Medical Practice

We Shouldn’t Tolerate Sloppy Allergy Lists

By HANS DUVEFELT

The medication and allergy lists seem like they would be the most important parts of a health record to keep current and accurate. But we all see errors too often.

I think it shouldn’t be possible to enter an allergy without describing the reaction. Because without that information the list becomes completely useless.

The other day I saw a patient who needed an urgent CT angiogram. The allergy list said “All Contrast Materials”, which isn’t even “structured data entry”, and thus not recognized by the computer if my EMR (Me again, Greenway!) would have been clever enough to check for allergies when I order a CT scan.

After a lot of probing, the “allergy” in this case turned out to be a host of nonspecific, chronic symptoms after several lumbar CT myelograms in a short period of time many years ago.

Some people claim to be penicillin allergic because “it never works”. Others list ciprofloxacin or sulfa antibiotics because they get a yeast infection after taking them. Others were slightly nauseous after their first dose of an SSRI like fluoxetine or fatigued after starting gabapentin.

Some symptoms listed as allergies are poorly understood. For example, morphine causes itching in many patients, even skin manifestations like blushing as well as sweating. But this is not usually a histamine mediated symptom, and not an allergy. Other opioids, like hydromorphone, tend to have less risk for itching.

Cough from ACE inhibitors isn’t a true allergy, but we often note that in our allergy lists. People with this side effect can safely be switched to angiotensin receptor blockers, ARBs.

Angioedema from ACE inhibitors is an allergic and serious reaction with significant risk for cross-allergy also from ARBs. So it is essential to distinguish between the two in our allergy lists.

Medication and allergy history is one of the few things specialists look to us for. They often ignore and repeat the tests we had done, for example. But a good allergy history is something we can and should try to collect for every patient.

The big challenge is that patients often don’t remember the details of their allergies or side effects years after the fact. So, principle number one is to put down new reactions carefully when we hear about them.

My personal trick with new patients sporting long lists of proclaimed allergies is to ask: “Did you almost die from any of these medications I see listed as allergies?” That is the first step in a reality check about the real magnitude of their allergies.

The other list we could do better with is the PROBLEM LIST. Since we went electronic, it has bulked up and become much less helpful than it used to be. I just reread a post I wrote about that eleven years ago.

Hans Duvefelt is a Swedish-born rural Family Physician in Maine. This post originally appeared on his blog, A Country Doctor Writes, here.

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