5.1. Key priorities for implementation
From the full set of recommendations, the GDG selected 11 key priorities for implementation. The criteria used for selecting these recommendations are listed in detail in The guidelines manual (2012).125 The reasons behind selection of each of these recommendations are shown in the table linking the evidence to the recommendation in the relevant chapter.
Assessment
- When assessing a person presenting with possible drug allergy, take a history and undertake a clinical examination. Use the following boxes as a guide when deciding whether to suspect drug allergy.
Boxes 1–3 Signs and allergic patterns of suspected drug allergy with timing of onseta
Box 1
Immediate, rapidly evolving reactions.
Box 2
Non-immediate reactions without systemic involvement.
Box 3
Non-immediate reactions with systemic involvement.
Documenting and sharing information with other healthcare professionals
Documenting new suspected drug allergic reactions
- 2.
When a person presents with suspected drug allergy, document their reaction in a structured approach that includes:
- -
the generic and proprietary name of the drug or drugs suspected to have caused the reaction, including the strength and formulation
- -
a description of the reaction (see recommendation 1)
- -
the indication for the drug being taken (if there is no clinical diagnosis, describe the illness)
- -
the date and time of the reaction
- -
the number of doses taken or number of days on the drug before onset of the reaction
- -
the route of administration
- -
which drugs or drug classes to avoid in future.
Maintaining and sharing drug allergy information
- 3.
Prescriptions (paper or electronic) issued in any healthcare setting should be standardised and redesigned to record information on which drugs or drug classes to avoid to reduce the risk of drug allergy.
- 4.
Check a person's drug allergy status and confirm it with them (or their family members or carers as appropriate) before prescribing, dispensing or administering any drug (see also recommendation 20). Update the person's medical records or inform their GP if there is a change in drug allergy status.
Providing information and support to patients
- 5.
Discuss the person's suspected drug allergy with them (and their family members or carers as appropriate) and provide structured written information (see recommendation 10). Record who provided the information and when.
- 6.
Ensure that the person (and their family members or carers as appropriate) is aware of the drugs or drug classes that they need to avoid, and advise them to check with a pharmacist before taking any over-the-counter preparations.
Providing information and support to people who have had specialist drug allergy investigations
- 7.
Allergy specialists should give the following written information to people who have undergone specialist drug allergy investigation:
- -
the diagnosis – whether they had an allergic or non-allergic reaction
- -
the drug name and a description of their reaction (see recommendation 1)
- -
the investigations used to confirm or exclude the diagnosis
- -
drugs or drug classes to avoid in future
- -
any safe alternative drugs that may be used.
Non-specialist management and referral to specialist services
General
- 8.
Refer people to a specialist drug allergy service if they have had:
- -
a suspected anaphylactic reaction (also see Anaphylaxis, NICE clinical guideline 134) or
- -
a severe non-immediate cutaneous reaction (for example, drug reaction with eosinophilia and systemic symptoms [DRESS], Stevens–Johnson Syndrome, toxic epidermal necrolysis).
Non-steroidal anti-inflammatory drugs (including selective cyclooxygenase 2 inhibitors)
- 9.
For people who have had a mild allergic reaction to a non-selective NSAID but need an anti-inflammatory:
- -
discuss the benefits and risks of selective cyclooxygenase 2 (COX-2) inhibitors (including the low risk of drug allergy)
- -
consider introducing a selective COX-2 inhibitor at the lowest starting dose with only a single dose on the first day.
Beta-lactam antibiotics
- 10.
Refer people with a suspected allergy to beta-lactam antibiotics to a specialist drug allergy service if they:
- -
need treatment for a disease or condition that can only be treated by a beta-lactam antibiotic or
- -
are likely to need beta-lactam antibiotics frequently in the future (for example, people with recurrent bacterial infections or immune deficiency).
General anaesthesia
- 11.
Refer people to a specialist drug allergy service if they have had anaphylaxis or another suspected allergic reaction during or immediately after general anaesthesia.
5.2. Full list of recommendations
Assessment
- When assessing a person presenting with possible drug allergy, take a history and undertake a clinical examination. Use the following boxes as a guide when deciding whether to suspect drug allergy.
Boxes 1–3 Signs and allergic patterns of suspected drug allergy with timing of onsetb
- 2.
Be aware that the reaction is more likely to be caused by drug allergy if it occurred during or after use of the drug and:
- the drug is known to cause that type of reaction or
- the person has previously had a similar reaction to that drug or drug class.
- 3.
