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Drug Reactions


Reactions to medications may be wide ranging, from complaints of bad aftertaste to more serious problems with allergic reactions and anaphylaxis. Most calls will encompass three major groups of symptoms: rashes, anaphylaxis, or other complaints of patient intolerance. All drugs have side effects, and explaining to the patient what to expect before administering the drug may eliminate many calls. This is especially important when the side effects are severe or require additional management to control.

Many drug combinations may augment side effects, be frankly dangerous, or change the biologic action of one or the other medication. If you have any questions about drug interactions, contact your pharmacist.

Rashes and Anaphylaxis

Rash is a common manifestation of drug reaction. The first step to management is to rule out anaphylaxis because urticarial rash is a primary symptom.

Phone Call

Questions

  • 1.

    How long has the rash been present?

  • 2.

    Is the rash urticarial? (i.e., raised, blanching, itchy, etc.)?

    • Rule out anaphylaxis, symptoms of which include an urticarial rash (hives), wheezing, shortness of breath (SOB), and decreased blood pressure (BP).

  • 3.

    Is the patient taking any new medications? When was it last administered?

    • This includes any recent intravenous (IV) contrast dye.

  • 4.

    Does the patient have any known allergies or intolerances?

  • 5.

    Has the patient undergone a surgical procedure, and if so, how long ago?

  • 6.

    Are there any other symptoms?

    • Rashes are associated with upper respiratory infection symptoms or other irritant exposures.

  • 7.

    Are there any changes in vital signs such as hypotension or fever?

Orders

If the patient has signs of anaphylaxis:

  • 1.

    Start an IV with normal saline (NS) if not already in place.

  • 2.

    Have the following medications at the bedside:

    • Epinephrine (1:1000) for subcutaneous (SC) administration and epinephrine (1:10,000) for IV administration. (Label these carefully by their route of administration, so no mistake is made. Either may be necessary depending on the severity of the reaction.)

    • Diphenhydramine (Benadryl) 50 mg for IV administration.

    • Hydrocortisone (Solu-Cortef) 250 mg for IV administration.

  • 3.

    Support SOB with oxygen if necessary as described in Chapter 28 .

Degree of Urgency

If the patient is anaphylactic, he or she must be evaluated immediately. Most other rashes may be seen in 1 to 2 hours.

Surgical Chart Biopsy

  • Check for tachycardia, or hypotension. Is the patient newly febrile?

  • Review administration record of recent medications. What? When? New medication?

  • Review documented known allergies to medications.

Elevator Thoughts

Drug eruptions follow patterns specific to their medication class. The list of drugs causing rashes/eruptions continues to grow as new drugs reach the market. If unsure, use electronic drug databases or discuss a potential drug eruption with an in-patient pharmacist.

Urticaria

Lesion: The lesion is well circumscribed, raised, irregularly bordered, firm, blanching, transient, mobile, and often erythematous with central pallor.

Etiologies include the following:

  • 1.

    Histamine-releasing drugs

    • a.

      IV contrast

    • b.

      Narcotics

    • c.

      Antibiotics

      • i.

        β-lactams (penicillin and cephalosporins)

      • ii.

        Sulfonamides

      • iii.

        Tetracycline

      • iv.

        Isoniazid

      • v.

        Polymyxin

    • d.

      Anesthetic agents (curare)

    • e.

      Vasoactive agents (atropine, amphetamine, and hydralazine)

    • f.

      Miscellaneous (thiamine, dextran, deferoxamine)

  • 2.

    Nonhistamine releasers (aspirin and other nonsteroidal anti-inflammatory drugs [NSAIDs])

  • 3.

    Nondrug (hereditary angioedema, food allergies, and idiopathic reactions)

Maculopapular (Morbilliform)

Lesion: The lesion may be raised or nonraised, erythematous, irregularly bordered, and firm.

Etiologies include the following:

  • 1.

    Antibiotics

    • a.

      β-lactams (penicillins and cephalosporins)

    • b.

      Sulfonamides

    • c.

      Chloramphenicol

  • 2.

    Antihistamines

  • 3.

    Antidepressants (amitriptyline)

  • 4.

    Diuretics (thiazides)

  • 5.

    Oral hypoglycemics

  • 6.

    Sedatives (barbiturates)

  • 7.

    Antiinflammatory agents (gold and phenylbutazone)

  • 8.

    Nondrug (bacterial or viral infection, Reiter syndrome, inflammatory bowel disease, sarcoidosis, and serum sickness)

Vesicular

Lesion: The lesion is well circumscribed, elevated, and blister-like and may be filled with clear fluid (vesicle) or purulent material (pustule).

Etiologies include the following:

  • 1.

    Antibiotics (sulfonamides and dapsone)

  • 2.

    Anti-inflammatory agents (penicillamine)

  • 3.

    Sedatives (barbiturates)

  • 4.

    Halogens (iodides and bromides)

  • 5.

    Chemotherapeutic (cetuximab)

  • 6.

    Nondrug (bacterial or viral infection, toxic epidermal necrolysis, and inflammatory bowel disease)

Purpuric

Lesion: The lesion is erythematous to purplish, large, macular or papular, and nonblanching.

Etiologies include the following:

  • 1.

    Antibiotics (sulfonamides and chloramphenicol)

  • 2.

    Diuretics (thiazides)

  • 3.

    Antiinflammatory agents (phenylbutazone, salicylates, and indomethacin)

  • 4.

    Drug-induced thrombocytopenia (i.e., after heparin administration)

  • 5.

    Vasculitis (sepsis, bacterial or viral infection, and Henoch-Schönlein purpura)

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