A lot of people think they have allergy to medications when they don’t. In this episode, I welcome Allergist and Immunologist Farah Khan to chat about drug allergies and share some misconceptions. We discuss:

• What a true drug allergy looks like
• Why not all rashes while on antibiotics are a drug allergy
• Are true drug allergies hereditary?
• What to do if you truly feel your child has a drug allergy

Connect with Farah Kahn on Instagram @khanallergy

00;00;01;02 – 00;00;25;05

Farah Khan

My kid has had him on his own before and there weren’t any issues, and then they end up on it again for an ear infection. And then usually within ten, 15, 30 minutes, you’ll start to notice that they develop, some symptoms like itching all over or welts, or hives. They’ll start to have some coughing or trouble breathing or they’ll have repetitive vomiting or belly pain.

 

00;00;25;05 – 00;00;36;19

Farah Khan

And it’s usually a combination of these symptoms and the timing of when they took that medication. That kind of clues is in to, hey, this probably is a drug reaction.

 

00;00;36;22 – 00;00;57;09

Dr. Mona

Hey everyone, welcome back to the show. I continued to get to talk to the most amazing guests on this podcast, and 2023 is not going to be any different. I get to have conversations about parenthood, child health, development and so much more. So thank you for tuning in, for being here today and for all of your reviews and love for the podcast.

 

00;00;57;09 – 00;01;16;22

Dr. Mona

This is how the podcast continues to grow. On today’s episode, I welcome Farah Khan, who is a practicing allergist and immunologist, and we’re talking about is my child really allergic to that medicine? A conversation about medication allergies and what they really look like. Thank you so much for joining us today, Doctor Khan.

 

00;01;16;24 – 00;01;23;05

Farah Khan

Absolutely. Thank you so much for having me. I’m so excited to talk about this. This is a topic that is near and dear to my heart.

 

00;01;23;07 – 00;01;57;10

Dr. Mona

Yes, and mine too. You know the reason why I wanted you to come on, and I’m so glad you reached out is because medication allergies do happen. But I feel like in my practice and also on social media, sometimes people feel that they are allergic to medicine, when in actuality they’re not. So we’re going to go over what medication allergies may look like, what to do if a family feels like their child does have a medication allergy and just separate some fact from fiction, obviously we’re not able to show visuals of what an allergy may look like, but this will be something that I know doctor Khan will describe, and I really think it’ll empower

 

00;01;57;10 – 00;02;03;12

Dr. Mona

you to know, okay, this is not a medication allergy, or maybe it is and what to do next. So thank you so much.

 

00;02;03;14 – 00;02;04;19

Farah Khan

Yeah of course.

 

00;02;04;21 – 00;02;12;17

Dr. Mona

So tell us more about what you do as an allergist and immunologist. Do you see a lot of children and families that come in with a concern for medication allergies?

 

00;02;12;19 – 00;02;39;20

Farah Khan

Absolutely. We often get referrals from pediatricians. In the area just to figure out, like, hey, is this kid really allergic to penicillin? Can I give them amoxicillin the next time they have an ear infection? And with kids, what we mostly see is this penicillin class of antibiotics because, their first line therapies for a lot of bread and butter conditions that we see, like the ear infection and the sinus infection, bronchitis, whatever upper respiratory infection, you’re managing.

 

00;02;39;20 – 00;02;46;15

Farah Khan

And I welcome those patients into our clinic with open arms because it’s such an important issue to talk about.

 

00;02;46;17 – 00;03;19;27

Dr. Mona

Oh, absolutely. And you know, one of the biggest things that I mentioned earlier already is that parents feel like their children have an allergy. But as we know, sometimes it’s not really an allergy. So I guess my first question is what are the signs of an allergy to a medication? So I agree that, you know, amoxicillin, which is part of the penicillin class, is one of the most commonly prescribed antibiotics if we do prescribe it for anyone listening, your child has probably had that for things like ear infections or maybe a pneumonia, the more commonly an ear infection as a first line.

