Drug allergy concern: guselkumab
Question:
11/1/2018
I was referred a complicated patient with h/o multiple drug sensitivities (some likely IgE mediated, others clearly not) by her rheumatologist for evaluation (skin test) of possible sensitivity to guselkumab (Tremfaya). Any suggestions/references on non-irritating concentrations for prick and ID testing to help r/o likelihood of IgE sensitivity to this biological?
Answer:
I consulted Mariana Castells, MD, PhD, Director of Drug Hypersensitivity and Desensitization Center at Brigham and Women’s Hospital. I am grateful to Dr Castells for her response.
According to Dr Castells, reactions to guselkumab are rare and there are no reports of anaphylaxis. Although it is a fully human IgG1lambda anti-IL23 monoclonal antibody, patients who have received other IgG1lambda monoclonal antibodies may become sensitized since allergenic carbohydrate epitopes have been described with fully human therapeutic monoclonal antibodies (Isabwe et al JACI 2018). The most common side effects of guselkumab include infections and local reactions, for which the rate is increased as compared to other subcutaneous MoAbs at 4.5%, as reported by the FDA. Skin testing is recommended with the full concentration for prick testing and with 1/100 and 1/10 dilutions for intradermal testing. There is no reported skin toxicity or irritant effect. The positive and negative predictive values of skin tests to this medication are not known since it is a new medication, but a positive skin test with a negative control would be suggestive of IgE sensitization and would require either avoidance of the medication or desensitization.
I hope that this information is useful to you.
Jacqueline A. Pongracic, MD, FAAAAI