • Timing of the reaction relative to the initiation of each of the patient's current medications

  • Likelihood of cross-reactivity relative to documented allergy history (e.g., previous documented allergy to penicillin in a patient currently receiving a beta-lactam antibiotic)

  • Presence of risk factors (see section on Factors related to the Risk or Severity of Allergic Drug Reactions)

  • Co-administration of medications that may increase the risk of an allergic reaction when used in combination (e.g., lamotrigine and valproate)

  • Severity of the reaction (e.g., localized rash versus a systemic reaction involving one or more organs)

  • Medications that may interfere with the identification or treatment of the allergic reaction (e.g., chronic use of antihistamines when skin testing may be warranted; chronic beta-blocker use in a patient with anaphylaxis)

  • Need for drug desensitization or induction of drug tolerance (see Tabe e-88-5)

Plan*

  • Management of the allergic reaction (see Table e-88-3 if patient presents with anaphylaxis)

  • Management of the condition for which the allergic medication was indicated (e.g., treatment of the underlying infection for which the allergenic antibiotic was indicated)

  • Patient education (e.g., recognition of likely allergenic medication, risk of cross-reactivity with related agents, use of epinephrine self-injectors if applicable)

  • Referals to other providers when appropriate (e.g., allergist)

Implement*

  • Provide education to health care providers on an effective management plan of allergic reaction

  • Drug desensitization or graded challenge protocols, if appropriate

  • Drug skin testing, if appropriate

Follow-up: Monitor and Evaluate

  • Assess responsiveness to the management plan and revise the plan, if applicable

  • Identify causative medication based on responsiveness to drug discontinuation and treatment

  • Document allergic reaction and update drug allergy information in medical record

  • Reinforce patient education on allergic medication, type of reaction, potential cross-reactive medication and self-management of reaction (if applicable)

*Collaborate with patient, caregivers, and other health professionals

KEY CONCEPTS

KEY CONCEPTS

  • image Drug allergy is responsible for 6% to 10% of adverse reactions to medications. Most of these immune events are mediated by IgE or activated T cells.

  • image Two theories—the prohapten/hapten concept and the p-i concept—have been proposed to explain how drugs stimulate the immune response.

  • image Anaphylaxis is an acute, life-threatening allergic reaction involving multiple organ systems that generally begins within 1 hour but almost always within 2 hours after exposure to the inciting allergen. Anaphylaxis requires prompt treatment to restore respiratory and cardiovascular ...

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