 

00;03;20;03 – 00;03;29;24

Dr. Mona

So if a child does have an allergy to, let’s just say penicillin as an example, or amoxicillin, what would an allergy to that medication actually look like?

 

00;03;29;27 – 00;03;50;19

Farah Khan

Yeah. So some of the classic signs and symptoms that go along with a classic drug allergy, which is usually mediated by a very specific allergy cell called IgG. Those signs and symptoms look like this. My kid has had them off and so on before, and there weren’t any issues. And then they end up on it again for an ear infection.

 

00;03;50;19 – 00;04;19;07

Farah Khan

And then usually within ten, 15, 30 minutes you’ll start to notice that they develop, some symptoms like itching all over or welts, or hives. They’ll start to have some coughing or trouble breathing or they’ll have repetitive vomiting or belly pain. And it’s usually a combination of these symptoms and the timing of when they took that medication that kind of cruises into, hey, this probably is a drug reaction.

 

00;04;19;29 – 00;04;38;15

Farah Khan

Drug allergies do not present like days and weeks later. So it’s never going to be oh, my kid wasn’t in my facility a couple of weeks ago for, a pneumonia. And then a couple of weeks later, they started to have this weird rash. That is not how drug, reaction, immediate drug reaction work.

 

00;04;38;17 – 00;04;53;11

Dr. Mona

And in terms of the day of the medicine. So, for example, just say they started the amoxicillin on a Monday. Do we normally see it on a certain day of starting the medicine? Can you see it, you know, a few days into starting the medicine. Or does it just depend.

 

00;04;53;13 – 00;05;15;05

Farah Khan

So what I’ll say is that usually your immune system, these cells need to be something we called sensitized. So it means your immune system needs to have seen the penicillin based antibiotic previously. And usually it’s within that first ingestion that first dose that within you know 30 minutes. Sometimes it takes an hour or two for these symptoms to develop.

 

00;05;15;05 – 00;05;32;16

Farah Khan

But usually it’s pretty quick and onset, that you start to see the symptoms. What I think is really confusing is that oftentimes there’s a virus that leads to the ear infection or the upper respiratory infection, especially the kids that are in daycare or in school or have siblings that are in school and they’re bringing home all kinds of germs.

 

00;05;32;19 – 00;06;02;17

Farah Khan

Oftentimes it’s the virus that runs into then, bacterial infection that requires the antibiotics and the rash that may develop on like day three or day five or day seven of the antibiotics. It is oftentimes not related to the antibiotic. It is usually the underlying illness. And I know as a pediatrician you probably see this a lot. And there’s no data to qualify, like how many calls pediatricians get about rash when kids are on antibiotics.

 

00;06;02;17 – 00;06;23;03

Farah Khan

But I know the number is like astronomically high. And then it’s trying to figure out, like, do I push through this and, you know, stay on the antibiotic because it’s not a drug reaction, but usually it’s very uncommon for a drug allergy to present, like, you know, 5 or 6 hours later on day 5 or 6, it’s usually the underlying illness and not the antibiotic.

 

00;06;23;06 – 00;06;41;18

Dr. Mona

Well, I’m so glad you brought that up, because that was going to be my next question, because, you know, you brought up like in the beginning, you said, okay, so within 10 to 15 minutes of taking the antibiotic, they developed itching all over and hives and hives. We commonly do see, like you said already with viral illnesses. And so just to kind of clarify and for everyone listening.

 

00;06;41;18 – 00;07;00;26

Dr. Mona

So the differentiation here would be that with a true drug allergy, you would see this on the first time you take meaning. When we say first time, to say you had amoxicillin as an eight month old, there was no issue. But then now you got it again as a 14 month old. Okay. So you’re taking it again as a 14 month old.

 

00;07;01;01 – 00;07;14;24

Dr. Mona

And on the first day of taking the amoxicillin, you notice within 10 to 15 minutes itching all over hives. Also with a drug allergy, would we also see swelling in like the lips or eyes or not necessarily.

 

00;07;14;27 – 00;07;25;01

Farah Khan

You absolutely can have, swelling in the lips, mouth, face, eyes, sometimes in the fingers and toes and genitalia as well.

