201. Reclassifying Anaphylaxis to Neuromuscular Blocking Agents Based on the Presumed Patho-Mechanism: IgE-Mediated, Pharmacological Adverse Reaction or "Innate Hypersensitivity"?
- Author
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Spoerl D, Nigolian H, Czarnetzki C, and Harr T
- Subjects
- Anaphylaxis metabolism, Cross Reactions immunology, Drug Hypersensitivity metabolism, Drug-Related Side Effects and Adverse Reactions complications, Drug-Related Side Effects and Adverse Reactions immunology, Humans, Hypersensitivity, Immediate diagnosis, Hypersensitivity, Immediate etiology, Hypersensitivity, Immediate metabolism, Immunity, Innate, Immunoglobulin E immunology, Mast Cells immunology, Mast Cells metabolism, Nerve Tissue Proteins metabolism, Neuromuscular Blocking Agents administration & dosage, Receptors, G-Protein-Coupled metabolism, Receptors, Neuropeptide metabolism, Skin Tests methods, Anaphylaxis diagnosis, Anaphylaxis etiology, Drug Hypersensitivity diagnosis, Drug Hypersensitivity etiology, Neuromuscular Blocking Agents adverse effects
- Abstract
Approximately 60% of perioperative anaphylactic reactions are thought to be immunoglobulin IgE mediated, whereas 40% are thought to be non-IgE mediated hypersensitivity reactions (both considered non-dose-related type B adverse drug reactions). In both cases, symptoms are elicited by mast cell degranulation. Also, pharmacological reactions to drugs (type A, dose-related) may sometimes mimic symptoms triggered by mast cell degranulation. In case of hypotension, bronchospasm, or urticarial rash due to mast cell degranulation, identification of the responsible mechanism is complicated. However, determination of the type of the underlying adverse drug reaction is of paramount interest for the decision of whether the culprit drug may be re-administered. Neuromuscular blocking agents (NMBA) are among the most frequent cause of perioperative anaphylaxis. Recently, it has been shown that NMBA may activate mast cells independently from IgE antibodies via the human Mas-related G-protein-coupled receptor member X2 (MRGPRX2). In light of this new insight into the patho-mechanism of pseudo-allergic adverse drug reactions, in which as drug-receptor interaction results in anaphylaxis like symptoms, we critically reviewed the literature on NMBA-induced perioperative anaphylaxis. We challenge the dogma that NMBA mainly cause IgE-mediated anaphylaxis via an IgE-mediated mechanism, which is based on studies that consider positive skin test to be specific for IgE-mediated hypersensitivity. Finally, we discuss the question whether MRGPRX2 mediated pseudo-allergic reactions should be re-classified as type A adverse reactions., Competing Interests: The authors declare no conflict of interest.
- Published
- 2017
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