Student Project Immune System and Disorder

DRUG PROVOCATION TEST

In Immediate Reaction

SGD B4
DITA PRADNYANDARI

(1002005119)

ELLEN K.

(1002005148)

BIANCA JEANNE

(1002005116)

NI KETUT HANNY PUSPITA

(1002005007)

I G AG ARI K NARAYANA

(1002005027)

B BOSMAN ARIESTA GST PT

(1002005053)

GST A RISKA PERTIWI

(1002005069)

KIRANJIT KAUR

(1002005210)

FAIRUZIAH B B ALKATIRI

(1002005185)

VANNEETHA ARIVANANTHAN

(1002005212)

Faculty Of Medicine

UDAYANA UNIVERSITY
2011
CHAPTER I
INTRODUCTION
Adverse drug reactions (ADRs) are regarded as an important public health problem as they may be
potentially life threatening. According to WHO, adverse drug reaction is a harmful, unintended reactions to
medicines that occur at doses normally used for treatment. 1 There are two major subtypes of ADR, type A
reactions which are dose dependent and predictable, and type B which are not dose dependent and unpredictable.
Drug hypersensitivity regarded to be the B type of ADR. Further, Gell and Coombs divided drug hypersensitivity

into four classes, type I (IgE mediated), type II (IgG mediated: cytotoxic mechanism), type III (IgG mediated:
immune complex deposition), and type IV (cell mediated) which also can be divided into 4 sub group (a d)
based on the cell mediator.2
Prevalence and incidence of drug hypersensitivity vary from many studies based on hospitalized patient
(hospital based populations). In USA the incidence ranges from 6% until 15%. From French pharmacovigilance
study 6,1%, in Germany 3,8 % and Australia 2% 4%. From out patients and general populations, the study
shows 1% - 3% and commonly caused by antibiotics. Annually 1500 patient died because of drug anaphylaxis in
USA. Drugs are the leading cause of anaphylaxis in UK (88 of 202 fatality case).3
The effect of drug hypersensitivity can be immediate (IgE-mediated, allergic reactions: anaphylactic shock,
generalized urticaria, angioedema, or bronchospasm) and non-immediate allergic reactions. Non-immediate
reactions may occur several days after the drug administration and include urticaria, maculopapular eruptions,
fixed drug eruptions, vasculitis, toxic epidermal necrolysis, the Stevens-Jonson syndrome, and drug reaction with
eosinophilia and systemic symptoms. But the most life threatening is anaphylaxis shock.4
Because of the dangerous effect of drug hypersensitivity, medical practitioner must be aware when
prescribing drugs. Patient one with another has different respond to drug. It increases the difficulties for physician
Drug
2
to determine which drug is the best and not causing hypersensitivity effect for the patient. Therefore some test

Provocation

need to be performed to get information about the hypersensitivity and the allergen of the patient.
On that purpose, drug provocation test can be performed. Drug provocation test (DPT) is the controlled
administration of a drug in order to diagnose drug hypersensitivity reactions. DPT can be used as diagnostic test
for both immediate and non-immediate reactions.5 DPTs are performed under medical surveillance, whether this
drug is an alternative compound, or structurally/pharmacologically related, or the suspected drug itself. DPT is
sometimes termed controlled challenge or re-exposure, drug challenge, graded or incremental challenge, test
dosing, re-challenge, or testing for tolerance. DPT is recommended by some specialized centers, allergy societies,
and text books, whereas other societies advise against performing DPTs, and some review articles and textbooks
do not even mention the method.6
The topic DPT is controversial in general. Therefore it is considered important to every medical practitioner
to know about DPT. Specific protocols for every single drug or at least group of drugs would be helpful, where
indication, contraindication, substance, dosing, grading of the reaction and test as well as scoring criteria are
defined.
The objective of this student project is to describe the DPT from the principle of the test, mechanism of
drug allergy, indication-contraindication, procedure of the test, test interpretation, safety of the tests, risks of
severe reactions, and treatment of the reactions observed.7 We focus in DPT for drug with immediate response.