 

00;07;25;03 – 00;07;43;16

Dr. Mona

So this is great kind of clarification because if it’s a virus, just to kind of clarify, we’re seeing virus, virus rashes can happen unknowingly at any time in the. Yes. But yes, you’re right that we do see commonly day three, day four of a child taking an antibiotic that all of a sudden they have this viral rash, right.

 

00;07;43;19 – 00;07;58;23

Dr. Mona

Let’s just use hives as an example. And so then the parent thinks, okay, well yes, I’ve been on antibiotics for three days. It must be the antibiotic. And they come in and they’re the child’s just itching or even just a rash like without it. So this is more part of a viral process. Most likely.

 

00;07;58;25 – 00;08;19;25

Farah Khan

Yes. And I think the other big clue for parents is sometimes they don’t even realize their kid has a rash until they, you know, go to bathe them or change their diaper. And the kid has been totally fine, you know, maybe a little under the weather and not eating great, but is acting fine, engaging appropriately. And then they undress them and realize, oh my goodness, there’s this, you know, red bumpy rash.

 

00;08;20;04 – 00;08;25;15

Farah Khan

It has to be the drug and it sort of inappropriately gets blamed on the antibiotic.

 

00;08;25;17 – 00;08;49;24

Dr. Mona

Well, yeah. Because then what happens is then just say we don’t know for sure and I’m going to use clinicians as responsibility to. So I hope anyone who’s listening, who’s maybe general pediatrician, because I do believe that some of us over call, drug out. You know, sometimes we we do see that rash. And I’ve learned, obviously, through my training and through my practice that okay, I used to over call it I did, and I’m being very honest, like, oh yeah, that must be right.

 

00;08;49;24 – 00;09;07;09

Dr. Mona

Because the kids coming in was on antibiotics and the parents telling you and you’re like, yeah, they’re red all over. But then yes, you practice. I just have to practice more and obviously see true drug allergy. Then you’re like, no, this is viral rash. Like it makes sense. So this is such an important clarification. And this is why I wanted to talk to you about this.

 

00;09;07;12 – 00;09;20;00

Dr. Mona

What other misconceptions do you hear about drug allergies? Maybe like you have a family coming in concerned about a drug allergy, and you have to kind of demystify or clarify a lot of things about, misconceptions about drug allergies.

 

00;09;20;03 – 00;09;52;02

Farah Khan

Yeah. I think the one that drives me the most bananas is when parents will say, oh, I have a penicillin allergy. Therefore, my kids have never received penicillin because, you know, they’re afraid that they might have a reaction. And I can tell you with 100% certainty, and there’s usually never this guaranteed certainty in medicine. But the classic drug allergy that’s mediated by this cell, it is not not inherited.

 

00;09;52;02 – 00;10;16;25

Farah Khan

It is not genetic. You’re not passing it on to your kids. So I think sometimes parents do a disservice to their kids, because then it means that primary care providers have to reach for other antibiotics, which, you know, doesn’t sound that bad. But when you start to realize that the those other antibiotics, which are typically a little more potent, which means they have a little more, you know, side effects, then we’re dealing with other issues that may come up with it.

 

00;10;16;25 – 00;10;36;17

Farah Khan

It does start to become a bigger issue. And so I always tell parents, like just because you had, you know, upset stomach and diarrhea or even if it was true, anaphylaxis to penicillin, it does not mean your kid is allergic. And if it’s the first line therapy, you know, I don’t mind them having a conversation with the pediatrician and voicing their concern.

 

00;10;36;19 – 00;10;40;19

Farah Khan

But it shouldn’t preclude the child from getting first line therapy.

 

00;10;40;21 – 00;11;06;09

Dr. Mona

Yeah. And, you know, I think this is such an important conversation because I can speak only for myself, but I don’t like prescribing a lot of antibiotics. But if I do need one, amoxicillin or the penicillin family, as we know, is a great family of antibiotics, right? Like it really helps a lot of different medical issues. And so if we don’t have access to that, it does, like you said, closed out or shut off a lot of different opportunities that we have to kind of search.

