Immunoglobulin E Antibodies to Rocuronium

Background Diagnosis of allergy from neuromuscular blocking agents is not always straightforward. The objectives of the current study were to investigate the value of quantification of immunoglobulin E (IgE) by ImmunoCAP (Phadia AB, Uppsala, Sweden) in the diagnosis of rocuronium allergy and to study whether IgE inhibition tests can predict clinical cross-reactivity between neuromuscular blocking agents. Methods Twenty-five rocuronium-allergic patients and 30 control individuals exposed to rocuronium during uneventful anesthesia were included. Thirty-two sera (total IgE > 1,500 kU/l) were analyzed for potential interference of elevated total IgE titers. Results were compared with quantification of IgE for suxamethonium, morphine, and pholcodine. Cross-reactivity between drugs was assessed by IgE inhibition and skin tests. Results Sensitivity of IgE for rocuronium, suxamethonium, morphine, and pholcodine was 68, 60, 88, and 86%, respectively. Specificity was 100% for suxamethonium, morphine, and pholcodine IgE and 93% for rocuronium IgE. ROC analysis between patients and control individuals changed the threshold to 0.13 kUa/l for rocuronium, 0.11 kUa/l for suxamethonium, 0.36 kUa/l for morphine, and 0.43 kUa/l for pholcodine. Corresponding sensitivity was 92, 72, 88, and 86%, respectively. Specificity was unaltered. Interference of elevated total IgE with quantification of IgE was demonstrated by the analysis in sera with a total IgE greater than 1,500 kU/l. IgE inhibition did not predict clinical relevant cross-reactivity. Conclusions The rocuronium ImmunoCAP constitutes a reliable technique to diagnose rocuronium allergy, provided an assay-specific decision threshold is applied. IgE assays based on compounds bearing ammonium epitopes are confirmed to represent reliable tools to diagnose rocuronium allergy. High total IgE titers were observed to affect specificity of the assays.

Download Full-text

Anaphylaxis during Anesthesia in Norway

Anesthesiology ◽

10.1097/00000542-200505000-00006 ◽

2005 ◽

Vol 102 (5) ◽

pp. 897-903 ◽

Cited By ~ 136

Author(s):

Torkel Harboe ◽

Anne Berit Guttormsen ◽

Aagot Irgens ◽

Turid Dybendal ◽

Erik Florvaag

Keyword(s):

General Anesthesia ◽

Network Formation ◽

Immunoglobulin E ◽

Neuromuscular Blocking ◽

Neuromuscular Blocking Agents ◽

Skin Tests ◽

Blocking Agents ◽

High Prevalence ◽

Special Concern

Background Several studies have recognized neuromuscular blocking agents as the most common cause of anaphylaxis during general anesthesia, but the reported frequencies vary considerably between countries. In Norway, the issue has raised special concern because of reports from the Norwegian Medicines Agency that suggest a high prevalence. This article presents the results from a standardized allergy follow-up examination of 83 anaphylactic reactions related to general anesthesia performed at one allergy center in Bergen, Norway. Methods Eighty-three cases were examined during the 6-yr period of 1996-2001. The diagnostic protocol consisted of case history, serum tryptase measurements, specific immunoassays, and skin tests. Results Immunoglobulin E-mediated anaphylaxis was established in 71.1% of the cases, and neuromuscular blocking agents were by far the most frequent allergen (93.2%). Suxamethonium was the most frequently involved substance, followed by rocuronium and vecuronium. The few reactions in which other allergies could be detected were mainly linked to latex (3.6%). Conclusions Neuromuscular blocking agents were the dominating antigens causing immunoglobulin E-mediated anaphylaxis in this study. The data could not be used for estimation of the incidence of allergy toward neuromuscular blocking agents in Norway. Larger patient samples, standardization of reporting, and diagnostic protocols should be pursued by network formation to produce data more suitable for epidemiologic research.

Download Full-text

Assessing cross-reactivity to neuromuscular blocking agents by skin and basophil activation tests in patients with neuromuscular blocking agent anaphylaxis

British Journal of Anaesthesia ◽

10.1016/j.bja.2019.03.001 ◽

2019 ◽

Vol 123 (1) ◽

pp. e144-e150 ◽

Cited By ~ 5

Author(s):

Jamma Li ◽

Oliver G. Best ◽

Michael A. Rose ◽

Sarah L. Green ◽

Richard B. Fulton ◽

...

