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Lets say a patient is listed as having a sulfa allergy. What drugs should we avoid completely, and what drugs should we use in caution?
Drugs to avoid in sulfa allergy
- Thread starter pharmacy7424
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Up to Date has a nice chart showing the arylamine moiety attached to the sulfonamide on all 'sulfa antibiotics', and how it is not present on any of the other sulfonamide-containing drugs. This statement is consistent with what I learned in school as well:
"The presence of the arylamine moiety is believed central to the pathogenesis of hypersensitivity reactions, and only the antimicrobial sulfonamides contain it."
"The presence of the arylamine moiety is believed central to the pathogenesis of hypersensitivity reactions, and only the antimicrobial sulfonamides contain it."
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So we have Bactrim, sulfadiazine, and sulfisoxazole.
What about sulfasalazine? Anything else I'm missing?
What about sulfasalazine? Anything else I'm missing?
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I get to use this twice in one day
The imprecise term "sulfa drugs" is most often applied to sulfonamide antimicrobials, although it is variably applied to other medications as well. Widespread use of this term has contributed to ongoing confusion about relevant cross-reactivity. The following defines common sulfur moieties found in current practice:
A. Sulfonamides — Sulfonamide medications are drugs that contain a sulfonamide moiety (SO2NH2)1. There are two distinct groups of sulfonamides that differ in chemical structure as well as clinical use:
1. Antimicrobial (arylamine) sulfonamides — Antimicrobial sulfonamides contain an arylamine group (an amine group linked to a benzene ring). This moiety is attached to the sulfonamide group. The presence of the arylamine moiety is believed central to the pathogenesis of hypersensitivity reactions, and only the antimicrobial sulfonamides contain it2. These drugs also contain a substituted aromatic ring attached to the sulfonamide core. Included in this group of medications are sulfamethoxazole, sulfisoxazole, and sulfadiazine.
2. Non-antimicrobial (non-arylamine) sulfonamides — The non-antimicrobial sulfonamides do not contain an arylamine group or a substituted aromatic ring2. Members of this group include diuretics, hypoglycemic and antihypertensive agents, as well as celecoxib, sulfasalazine, and sumatriptan.
B. Sulfones — Sulfones are a distinct class of medications that are not sulfonamides. Dapsone (diaminodiphenylsulfone) is the only sulfone in common clinical use. The hypersensitivity reactions reported with sulfones are clinically similar to those of sulfonamide antimicrobials, may have similar pathogenesis, and may have cross-reactivity concerns also.
C. Medications sometimes confused with sulfonamides — The following groups of medications are unrelated to sulfonamides:
Some medications contain sulfur atoms in their chemical structure but do not contain specific sulfonamide or sulfone moieties. These are not generally thought of as "sulfa" medications and include amoxicillin, captopril, omeprazole, ranitidine, and others.
Another group of medications contains sulfate ions, such as albuterol sulfate. The sulfate moieties in these compounds are nota known source of allergic or immunologic issues2.
Sulfites
are chemicals used to preserve certain foods, beverages, and medications. Sulfites are associated with a distinct constellation of symptoms known as sulfite sensitivity, which is primarily mediated via non-immunologic mechanisms. Reactions to these latter medications and substances are reviewed separately. Sulfite sensitivity typically causes respiratory reactions in patients with asthma and is unrelated to sulfonamide hypersensitivity.
There is minimal evidence of cross reactivity between the antimicrobial sulfonamides and the non-antimicrobial sulfonamides. Because the non-antimicrobial sulfonamides have been implicated in hypersensitivity reactions in rare reports, however, it is impossible to say with certainty that cross-reactivity does not occur. There is only anecdotal evidence of cross reactivity among different non-antimicrobial sulfonamides, and it is not well characterized. One important exception to this statement is the potential cross reactivity between different sulfonamide-containing diuretics, which is suggested by case reports.
A 2001 article in the journal Pharmacotherapy stated that "with sulfonamide antibiotics, the well-defined stereospecificity of IgE-mediated type I allergic reactions makes cross-reactivity with other drug classes highly unlikely because no other sulfonamide-containing drugs contain the antigenic N1 moiety, and only a very few contain the possibly antigenic N4 arylamine". 3 The article also stated that nearly all hypersensitivities to sulfonamide antimicrobials are not type I allergic reactions and "appear to be mediated by cytotoxic or immunogenic hydroxylamine and nitrosoamine metabolites rather than by the sulfonamide group itself" 3.