 

00;11;06;09 – 00;11;34;04

Dr. Mona

And is that going to be available? Is that even going to be tolerated? Right. Some of those other medicines like amoxicillin or augmentin, well, definitely mocks are selling. They taste good, right? Better than the like other medicines because they can the pharmacist can make them taste like bubble gum or, you know, so there is tolerability. So we definitely like Doctor Khan saying we don’t want to over call it not just because it’s not good medical practice, but also because it could shut off a lot of opportunity for really great options of medication.

 

00;11;34;04 – 00;11;51;04

Dr. Mona

If your child does need that, you know they may not. But it is a class of antibiotics and, you know, speaking even about pregnancy, like I actually do have an allergy fully evaluated. I developed, in my adulthood, I had, strep and I got a max Cicilline, and I developed full body again the day I took it.

 

00;11;51;04 – 00;12;11;22

Dr. Mona

Full body rash, lip swelling, eye swelling. No difficulty breathing, but the rash was diffuse, and my lips were, like, were like duck lips. And my eyes were, like, swollen shut. And at that point, I was I was in medical school, and I was like, what is going on? And my classmates or I was in residency arts, our medical school and my my classmates were like, maybe this is all virus.

 

00;12;11;22 – 00;12;24;09

Dr. Mona

I went back to the clinic, they saw it, and they were like, oh yeah, like, this is totally. And so then I had to go. I did see an allergist and stuff like that. What I bring this point up is that when I got pregnant with my first son, right, I had to tell them about the allergy. Right.

 

00;12;24;09 – 00;12;44;29

Dr. Mona

And I didn’t think I would be on antibiotic because I didn’t have any like Group B strep. But it did shut off a lot of opportunities for them, even when my pregnancy, if I did need an antibiotic and I ended up needing antibiotics for, whatever reason. So it’s really important that we know for sure, because even for you in your childhood down the line as an adult, you could need that.

 

00;12;44;29 – 00;13;05;15

Dr. Mona

And we want to be completely sure that there is an allergy versus suspected versus question mark. So that brings me to my next question. So if there is a concern, meaning what we talked about the 10 to 15 minutes itching all over hives, whether there’s coughing, trouble breathing or obviously any swelling if they are concerned, what is the role of the allergies?

 

00;13;05;15 – 00;13;11;06

Dr. Mona

Do they need to see an allergist to kind of get that official diagnosis and what would happen at those visits?

 

00;13;11;08 – 00;13;45;28

Farah Khan

Yeah. So the one statistic that sort of sticks out any time I have this conversation is about 10% of the general population is walking around with the penicillin allergy label, so 10% for the general population and about 95% of those people that are labeled as penicillin allergic are not actually allergic, which is kind of astounding. So you know, what I generally tell any primary care provider is if there’s any question, if you can’t dedicate the time to have that conversation and address all these questions, send them to your local allergist.

 

00;13;45;28 – 00;14;05;23

Farah Khan

We’re here. This is what we’ve, you know, had our subspecialty training and we’re happy to have that conversation. And sometimes actually a lot of the time I can have a detailed conversation with the parent. And the history is not suggestive. And I don’t have to do anything further for that kid. You know, I just answer their questions and we can say that this child is not penicillin allergic.

 

00;14;05;23 – 00;14;29;01

Farah Khan

They can have augmentin or amoxicillin in the future. And sometimes if there’s a lot of parental concern that I can’t really push through, or if the history is maybe suggestive or question mark, then we can do skin testing. But even with our recent guidelines or drug allergy practice parameters that were released, the emphasis really is on just challenging with an oral dose in a monitored setting.

 

00;14;29;01 – 00;14;49;27

Farah Khan

So we would have that child come in and then usually what we do is start with a small 10% dose. Watch them for 30 minutes or an hour. And as long as they don’t have any signs or symptoms of a reaction, we give them the remaining dose. And then again, you hang out for an hour or two, and as long as you don’t have any symptoms, then that’s sort of objective proof that your vital signs, your body, everything was good to go.

 

00;14;49;27 – 00;14;54;28

Farah Khan

You were not having an allergic reaction and you can have penicillins in the future.

