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Evaluation of Adverse Events in Self-Reported Sulfa-Allergic Patients Using Topical Carbonic Anhydrase Inhibitors

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Evaluation of Adverse Events in Self-Reported Sulfa-Allergic Patients Using Topical Carbonic Anhydrase Inhibitors JOURNAL OF OCULAR PHARMACOLOGY AND THERAPEUTICS Volume 29, Number 5, 2013 ª Mary Ann Liebert, Inc. DOI: 10.1089/jop.2012.0123 Evaluation of Adverse Events in Self-Reported Sulfa-Allergic Patients Using Topical Carbonic Anhydrase Inhibitors Guilherme B. Guedes,1 Abraar Karan,1 Hylton R. Mayer,2 and M. Bruce Shields1 Abstract Purpose: To investigate whether a self-reported history of allergy to sulfa-based drugs is a predictor for sub- sequent adverse reactions to topical carbonic anhydrase inhibitors (CAIs). Methods: A retrospective case-controlled cohort study via chart review was performed on 1,287 patients with a diagnosis of glaucoma. The outcome measure was the development of an adverse reaction (either ocular, systemic, or both) within at least 30 days after receipt of 1 of 4 classes of topical glaucoma medications: CAIs (dorzolamide and brinzolamide), prostaglandin analogues, beta-adrenergic blockers, and alpha2-adrenergic agonists. Results: Patients with a self-reported history of sulfa allergy had significantly more ocular adverse reactions after the initiation of any of the topical antiglaucoma medications when compared to those patients with no reported allergies. Patients with a self-reported sulfa allergy and patients who self-reported other, nonsulfa-related al- lergies had similar rates of adverse reactions to most of the topical medications. The patients reporting a sulfa allergy who used topical CAIs did not have more adverse reactions compared with patients who reported having other, nonsulfa-related allergies who used topical CAIs. Self-reported sulfa-allergic patients had similar rates of adverse reactions to topical CAIs compared with topical prostaglandin analogues. Conclusion: It may be safe to use a topical CAI in patients who report a history of a sulfa allergy. Patients with medication allergies of any kind may be more likely to develop allergic reactions to other, unrelated drug classes. Introduction quite different (Fig. 1). The nonsulfonamide medications, including dorzolamide, brinzolamide, and acetazolamide, llergic reactions to antibiotics are most com- are useful antiglaucoma agents, but traditional practice has Amonly triggered by sulfa-based antibiotics, specifically been to avoid these medications in patients who report a those which contain the sulfonamide functional group— sulfa allergy. Avoiding these glaucoma agents may contrib- 1,2 SO2NH2. Accordingly, patients who report sulfa allergy ute to the progression of glaucomatous vision loss, or hasten likely experienced it in response to a previous sulfonamide the decision for more risky options to control glaucoma, such antibiotic.1 The presence, or possibility, of a sulfa allergy can as incisional surgery. influence a patient’s health care in 2 significant ways: A At issue is whether a history of allergy to a sulfa-based sulfa-allergic patient may have an allergic reaction to an- antibiotic is a predictor for a subsequent allergic reaction to a other sulfonamide-containing medication, or a patient re- structurally different compound containing a sulfa group, porting a history of sulfa allergy may receive suboptimal care such as the nonsulfonylarylamines. To answer this question, of certain conditions in an effort to avoid the use of a sulfa- we conducted a retrospective case-controlled cohort study to containing medication.3 investigate adverse events in glaucoma patients with self- Certain nonantibiotic, sulfa-containing medications have reported sulfa allergy who were using sulfa-containing or traditionally been avoided in patients who report a history of nonsulfa-containing antiglaucoma medications. As with the sulfa-based antibiotic allergies, even though the chemical typical clinical experience, this retrospective study did not composition of the antibiotic sulfonylarylamine sulfonamide involve formal allergy testing to confirm self-reported med- and nonantibiotic, nonsulfonylarylamine compounds are ication allergies, nor were formal allergy tests used to 1Department of Ophthalmology, Yale University, New Haven, Connecticut. 2Eye Doctors of Washington, Chevy Chase, Maryland. 