Q:

I have a 57y/o pt. who had anaphlaxis requiring ICU care during a bowel prep with polyethylene glycol. Subsequently, PEG was avoided, but she went into shock during colonoscopy due to unlisted PEG in the lubricant. She required an IV epi drip and glucagon (because she is on a Beta blocker for ASHD) and was hospitalized for 2 days. She then stopped taking Multaq and Aldactone because they contain PEG, although she had not reacted to them. I'm aware of previous case reports regarding bowel preps, but don't know how to advise her about other meds with PEG.

A:

Thank you for your recent inquiry.

Anaphylaxis to polyethylene glycol ingestion is well recognized. Copied below for your convenience is a very extensive case report as well as a reference to another such report.

Unfortunately as you can see from reading the first case, polyethylene glycols are somewhat ubiquitous and very difficult to avoid. Evidently, based upon your patient's ability to ingest small amounts contained in excipients, the phenomenon in her case is dose related. Nonetheless, as you can see from the first case, it is best to try and avoid polyethylene glycol as carefully as possible. This is a difficult task given the ubiquitous nature of these substances, but it is clearly the safest strategy to employ.

Thank you again for your inquiry and we hope this response is helpful to you.

ALLERGY 62 (1) pages 92,3 2007

We reported an anaphylaxis after oral intake and contact urticaria due to polyethylene glycols.

Polyethylene glycols (PEGs) or macrogols are hydrophilic substances used in many drugs and cosmetics. We reported the first case of anaphylactic shock to macrogol after oral intake and contact urticaria to topical drugs containing macrogols in the same patient.

A 58-year-old man consulted for an anaphylactic shock in 2002 30 min after oral intake of citrate de betaine UPSA® effervescent tablets (UPSA, Agen, France) for dyspepsia. He reported also several reactions of immediate contact urticaria after using corticosteroid creams betneval® (betamethasone valerate; GlaxoSmithKline, Marly-le-Roi, France) and nerisone® (diflucortolone valerate; Schering SA, Lys-lez-Cannoy, France) in 2005 for an eczema. In 1995, he presented a maculopapulous exanthema after oral intake of penglobe® (bacampicillin; AstraZeneca, Rueil-Malmaison, France). He was considered to be allergic to aminopenicillins.

Patch testing with the European standard series, corticosteroid series and the used topical drugs were all negative at 30 min, 48 and 72 h (except Myroxylon Pereirae and fragrance mix with a past relevance).

Then, we performed prick tests. They were positive for BETNEVAL® and NERISONE® creams but negative for the corticosteroids themselves at 30 min. The only two common ingredients of these creams were macrogol (cetomacrogol 1000 in BETNEVAL® cream and macrogol stearate 40 in NERISONE® cream) and stearylic alcohol.

Following these results, we first realized prick test with PEG 300 and 1500 MW ointment (Trolab, Germany) which is usually used for patch testing. It was positive at 30 min. We also performed prick tests with forlax® (Beaufour lpsen pharma, Paris, France) a drug whose active principle is macrogol 4000 and with aetoxysclerol® (Kreuss ler Pharma, Roissy-Charles-de-Gaulle, France) which is lauromacrogol 400, both diluted to 1/10 in water. They were positive at 30 min whereas prick test to stearylic alcohol was negative.

Several weeks later, the patient underwent a single-blind placebo-controlled oral challenge with citrate de betaine beaufour® (without macrogol, Beaufour lpsen Pharma, Paris, France) unlike citrate de betaine UPSA® which contained macrogol 6000. This test was negative. Our patient was probably not allergic to bacampicillin but to macrogol 6000 present in penglobe® (not available nowadays) because allergological tests to penicillins (including oral challenge to ampicillin) were negative.

We concluded to an immediate hypersensitivity to macrogol or PEG. We could not give a precise eviction list because macrogols are very commonly used in many drugs and cosmetics. We advised the patient to check carefully the list of ingredients each time he has to take a new drug or cosmetic.

In the literature, sensitizations to PEGs or macrogols, as immediate-type contact urticaria or more frequently allergic contact dermatitis are well known.

Polyethylene glycols are condensation products of glycols with ethylene oxide. Their chemical formula is HO (CH2 CH2)× OH. Their molecular weights varied from 200 to 700 Da in a liquid form to 1000–6000 Da in a solid form, according to the condensation degree. Polyethylene glycols of weak molecular weight (200–400 Da) have a greater sensitization capacity (1). Our patient had immediate reactions both to weak and high-molecular weight PEGs, which is not usual.