 

00;14;55;00 – 00;15;15;11

Dr. Mona

Oh, this is so helpful. Yeah, this is really important information because like I said, you said that, you know, 10% of the population has a quote unquote allergy and 95% of them actually do not. Right? Yeah. I mean, that’s a small, small percentage of people. And so I think it’s so important that we hear, you know, what can actually be evaluated, I guess.

 

00;15;15;11 – 00;15;33;23

Dr. Mona

Do you have a lot of families who still, like, just say they they went to their pediatrician and their pediatrician was like, oh, this looks like an allergy. Okay. And maybe it wasn’t okay. And so then they come to you and then you tell them this, like, you tell them why? Why not? You know why. It’s more likely like a viral induced rash or whatever.

 

00;15;33;27 – 00;15;42;15

Dr. Mona

Do you still get a lot of hesitance that they are still hesitant to use that medicine again, or do you feel often that they feel comfortable after the conversation?

 

00;15;42;17 – 00;16;01;27

Farah Khan

I think for the most part, parents just need that reassurance, and sometimes it’s just talking about that one thing for, you know, a dedicated 15, 20, 30 minutes, which sometimes you don’t get in your primary care visit because there’s also a bunch of other things that need to be addressed, you know, like school forms or immunizations or, oh, he had this weird thing going on.

 

00;16;02;05 – 00;16;30;01

Farah Khan

You know, there’s just a lot to unpack. I feel like with every visit. And so most of the time I can answer questions. And there are parents that are like, you know what? I think they need some objective proof. And in that case, I don’t mind at all challenging that kid and providing them some objective guidance. The other thing I want to point out is sometimes kids will sort of go several years just being penicillin allergic label just because there’s a lot happening and it sort of goes under the radar for a while.

 

00;16;30;03 – 00;16;49;21

Farah Khan

When I really start to push for this to be evaluated again, is with teenagers that are in high school and looking to leave for college because then it then it becomes, you know, they have this penicillin allergy label and then they’re living away from home and they don’t really know what it means. And they end up with a sinus infection or pneumonia, and they need antibiotics.

 

00;16;49;21 – 00;17;12;28

Farah Khan

And, you know, again, they can’t get penicillin. And with penicillin specific antibiotics, what we have is some really great data that suggest even if you had a true anaphylactic event in young childhood, over the course of a decade, your immune system sort of forgets that it had that reaction because it loses those antibodies that it made in response to that allergic reaction.

 

00;17;13;00 – 00;17;33;00

Farah Khan

And you can become non allergic again. So if you, you know, had a reaction when you were 3 or 4 and now you’re 18 and looking to move away from home, I really stress to those families and those teenagers like, hey, you’re about to be on your own. Let’s addresses. It’s one less thing you have to worry about, just in case you end up, you know, in the student clinic or in the urgent care.

 

00;17;33;05 – 00;17;37;04

Farah Khan

You don’t have to worry about carrying this penicillin label around.

 

00;17;37;07 – 00;17;55;26

Dr. Mona

Well, that is actually very useful advice for me because of my story, too, because that was about that was more than ten years ago that that happened. So I should probably go get that evaluated myself. Because like I said, I don’t want the label if it’s not something that’s in my reality anymore. And I think that’s your comment makes so much sense because, you know, when they’re out in the world, yes.

 

00;17;55;26 – 00;18;11;07

Dr. Mona

If they go to the clinic and they forget to look at the allergies, or even if they do, you want to make sure that they’re not being over labeled and over called. And then I also bring up things like pregnancy and if that is something that happened, a person’s future, and life, you know, there’s always going to be some need for an antibiotic potentially.

 

00;18;11;07 – 00;18;28;20

Dr. Mona

So we want to make sure that that’s all clear. This is so helpful I love this I think it’s so great that we talk about all this stuff. And I again, I hope a lot of my general pediatricians are listening to because like I said, I often am in visits and I will see the allergy section of, patients chart.

