VIR and opioids

Q: Vancomycin Infusion Reaction (VIR) (Red Man Syndrome) can be attenuated by simultaneous administration of morphine.

A) True

B) False

Answer: B (False)

VIR, by definition (though IgE-mediated reaction is possible with previous exposure), is a dose- or rate-related mast cell degranulation. This mast cell degranulation gets enhanced or accelerated by the simultaneous administration of opioids like morphine, meperidine, or codeine. Interestingly, this risk is way less and can be an exception in fentanyl, which rarely induces histamine release.

Other known medications to enhance VIR are radiocontrast dye, some muscle relaxants like succinylcholine, atracurium, cisatracurium, doxacurium, mivacurium, tubocurarine, dextran, polygeline, and ciprofloxacin.

#pharmacology

# allergy-immunology

References:

1. Wong JT, Ripple RE, MacLean JA, et al. Vancomycin hypersensitivity: synergism with narcotics and "desensitization" by a rapid continuous intravenous protocol. J Allergy Clin Immunol 1994; 94:189.

2. Wazny LD, et al. Desensitization protocols for vancomycin hypersensitivity. The Annals of Pharmacotherapy 2001; 35:1458. Copyright © 2001 Harvey Whitney.

3. Alvarez-Arango S, Ogunwole SM, Sequist TD, Burk CM, Blumenthal KG. Vancomycin Infusion Reaction - Moving beyond "Red Man Syndrome". N Engl J Med. 2021 Apr 8;384(14):1283-1286. doi: 10.1056/NEJMp2031891. Epub 2021 Apr 3. PMID: 33830710; PMCID: PMC9235042.

4. Zhu LJ, Liu AY, Wong PH, Arroyo AC. Road Less Traveled: Drug Hypersensitivity to Fluoroquinolones, Vancomycin, Tetracyclines, and Macrolides. Clin Rev Allergy Immunol. 2022 Jun;62(3):505-518. doi: 10.1007/s12016-021-08919-5. Epub 2022 Jan 29. PMID: 35092578; PMCID: PMC9167562.