Polyethylene glycols are used as solvent and excipient in topical or systemic drugs, as active principle of drugs, in electrodes gels, insect repulsives, cosmetic and hygiene products, cutting fluids, glue and epoxy hardeners (plasticizers; 1). There are many PEGs derivatives, such as cetomacrogol, lauromacrogol, nonoxynol.

One case of anaphylaxis to macrogol after an intra-articular injection of corticoid has been reported (2). We found rare reports of bronchospasm, anaphylaxis, urticaria or angioedema after ingestion of PEGs solutions for preparation before coloscopy but no allergological exploration was made (3).

This observation underlined that allergy to excipients even if it is a rare event should be considered, a fortiori if there are multiple allergic reactions. To our knowledge, it is the first case of anaphylactic shock to macrogol after oral intake and contact urticaria to topical drugs containing macrogols in the same patient.

We reported an anaphylaxis after oral intake and contact urticaria due to polyethylene glycols.

Polyethylene glycols (PEGs) or macrogols are hydrophilic substances used in many drugs and cosmetics. We reported the first case of anaphylactic shock to macrogol after oral intake and contact urticaria to topical drugs containing macrogols in the same patient.

A 58-year-old man consulted for an anaphylactic shock in 2002 30 min after oral intake of citrate de betaine UPSA® effervescent tablets (UPSA, Agen, France) for dyspepsia. He reported also several reactions of immediate contact urticaria after using corticosteroid creams betneval® (betamethasone valerate; GlaxoSmithKline, Marly-le-Roi, France) and nerisone® (diflucortolone valerate; Schering SA, Lys-lez-Cannoy, France) in 2005 for an eczema. In 1995, he presented a maculopapulous exanthema after oral intake of penglobe® (bacampicillin; AstraZeneca, Rueil-Malmaison, France). He was considered to be allergic to aminopenicillins.

Patch testing with the European standard series, corticosteroid series and the used topical drugs were all negative at 30 min, 48 and 72 h (except Myroxylon Pereirae and fragrance mix with a past relevance).

Then, we performed prick tests. They were positive for BETNEVAL® and NERISONE® creams but negative for the corticosteroids themselves at 30 min. The only two common ingredients of these creams were macrogol (cetomacrogol 1000 in BETNEVAL® cream and macrogol stearate 40 in NERISONE® cream) and stearylic alcohol.

Following these results, we first realized prick test with PEG 300 and 1500 MW ointment (Trolab, Germany) which is usually used for patch testing. It was positive at 30 min. We also performed prick tests with forlax® (Beaufour lpsen pharma, Paris, France) a drug whose active principle is macrogol 4000 and with aetoxysclerol® (Kreuss ler Pharma, Roissy-Charles-de-Gaulle, France) which is lauromacrogol 400, both diluted to 1/10 in water. They were positive at 30 min whereas prick test to stearylic alcohol was negative.

Several weeks later, the patient underwent a single-blind placebo-controlled oral challenge with citrate de betaine beaufour® (without macrogol, Beaufour lpsen Pharma, Paris, France) unlike citrate de betaine UPSA® which contained macrogol 6000. This test was negative. Our patient was probably not allergic to bacampicillin but to macrogol 6000 present in penglobe® (not available nowadays) because allergological tests to penicillins (including oral challenge to ampicillin) were negative.

We concluded to an immediate hypersensitivity to macrogol or PEG. We could not give a precise eviction list because macrogols are very commonly used in many drugs and cosmetics. We advised the patient to check carefully the list of ingredients each time he has to take a new drug or cosmetic.

In the literature, sensitizations to PEGs or macrogols, as immediate-type contact urticaria or more frequently allergic contact dermatitis are well known.

Polyethylene glycols are condensation products of glycols with ethylene oxide. Their chemical formula is HO (CH2 CH2)× OH. Their molecular weights varied from 200 to 700 Da in a liquid form to 1000–6000 Da in a solid form, according to the condensation degree. Polyethylene glycols of weak molecular weight (200–400 Da) have a greater sensitization capacity (1). Our patient had immediate reactions both to weak and high-molecular weight PEGs, which is not usual.

Polyethylene glycols are used as solvent and excipient in topical or systemic drugs, as active principle of drugs, in electrodes gels, insect repulsives, cosmetic and hygiene products, cutting fluids, glue and epoxy hardeners (plasticizers; 1). There are many PEGs derivatives, such as cetomacrogol, lauromacrogol, nonoxynol.

One case of anaphylaxis to macrogol after an intra-articular injection of corticoid has been reported (2). We found rare reports of bronchospasm, anaphylaxis, urticaria or angioedema after ingestion of PEGs solutions for preparation before coloscopy but no allergological exploration was made (3).

