Presumed “sulfa allergy” in patients with intracranial hypertension treated with acetazolamide or furosemide: cross-reactivity, myth or reality?

doi:10.1016/j.ajo.2004.02.019

American Journal of Ophthalmology

Volume 138, Issue 1, July 2004, Pages 114-118

https://doi.org/10.1016/j.ajo.2004.02.019 Get rights and content

Abstract

Purpose

To determine whether acetazolamide or furosemide produce allergic cross-reactions in patients with self-reported “sulfa allergy.”

Design

Retrospective case series.

Methods

A retrospective review included patients with intracranial hypertension and a self-reported sulfa allergy treated with either acetazolamide or furosemide seen at the University of Iowa Hospitals and Clinics from 1972 to 2003. All presumed medication-related side effects were collected, including both predictable adverse effects (for example, paresthesias, fatigue) and unpredictable adverse reactions (for example, cutaneous fixed eruptions, urticaria, Stevens-Johnson syndrome, toxic epidermal necrolysis, angioedema, anaphylaxis).

Results

We reviewed 363 charts. Of these, 329 patients (91%) were excluded. Of the remaining 34 cases that did report a so-called sulfa allergy, 13 (38%) received acetazolamide alone, 7 (21%) received furosemide alone, and 14 (41%) received both acetazolamide and furosemide. Of the 27 patients who received acetazolamide, 10 (37%) had no documented allergic cross-reaction to sulfa, and 2 (7%) cases had urticaria. The remaining 15 (56%) of acetazolamide-treated patients experienced predictable adverse reactions for this drug (for example, paresthesias). No patient experienced a severe allergic cross-reaction to sulfa. Of 21 patients who received furosemide, no unpredictable adverse reactions or allergic cross-reactions to sulfa were noted.

Conclusions

We find little clinical or pharmacological evidence to suggest that a self-reported sulfa allergy is likely to produce a life-threatening cross-reaction with acetazolamide or furosemide. These medications should be considered for intracranial hypertension if the risk-to-benefit ratio warrants their use.

Section snippets

Methods

A retrospective chart review was performed of all patients with the diagnosis of presumed idiopathic intracranial hypertension from 1972 to 2003 at the University of Iowa Hospitals and Clinics, Department of Ophthalmology, Division of Neuro-Ophthalmology. This study was performed with appropriate institutional review board approval and in compliance with applicable Health Insurance Portability and Accountability Act regulations. Inclusion criteria were as follows: 1) a clinical diagnosis of

Results

We reviewed 363 charts. All patients had been seen between 1972 and 2003 at the Department of Ophthalmology at the University of Iowa Hospitals and Clinics, Iowa City, Iowa. Patient follow-up ranged from 7 weeks to 21 years, with a median of 2.5 years, and a mean of 4.13 years. Of these 363 patients, 322 (89%) were excluded because of absence of self-reported sulfa allergy. Of the remaining 41 (11%) charts of patients with self-reported sulfa allergy, 5 additional charts were excluded because

Discussion

Although the literature on the treatment of idiopathic intracranial hypertension suggests that patients with sulfa allergy should not take acetazolamide or furosemide, the evidence supporting this recommendation is weak. The same product warnings appear for other sulfonamide nonantimicrobial agents used in ophthalmology, including brinzolamide, dorzolamide, and methazolamide.1

The majority of patients who report a sulfa allergy have actually had an adverse reaction to a sulfonamide antimicrobial

Biosketch

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Thus the pharmacologic literature provided with both medications suggests that individuals with a sulfa allergy should refrain from taking these medications. Lee et al.135 reviewed the charts of patients with intracranial hypertension and self-reported sulfa allergy who were given regimens of acetazolamide, furosemide, or a combination of acetazolamide and furosemide. They did not find any evidence of cross-reactivity in their patients and suggest use in these patients can be done safely.
Primary (idiopathic) intracranial hypertension has been considered to be a rare entity, but with no precise estimates of the pediatric incidence in the United States. There have been attempts to revise the criteria over the years and adapt the adult criteria for use in pediatrics. The clinical presentation varies with age, and symptoms tending to be less obvious in younger individuals. In the prepubertal population, incidentally discovered optic disc edema is relatively common. By far the most consistent symptom is headache; other symptoms include nausea, vomiting tinnitus, and diplopia. Treatment mainstays include weight loss when appropriate and acetazolamide. Furosemide may exhibit a synergistic benefit when used in conjunction with acetazolamide. Surgical interventions are required relatively infrequently, but include optic nerve sheath fenestration and cerebrospinal fluid shunting. Pain and permanent vision loss are the two major complications of this disorder and these manifestations justify aggressive treatment. Once intracranial hypertension has resolved, up to two thirds of patients develop a new or chronic headache type that is different from their initial presenting headache.

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Original articlePresumed “sulfa allergy” in patients with intracranial hypertension treated with acetazolamide or furosemide: cross-reactivity, myth or reality?☆

Abstract

Purpose

Design

Methods

Results

Conclusions

Section snippets

Methods

Results

Discussion

Biosketch

Am J Ophthalmol

Am J Ophthalmol

Am J Emerg Med

J Allergy Clin Immunol

Mol Immunol

Physician's desk reference

Fatal anaphylactic reaction after oral (Diamox) for glaucoma

Ned Tijdschr Geneskd

Fatal anaphylactic reaction after oral acetazolamide (Diamox) for glaucoma

Ned Tijdschr Geneeskd

Fatal reaction to acetazolamide

Br J Ophthalmol

Sulfonamide hypersensitivity and acetazolamide

Arch Ophthalmol

Some observations on the use of acetazolamide as an oral diuretic in various edematous states and in uremia with hyperkalemia

Am Pract Digest Treat

Anaphylactic shock after a single oral intake of acetazolamide (Diamox)

Br J Ophthalmol

Original article
Presumed “sulfa allergy” in patients with intracranial hypertension treated with acetazolamide or furosemide: cross-reactivity, myth or reality?☆