456 EVALUATION OF SULFA-ALLERGIC PATIENTS USING CAIS 457 FIG. 1. The sulfonamide antibiotics have an arylamine group (the R-NH2, which is circled, with the R group being an aromatic ring), while the carbonic anhydrase inhibitors (CAIs) (nonantibiotics) do not contain an aromatic amine. confirm the allergic nature of patients’ adverse reactions.4 prostaglandin analogues, alpha2-adrenergic agonists, and For this reason, this study measured adverse reactions, beta-adrenergic blockers. not necessarily true allergic reactions, to topical glaucoma medications in patients who self-reported a sulfa allergy. We Methods also examined adverse events in glaucoma patients with unconfirmed, self-reported allergies to other nonsulfa- A retrospective case-controlled cohort study via chart re- containing medications who were using topical antiglaucoma view was performed on 1,287 patients with a diagnosis of medications, such as carbonic anhydrase inhibitors (CAIs), glaucoma who were seen by 2 of the authors (M.B.S. and 458 GUEDES ET AL. H.R.M.) during the year of 2009. The study was approved by condition that there was a 1-month gap between start of the the Yale University School of Medicine Human Investigation drug usage. The 4 study groups were divided by which 1 of Committee. All charts were collected and reviewed from the the 4 medication classes a patient was using; the 4 control archives of the Yale Eye Center. Demographic information, groups were decided on this criterion as well. prescription-drug information, indications for all new pre- Because ascertaining true allergic events in the clinical scriptions, surgeries, clinical events, diagnoses, and physi- setting is often difficult, and no formal allergy testing was cians’ notes were documented. Inclusion criteria for the performed in this retrospective study, the primary outcome source population were (1) a clinical diagnosis of primary measure was the development of an adverse reaction (either open-angle, pigment dispersion, or exfoliation glaucoma, or ocular, systemic, or both) within at least 30 days of initiation ocular hypertension in at least 1 eye, (2) treatment with the of a topical glaucoma medication. Adverse reactions were topical CAIs dorzolamide or brinzolamide, or with prosta- defined in this study as reactions significant enough to cause glandin analogues, beta-adrenergic blockers, or alpha2- discontinuation of treatment. Adverse ocular reactions in- adrenergic agonists, (3) at least 1 follow-up visit after 4 cluded itching, eyelid swelling, intolerable conjunctival hy- weeks of therapy. peremia, chemosis, mucoid discharge, significant papillary Exclusion criteria included (1) patients who started more or follicular reaction, or eyelid dermatitis. Adverse systemic than 1 topical medication at the same time, (2) patients who reactions included urticaria, anaphylactic shock, erythema underwent surgery less than 4 weeks after the initiation of multiform, asthma, and eczema. Statistical analysis was topical medical therapy, (3) patients using oral sulfa-based carried out using 2-proportion chi square tests with a sig- medications such as acetazolamide or methazolamide. nificance level of 0.05. Cross testing was conducted across The typical practice to elicit an allergy history in the au- classes of drugs and across allergy histories. thors’ clinic was for a technician, resident, or attending physician to ask an open-ended question, ‘‘Do you have any Results allergies to medications?’’ The vast majority of patients simply reported having a sulfa allergy or allergy to some The study group consisted of 94 self-reported sulfa-allergic other medication. No efforts were made to interpret, char- patients from the study’s source population. The control acterize, or quantify the nature of a patient’s self-reported group consisted of 205 randomly selected patients from the allergies that were recorded in the chart. No confirmatory or study’s source population with glaucoma who self-reported formal allergy testing was performed to verify a patient’s no medication allergies or nonsulfa medication allergies. The self-reported allergy history. Only a few patients identified a study and control groups were evenly matched by race, named medication, such as Bactrim or Aspirin. No efforts gender, and age (Table 1). were made to identify or classify details regarding the class Patients with previous self-reported sulfa allergy had of sulfa medication patients reported. The typical clinical significantly more ocular adverse reactions after the initia- practice of M.B.S. and H.R.M. was to discuss the higher tion of any of the topical antiglaucoma medications when possible risk of allergic reactions to topical CAIs in patients compared to those patients with no self-reported allergies who self-reported a sulfa allergy, when initiating therapy. (Table 2). Patients who reported a history of a sulfa allergy The physician’s decision to prescribe CAIs to these patients and patients who reported other, nonsulfa-related allergies was based on the determination that the benefits outweighed had statistically similar rates of reactions to most of the the potential risks of other intraocular pressure-lowering topical medications. alternatives. The self-reported sulfa-allergic patients using topical CAIs The study group comprised of patients from the cohort did not have more adverse events than patients who re- who self-declared a sulfa allergy. The control
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