PPI allergy, evaluation and alternate approach
Question:
12/10/2019
I have a patient with prior reaction (lip swelling; and biopsy of a lesion confirmed to be urticaria) to nexium approximately 10 years ago. This patient currently has bleeding duodenal ulcers and needs to be on a pantoprazole drip followed by oral treatment thereafter. In the literature, there is a desensitization protocol to oral omeprazole (Ref: Confino-Cohen, Goldberg (2006)). Any recent literature on a desensitization protocol to pantoprazole and specifically desensitization to use of pantoprazole drip thereafter. It appears that this would have to done IV given, since the tablets available are delayed release.
Answer:
Unfortunately, I do not know of an oral desensitization protocol available for oral desensitization of PPI. However, there may be an additional option as I have described below.
In Confino-Cohen, et al (1) only omeprazole and pantoprazole were addressed. Patrizia Bonadonna, et al (2) Looked at skin test validity for esoprazole, lansoprazole. omeprazole, pantoprazole and rabeprazole. They report positive predictive value of 100% and negative predictive value of 91.9%. Maybe more importantly, they reported cross-reactivity between pantoprazole and omeprazole (4 of 5 patients) and, more rarely, to esomeprazole. On the contrary, patient’s mono-sensitized to lansoprazole and rabeprazole, which have a different side chain, had negative test results with omeprazole, pantoprazole, and esomeprazole. (1)
Following the skin test protocol described by Bonadonna, et al, if your patient is negative for lansoprazole or rabeprazole, either of these may be suitable choices for a 2 day oral challenge rather than an IV desensitization protocol, especially since your patient’s reaction was limited to the skin.
In summary, it may be reasonable to consider skin testing your patient with lansoprazole or rabeprazole and if negative proceeding with an oral challenge with either lansoprazole or rabeprazole.
(1) Confino-Cohen, Goldberg. Anaphylaxis to omeprazole: diagnosis and desensitization protocol Ann Allergy Asthma Immunol. 2006;96:33–36.
(2) Patrizia Bonadonna, Hypersensitivity to proton pump inhibitors: Diagnostic accuracy of skin tests compared to oral provocation test. J ALLERGY CLIN IMMUNOL VOLUME 130, NUMBER 2
Respectfully submitted Jeffrey G Demain, MD, FAAAAI