Successful outpatient graded administration of trimethoprim-sulfamethoxazole in patients without HIV and with a history of sulfonamide adverse drug reaction

• Published in: The journal of allergy and clinical immunology in practice (Cambridge, MA) Vol. 2; no. 1; p. 52
• Main Authors: Pyle, Regan C, Butterfield, Joseph H, Volcheck, Gerald W, Podjasek, Jenna C, Rank, Matthew A, Li, James T C, Harish, Amitha, Poe, Kimberly L, Park, Miguel A
• Format: Journal Article
• Language: English
• Published: United States 01.01.2014
• Subjects: Adult; Aged; Allergy and Immunology; Ambulatory Care; Anti-Infective Agents - administration & dosage; Anti-Infective Agents - adverse effects; Anti-Infective Agents - immunology; Desensitization, Immunologic - adverse effects; Desensitization, Immunologic - methods; Drug Administration Schedule; Drug Hypersensitivity - diagnosis; Drug Hypersensitivity - etiology; Drug Hypersensitivity - immunology; Drug Hypersensitivity - prevention & control; Female; Humans; Male; Middle Aged; Retrospective Studies; Time Factors; Treatment Outcome; Trimethoprim, Sulfamethoxazole Drug Combination - administration & dosage; Trimethoprim, Sulfamethoxazole Drug Combination - adverse effects; Trimethoprim, Sulfamethoxazole Drug Combination - immunology; Trimethoprim-sulfamethoxazole; Drug intolerance; TMP-SMX; Graded challenge; Immunologic; Pneumocystis carinii pneumonia; Orally; Adverse drug reaction; Drug hypersensitivity; PCP; ADR; PO
• ISSN: 2213-2198
• DOI: 10.1016/j.jaip.2013.11.002

The outcomes of trimethoprim-sulfamethoxazole (TMP-SMX) desensitization have been widely reported in the HIV literature but less so in the non-HIV literature. To evaluate the safety and efficacy of graded administration of TMP-SMX in patients without HIV and with a history of TMP-SMX adverse drug reaction (ADR). A retrospective chart review, 2004-2012, of all the patients without HIV seen in the Division of Allergic Diseases and with a history of TMP-SMX ADR who underwent outpatient graded administration of TMP-SMX was conducted. The medical record was reviewed for age, sex, details of the initial ADR to TMP-SMX, an indication for TMP-SMX administration, and outcome. Patients also were contacted by telephone, and medical records were reviewed to determine long-term outcomes. Seventy-two patients (46 women [64%]; mean [SD] age, 57.7 ± 13.89 years]) were included. The most common patient-reported reactions to TMP-SMX were rash 39 (54%), and hives 9 (13%). TMP-SMX administration was needed for the following indications: prophylaxis (62 [86%]) and treatment of infection (10 [14%]). Forty-three of the patients (60%) underwent a 1-day TMP-SMX administration protocol. Thirty-five of the 43 (81%) underwent a 6-step (90 minutes to 6 hours) protocol and 7 of the 43 (16%) underwent a novel 14-step TMP-SMX protocol. Twenty-nine (40%) underwent a >1-day TMP-SMX administration protocol. Our overall success rate was 90% (mean duration of 11 months). Ninety-eight percent of the patients successfully completed a 1-day graded administration protocol, and 76% successfully completed a >1-day protocol. TMP-SMX was stopped in 8 patients because of the ADR. We report the largest case series of successful outpatient graded administration of TMP-SMX with both 1-day and >1-day protocols, which have shown to be safe and well tolerated in patients without HIV and with a history of sulfonamide ADR.