Be aware that the reaction is less likely to be caused by drug allergy if:
- there is a possible non-drug cause for the person's symptoms (for example, they have had similar symptoms when not taking the drug) or
- the person has gastrointestinal symptoms only.
Measuring serum tryptase after suspected anaphylaxis
- 4.
After a suspected drug-related anaphylactic reaction, take 2 blood samples for mast cell tryptase in line with recommendations in Anaphylaxis (NICE clinical guideline 134).
- 5.
Record the exact timing of both blood samples taken for mast cell tryptase:
- in the person's medical records and
- on the pathology request form.
- 6.
Ensure that tryptase sampling tubes are included in emergency anaphylaxis kits.
Measuring serum specific immunoglobulin E
- 7.
Do not use blood testing for serum specific immunoglobulin E (IgE) to diagnose drug allergy in a non-specialist setting.
Documenting and sharing information with other healthcare professionals
Recording drug allergy status
- 8.
Document people's drug allergy status in their medical records using 1 of the following:
- ‘drug allergy’
- ‘none known’
- ‘unable to ascertain’ (document it as soon as the information is available).
- 9.
If drug allergy status has been documented, record all of the following at a minimum:
- the drug name
- the signs, symptoms and severity of the reaction (see recommendation 1)
- the date when the reaction occurred.
Documenting new suspected drug allergic reactions
- 10.
When a person presents with suspected drug allergy, document their reaction in a structured approach that includes:
- the generic and proprietary name of the drug or drugs suspected to have caused the reaction, including the strength and formulation
- a description of the reaction (see recommendation 1)
- the indication for the drug being taken (if there is no clinical diagnosis, describe the illness)
- the date and time of the reaction
- the number of doses taken or number of days on the drug before onset of the reaction
- the route of administration
- which drugs or drug classes to avoid in future.
Maintaining and sharing drug allergy information
- 11.
Prescriptions (paper or electronic) issued in any healthcare setting should be standardised and redesigned to record information on which drugs or drug classes to avoid to reduce the risk of drug allergy.
- 12.
Ensure that drug allergy status is documented separately from adverse drug reactions and that it is clearly visible to all healthcare professionals who are prescribing drugs.
- 13.
Check a person's drug allergy status and confirm it with them (or their family members or carers as appropriate) before prescribing, dispensing or administering any drug (see also recommendation 20). Update the person's medical records or inform their GP if there is a change in drug allergy status.
- 14.
Ensure that information about drug allergy status is updated and included in all:
- GP referral letters
- hospital discharge letters
- 15.
Carry out medicines reconciliation for people admitted to hospital in line with recommendations in Technical patient safety solutions for medicines reconciliation on admission of adults to hospital (NICE patient safety solutions guidance 1).
Documenting information after specialist drug allergy investigations
For recommendations on referral to specialist services see Chapter 12.
- 16.
After specialist drug allergy investigations, allergy specialists should document:
- the diagnosis, drug name and whether the person had an allergic or non-allergic reaction
- the investigations used to confirm or exclude the diagnosis
- drugs or drug classes to avoid in future.
Providing information and support to patients
- 17.
Discuss the person's suspected drug allergy with them (and their family members or carers as appropriate) and provide structured written information (see recommendation 10). Record who provided the information and when.
- 18.
Provide information in line with the recommendations in Patient experience in adult NHS services (NICE clinical guideline 138).
- 19.
Ensure that the person (and their family members or carers as appropriate) is aware of the drugs or drug classes that they need to avoid, and advise them to check with a pharmacist before taking any over-the-counter preparations.
- 20.
Advise people (and their family members or carers as appropriate) to carry information they are given about their drug allergy at all times and to share this whenever they visit a healthcare professional or are prescribed, dispensed or are about to be administered a drug.
Providing information and support to people who have had specialist drug allergy investigations
For recommendations on referral to specialist services see Chapter 12.
- 21.
Allergy specialists should give the following written information to people who have undergone specialist drug allergy investigation:
- the diagnosis – whether they had an allergic or non-allergic reaction
- the drug name and a description of their reaction (see recommendation 1)
- the investigations used to confirm or exclude the diagnosis
- drugs or drug classes to avoid in future
- any safe alternative drugs that may be used.
- 22.
Explain to people in whom allergy to a drug or drug class has been excluded by specialist investigation that they can now take this drug or drug class safely and ensure that their medical records are updated.
Non-specialist management and referral to specialist services
General
- 23.
If drug allergy is suspected:
- consider stopping the drug suspected to have caused the allergic reaction and advising the person to avoid that drug in future
- treat the symptoms of the acute reaction if needed; send people with severe reactions to hospital
- document details of the suspected drug allergy in the person's medical records (see recommendations 10 and 13)
- provide the person with information (see Chapter 10).
