Assessing cross-reactivity to neuromuscular blocking agents by skin and basophil activation tests in patients with neuromuscular blocking agent anaphylaxis

Jamma Li, Oliver G. Best, Michael A. Rose, Sarah L. Green, Richard B. Fulton, Marc J. Capon, Benedict A. Krupowicz, Suran L. Fernando

Research output: Contribution to journalArticlepeer-review

8 Citations (Scopus)


BACKGROUND: Following diagnosis of neuromuscular blocking agent (NMBA) anaphylaxis, identifying safe alternatives for subsequent anaesthesia is critical. A patient with anaphylaxis to one NMBA can also have an allergic reaction to other NMBAs (cross-reactivity). Whilst drug provocation testing is standard for identifying or excluding allergy, there is significant risk. In vitro, after an allergen activates basophils, basophils express surface activation markers that can be measured by basophil activation testing (BAT). We compared cross-reactivity between NMBAs assessed by BAT against that by skin testing. METHODS: All patients attending an anaesthetic allergy clinic in Sydney, Australia between May 2017 and July 2018 diagnosed with NMBA anaphylaxis qualified for this study comparing intradermal skin tests and BAT with a panel of NMBAs (rocuronium, vecuronium, pancuronium, suxamethonium, cisatracurium). RESULTS: Of the 61 patients participating, sensitisation on skin testing and on BAT completely matched in only nine patients (15%). Sensitisation was not in agreement for pancuronium, cisatracurium and rocuronium, but was in agreement for vecuronium and suxamethonium. Nine patients with negative skin tests subsequently tolerated cisatracurium, and one false positive on BAT to cisatracurium was detected. CONCLUSIONS: The utility of BAT in identifying safe NMBAs for subsequent anaesthesia needs further evaluation. BAT detects a different cross-reactivity profile to skin tests. Negative skin testing and BAT might increase confidence in performing drug provocation testing, but this and follow-up of subsequent anaesthesia in our cohort is necessary to determine the clinical significance of BAT sensitisation.
Original languageEnglish
Pages (from-to)e144-e150
Number of pages7
JournalBritish Journal of Anaesthesia
Issue number1
Publication statusPublished - Jul 2019
Externally publishedYes


  • Adolescent Adult Aged Anaphylaxis/*immunology Australia Basophils/*immunology Cross Reactions/immunology Drug Hypersensitivity/*immunology Female Humans Male Middle Aged Neuromuscular Blocking Agents/*immunology Skin Tests/methods/*statistics & numerical data Young Adult anaphylaxis basophil degranulation test drug hypersensitivity neuromuscular blocking agents skin tests
  • skin tests
  • basophil degranulation test
  • neuromuscular blocking agents
  • anaphylaxis
  • drug hypersensitivity


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