Keyword(s):

Blocking Agent ◽

Cross Reactivity ◽

Neuromuscular Blocking ◽

Neuromuscular Blocking Agent ◽

Neuromuscular Blocking Agents ◽

Basophil Activation ◽

Blocking Agents

Download Full-text

Evaluation of a New Routine Diagnostic Test for Immunoglobulin E Sensitization to Neuromuscular Blocking Agents

Anesthesiology ◽

10.1097/aln.0b013e31820164d2 ◽

2011 ◽

Vol 114 (1) ◽

pp. 91-97 ◽

Cited By ~ 52

Author(s):

Dominique Laroche ◽

Sylvie Chollet-Martin ◽

Pierre Léturgie ◽

Laure Malzac ◽

Marie-Claude Vergnaud ◽

...

Keyword(s):

Skin Test ◽

Quaternary Ammonium ◽

Immunoglobulin E ◽

Solid Phase ◽

Specific Ige ◽

Neuromuscular Blocking ◽

Neuromuscular Blocking Agents ◽

Skin Tests ◽

Hypersensitivity Reactions ◽

Immediate Hypersensitivity

Background Neuromuscular blocking agents (NMBA) are responsible for most immediate hypersensitivity reactions during anesthesia, as a result of the presence of a quaternary ammonium ion. The aim of this study was to evaluate the diagnostic performance of a commercial immunoglobulin E (IgE) test (quaternary ammonium morphine [QAM]) for diagnosing sensitivity to NMBA. Methods We tested 168 patients exposed to NMBAs during anesthesia. Of those patients, 54 had an uneventful procedure and 114 had immediate hypersensitivity reactions, and 57 patients had positive skin tests to the administered NMBA, whereas 57 had negative skin tests. Specific IgE concentrations determined with the QAM method based on a morphine solid phase were compared with those obtained with a recommended experimental method with a choline solid phase. Results For the QAM test, a 0.35 kUA/l positivity cutoff was chosen from the receiver operating characteristics curve. QAM-specific IgE was found in 84.2% of skin test-positive reactors (80.7% with the recommended method; no significant difference), and binding was inhibited by the culprit NMBA in 80% of cases. The frequency of QAM-specific IgE positivity was significantly higher in skin test-negative reactors (24.6%) than in controls (9.3%), suggesting NMBA sensitivity. Conclusion Sensitivity of the QAM test (84.2%), together with its simplicity and suitability for routine laboratory use, makes it a valuable tool, in conjunction with skin tests, for diagnosing NMBA sensitivity in patients who react after NMBA injection. The QAM test is of particular interest when skin tests are not available or not reliable or give results poorly compatible with mediator release or clinical features.

Download Full-text

Anaphylactic and Anaphylactoid Reactions Occurring during Anesthesia in France in 1999–2000

Anesthesiology ◽

10.1097/00000542-200309000-00007 ◽

2003 ◽

Vol 99 (3) ◽

pp. 536-545 ◽

Cited By ~ 380

Author(s):

Paul Michel Mertes ◽

Marie-Claire Laxenaire ◽

François Alla ◽

Keyword(s):

Predictive Value ◽

Immunoglobulin E ◽

Clinical Manifestations ◽

Clinical History ◽

Diagnostic Value ◽

Cross Reactivity ◽

Neuromuscular Blocking ◽

Skin Tests ◽

Expert Advice ◽

Anaphylactoid Reactions

Background Anaphylactic and anaphylactoid reactions occurring during anesthesia remain a major cause of concern for anesthesiologists. The authors report the results of a 2-yr survey of such reactions observed during anesthesia in France. Methods Between January 1, 1999, and December 31, 2000, 789 patients who experienced immune-mediated (anaphylaxis) or nonimmune-mediated (anaphylactoid) reactions were referred to one of the 40 participating centers. Anaphylaxis was diagnosed on the basis of clinical history, skin tests, and/or specific immunoglobulin E assay. Results Anaphylactic and anaphylactoid reactions were diagnosed in 518 cases (66%) and 271 cases (34%), respectively. The most common causes of anaphylaxis were neuromuscular blocking agents (NMBAs) (n = 306, 58.2%), latex (n = 88, 16.7%), and antibiotics (n = 79, 15.1%). Rocuronium (n = 132, 43.1%) and succinylcholine (n = 69, 22.6%) were the most frequently incriminated NMBAs. Cross-reactivity between NMBAs was observed in 75.1% of cases of anaphylaxis to an NMBA. No difference was observed between anaphylactoid and anaphylactic reactions when the incidences of atopy, asthma, or drug intolerance were compared. However, atopy, asthma, and food allergy were significantly more frequent in the case of latex allergy when compared with NMBA allergy. Clinical manifestations were more severe in anaphylaxis. The positive predictive value of tryptase for the diagnosis of anaphylaxis was 92.6%; the negative predictive value was 54.3%. The diagnostic value of specific NMBA immunoglobulin E assays was confirmed. Conclusions These results further corroborate the need for systematic screening in the case of anaphylactoid reaction during anesthesia and for the constitution of allergoanesthesia centers to provide expert advice to anesthesiologists and allergists.

Download Full-text