Practices of French and Francophones allergists in the management of allergic risks and complications of anti-SARS- COV- 2 vaccination

Background: The SARS-COV- 2 vaccination campaign has massively mobilized the allergists' community to screen patients deemed at risk for the SARS-COV- 2 vaccines. To describe data regarding the management of medical calls regarding the allergic risk for the SARS-COV- 2 vaccination, amongst French allergists. Method(s): A questionnaire-based survey was launched on the AdviceMedica platform (a platform of medical advice exchange between peers) between July and October 2021 (including two reminders). Result(s): Fifty-four allergists answered the survey. Three quarters of the responders were full-time allergists. Overall, 42% and 35% had an exclusive hospital or private practice, respectively. Allergists were mostly contacted by telephone (96.3%) and e-mail (79.6%), by general practitioners (92.6%) or physicians practicing in vaccination centers (88.8%) (median of vaccine related medical calls: 10 per week (Q25-Q75: 7-20, range (2-300). Allergists favored in-person visits rather than teleconsultations (85.2% vs. 61.1%). Allergy testing was prescribed for suspicions of allergy to polyethylene glycol (84.4%) or other vaccines and non-identified drugs (64.4%). Half of the responders (29, 53.7%) could perform vaccination and four (13.7%) declared reactions during vaccination. The responders used several tools in taking their clinical decision: exchanges with peers from the AdviceMedica platform (40.4%), advice from tertiary university hospital allergy units (25%), recommendations of the French Society of Allergy (17.3%). The three most frequent drawbacks that the allergists encountered were: having a hard time adding supplementary patient visits within optimal delays (three quarters of the responders), the reluctance expressed by the physicians requiring the advice and by the patients (two thirds) and the fact that the learnt society recommendations were deemed not to cover many on-field situations (one third). The major benefits from screening were estimated to be the lack of allergy contraindication to vaccination (88.7%) and the increased visibility of the allergist's role (69.8%). Conclusion(s): This survey put numbers on the management of screening patients deemed at risk for the SARS-COV- 2 vaccination amongst French allergists. Peer exchange was the most frequent tool in taking a clinical decision.

Anaphylactic shock induced by a depot corticosteroid: Reflections on a clinical case

Introduction (contexte de la recherche): IgE-mediated reactions to systemic corticosteroids (CSs) are rare. Hydrocortisone and methylprednisolone succinate ester are the most frequent elicitors. Excipients of depot corticosteroids (like carmellose or macrogol) may also be involved. The involvement of the dipropionate form of betamethasone (present in the depot Diprostene) has not been studied. Objectif: To describe the case of a 40-year-old woman, who presented an anaphylactic shock reaction upon intra-articular administration of Diprostene (Betamethasone sodium phosphate and betamethasone dipropionate), associated with an iodinated radiocontrast media (ICM, Xenetix). Methodes: An allergy work-up was performed, according to recommendations for severe immediate reactions. Nine months after the reaction [hypotension (7/5 mmHg), erythema and desaturation at 94%, treated with adrenalin, methylprednisolone hemisuccinate, dexchlorpheniramine] the patient underwent skin prick tests (SPT) and intradermal tests (IDT) with ICM, bethamethasone and Diprostene (commercial molecules). Latex and chlorexidine were also studied. Resultats: The tests resulted negative for ICM, latex and chlorexidine (including serum specific IgE ImmunoCAP ThermoFisher Scientific), bethametasone phosphate (IDT 0.4 mg/mL) and carmellose (IDT 0.5 mg/mL). SPT elicited a positive reaction towards Diprostene in immediate reading, (for 5, 0.5, 0.05 mg/mL) with an erythema (10, 8, 5 mm respectively) and a wheal (of at least 3 mm for each SPT). We performed an oral drug challenge to bethametasone phosphate for a total of 8 mg and it was well tolerated. The basal tryptase was 5.5 microg/mL. Tryptasemia 30 minutes after the reaction was 26.8 microg/mL. Conclusion(s): We describe an anaphylactic reaction to Diprostene, proven by positive ST. The hypothesis of allergy to betamethasone dipropionate is under investigation. The hypothesis of allergy to macrogol, the other excipient of (which was not tested separately) is less likely, since the patient received Commirnaty SARS-CoV-2 vaccine 3 months after the reaction. The allergy work-up is ongoing (tests are programmed for betamethasone dipropionate alone).Copyright © 2023

