We may need to test and remove patient-declared allergies from their clinical records
Clinicians are often uncertain of the safety or suitability of particular drugs when patients report adverse reactions.
Their “allergies” are added to medical records despite, at times, a lack of confirmation of immune-mediated mechanisms—and thereafter, treatment regimens become complicated.
Researchers at Cleveland Clinic, however, have identified “greater and greater adverse drug reactions” reported by patients as indicators that mental or behavioral interventions may be needed.
Polyallergy—also known as multiple chemical sensitivity (MCS) or multiple drug intolerance syndrome—and mental health/functional somatic syndrome disorders, health care utilization, or other clinical phenomena have not been examined extensively, say Xavier Jimenez, MD, MA, and colleagues, from Cleveland’s Chronic Pain Rehabilitation Program, Neurological Institute, Department of Psychiatry and Psychology.
“This study demonstrates that polyallergy/multiple chemical sensitivity may serve as a crude yet meaningful indicator of comorbid psychopathology,” they say in a paper published in the May/June 2019 issue of Psychosomatics. The paper reviews drug intolerance mechanisms and examines both clinical and investigational implications.
“This study reveals a clear, statistically-significant association between increasing patient-reported, chart-documented adverse drug reactions and various demographic, diagnostic, pharmacological, and health care utilization trends,” say the researchers.
Their findings are important as they suggest certain clinically-relevant expectations emerging from greater and greater self-reported or documented allergies: “Increasing polyallergy, alongside other clinical data, may facilitate clinical interventions, such as the consideration of mental or behavioral health approaches.”
Comparable studies have supported their findings. A retrospective analysis by Macy et al (referenced in the paper) examined more than 450,000 patients with at least one reported allergy. Multiple drug intolerance syndrome (MDIS, defined broadly as anyone with three or more unrelated drug class allergies) was present more often in older, female, high utilizers of health care with increased rates of anxiety.
Omer et al (also referenced) reviewed 25,000 patients with at least one reported allergy, and found that MDIS was more common in females with high comorbidity and health care utilization.
The Cleveland study was powered by a large clinical sample (more than 2 million patients, 55% female, with an average age of 45). It spanned six years. Additionally, the study examined data across multiple realms (demographic, medical, psychiatric, pharmacological, and health care utilization), offering a multidimensional understanding of patients with polyallergy.
“Once determined that an allergy is unwarranted, it is clinically suggested that it be removed in order to offer greater pharmacological opportunities for future health care providers.”
Polyallergy management
If mental health comorbidities, somatic/interoceptive hypervigilance, and/or other features are identified, it may be prudent to educate patients about post-traumatic stress disorder, central sensitization, and other pathophysiological mechanisms involved in medication intolerance, distinguishing this phenomenon from immune-mediated hypersensitivities, say the researchers.
“This may lead to a transparent re-evaluation of allergy lists with the patient, safe retesting of medications in supervised settings, and eventual removal of incorrectly-documented allergies.”
Medication retesting has been previously performed: in a cohort of 480 patients with MDIS and known negative allergy test results, quoted in the Psychosomatics paper, retesting revealed negative allergic responses in 87% of retests, while those few with allergic responses were mild in severity and easily managed with oral antihistamines or corticosteroids.
“Once determined that an allergy is unwarranted, it is clinically suggested that it be removed in order to offer greater pharmacological opportunities for future health care providers,” say the researchers. Certain approaches, such as mindfulness-based stress reduction (MBSR), may address shared pathologies such as central sensitization, anxiety, and somatic hyperarousal. MBSR has been shown to be effective in managing stress, anxiety, fibromyalgia, and chronic pain.
As applied to polyallergy, one study demonstrated statistically-significant improvements among women with comorbid MCS, chronic fatigue syndrome, and fibromyalgia exposed to MBSR as compared to a control group receiving usual care.
“Educating patients about polyallergy and challenging inappropriately-perceived allergies is justified,” conclude the researchers.
The paper, Polyallergy (Multiple Chemical Sensitivity) is Associated with Excessive Healthcare Utilization, Greater Psychotropic Use, and Greater Mental Health/Functional Somatic Syndrome Disorder Diagnoses: A Large Cohort Retrospective Study, is here.