CHAPTER II
CONTENT

2.1

Immune Mechanism and Drug Induced Immediate Hypersensitivity (IgE mediated/Allergy)

Drugs are exogenous molecules recognized by the body as foreign substances. As a result, an immune

response is generated in many cases. Drug immunogenicity increases with increasing molecular size and
complexity. Macromolecular drugs such as proteins and peptide hormones are strongly antigenic. However, most
drug substances are haptens, and their potential for inducing an allergic response depends on their capacity to
acquire antigenicity upon covalently binding to macromolecules generally proteins. 8 Two phases, sensitization
and elicitation, are necessary to induce a drug-specific immune response.
IgE-mediated reactions to drugs are usually thought to depend on the prior development of an immune
response to a hapten/carrier complex: B cells need to mature into IgE-secreting plasma cells, and T cells help in
this process by interacting with B cells (i.e. CD40-CD40L interaction) and by releasing IL-4/IL-13, which are
switch factors for IgE synthesis. This sensitization phase is asymptomatic and may have occurred during an
earlier drug treatment. Upon renewed contact with the drug, a hapten carrier complex is formed again, which then
cross-links preformed drug-specific IgE on mast cells. The drug itself is normally too small to cross-link two
adjacent IgE molecules, and needs to bind to proteins to cross-link.
IgE-mediated reactions can cause mild to very severe, even lethal, diseases. In sensitized individuals the
Drug
4
reaction can start within seconds after contact with the parentally applied drug, and minutes after oral drug

Provocation

uptake. Symptoms reach from simple local itch, local wheal-and-flare reaction upon parenteral drug application,
to acute bronchospasm and generalized urticaria and edema, preferentially periorbital, perioral or genital. More
Drug
4
severe and complex reactions are called anaphylaxis, whereby in most cases with anaphylaxis some circulatory

Provocation

events with collapse and (transient) unconsciousness are observed together with a generalized redness, itch or
urticaria. Most IgE-mediated reactions to drugs are less severe and often only an urticaria, angioedema or a
local wheal may develop. However, any IgE-mediated drug allergy can be potentially life-threatening.2
2.2

Risk and Disadvantages of Drug Provocation Test

There are several limitations to the seemingly straight forward procedure of DPT. Many people do not

take only one drug at a time, and certain adverse events are sometimes indicative, but hardly ever specific for a
certain substance.6
Risks and disadvantages of drug provocation tests:

 Potentially dangerous
Read out might be difficult (if subjective, unspecific symptoms prevail)
Does not clarify the pathogenic mechanism of the reaction
Not completely pathognomic reactions
False-negative results can occur
False-positive results can occur
Co-factors, that are essential for the clinical symptoms might be absent
Does not indicate mere sensitization which may become positive under certain circumstances6
2.3

Indications for Performing Drug Provocation Test

Caution and surveillance is mandatory in all cases, before performing any DPT. Severe reactions in the

history, patients with a reduced health status or at increased risk during emergency treatment, require a guarded
and especially critical evaluation.6 The indications for DPT fall into four according to European Network of Drug
Allergy (ENDA) of European Academy of Allergology and Clinical Immunology, partially overlapping groups6,7 :
1.

To exclude hypersensitivity in non-suggestive history of drug hypersensitivity and in patients with nonspecific symptoms, such as vagal symptoms under local anesthesia;

2.

To provide safe pharmacologically and/or structurally non-related drugs in proven hypersensitivity such as
Drug
5
other antibiotics in lactam-allergic patients. This may also be helpful for anxious people who would

Provocation

refuse to take the recommended drug without proof of tolerance;

3.

To exclude cross-reactivity of related drugs in proven hypersensitivity, for example a cephalosporin in a

penicillin-allergic subject or an alternative NSAID in an aspirin-sensitive asthmatic;

4.

To establish a firm diagnosis in suggestive history of drug hypersensitivity with negative, non-conclusive or
non-available allergologic tests, for example a maculopapular eruption during aminopenicillin treatment
with negative allergological tests.

2.4

Contraindications for Performing Drug Provocation Test

DPT with a suspected drug should not be performed in pregnant women or in patients at increased risk due

to co-morbidity like acute infections or uncontrolled asthma, or underlying cardiac, hepatic, renal, or other
diseases, where exposure might provoke a situation which is beyond medical control.
However, exceptions can be made if the drug under suspicion is essential for the patient, e.g. neurosyphilis
and penicillin therapy. A pregnant woman suspected for local anaesthetic hypersensitivity, scheduled for epidural
anaesthesia/analgesia during labour, and with negative intradermal skin tests performed in the delivery room,
may undergo a DPT with the local anaesthetic in the delivery room by the anaesthetist before the insertion of the
epidural catheter.
DPT should never be performed on patients who have experienced fatal adverse reaction such as
anaphylaxis reactions and immunocytotoxic reactions, drug induced hypersensitivity reactions (with eosinophilia)
/ DRESS or autoimmune disease7, vasculitic syndromes, exfoliative dermatitis, erythema multiforme major /
Stevens-Johnson syndrome, and toxic epidermal necrolysis.6

