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IgE antibody detection in the diagnosis of hypersensitivity to neuromuscular blocking agents

ACTA ANAESTHESIOLOGICA SCANDINAVICA (2012)

Journal

ACTA ANAESTHESIOLOGICA SCANDINAVICA

Volume 56, Issue 2, Pages 263-264

Publisher

WILEY-BLACKWELL

DOI: 10.1111/j.1399-6576.2011.02540.x

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Relationship of perioperative anaphylaxis to neuromuscular blocking agents, obesity, and pholcodine consumption: a case-control study

Paul H. M. Sadleir, Russell C. Clarke, Catherine E. Goddard, Conor Day, William Weightman, Alex Middleditch, Peter R. Platt

Summary: Through a restricted case-control study, it was found that obesity is a risk factor for NMBA anaphylaxis, with the risk increasing with BMI grade. Pholcodine consumption is also a significant risk factor, while sex is not.

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Molecular Insights of Nickel Binding to Therapeutic Antibodies as a Possible New Antibody Superantigen

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Summary: The binding of nickel by immune proteins can lead to Type IV contact dermatitis and Type I hypersensitivity reactions, with a possible common mechanism underlying both. Investigations showed that specific amino acid sequences influence nickel binding interactions with antibodies, potentially revealing the underlying mechanism for selecting nickel-binding antibodies. This understanding could also lead to the engineering of therapeutic antibodies for biotechnological applications utilizing nickel binding.

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Pholcodine exposure increases the risk of perioperative anaphylaxis to neuromuscular blocking agents: the ALPHO case-control study

Paul Michel Mertes, Nadine Petitpain, Charles Tacquard, Marion Delpuech, Cedric Baumann, Jean Marc Malinovsky, Dan Longrois, Aurelie Gouel-Cheron, Diane Le Quang, Pascal Demoly, Jean Louis Gueant, Pierre Gillet, ALPHO Study Grp

Summary: This study assessed the relationship between pholcodine exposure and NMBA-related anaphylaxis. It found that exposure to pholcodine and other quaternary ammonium compounds in the environment can increase sensitivity to NMBAs. Pholcodine and quaternary ammonium sIgEs have a high negative predictive value but a very low positive predictive value for identifying NMBA-related reactions.

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Pholcodine, perioperative anaphylaxis, and the European Medicines Agency: finally the decision to remove pholcodine from the market in the European Union

Erik Florvaag, Gunnar Johansson

Summary: Two recent case-control studies published in the British Journal of Anaesthesia have revealed that the intake of pholcodine-containing cough medicines prior to general anesthesia significantly increases the risk of anaphylaxis caused by neuromuscular blocking agents. These findings from a French multicentre study and a single-centre study from Western Australia strongly support the pholcodine hypothesis for IgE-sensitisation to neuromuscular blocking agents. The European Medicines Agency, which faced criticism for its previous inaction, has finally recommended the cessation of sales for all pholcodine-containing medicines in the EU by December 1, 2022. Only time will tell whether this measure will effectively reduce the incidence of perioperative anaphylaxis in the EU, similar to the results seen in Scandinavia.

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Effects of neuromuscular blocking agents on the clinical performance of i-gel® and surgical condition in elderly patients undergoing hand surgery: a prospective randomized controlled trial

Choon-Kyu Cho, Minhye Change, Seok-Jin Lee, Tae-Yun Sung

Summary: The use of rocuronium did not increase the success rate of inserting the i-gel or improve surgical conditions in elderly patients. However, it did reduce peak inspiratory pressure, decrease the frequency of spontaneous breathing, lower the requirement for additional fentanyl, and shorten patients' recovery time.

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Use of Sedatives and Neuromuscular-Blocking Agents in Mechanically Ventilated Patients with COVID-19 ARDS

Amedee Ego, Lorenzo Peluso, Julie Gorham, Alberto Diosdado, Giovanni Restuccia, Jacques Creteur, Fabio Silvio Taccone

Summary: Patients with COVID-19 related ARDS had significantly longer duration and higher consumption of sedatives and NMBA compared to non-COVID ARDS patients, suggesting the need for different sedation strategies and protocols in COVID-19 patients with ARDS.

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Reversing neuromuscular blocking agent decamethonium by carboxylatopillar[6]arene based on host-guest encapsulation

Yao Chai, Longming Chen, Yahan Zhang, Liang Zhao, Zhao Meng, Junyi Chen, Chunju Li, Qingbin Meng

Summary: This study utilized carboxylatopillar[6]arene (CP6A) as a reversal agent to reverse the neuromuscular blocking effect of decamethonium (C10). The experiment confirmed the strong affinity between CP6A and C10, and showed that CP6A could decrease the concentration of C10 in mice blood and facilitate its excretion through urinary clearance, leading to rapid recovery from muscle relaxation.