Allergist coorporation, the COVID-19 vaccination's keystone

Background: The French vaccination campaign against COVID-19 was accompanied by an overwhelming increase in allergists work load highlighting our key role in the stratification of the allergy risk prior to vaccination. Method(s): In order to describe our triage and testing experience for the COVID-19 vaccination all requests were analysed in a standardized way prospectively. Our final goal was to filter the requests and avoid any delay in the vaccination process. We first set up and validated locally a questionnaire (completed by the requesting practitioner) allowing to evaluate the risk of allergy to the vaccine, based on the clinical history of the patient. Questionnaire-based allergy advices were delivered (regular vaccination or allergy testing prior to vaccination). Result(s): From January 2021 to January 2022, we addressed 1047 requests. Forty-one patients (4%) were tested. 96% had allergies to other compounds, not increasing the risk of reacting to the covid vaccines and were vaccinated safely. Half of the tested patients experienced an immediate reaction to the vaccine and the other half had a history of allergy to the vaccine's components. We identified 3 groups of patients: -Suspicions of polyethylene glycol (PEG) containing laxative allergy comprised 8 patients (26%), including 2 cases with proven IgE-mediated allergy to PEG. They were 63% (5) women, 63% (5) atopic (average age of 49 +/-10 yrs). Two thirds (63%, 5 patients) had an immediate reaction to PEG, including 3 and 2 patients with anaphylaxis with and without shock, respectively. The two allergic patients refused vaccination and received a certificate of contraindication to PEG-containing vaccines (as per French law). -Reactions to the covid vaccine comprised 21 patients: most were women (86%, 18 patients) and 29% (6) were atopic (average age was 51 +/-19 yrs). Three quarters (76%, 16 patients) presented a reaction within 1 hour after the vaccination, considered as potential anaphylaxis in 12 patients (8 patients with and 5 without shock). 100% (21 patients) were tested negative. Twenty patients (95%) were further vaccinated without reaction. One required H1 antihistamine. -Suspicions of allergy to PEG or polysorbate as excipients included 12 patients (29%). Most clinical histories were anaphylactic (42% without and 33% with shock). Following negative excipient skin testing, regular vaccination was authorized. Conclusion(s): Overall, only 4% of the initial requests were deemed eligible for allergy testing. We did not diagnose any allergy in patients who reacted to the vaccines and we delivered two certificates of contraindication to mRNA COVID-19 PEG-containing vaccines in two cases of confirmed IgE-mediated allergy to PEG.

Réintroduction du vaccin COMIRNATY® chez une patiente présentant une allergie confirmée au PEG

Introduction (contexte de la recherche) Une allergie à l'un des composants du vaccin contre la Covid-19, comme le polyéthylène glycol (PEG), fait partie des contre-indications à la vaccination par COMIRNATY®. Un avis allergologique est nécessaire pour confirmer une éventuelle suspicion d'allergie au PEG. Objectif Présentation d'une proposition de prise en charge des patients ayant des antécédents de réaction allergique immédiate à l'un des composants du vaccin contre la Covid-19. Méthodes Nous présentons le cas d'une patiente travaillant dans le secteur médical, ayant présenté une réaction anaphylactique immédiate (nausée, vomissements, urticaire généralisée et céphalée) après avoir pris un laxatif contenant du PEG en tant que principe actif (MACROGOL®), 15 années auparavant, dans un contexte de constipation. Nous avons confirmé l'allergie au PEG par un test cutané (en prick) positif. Le prick test au vaccin COMIRNATY® était également positif. Après avoir évalué de façon stricte la balance bénéfice-risque individuelle de la vaccination, nous avons vacciné la patiente en hôpital de jour d'allergologie selon un protocole de réintroduction progressive et sous surveillance clinique rapprochée. Résultats La patiente a bénéficié de la réintroduction de ce vaccin (sans prémédication) selon un protocole en 4 étapes (dose totale 0,3 mL). Le protocole a été réalisé en milieu sécurisé dans le service d'allergologie et après avoir obtenu le consentement de la patiente. Une surveillance clinique classique d'un test de réintroduction à risque a été réalisée. Les résultats du test de réadministration du vaccin n'ont montré aucune réaction allergique après une surveillance prolongée (2 heures après la dernière dose). Conclusions En présence d'une balance bénéfice-risque favorable à la vaccination et avec une surveillance stricte, la réintroduction du vaccin COMIRNATY® chez les patients avec une allergie confirmée au PEG est possible, avec une bonne tolérance.

Enquête COMPac (Complications allergiques des vaccins de la Covid) : étude des pratiques des allergologues français et francophones

Déclaration de liens d’intérêts: Les auteurs n’ont pas précisé leurs éventuels liens d’intérêts.

Modèle de stratification du risque allergique à la vaccination SARS-COV2 via un questionnaire (et bénéfice du bilan allergologique)

Déclaration de liens d’intérêts: Les auteurs n’ont pas précisé leurs éventuels liens d’intérêts.