The use of drug provocation testing in the investigation of suspected immediate perioperative allergic reactions: current status

Lene H. Garvey, Didier G. Ebo, Mogens Krøigaard, Sinisa Savic, Russell Clarke, Peter Cooke, Pascale Dewachter, Tomaz Garcez, Anne B. Guttormsen, Philip M. Hopkins, David L. Hepner, David A. Khan, Helen Kolawole, Peter Kopac, Stuart Marshall, Paul Michel Mertes, Peter Platt, Michael Rose, Vito Sabato, Paul SadleirLouise Savic, Kathrin Scherer, Tomonori Takazawa, Gerald W. Volcheck, Susanna Voltolini, Jose J. Laguna

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Suspected perioperative allergic reactions are often severe. To avoid potentially life-threatening re-exposure to the culprit drug, establishing a firm diagnosis and identifying the culprit is crucial. Drug provocation tests are considered the gold standard in drug allergy investigation but have not been recommended in the investigation of perioperative allergy, mainly because of the pharmacological effects of drugs such as induction agents and neuromuscular blocking agents. Some specialised centres have reported benefits of provocation testing in perioperative allergy investigation, but the literature on the subject is limited. Here we provide a status update on the use of drug provocation testing in perioperative allergy, including its use in specific drug groups. This review is based on a literature search and experiences of the authors comprising anaesthesiologists and allergists with experience in perioperative allergy investigation. In addition, 19 participating centres in the International Suspected Perioperative Allergic Reaction Group were surveyed on the use of provocation testing in perioperative allergy investigation. A response was received from 13 centres in eight European countries, New Zealand, and the USA. Also, 21 centres from the Australian and New Zealand Anaesthetic Allergy Group were surveyed. Two centres performed provocation routinely and seven centres performed no provocations at all. Nearly half of the centres reported performing provocations with induction agents and neuromuscular blocking agents. Drug provocation testing is being used in perioperative allergy investigation in specialised centres, but collaborations between relevant specialties and multicentre studies are necessary to determine indications and establish common testing protocols.

Original languageEnglish
Pages (from-to)e126-e134
Number of pages9
JournalBritish Journal of Anaesthesia
Issue number1
Publication statusPublished - Jul 2019


  • allergy
  • anaphylaxis
  • challenge testing
  • drug hypersensitivity
  • drug provocation test
  • perioperative period

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