Table 1. Drug-induced reactions, where DPT is generally not recommended or contraindicated 6,7
Generalized bullous fixed drug eruptions
Acute generalized exanthematous pustulosis (AGEP)*
Toxic epidermal necrolysis (TEN)*
Stevens Johnson syndrome*
Drug hypersensitivity syndromes (with eosinophilia) / DRESS*
Systemic vasculitis
Specific organ manifestations, e.g.

Drug
Provocation

blood-cytopenia
hepatitis
nephritis
pneumonitis
Severe anaphylaxis
Drug-induced autoimmune disease (systemic lupus erythematosus, pemphigus
vulgaris, bullous pemphigoid, etc.)
* patch testing justified under special conditions, but not oral intake.

2.5

Preparation and Method of Drug Provocation Test

2.5.1 Preparation for provocation procedures

There are some preparations before perform a DPT:
a.

Ethical considerations and Consideration for The Patient

Ethical issue should be noticed, because this test is a trial in human. The risk-benet ratio must be

acceptable, the condition being treated must be serious, no alternative testing method is available or the results
are inconclusive. The patient must be informed of the consequences of both the use of alternative treatments and
the risks involved in DPT. Written informed consent must be done by the patient before receive DPT.6
Patient should be washed out from drug that may alter the result of DPT. The duration varies, depend on the
drug.
Table 2. Drugs that may alter the result of DPT, therefore should be washed out according to free interval 6
Medication
Antihistamine (H1 blocker)
Antidepressants
Glucocorticosteroids*
Long Term
Short Term, High Dose (>50 mg p.e)
Short Term, Low Dose (<50 mg p.e)
*

withdrawal may not be possible

b.

Route
Oral, Intravenous
Oral, Intravenous

Free Interval
5 days
5 days

Oral, Intravenous
Oral, Intravenous
Oral, Intravenous

3 weeks
1 week
3 days
Drug

Provocation

Safe guards for DPT

To keep DPT safe for the patients there are some procedure need to be followed.6

Accurate and comprehensive records should include a sucient description of the initial episode treated,
the drug exposure as well as a detailed description of the adverse eects.

Certain co-medication is contraindicated if it may cause problems if emergency treatment becomes

essential, e.g. -blocking agents or that may even aggravate immediate type reactions such as ACEinhibitors.

Procedures must be managed by an expert.

Resuscitation and monitoring facilities should be available for emergencies and initial detection of disorder
arising from DPT.

Adrenaline (epinephrine), bronchodilator, oxygen, intravenous saline and short acting steroid must be
available in advance against anaphylaxis, shock, or other emergency cases.9

c.

Documentation
DPT should be regarded as a serious and potentially dangerous test procedure. Therefore it is important to

document the patients personal details, medical history, and concomitant drug therapy before DPT. Before and
after the provocation, all relevant physical signs, changes in laboratory parameters, spirometry and others if
relevant for the particular patient such as electrocardiogram changesmust be recorded and retained.6
d.

Practical aspects
It is essential to have well-trained medical sta, that is immediately available in case of emergency, and

facilities for continuous monitoring of the patients condition. Intravenous access and intensive care room
access/emergency treatment should be available depending on the severity of the previous reaction and the type
of drug. Procedures like spirometry, monitoring of blood pressure, pulse and vital signs must be performed
according to the patients individual situation. Evolution of life-threatening reactions may make fast access to
Drug
8
intubation essential.

