Clinical Village – Station 2

Intradermal Tests: Drug Concentration Chart

Blanca Andrés, M Teresa Dordal, Gustavo Perdomo, María Rueda, Patricia Mujal, Mireia Romero and Ramon Lleonart CAF SCAIC (Drug Allergy Section of Catalan Allergy Society)

Take Home

Drug classes

Generic drug Undiluted

concentration Skin Prick

Test

Intradermal test (IDT)

Dilution Maximum

concentration

Betalactam antibiotics

Penicilloyl- poly-L-lysine

5x10-5mM 5x10-5mM 1/1 5x10-5mM

Minor determinant

mixture 2x10-2mM 2x10-2mM 1/1 2x10-2mM

Benzylpenicillin 10.000UI 10.000UI

Amoxicillin 200mg/mL 20mg/mL 1/10 20mg/mL

Ampicillin 20mg/mL 20mg/mL

Cephalosporins 2mg/mL 2mg/mL

Drug classes

Generic drug Undiluted

concentration (mg/mL)

Skin Prick Test

(mg/mL)

Intradermal test (IDT)

Dilution

Maximumconcentration

(mg/mL)

Perioperative drugs

Thiopental 25 25 1/10 2.5

Propofol 10 10 1/10 1

Ketamine 10 10 1/10 1

Etomidate 2 2 1/10 0.2

Midazolam 5 5 1/10 0.5

Fentanyl 0.05 0.05 1/10 0.005

Alfentanil 0.5 0.5 1/10 0.05

Sufentanil 0.005 0.005 1/10 0.0005

Remifentanil 0.05 0.05 1/10 0.005

Morphine 10 1 1/1000 0.01

Atracurium 10 1 1/1000 0.01

Cis-atracurium 2 2 1/100 0.02

Mivacurium 2 0.2 1/1000 0.002

Rocuronium 10 10 1/200 0.05

Vecuronium 4 4 1/10 0.4

Pancuronium 2 2 1/10 0.2

Suxamethonium 50 10 1/500 0.1

Drug classes

Generic drug Unidiluted

concentration (mg/mL)

Skin Prick Test

(mg/mL)

Intradermal test (IDT)

Dilution

Maximum concentration

(mg/mL)

Anti-coagulants

Heparins Undiluted 1/10

Heparinoids Undiluted 1/10

Platinum salts

Carboplatin 10 10 1/10 1

Oxaliplatin 5 1 1/50 0.1

Cisplatin 1 1 1/10 0.1

Taxol Paclitaxel 6 6 1/6 1

Docetaxel 10 10 1/10 1

NSAIDs Metamizol 400 400 1/1000 0.4

Biologicals

Adalimumab 50 50 1/10 5

Etanercept 50 25 1/10 5

Infliximab 10 10 1/10 1

Omalizumab 125 12.5

ug/mL 1/100 1.25 ug/mL

Rituximab 10 10 1/10 1

Cetuximab 5 5 1/10 0.5

Cortico-steroids

Hydrocortisone phosphate

100 100 1/10 10

Methyl-prednisolone

20 20 1/10 2

Triamcinolone 40 40 1/10 4

Budesonide 0,5 0,5

Dexamethasone 4 4 1/10 0.4

Other

Local anaesthetics

Undiluted 1/10

Iodinated contrast media

Undiluted 1/10

Gadolinium chelates

Undiluted 1/10

Patent blue Undiluted 1/10

Methylene blue 1/100

Fluorescein Undiluted 1/10

Proton pump inhibitors

40 1/10 4

Chlorhexidina digluconate

5 1/2500 0.002

Take Home

Intradermal test may be a useful diagnostic tool if we use the proper (validated) concentrations to avoid nonspecific responses.

REFERENCES: - Brockow K, Garvey LH, Aberer W et al on behalf of the ENDA/EAACI Drug Allergy Interest Group. Skin test concentrations for systemically administered drugs – an ENDA/EAACI Drug Allergy Interest Group position paper. Allergy 2013;68:702-712 - Corominas M, Gastaminza G, Lobera T. Hypersensitivity reactions to biological drugs. J Investig Allergol Clin Immunol 2014;24(4):212-225 - Lieberman P, Rahmaoui A, Wong DA. The safety and interpretability of skin tests with omalizumab. Ann Allergy Asthma Immunol 2010;105:493-495

5. INTERPRETATION:

After 20 minutes the area is examined for a reaction. A positive reaction looks like a small hive with swelling and redness.

The new hive can be marked with ink.

Measure the diameter of the hive (P20) and compare with the initial wheal (Pi).

POSITIVITY CRITERIA (ENDA/EAACI): P20 = Pi + 3 mm

Clinical Village – Station 2

Intradermal tests: how to perform them? M Teresa Dordal, Blanca Andrés, Gustavo Perdomo, María Rueda, Patricia Mujal, Mireia Romero and Ramon Lleonart

CAF SCAIC (Drug Allergy Section of Catalan Allergy Society)

2. DEFINITION:

Intradermal test (IDT) is a method of skin testing that can be used to determine whether an individual is sensitized to a specific allergen.

The test involves the injection of a small amount of the suspected allergen under the surface of the skin.

1. INDICATIONS:

Drug hypersensitivity reactions Hymenoptera venom allergy Allergic BronchoPulmonary Aspergillosis (ABPA)

Take home

5. SECURITY: All patients should be under close observation for potential

anaphylactic reaction following IDT.

Delayed positivity must be checked, specially when a delayed adverse reaction is evaluated.

3. PREPARATION

Make sure to verify the patient’s identity and the correct allergen or drug dilution to be used. Only drugs for parenteral administration must be used.

Some drugs may interfere with the results of IDT and should be discontinued prior to the test procedure: antihistamines, corticosteroids and some antidepressants.

Perform hand-hygiene and put on gloves.

Select an area on the inner forearm. Be careful with areas that have superficial blood vessels or covered with hair.

Cleanse the area with an alcohol swab. Allow the alcohol to dry before performing the injection.

4. INJECTION METHOD

Stabilize the skin

Use syringes preferably with a 0.50 mm x 16 mm needle.

Charge 0.02 ml of the allergen or drug into the syringe.

Place the needle with the bevel side up.

Insert the needle at a shallow angle, approximately 10-15º, when penetrating the skin. The point of the needle should be seen through the skin.

Press in the plunger slowly injecting the agent while watching for a small wheal to appear at the injection site. The wheal must be 5 mm in diameter.

Chart the site of the administration and circle the injection site marking the wheal with ink (Pi).

A negative control with serum saline must be carried out.

Amoxicillin 20 mg/ml

Penicillin G 10.00 UI

Amoxicillin 20 mg/ml

Amoxicillin + clavulanic acid 20 mg/ml

Amoxicillin + clavulanic acid 20 mg/ml

Pantoprazol 1/100

Esomeprazol 1/100

Meropenem 48 h

Amoxicillin 20 mg/ml Day 5

Amoxicillin + clavulanic acid 20 mg/ml

Day 5

Be careful. Select properly the patient, the drug to be used and the dilution to be applied.

Experience is mandatory in both the technique and the interpretation.