- 24.
Refer people to a specialist drug allergy service if they have had:
- a suspected anaphylactic reaction (also see Anaphylaxis, NICE clinical guideline 134) or
- a severe non-immediate cutaneous reaction (for example, drug reaction with eosinophilia and systemic symptoms [DRESS], Stevens–Johnson Syndrome, toxic epidermal necrolysis).
Non-specialist management: Non-steroidal anti-inflammatory drugs (including selective cyclooxygenase 2 inhibitors)
- 25.
Explain to people with a suspected allergy to a non-selective non-steroidal anti-inflammatory drug (NSAID) (and their family members or carers as appropriate) that in future they need to avoid all non-selective NSAIDs, including over-the-counter preparations.
- 26.
For people who have had a mild allergic reaction to a non-selective NSAID but need an anti-inflammatory:
- discuss the benefits and risks of selective cyclooxygenase 2 (COX-2) inhibitors (including the low risk of drug allergy)
- consider introducing a selective COX-2 inhibitor at the lowest starting dose with only a single dose on the first day.
- 27.
Do not offer a selective COX-2 inhibitor to people in a non-specialist setting if they have had a severe reaction, such as anaphylaxis, severe angioedema or an asthmatic reaction, to a non-selective NSAID.
Referral to specialist drug allergy services
- 28.
Refer people with a suspected allergy to beta-lactam antibiotics to a specialist drug allergy service if they:
- need treatment for a disease or condition that can only be treated by a beta-lactam antibiotic or
- are likely to need beta-lactam antibiotics frequently in the future (for example, people with recurrent bacterial infections or immune deficiency).
- 29.
Consider referring people to a specialist drug allergy service if they are not able to take beta-lactam antibiotics and at least 1 other class of antibiotic because of suspected allergy to these antibiotics.
- 30.
Refer people who need treatment with an NSAID to a specialist drug allergy service if they have had a suspected allergic reaction to an NSAID with symptoms such as anaphylaxis, severe angioedema or an asthmatic reaction.
- 31.
Be aware that people with asthma who also have nasal polyps are likely to have NSAID-sensitive asthma unless they are known to have tolerated NSAIDs in the last 12 months.
- 32.
Refer people to a specialist drug allergy service if they need a procedure involving a local anaesthetic that they are unable to have because of suspected allergy to local anaesthetics.
- 33.
Refer people to a specialist drug allergy service if they have had anaphylaxis or another suspected allergic reaction during or immediately after general anaesthesia.
5.3. Key research recommendations
5.3.1. Designing systems for documenting drug allergy
Which documentation strategies would be most clinically and cost effective to minimise the number of people who are re-exposed to drugs to which they have a suspected or confirmed allergy, looking in particular at:
- electronic health records that include features specifically designed to record and alert clinicians to drug allergy information, compared with systems without such features, and
- different formats for patient-held, structured drug allergy documentation?
5.3.2. Communicating information about drug allergy
In people with suspected or confirmed drug allergies, are patient-focused information strategies more effective than standard NHS practice in increasing people's likelihood of disclosing their drug allergy (or their suspected drug allergy) and therefore reducing the risk of being re-exposed to the affected drug?
5.3.3. Using selective cyclooxygenase 2 inhibitors in people with previous severe allergic reactions to non-selective non-steroidal anti-inflammatory drugs
Should all patients who have experienced a severe allergic reaction to a non-selective non-steroidal anti-inflammatory drug (NSAID) be assessed by specialist drug allergy services or should they be advised to take a selective cyclooxygenase 2 (COX-2) inhibitor without further investigations if clinically appropriate?
5.3.4. Oral antibiotic challenge for diagnosing antibiotic allergy in children
In children who have a suspected allergy to an antibiotic, is it clinically and cost effective to proceed directly (without prior skin or intradermal tests) to a diagnostic oral antibiotic challenge rather than referring them to specialist drug allergy services?
Footnotes
- a
Note that these boxes describe common and important presenting features of drug allergy but other presentations are also recognised
- b
Note that these boxes describe common and important presenting features of drug allergy but other presentations are also recognised
Publication Details
Copyright
Publisher
National Institute for Health and Care Excellence (NICE), London
NLM Citation
National Clinical Guideline Centre (UK). Drug Allergy: Diagnosis and Management of Drug Allergy in Adults, Children and Young People. London: National Institute for Health and Care Excellence (NICE); 2014 Sep. (NICE Clinical Guidelines, No. 183.) 5, Guideline summary.