Provocation

DPT should be performed placebo-controlled, single blinded, and, in certain situations where psychological
aspects may prevail, even double-blind. This is most importance, since even in healthy students and hospital sta
without any medication but placebo capsules, 41% reported (mostly subjective) symptoms like sedation,
irritation, but even nasal congestion, fever, exanthemas and urticarial within a 3-day observation period.
The subjects health status should be good on the day of testing, without any sign of allergy or viral
infection that could stimulate an immune responseeven though this might have been a potential co-factor for the
original reaction. Patients should be observed as long as severe exposure-related reactions may be expected. This
depends on the type of previous drug reaction, the drug under investigation and the individual situation of the
patient. If mild reactions had occurred, observation after stabilization is recommended for at least 2 hours. After
severe reactions hospitalization is mandatory because of the possibility of biphasic episodes that can be lethal if
not recognized early and treated adequately. After release, the patient should be equipped with an adequate
emergency treatment if further symptoms such as urticarial seem possible (antihistamines, betamimetics,
glucocorticosteroids). In general terms a safety rst policy should be followed and in many cases an observation
period of 24 hours is desirable. Local regulations may inuence this procedures.6
2.5.2 Route of administration
The dierent routes of administrations include oral, parenteral (iv, im, sc), and topical (nasal), bronchial,
conjunctival, cutaneous, etc. The administration of DPT depends on the type of the drugs. Although the drug

should in principle be administered in the same way as it was given when the reaction occurred, the oral route is
favored if possible, since absorption is slower and developing adverse reactions can thus be treated earlier as
compared to DPT performed by the parenteral route.6
2.5.3 Dosage of test preparations and time intervals
They are dependent on numerous variables, including the type of drug itself, the severity of the drug
hypersensitivity reaction under investigation, the route of administration, the expected time latency between
Drug
9
application and reaction, the state of health of the individual patient, and his/her co-medication.

Provocation

According to general consideration of drug provocation6 one should start with allow dose, carefully
increasing and stopping as soon as the rst objective symptoms occur. If no symptoms appear, the maximum
single dose of the specic drug must be achieved, and the administration of the dened daily dose is desirable.
Practically, there is no absolute protocol in performing DPT and how much dose should be given. Here we
show one study based on single blind, placebo-controlled DPT performed in University of Sao Paulo 7, the DPT
start with 12 doses of placebo, followed by increasing doses of the suspected causal drug once every 20 minutes
until the therapeutic single dose was administered or symptom of drug hypersensitivity arise.
In case of a previous immediate reaction (i.e. occurring less than1 hour after drug administration) the
starting dose should be between 1:10.000 and 1:10 of the therapeutic dose, dependent on the severity of the
reaction; the time interval between doses should be at least 30 min, but many drugs and specic situations might
require longer intervals6.

e symptoms, respiratory rate, blood pressure, oxygen saturation, peak expiratory flow and focused physical e

In case of previous non-immediate reactions (i.e. occurring more than1 hour after the last drug
administration) the starting dose should not exceed 1:100 of the therapeutic dose. If DPT is performed in order to
nd an alternative drug, one should reach the maximum single therapeutic dose; in some cases it may be essential
to deliver a dened daily dose over a prolonged period of time6.
2.5.4 Time interval between reaction and provocation test
At least 5 times the drug elimination half time should be waited in order to guarantee complete elimination.
The reaction under investigation should have resolved completely, clinically and according to lab resultsif
measured initially and being abnormal.

Drug
Provocation
2.6

10

Test Results

2.6.1 Assessment of test results

The assessment of adverse reactions to drugs during provocation testing is very difcult in the absence of
objective clinical signs. A DPT can be termed positive, if it reproduces the original symptoms. If the original
reaction is just manifested with subjective symptoms and challenge testing again leads to similar, non-veriable
symptoms, placebo challenge steps must be performed. If these placebo steps are negative, repetition of the
previous dosing of the drug under investigation is highly recommended. 6 The subjective symptoms resulting from
the patients anxiety and past experiences must also be taken into account.10
Always try to objectify the test result by exact surveillance of skin alterations (photographs are helpful) and
other signs of the original drug reaction. For example, in vivo tests that might be applicable are rhinomanometry
(in some cases with occupational rhinitis) and peak-ow and/or spirometry for respiratory symptoms, and
determination of cardiovascular parameters for anaphylactic symptoms.6
General clinical tests such as a complete blood count, total platelet count or eosinophilia, the determination
of mediator release (histamine in blood or methylhistamine in urine; eosinophil cationic protein and serum
tryptase) can sometimes be helpful. Measuring cytokines, immune complexes, complement components,
complement split factors and others are still research tools with no dened reliability for clinical use. Specic
tests like the lymphocyte transformation test, the CAST-ELISA and 15-HETE-determination, ow cyto-metric
basophil activation tests, or leukocyte cytotoxicity assays may soon have a role in patient evaluation and
management, but negative predictive values need to be systematically investigated rst.6
2.6.2 Interpretation of test result