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Tools for Etiologic Diagnosis of Drug-Induced Allergic Conditions

Rosa Rodriguez-Perez, Leticia de las Vecillas, Rosario Cabanas, Teresa Bellon

Summary: Drug hypersensitivity reactions can have severe consequences and lifelong effects. Accurate diagnosis and identification of the culprit drug are crucial for prevention and finding alternative treatments. However, diagnosis can be challenging and requires a combination of in vivo and in vitro tests, as well as collaborative research to improve accuracy.

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MRGPRX2 activation in mast cells by neuromuscular blocking agents and other agonists: Modulation by sugammadex

Nithya A. Fernandopulle, Stephanie S. Zhang, Paul F. Soeding, Graham A. Mackay

Summary: The study found that sugammadex can reduce MRGPRX2 activation induced by NMBAs and other MRGPRX2 agonists, but may be ineffective in controlling acute symptoms. However, sugammadex may have some benefits in reducing MRGPRX2-induced release of CCL2.

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IgE plus plasmablasts predict the onset of clinical allergy

Elisabeth M. Simonin, Susanna Babasyan, Justine Tarsillo, Bettina Wagner

Summary: In this study, it was found that IgE+ plasmablasts develop following allergen exposure and B cell activation, and they directly contribute to the mechanisms of IgE-mediated allergies. Furthermore, the presence of IgE+ plasmablasts in peripheral blood not only coincides with clinical allergy, but also predicts the development of clinical disease.

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Comparison of neuromuscular block measured by compressomyography at the upper arm and electromyography at the adductor pollicis muscle in obese and non-obese patients: An observational study

G. H. M. Honing, B. Torensma, C. H. Martini, K. B. Hoek, M. van Velzen, E. Olofsen, M. Niesters, A. Dahan, M. Boon

Summary: This study evaluated the agreement between neuromuscular block measured by compressomyography at the upper arm and electromyography at the adductor pollicis muscle in obese and non-obese patients, and found variable disagreement between the two methods. This may have consequences for decisions regarding reversal and extubation in clinical practice.

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Article Biochemical Research Methods

Detection of drug-specific immunoglobulin E (IgE) and acute mediator release for the diagnosis of immediate drug hypersensitivity reactions

Knut Brockow

Summary: Diagnosing drug hypersensitivity reactions is complex, involving skin tests and in vitro tests to detect sensitization. Sensitivity of in vitro tests for specific IgE depends on the drug, and caution is advised in interpreting the results. Clear medical decisions and further research are needed.

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The Nonirritating Concentrations of Neuromuscular Blocking Agents and Related Compounds

Alexei Gonzalez-Estrada, Ismael Carrillo-Martin, Dan Morgenstern-Kaplan, W. Tatiana Garzon-Siatoya, J. Ross Renew, Vivian Hernandez-Torres, Gerald W. Volcheck

Summary: This study aimed to determine the maximal nonirritant concentrations (NICs) of neuromuscular blocking agents (NMBAs), NMBA-reversal agents, and the sugammadex-rocuronium inclusion complex (SR-Cx) in NMBA-tolerant and NMBA-naive participants. The results showed that undiluted concentrations of skin prick testing (SPT) were nonirritant and could be used for testing. The study also proposed increasing the currently recommended maximal intradermal test (IDT) NICs for succinylcholine, neostigmine, sugammadex, and S-R-Cx, while decreasing the maximal IDT NIC of vecuronium compared to current guidelines and prior reports.

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Dosing of neuromuscular blocking agents in patients with obesity: A narrative review

Brian L. Erstad, Jeffrey F. Barletta

Summary: The choice of weight descriptor for weight-based dosing of neuromuscular blocking agents in patients with obesity remains a topic of debate, with actual body weight recommended for succinylcholine and ideal body weight or adjusted body weight recommended for non-depolarising NMBAs. Studies conducted in perioperative settings have evaluated single doses or short-term infusions of NMBAs in obese patients, with the understanding that final dosing regimens must consider patient-specific factors.

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How to Prevent and Mitigate Hypersensitivity Reactions to Biologicals Induced by Anti-Drug Antibodies?

Alessandra Vultaggio, Margherita Perlato, Francesca Nencini, Emanuele Vivarelli, Enrico Maggi, Andrea Matucci

Summary: Biologicals are commonly used for rheumatologic diseases, cancers, and chronic inflammatory conditions, but they may lead to the development of anti-drug antibodies (ADA), limiting their clinical usage due to safety concerns. Strategies such as concomitant immunosuppressive treatment and regular infusion regimens can help reduce the risk of immediate hypersensitivity reactions (HSRs) associated with ADA. Drug desensitization (DD) may be considered for patients needing reintroduction of the biological culprit, especially in cases of IgE-mediated HSRs, potentially inhibiting mast cell degranulation and cytokine production.

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