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Appendix 1


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TABLE A1–1: Classification of Allergic Drug Reactions
Type Descriptor Characteristics Typical Onset Drug Causes
I Immediate (IgE mediated) Allergen binds to IgE on basophils or mast cells, resulting in release of inflammatory mediators Within 1 hour (may be within 1–6 hours)

Penicillin anaphylaxis, angioedema

Blood products

Polypeptide hormones



II Delayed; Cytotoxic Cell destruction occurs because of cell-associated antigen that initiates cytolysis by antigen-specific antibody (IgG) and complement. Most often involves blood elements. Typically >72 hours to weeks Penicillin, quinidine, quinine, heparin, thiouracils, sulfonamides, methyldopa
III Delayed; Immune complex Antigen–antibody (IgG or IgM) complexes form and deposit on blood vessel walls and activate complement. Result is a serum sickness-like syndrome or vasculitis. >72 hours to weeks May be caused by penicillins, sulfonamides, minocycline, hydantoins

Delayed; T Cell-mediated

Antigens cause activation of T lymphocytes, which release cytokines and recruit effector cells

>72 hours


Th1 cells and interferon-γ, monocytes and eosinophils respond to the antigen

1–21 days

Tuberculin reaction, contact dermatitis


Th2 cells, interleukin-4 and interleukin-5 respond to the antigen

1–6 weeks

Maculopapular rashes with eosinophilia


Cytotoxic T cells, perforin, granzyme B, FasL respond to the antigen

4–28 days

Bullous exanthems; fixed drug eruptions


T cells and interleukin-8 respond to the antigen

>72 hours

Acute generalized exanthematous pustulosis


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TABLE A1–2: Top 10 Drugs and Agents Reported to Cause Skin Reactions
Reactions per 1000 Recipients















Dihydralazine hydrochloride


Penicillin G




Data from Roujeau JC, Stern RS. Severe adverse cutaneous reactions to drugs. N Engl J Med 1994;331:1272-1285.


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TABLE A1–3: Treatment of Anaphylaxis
  1. Remove the inciting allergen, if possible.

  2. Assess airway, breathing, circulation, and orientation. Support the airway.

  3. Cardiopulmonary resuscitation: Start chest compressions (100/min) if cardiovascular arrest occurs at any time.

  4. Administer epinephrine 1:1000 (adults: 0.3–0.5 mg; children: 0.01 mg/kg) IM in the lateral aspect of the thigh.

  5. Place patient in recumbent position.

  6. Administer oxygen 8–10 L/min through facemask or up to 100% oxygen as needed; monitor by pulse oximetry, if available.

  7. Repeat IM epinephrine every 5–15 minutes for up to 3 injections if the patient is not responding.

  8. Establish IV line for venous access. Keep line open with 0.9% saline solution. For hypotension or failure to respond to epinephrine, administer 1–2 L at a rate of 5–10 mL/kg in the first 5–10 minutes. Children should receive up to 30 mL/kg in the first hour.

  9. Consider nebulized albuterol 2.5–5 mg in 3 mL of saline for lower airway obstruction; repeat as necessary.

  10. In cases of refractory bronchospasm or hypotension not responding to epinephrine because a β-adrenergic blocker is complicating management, glucagon 1–5 mg IV (20–30 mcg/kg; maximum, 1 mg in children) given IV over 5 minutes.

  11. Give epinephrine by ...

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