Drug
11
Hypersensitivity reactions are unpredictable adverse drug reactions (ADRs) to drug doses that are wellProvocation

tolerated by most individuals. These can be immune-mediated (allergic) or non-immune-mediated (non-allergic)

reactions. Immune-mediated reaction can be immediate (IgE-mediated allergic reactions) and non-immediate
(provocation test). Drug hypersensitivity type immediate reaction may reproduce several symptoms such as
immediate anaphylactic with or without shock, generalized urticaria, angioedema, or bronchospasm. Nonimmediate reactions may occur several days after the drug administration and include urticaria, maculopapular
eruptions, xed drug eruptions, vasculitis, toxic epidermal necrolysis, the StevensJohnson syndrome, and drug
reaction with eosinophilia and systemic symptoms.7
The drug provocation test result was considered positive if any of the symptoms or signs of any drug
hypersensitivity reaction described previously were documented up to 2 hours after the last dose was
administered (3 hours for provocations to aspirin and other non-steroidal anti-inammatory drugs [NSAIDs]), for
drug hypersensitivity type immediate reaction. The drug provocation test result was considered negative if no
sign of drug hypersensitivity occurred after the usual daily dose had been administered.7
In patient who received more than 1 drug during the hypersensitivity episode or claimed to have
hypersensitivity reaction to more than 1 drug, other drug provocation tests were performed a few days to few
months later.7

Tabel 3. Symptoms of positive drug hypersensitivity for several drug 10

Drug
Acetylsalicylic acid

Possible Symptoms
Urticaria, angioedema, conjunctivitis, erythema,

Mefenamic acid
Amoxicillin
Phenoxymethylpenicillin
Ofloxacin
Lidocaine
Acetaminophen (paracetamol)
Diclofenac

tightness of the chest

Urticaria, vertigo, hypertension
Urticaria, angioedema
Urticaria, erythema
Angioedema
Urticaria
Urticae
Urticaria, angioedema

A prospective single-center study between July 1999 and December 2001, of 303 patients with a suspected history of drug hypersensitivity reactions
who underwent 785 drug provocation tests

Drug
Provocation

12

Table 4. Drugs implicated in positive test results, dose of each drug that resulted in the reaction, and clinical manifestations
presented during the test7
Patient

1
2
3
4
5
6
7

Drug

Dose That Resulted

Clinical

in Reaction during

Manifestations during

the Test

test

Etoricoxib
Etoricoxib
Paracetamol
Paracetamol
Paracetamol
Bupivacaine
Bupivacaine

90 mg
90 mg
50 mg
300 mg
500 mg
10 mg
Skin prick test

Facial angioedema
Facial angioedema
Laryngeal angioedema
Urticaria
Urticaria
Urticaria
Anaphylaxis (pruritus,

8
9

Lidocaine
Cephalexin

(2 mg/100 mL)
40 mg
50 mg

flush, and wheezing

Laryngeal angioedema
Anaphylaxis (flush,

10

Ketokonazole

60 mg

dyspnea, and shock)

Urticaria and facial
Angioedema

Single-blind, placebo, retrospective analysis of 500 patients with ADRs who sought treatment and were submitted to DPTs when indicated between
2006 and 2010
* with modification

2.6.3 Predictive Value

The predictive value of DPT mainly depends on the type/mechanism of reaction and the drug involved.
When performing DPT, one has to consider the considerable number of false-positive and false-negative results.
A negative test does not prove tolerance for the drug in the future and a positive result might not indicate lifelong
hypersensitivity.6 The causality of a reaction needs stringent criteria; the message of a provocation test with all its
variables regarding sensitivity and specicity depends on the diagnostic aim. A test with high sensitivity is
needed when looking for explanations of suspected drug hypersensitivity reactions, but in order to prove causality
high specicity would be essential. In clinical practice, it might be more useful to look for safe alternatives
instead of proving that a drug was the denitive cause of the problem.

Drug
Provocation

13

2.6.4 False Negative and False Positive Results

A negative test does not exclude a drug as being the culprit for a reaction since there are some crucial
factors that influence the test result. In summary, there is no absolute certainty for future situations.6,7
Table 5. Important Considerations When Interpreting DPT Results. 6

Potential reason for

False-positive reactions
False-negative results
Psychological symptoms
Antiallergic drugs
Preexisting symptoms (e. g urticaria)
Missing co-factor (light,

Drug-induced aggravation of

medication, viral infection, physical

preexisting disease

exercise)

Self-infliction

co-

Exposure and/or observation time

too short

Too short/too long time interval

from reaction

Dosage too low

Desensitization by testing

2.6.5 Consequences of test result

The patient nally needs adequate documentation of those drugs that he should not receive any more and
those that had been tolerated in the test. The personal use of Medic-Alert tags and/or bracelets should be
encouraged. An allergy passport to be presented before any drug prescription in the future should be issued and
contain at least:
o The (generic and company) name of drug and the active ingredient;
o The date and type of reaction and its severity;
o The method used for evaluation (e.g. history, skin test, IgE-detection, LTT, or DPT), including date and
comments;
o Recommended safe alternatives and the tolerated dose (in the DPT).
2.7

Drug Provocation Test Accuracy

Drug
Provocation

14

Provocation test has become a gold standard for the indication of drug hypersensitivity.11 It is independent
of pathogenesis and takes individual factors into account such as the metabolism and genetic disposition of
individual. Provocation tests have the finest sensitivity but can only be performed under the most rigorous
surveillance conditions and are therefore restricted to certain specialist centers with on-site intensive care
facilities.11 Provocation test sensitivity and specificity is used depend on the diagnostic aim. Test with high
sensitivity need when looking for explanation of suspected drug hypersensitivity reactions, but in order to prove
causality high specificity would be essential.12

Drug
Provocation

15

CHAPTER III
SUMMARY

Drug provocation test is the controlled administration of a drug in order to diagnose drug hypersensitivity
reactions. DPT can be used as diagnostic test for both immediate and non-immediate reactions. There are several
limitations to the seemingly straight forward procedure of DPT, nevertheless the test still gold standard to detect
hypersensitivity.
Because this test including a trial in human, ethical consideration should be noticed before performing
DPT. Informed consent must be done. Patient also should be washed out from other drug that may alter the result
of DPT for certain free interval. Safety of the patient still number one, therefore any utilities that useful in
anaphylaxis or emergency case such as epinephrine, oxygen, bronchodilator, and etc. must be already. It also
must be performed by an expert.
The drug provocation test result was considered positive if any of the symptoms or signs of any drug
hypersensitivity reaction were documented up to 2 hours after the last dose was administered. The drug
provocation test result was considered negative if no sign of drug hypersensitivity occurred after the usual daily
dose had been administered.

REFERENCES
1.

WHO.Medicines:

safety

of

medicines

adverse

drug

reactions.2008.

Available

at

http://www.who.int/mediacentre/factsheets/fs293/en/index.html [accessed 27 October 2011)

2.

Pichler WJ.Drug hypersensitivity reactions: classification and relationship to T-cell activation.Basel Karger
2007;1:168189

3.

Gomes ER, Demoly P.Epidemiology of hypersensitivity drug reactions. Allergy Clin Immunol 2005;5:309
316

4.

Messaad D, et al.Drug provocation tests in patients with a history suggesting an immediate drug
hypersensitivity reaction.Annals of Internal Medicine 2004;140 (12):1001

5.

Romano A, Torres MJ, Castell M, et al.Diagnosis and management of drug hypersensitivity reactions. J
Allergy Clin Immunol 2011; 127(3):s67-s73

6.

Aberer W, et al.Drug provocation testing in the diagnosis of drug hypersensitivity reactions: general
considerations.Allergy 2003;58:854863

7.

Vivolo M, et al.Outcomes and safety of drug provocation tests.Allergy Asthma Proc 2011; 32:301306

8.

Higueras C.Drug provocation tests in children: indications and interpretation. Allergol Immunopathol
2009;37(6):32132

9.

Na HR, Lee JM, Jung JW, et al.Usefulness of drug provocation tests in children with a history of adverse
drug reaction.Korean J Pediatr 2011;54(7):304-309

10.

Komericki P, Grims R, Krnke B, Arbab E, Abrer W.Tryptase as Severity Marker in Drug Provocation
Tests. Int Arch Allergy Immunol 2006; 140:164169

11.

Castells MC. Anaphylaxis and hypersensitivity reactions. 1 st ed. Antibiotic induced anaphylactic.Springer
2011;10:p173

12.

Bircher A, Romano A, Blanca M, et al. Position paper: Drug provocation test in the diagnosis of drug
hypersensitivity reactions: general considerations. Allergy 2003;58:854863