This observation underlined that allergy to excipients even if it is a rare event should be considered, a fortiori if there are multiple allergic reactions. To our knowledge, it is the first case of anaphylactic shock to macrogol after oral intake and contact urticaria to topical drugs containing macrogols in the same patient.

We reported an anaphylaxis after oral intake and contact urticaria due to polyethylene glycols.

Polyethylene glycols (PEGs) or macrogols are hydrophilic substances used in many drugs and cosmetics. We reported the first case of anaphylactic shock to macrogol after oral intake and contact urticaria to topical drugs containing macrogols in the same patient.

A 58-year-old man consulted for an anaphylactic shock in 2002 30 min after oral intake of citrate de betaine UPSA® effervescent tablets (UPSA, Agen, France) for dyspepsia. He reported also several reactions of immediate contact urticaria after using corticosteroid creams betneval® (betamethasone valerate; GlaxoSmithKline, Marly-le-Roi, France) and nerisone® (diflucortolone valerate; Schering SA, Lys-lez-Cannoy, France) in 2005 for an eczema. In 1995, he presented a maculopapulous exanthema after oral intake of penglobe® (bacampicillin; AstraZeneca, Rueil-Malmaison, France). He was considered to be allergic to aminopenicillins.

Patch testing with the European standard series, corticosteroid series and the used topical drugs were all negative at 30 min, 48 and 72 h (except Myroxylon Pereirae and fragrance mix with a past relevance).

Then, we performed prick tests. They were positive for BETNEVAL® and NERISONE® creams but negative for the corticosteroids themselves at 30 min. The only two common ingredients of these creams were macrogol (cetomacrogol 1000 in BETNEVAL® cream and macrogol stearate 40 in NERISONE® cream) and stearylic alcohol.

Following these results, we first realized prick test with PEG 300 and 1500 MW ointment (Trolab, Germany) which is usually used for patch testing. It was positive at 30 min. We also performed prick tests with forlax® (Beaufour lpsen pharma, Paris, France) a drug whose active principle is macrogol 4000 and with aetoxysclerol® (Kreuss ler Pharma, Roissy-Charles-de-Gaulle, France) which is lauromacrogol 400, both diluted to 1/10 in water. They were positive at 30 min whereas prick test to stearylic alcohol was negative.

Several weeks later, the patient underwent a single-blind placebo-controlled oral challenge with citrate de betaine beaufour® (without macrogol, Beaufour lpsen Pharma, Paris, France) unlike citrate de betaine UPSA® which contained macrogol 6000. This test was negative. Our patient was probably not allergic to bacampicillin but to macrogol 6000 present in penglobe® (not available nowadays) because allergological tests to penicillins (including oral challenge to ampicillin) were negative.

We concluded to an immediate hypersensitivity to macrogol or PEG. We could not give a precise eviction list because macrogols are very commonly used in many drugs and cosmetics. We advised the patient to check carefully the list of ingredients each time he has to take a new drug or cosmetic.

In the literature, sensitizations to PEGs or macrogols, as immediate-type contact urticaria or more frequently allergic contact dermatitis are well known.

Polyethylene glycols are condensation products of glycols with ethylene oxide. Their chemical formula is HO (CH2 CH2)× OH. Their molecular weights varied from 200 to 700 Da in a liquid form to 1000–6000 Da in a solid form, according to the condensation degree. Polyethylene glycols of weak molecular weight (200–400 Da) have a greater sensitization capacity (1). Our patient had immediate reactions both to weak and high-molecular weight PEGs, which is not usual.

Polyethylene glycols are used as solvent and excipient in topical or systemic drugs, as active principle of drugs, in electrodes gels, insect repulsives, cosmetic and hygiene products, cutting fluids, glue and epoxy hardeners (plasticizers; 1). There are many PEGs derivatives, such as cetomacrogol, lauromacrogol, nonoxynol.

One case of anaphylaxis to macrogol after an intra-articular injection of corticoid has been reported (2). We found rare reports of bronchospasm, anaphylaxis, urticaria or angioedema after ingestion of PEGs solutions for preparation before coloscopy but no allergological exploration was made (3).

This observation underlined that allergy to excipients even if it is a rare event should be considered, a fortiori if there are multiple allergic reactions. To our knowledge, it is the first case of anaphylactic shock to macrogol after oral intake and contact urticaria to topical drugs containing macrogols in the same patient.

Allergy. 2006 Aug;61(8):1021.
Two cases of anaphylaxis to macrogol 6000 after ingestion of drug tablets.
Hyry H, Vuorio A, Varjonen E, Skyttä J, Mäkinen-Kiljunen S.

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology