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      Validation of a Rapid, Robust, Inexpensive Screening Method for Detecting the HLA-B *58:01 Allele in the Prevention of Allopurinol-Induced Severe Cutaneous Adverse Reactions

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          Abstract

          The HLA B *58:01 allele has been worldwide reported as a pharmacogenetic susceptibility to allopurinol-induced severe cutaneous adverse reactions (SCARs). To prevent these life-threatening conditions, the American College of Rheumatology hingly recommended that the HLA-B *58:01 be screened prior to the initiation of allopurinol therapy. Therefore, we developed a rapid, robust, inexpensive screening method using SYBR® Green real time PCR to detect the HLA-B *58:01 allele. A total of 119 samples were tested. The assay has a sensitivity of 100% (95% CI: 69.15%-100%), a specificity of 100% (95% CI: 96.67%-100%), a positive predictive value of 100% (95% CI: 69.15%-100%) and a negative predictive value of 100% (95% CI: 96.67%-100%). HLA-B *58:01 genotyping results showed 100% agreement with those obtained from Luminex SSO/SBT/SSP. The lowest limit of detection of this method is 0.8 ng/µL of DNA. The unit cost of the test is only $3.8 USD. This novel screening test using SYBR® real time PCR would be appropriate to identify individuals with the HLA-B *58:01 allele for the prevention of allopurinol-induced SCARs.

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          Allopurinol is the most common cause of Stevens-Johnson syndrome and toxic epidermal necrolysis in Europe and Israel.

          Sima Halevy, Pierre-Dominique Ghislain, Maja Mockenhaupt … (2008)
          Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare severe cutaneous adverse reactions. We sought to update knowledge on the causes of SJS or TEN with a focus on the rate of allopurinol-associated cases and to identify risk factors for allopurinol-associated SJS or TEN. We conducted a multinational case-control study. In all, 379 patients with severe cutaneous adverse reactions validated as SJS or TEN and 1505 matched hospitalized control subjects were enrolled. Allopurinol was the drug most frequently associated with SJS or TEN, with 66 exposed patients (17.4%) and 28 exposed control subjects (1.9%) (adjusted odds ratio = 18, 95% confidence interval: 11-32). Allopurinol use was greater than in a previous case-control European study. Daily doses equal to or greater than 200 mg were associated with a higher risk (adjusted odds ratio = 36, 95% confidence interval: 17-76) than lower doses (adjusted odds ratio = 3.0, 95% confidence interval: 1.1-8.4). The risk was restricted to short-term use (
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            Use of HLA-B*58:01 genotyping to prevent allopurinol induced severe cutaneous adverse reactions in Taiwan: national prospective cohort study

            Tai-Ming Ko, Chang-Youh Tsai, Shih-Yang Chen … (2015)
            Objective To evaluate the use of prospective screening for the HLA-B*58:01 allele to identify Taiwanese individuals at risk of severe cutaneous adverse reactions (SCARs) induced by allopurinol treatment. Design National prospective cohort study. Setting 15 medical centres in different regions of Taiwan, from July 2009 to August 2014. Participants 2926 people who had an indication for allopurinol treatment but had not taken allopurinol previously. Participants were excluded if they had undergone a bone marrow transplant, were not of Han Chinese descent, and had a history of allopurinol induced hypersensitivity. DNA purified from 2910 participants’ peripheral blood was used to assess the presence of HLA-B*58:01. Main outcome measures Incidence of allopurinol induced SCARs with and without screening. Results Participants who tested positive for HLA-B*58:01 (19.6%, n=571) were advised to avoid allopurinol, and were referred to an alternate drug treatment or advised to continue with their prestudy treatment. Participants who tested negative (80.4%, n=2339) were given allopurinol. Participants were interviewed once a week for two months to monitor symptoms. The historical incidence of allopurinol induced SCARs, estimated by the National Health Insurance research database of Taiwan, was used for comparison. Mild, transient rash without blisters developed in 97 (3%) participants during follow-up. None of the participants was admitted to hospital owing to adverse drug reactions. SCARs did not develop in any of the participants receiving allopurinol who screened negative for HLA-B*58:01. By contrast, seven cases of SCARs were expected, based on the estimated historical incidence of allopurinol induced SCARs nationwide (0.30% per year, 95% confidence interval 0.28% to 0.31%; P=0.0026; two side one sample binomial test). Conclusions Prospective screening of the HLA-B*58:01 allele, coupled with an alternative drug treatment for carriers, significantly decreased the incidence of allopurinol induced SCARs in Taiwanese medical centres.
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              HLA and pharmacogenetics of drug hypersensitivity.

              Simon Mallal, Rebecca Pavlos, Elizabeth Phillips (2012)
              Immunologically mediated drug reactions have been traditionally classified as unpredictable based on the fact that they cannot be predicted strictly on the pharmacological action of the drug. Such adverse drug reactions are associated with considerable morbidity and include severe cutaneous adverse reactions such as Stevens-Johnson syndrome/toxic epidermal necrolysis and the drug hypersensitivity syndromes (drug reaction with eosinophilia and systemic symptoms/drug-induced hypersensitivity syndrome). Over the last decade there have been many associations between these syndromes and Class I and II HLA alleles of the MHC, which have enriched and driven our knowledge of their immunopathogenesis. Significant translation has also occurred in the case of HLA-B*5701 screening being used to exclude at risk patients from abacavir and prevent abacavir hypersensitivity. The ultimate translation of the knowledge of how drugs interact with HLA would be applicable to preclinical drug screening programs to improve the safety and cost-effectiveness of drug design and development.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Allergy Asthma Immunol Res
                Journal ID (iso-abbrev): Allergy Asthma Immunol Res
                Journal ID (publisher-id): AAIR
                Title: Allergy, Asthma & Immunology Research
                Publisher: The Korean Academy of Asthma, Allergy and Clinical Immunology; The Korean Academy of Pediatric Allergy and Respiratory Disease
                ISSN (Print): 2092-7355
                ISSN (Electronic): 2092-7363
                Publication date (Print): January 2017
                Publication date (Electronic): 27 September 2016
                Volume: 9
                Issue: 1
                Pages: 79-84
                Affiliations
                [1 ]Sydney Medical School - Northern, University of Sydney, Sydney, Australia.
                [2 ]ImmunoRheumatology Laboratory, Pathology North-Northern Sydney, St Leonards, Australia.
                [3 ]Department of Allergy and Clinical Immunology, Hanoi Medical University, Hanoi, Vietnam.
                [4 ]Center of Allergology and Clinical Immunology, Bach Mai Hospital, Hanoi, Vietnam.
                [5 ]Department of Clinical Immunology and Allergy, Royal North Shore Hospital, Sydney, Australia.
                Author notes
                Correspondence to: Dinh Van Nguyen, PhD student, Sydney Medical School-Northern, University of Sydney, St. Leonards, NSW 2065, Australia. Tel: +61-94631634; vngu3162@ 123456uni.sydney.edu.au
                Co-Correspondence to: Christopher Vidal, PhD, ImmunoRheumatology Laboratory, Pathology North-Northern Sydney, Royal North Shore Hospital, Westbourne St., St. Leonards, NSW 2065, Australia. Tel: +61-2-9926-4148; christophervid@ 123456gmail.com
                Article
                DOI: 10.4168/aair.2017.9.1.79
                PMC ID: 5102839
                PubMed ID: 27826965
                SO-VID: 7358d408-ea27-4a6d-a5b9-a9f0601fa1b6
                Copyright © Copyright © 2017 The Korean Academy of Asthma, Allergy and Clinical Immunology • The Korean Academy of Pediatric Allergy and Respiratory Disease
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 17 May 2016
                Date accepted : 28 June 2016
                Categories
                Subject: Brief Communication

                ScienceOpen disciplines: Immunology
                Keywords: allopurinol hypersensitivity,hla-b antigens,real time polymerase chain reaction,stevens johnson syndrome,toxic epidermal necrolysis,drug reactions with eosinophilia and systemic symptoms,severe cutaneous adverse reactions
                Data availability:
                ScienceOpen disciplines: Immunology
                Keywords: allopurinol hypersensitivity, hla-b antigens, real time polymerase chain reaction, stevens johnson syndrome, toxic epidermal necrolysis, drug reactions with eosinophilia and systemic symptoms, severe cutaneous adverse reactions

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