In a large, retrospective cohort study4 performed on a medical database of over 8 million patients over a 12 year period, individuals who had a documented allergic reaction to a sulfonamide antibiotic did react more commonly to a sulfonamide non-antibiotic (10 percent) than others who tolerated sulfonamide antibiotics in the past (1.6 percent). However, those same individuals with documented sulfonamide antibiotic reactions reacted to the chemically distinct penicillins even more often (14 percent). This strongly suggests that the reactions observed to the other sulfonamides resulted from a general propensity for immunologic drug reactions, as opposed to specific cross-reactivity between different groups of sulfonamides. The converse was also noted: there was a higher risk of reaction to sulfonamide non-antibiotics in those with a history of reactions to penicillins than those with a history of reactions to sulfonamide antibiotics.
In closing, allergic or hypersensitivity-like reactions to a sulfonamide antibiotic generally prompt patients and their clinicians to avoid further administration of similar antibiotics, as well as all other drugs containing a sulfonamide moiety. Most manufacturers’ labels on sulfonamide containing drugs warn against use in patients who are allergic to sulfonamide antibiotics. Based on the most current data and expert opinion, these actions have been deemed unnecessary. In serious and severe cases such as Stevens - Johnson syndrome and toxic epidermal necrolysis, all sulfonamides and sulfones should be avoided at all times. However, in other cases an accurate patient history of what drug was taken and the type of reaction is needed, and if the allergic reaction is severe, drugs of that same class (i.e. sulfonamides) should be avoided or desensitization performed. For patients with a sulfonamide allergy, sulfones should also be avoided, but sulfites, sulfates, and sulfur atoms do not need to be due to no data showing risk of cross-sensitivity.
**Response to question of use of bisulfate (from propofol) in a patient with reported "anaphylactic sulfa allergy":
The bisulfate ions are not a known source of allergic or even immunologic reactions, and are also not associated with cross-sensitivity to patients with documented sulfonamide allergies. Therefore, this patient should not expect to have a reaction to the bisulfate moiety in the propofol injection.
The imprecise term "sulfa drugs" is most often applied to sulfonamide antimicrobials, although it is variably applied to other medications as well. Widespread use of this term has contributed to ongoing confusion about relevant cross-reactivity. The following defines common sulfur moieties found in current practice:
A. Sulfonamides — Sulfonamide medications are drugs that contain a sulfonamide moiety (SO2NH2)1. There are two distinct groups of sulfonamides that differ in chemical structure as well as clinical use:
1. Antimicrobial (arylamine) sulfonamides — Antimicrobial sulfonamides contain an arylamine group (an amine group linked to a benzene ring). This moiety is attached to the sulfonamide group. The presence of the arylamine moiety is believed central to the pathogenesis of hypersensitivity reactions, and only the antimicrobial sulfonamides contain it2. These drugs also contain a substituted aromatic ring attached to the sulfonamide core. Included in this group of medications are sulfamethoxazole, sulfisoxazole, and sulfadiazine.
2. Non-antimicrobial (non-arylamine) sulfonamides — The non-antimicrobial sulfonamides do not contain an arylamine group or a substituted aromatic ring2. Members of this group include diuretics, hypoglycemic and antihypertensive agents, as well as celecoxib, sulfasalazine, and sumatriptan.
B. Sulfones — Sulfones are a distinct class of medications that are not sulfonamides. Dapsone (diaminodiphenylsulfone) is the only sulfone in common clinical use. The hypersensitivity reactions reported with sulfones are clinically similar to those of sulfonamide antimicrobials, may have similar pathogenesis, and may have cross-reactivity concerns also.
C. Medications sometimes confused with sulfonamides — The following groups of medications are unrelated to sulfonamides:
Some medications contain sulfur atoms in their chemical structure but do not contain specific sulfonamide or sulfone moieties. These are not generally thought of as "sulfa" medications and include amoxicillin, captopril, omeprazole, ranitidine, and others.
Another group of medications contains sulfate ions, such as albuterol sulfate. The sulfate moieties in these compounds are nota known source of allergic or immunologic issues2.
Sulfites
are chemicals used to preserve certain foods, beverages, and medications. Sulfites are associated with a distinct constellation of symptoms known as sulfite sensitivity, which is primarily mediated via non-immunologic mechanisms. Reactions to these latter medications and substances are reviewed separately. Sulfite sensitivity typically causes respiratory reactions in patients with asthma and is unrelated to sulfonamide hypersensitivity.