 

00;18;28;20 – 00;18;46;00

Dr. Mona

Right. Maybe they may not have seen me before. And then I see that they have penicillin allergy or amoxicillin, and sometimes they’ll have question mark. And I’m like I’m asking them. I’m like, is this is this this? Or you tell me what happened and I do. I say, look, if you really think this is a real thing, I do want to have you seen Allergists?

 

00;18;46;00 – 00;18;58;27

Dr. Mona

Like, if this is something that you really feel like this was. And so I’m like, why don’t I ask, like, why was it a question mark? Did anything ever come to it? They’re like, it was a potential. So now we’re avoiding. I’m like, I’m like, yeah, I don’t know if this makes sense, you know? So it’s part of antibiotic stewardship.

 

00;18;58;27 – 00;19;18;00

Dr. Mona

You know, antibiotic stewardship, you know, is not over prescribing antibiotics, but part of it is also making sure that we’re not over labeling allergies. Would you say that of the small percentage of people that have true drug allergies, are the penicillin class the most common of those? For the small percentage, yes it is. Is there a reason why.

 

00;19;18;03 – 00;19;37;21

Farah Khan

That we know? We don’t know. We don’t know why. We just know that penicillin and these beta lactam antibiotics, which is sort of referring to the chemical structure, but they’re just more frequently prescribed and used for a lot of organisms that cause infections. And so it’s also the class of antibiotics that we have the most information on when you look in the literature.

 

00;19;38;08 – 00;19;39;18

Farah Khan

So yes.

 

00;19;39;21 – 00;19;46;06

Dr. Mona

That makes sense. This is so great. Is there anything else you want to add? Any final message for all of our listeners?

 

00;19;46;09 – 00;19;49;16

Farah Khan

Come see your local friendly allergist.

 

00;19;49;18 – 00;19;52;26

Dr. Mona

Yes, if you have any. Sure. Yeah.

 

00;19;52;28 – 00;20;05;02

Farah Khan

You know, this is what we do day in and day out, and sometimes it’s just a 15 or 20 minute conversation that can clear up a lot of hesitancy and concerns. And this is what we’re here for. Like use us, use us, use us.

 

00;20;05;04 – 00;20;22;02

Dr. Mona

And as the general pediatrician on this conversation, I will say, I hope you got this message loud and clear. But if you are being told that it is an allergy from your pediatrician and it doesn’t go in line to what we were talking about, right? Maybe again, three, four days. Your child just has a very mild rash on the body.

 

00;20;22;04 – 00;20;38;23

Dr. Mona

Really? Ask these questions to your general pediatrician. And maybe if you know you want that extra allergist referral, do it. Because like we said, it’s just important for the longevity of the life of your child and yourself that we’re not over labeling these things if it’s not really needed. So just really ask the questions to your pediatrician.

 

00;20;39;06 – 00;20;54;02

Dr. Mona

Get curious. It’s okay. That’s what we’re here for. And, you know, again, like I said, I hope a lot of my general pediatricians are listening to this and a lot of, my families listening to this will take this information to their pediatrician because I, like I said earlier, we do over call it I see it often.

 

00;20;54;11 – 00;21;07;20

Dr. Mona

I’m pretty sure urgent care is and ERS are very notorious for this too. So I’m sure you are commonly telling people this is an allergy. This is an analogy. Let me explain it. Thank you. Thank you so much for all the hard work you do. Yeah.

 

00;21;07;21 – 00;21;08;17

Farah Khan

Thank you.

 

00;21;08;20 – 00;21;23;04

Dr. Mona

And for everyone listening. If you learned something from this episode, which I sure you did, or if you found it helpful, make sure to leave a review for the podcast. Call out Doctor Khan and her amazing information and I can’t wait to invite another guest next week.

 

00;21;23;05 – 00;21;37;23

Dr. Mona

Thank you for tuning in for this week’s episode. As always, please leave a review, share this episode with a friend, share it on your social media. Make sure to follow me at PedsDocTalk on Instagram and subscribe to my YouTube channel, PedsDocTalk TV.

 

00;21;37;25 – 00;21;38;26

Dr. Mona

We’ll talk to you soon.