Drug Allergy Peer Feedback – CKLAASEN

Drug hypersensitivity is an immune-mediated reaction to a medication with symptoms ranging from mild to severe. Some protein and large polypeptide medications can directly stimulate antibody production. Most medications act as happens and bind to proteins and peptides found in the major histocompatibility complex (MHC) molecules. This binding makes the MHC-medication complex immunogenic, stimulating the production of anti-medication antibodies, T-cell responses, or both. Some medications can directly activate T-cells without binding to the MHC complex. Primary sensitization occurs when the person has their first dose of the medication and successive doses can lead to larger and larger reactions. This is why some people can take a medication previously with no issues, however that is the sensitization event and when they are prescribed the medication in the future they could have a hypersensitivity/allergic reaction.

Symptoms of medication allergies can vary, with symptoms ranging from mild to severe. The most serious reactions are anaphylaxis (Type 1 Hypersensitivity), skin rash, itching, and fever. Other symptoms include serum sickness, drug-induced immune hemolytic anemia, drug rash with eosinophilia and systemic symptoms (DRESS), pulmonary effect and renal effects. Serum sickness (type III Hypersensitivity) occurs 7-10 days after exposure. Drug-induced hemolytic anemia (type II Hypersensitivity) occurs when an antibody-medication-red blood cell reaction occurs or when the medication alters the RBC membrane. DRESS (Type IV Hypersensitivity) can occur 12 weeks after medication treatment or after a dose increase. Pulmonary effects (Type III & IV Hypersensitivity) are caused when certain medications induce wheezing and a deterioration in pulmonary function. Renal effects ( Types I, III, & IV Hypersensitivity) are usually tubulointerstitial nephritis which is inflammation of the kidney tubules and surrounding tissues.

Diagnosis can be based off of patient’s history of previous experiences with the medication. We can also do formal testing through skin prick testing, in office provocation testing (give the medication to watch the effects), and also blood testing. We would usually look at time of onset of symptoms, known effects of the medication , and results from a repeat medication challenge to distinguish between drug hypersensitivity or if it is a toxic or adverse effect or a possible drug interaction.

Treatment is usually discontinuing the medication. We can provide antihistamines, corticosteroids, and epinephrine to help with some of the hypersensitivity reactions. Most symptoms do not require medication and will stop in a few days once the medication is discontinued.

One potential addition I may have added would be the common reactions of the medication. That way the learner would know that a rash is not a common reaction for this medication (though it can be for other medications like sulfonamides). Also a mention of what hives look like and how it differs from a rash. Hives cause raised, flat welts on the skin that appear quickly, with a bumpy (not blistered) texture, and does not usually come with any dryness, peeling, or flaking. This would be an important distinction to make as it better informs the education and teaching we can provide to our patients and better inform them of what is better to look out for.

An addition of which other antibiotics also include beta-lactam rings such as cephalosporins, carbapenem and monobactams would have been beneficial to my learning. They also could have explored or commented on whether the girl would have a reaction to the above medications. This I believe is a real world issue we regularly see in the hospital setting and knowing that your patient has a penicillin allergy may not immediately alert the nurse to watch them closely if they were prescribed a carbapenem (or if it would cause a reaction). This also better informs the teaching and education we can provide to our patients so they have a better health literacy and can advocate for themselves should they be accidentally be prescribed an antibiotic they are allergic to in the future.

Project-based learning supported my learning with the following benefits – critical thinking, creativity, engagement, confidence, communication, and deep understanding.  This strategy stimulates critical thinking by teaching students how to break a problem down into steps and then how to find a solution. This project encouraged not only personal creativity but enabled us to use creativity to make connections to course information. We were able to have ownership of how we wanted the project to look which I believe promotes more student engagement – we all want to work hard and make a good project. This project improved my confidence not only in understanding the course information but also in my ability to engage in group projects. Our communication skills improved as we needed to share our ideas, explore the ideas of others, and problem solve any issues that arise. This project, through our research, was able to give me a deeper understanding of the topic as through the case studies I was able to make the link from class-room based information to real world scenarios. Some of the issues I did encounter with this project surrounded lack of clarity in the beginning with what our project was supposed to look like. There were lots of questions I feel not only with myself but with my colleagues as well where we weren’t exactly sure what was asked of us as the wording was open to interpretation. There were also some personal group work issues that took some time to resolve – this is both a positive and a negative in any group. The assessment by the peer feedback is subjective and open to personal interpretation which I believe is a negative of project based learning.

The group used an analysis case study to make a connection with the classroom based theory and how it applies to real-world situations. Through the implementation of real or invented stories the group was able to present a problem, apply theory to enhance understanding, and through analysis of the presented problem illustrate what the next steps would be and how the issue would be handled. In this case study the little girl through repeated exposure to amoxicillin developed an allergy to the medication. The group demonstrated the pathophysiology of why this occurred or what was happening inside her body. They then also demonstrated what outward effects occurred and that the medical professionals identified the allergy and created an alert in her chart. I believe that this case study improved my learning by utilizing a story format to relay the information in a more interesting format. This also improved my active listening skills and metacognitive skills. I was able to utilize learning strategies, monitor and evaluate my learning, and through self regulation recognize my ability to motivate my own learning. The technology used to create the visuals for the case study were well applied and kept me engaged with the story.

If I could make one change to the project I would remove the information about the girl eating candy, needing to go to the dentist and taking the initial doses. I understand the use of creative story telling to immerse the viewer in the world of the case study, as well as creating buy in for the viewer through the use of common events (eating candy is delicious, we all need to go to the dentist etc.) There is nothing wrong with the above details but it did make the case study much longer than necessary (about a minute longer) with details that were not relevant to the pathophysiology. This could have been succinctly summarized as the girl had previously taken this medication for a dental treatment, and following two treatments in the hospital. I believe this would better tailor the topic to the audience (which is nursing students) and present the information in a way we are more likely to experience – which is history taking from the client. I (much like most students) am constantly strained for time and find myself skimming most articles, and case studies due to time-constraints. Therefor this is why I would prefer to remove the above information from the case study as it would create a shorter video while still relaying the necessary information of the primary sensitization.

The information and pathophysiology of drug hypersensitivity reactions is vital information for my future practice as we are commonly seeing allergies listed in patient charts and we need to understand not only the importance of this information but also what symptoms to look out for. I will integrate this information into my future practice by conducting a medication review if I see a drug allergy listed on a patient chart. Reviewing the specific medication allergy will also let me know if there are other medications that have a similar structure and could cause a reaction in the patient. The review also lets me know what side effects are common and expected which should lead to better patient care – know when its a serious reaction and hold medication for doctor review. It also enables me to provide better patient education during their stay and on discharge when it comes to their medications. I can advise the patient what symptoms to watch for during in hospital care. Serious symptoms require them to call the nurse if they occur – anaphylaxis can occur rapidly and requires quick intervention, as well as continued monitoring after. This video also highlights the importance of asking patients about past medication use, what reactions occurred, and whether there is any family history of drug allergies.