There is minimal evidence of cross reactivity between the antimicrobial sulfonamides and the non-antimicrobial sulfonamides. Because the non-antimicrobial sulfonamides have been implicated in hypersensitivity reactions in rare reports, however, it is impossible to say with certainty that cross-reactivity does not occur. There is only anecdotal evidence of cross reactivity among different non-antimicrobial sulfonamides, and it is not well characterized. One important exception to this statement is the potential cross reactivity between different sulfonamide-containing diuretics, which is suggested by case reports.
A 2001 article in the journal Pharmacotherapy stated that "with sulfonamide antibiotics, the well-defined stereospecificity of IgE-mediated type I allergic reactions makes cross-reactivity with other drug classes highly unlikely because no other sulfonamide-containing drugs contain the antigenic N1 moiety, and only a very few contain the possibly antigenic N4 arylamine". 3 The article also stated that nearly all hypersensitivities to sulfonamide antimicrobials are not type I allergic reactions and "appear to be mediated by cytotoxic or immunogenic hydroxylamine and nitrosoamine metabolites rather than by the sulfonamide group itself" 3.
In a large, retrospective cohort study4 performed on a medical database of over 8 million patients over a 12 year period, individuals who had a documented allergic reaction to a sulfonamide antibiotic did react more commonly to a sulfonamide non-antibiotic (10 percent) than others who tolerated sulfonamide antibiotics in the past (1.6 percent). However, those same individuals with documented sulfonamide antibiotic reactions reacted to the chemically distinct penicillins even more often (14 percent). This strongly suggests that the reactions observed to the other sulfonamides resulted from a general propensity for immunologic drug reactions, as opposed to specific cross-reactivity between different groups of sulfonamides. The converse was also noted: there was a higher risk of reaction to sulfonamide non-antibiotics in those with a history of reactions to penicillins than those with a history of reactions to sulfonamide antibiotics.
In closing, allergic or hypersensitivity-like reactions to a sulfonamide antibiotic generally prompt patients and their clinicians to avoid further administration of similar antibiotics, as well as all other drugs containing a sulfonamide moiety. Most manufacturers’ labels on sulfonamide containing drugs warn against use in patients who are allergic to sulfonamide antibiotics. Based on the most current data and expert opinion, these actions have been deemed unnecessary. In serious and severe cases such as Stevens - Johnson syndrome and toxic epidermal necrolysis, all sulfonamides and sulfones should be avoided at all times. However, in other cases an accurate patient history of what drug was taken and the type of reaction is needed, and if the allergic reaction is severe, drugs of that same class (i.e. sulfonamides) should be avoided or desensitization performed. For patients with a sulfonamide allergy, sulfones should also be avoided, but sulfites, sulfates, and sulfur atoms do not need to be due to no data showing risk of cross-sensitivity.
**Response to question of use of bisulfate (from propofol) in a patient with reported "anaphylactic sulfa allergy":
The bisulfate ions are not a known source of allergic or even immunologic reactions, and are also not associated with cross-sensitivity to patients with documented sulfonamide allergies. Therefore, this patient should not expect to have a reaction to the bisulfate moiety in the propofol injection.
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my experience so far::
albuterol sulfate is ok for ppl with sulfa allergy. i told a customer i need to look up the info and she kept rushing me to get it filled. i felt like she was rushing for round 2 at the ER.
topamax use with caution, a customer got a rash even while taking zyrtec daily.
thiazide use with caution. a mail order pharmacist transferred a thiazide and overlooked the sulfa allergy. but the pt got it before so he's like it's ok! ^^
albuterol sulfate is ok for ppl with sulfa allergy. i told a customer i need to look up the info and she kept rushing me to get it filled. i felt like she was rushing for round 2 at the ER.
topamax use with caution, a customer got a rash even while taking zyrtec daily.
thiazide use with caution. a mail order pharmacist transferred a thiazide and overlooked the sulfa allergy. but the pt got it before so he's like it's ok! ^^
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Did you read any of the above. THERE IS NO CROSS REACTION WITH SULFA DRUGS AND THIAZIDE DIURETICS. There is a potential since the structures are similatr, but in the real world, it does not exist.
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ditto.
Sulfasalazine was originally marketed as an antibiotic until it was discovered to have anti-inflammatory action. And the answer is no, it shouldn't be used if the person has a sulfa allergy.
Some of the older oral diabetic drugs are sulfa derivatives, but not very many people use them any more.
Some of the older oral diabetic drugs are sulfa derivatives, but not very many people use them any more.
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We forgot zonisamide.
That is a hard contraindication in sulfonamide allergy
That is a hard contraindication in sulfonamide allergy
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not very many people use glyburide or glipizde or amayrl? Me thinks you are wrong
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