Recommendations for Prevention of Drug Re-Exposure in Toxic Epidermal Necrolysis

October 2019 | Volume 18 | Issue 10 | Features | 1049 | Copyright © October 2019

Kathleen F. O’Brien MS,ª Karl M. Saardi MD,B Laura S. Johnson MD,a,c Jeffrey W. Shupp MD,a,c Nemanja Rodic MD PhD,a,b and Helena B. Pasieka MD MSa,b

ªGeorgetown University School of Medicine, Washington, DC

BDepartment of Dermatology, MedStar Washington Hospital Center, Washington, DC

cThe Burn Center, Department of Surgery, MedStar Washington Hospital Center, Washington DC

DISCUSSION

In the United States, an aging population, polypharmacy, multiple prescribers, and use of various medical record systems that don’t integrate allergy data increase the risk of re-exposure. This case series documents that self-medicating, failure to recognize the offending agent, and/or reconcile allergies all contributed to drug re-exposure. Additionally, it documents that in those patients diagnosed with drug re-exposure induced TEN, re-exposure to the sensitizing drugs led to high mortality, greater BSA and mucosal surface involvement, and higher SCORTEN scores.

Currently, there are no standard recommendations to prevent or minimize the risk of re-exposure in patients diagnosed with SJS/ TEN. At our institution, we have made multiple efforts to reduce the risk. When a diagnosis of SJS/TEN is made, the allergies section of the EMR is updated by the dermatologist, severity categorized as critical, and a note made to reference the date of dermatology’s consult to make the details readily available. In some cases, medications known to cross-react with the allergen are also preemptively added to the allergy list.

Prior to discharge, we discuss the diagnosis, implicated drugs and classes, as well as a plan to prevent re-exposure. We ask that families to complete an inventory of all medication in patients’ homes and inform any prescribing pharmacies and physicians of the SJS/TEN diagnosis. Patients are sent home wearing their allergy alert bracelet from their hospitalization, and we recommend that they obtain medical identification jewelry listing both generic and brand names of the allergen. At follow up, we review medication allergies, and ask if all discontinued medications have been removed from the home. Ideally, national registries for sharing of allergy data for pharmacists will be developed in the near future.

Limitations to this study include small sample size, our reliance on patients’ recollection of initial drug reaction in some cases, and the possibility of a confounding diagnosis, such as generalized bullous fixed drug eruption.10 This case series demonstrates the potentially deadly effect of drug re-exposure, and the need for both streamlined and integrated medication allergy documentation systems.