100516 - Systemic reaction with dry powder device in patient allergic to milk

Background

Lactose is a common excipient in dry powder inhalers and is used to improve drug dispersion. Being of animal origin, it may contain traces of cow's milk proteins, which poses a risk for people with milk allergy. Allergic reactions induced by its use have been scarcely described in the literature. We present the case of a patient with moderate asthma and allergy to cow's milk proteins, who suffered a systemic reaction after using a dry powder inhaler.

Clinical case

A 16-year-old male was referred to Allergology consultations due to worsening asthma control. He had a history of rhinoconjunctivitis and allergic asthma due to sensitization to pollen and mites, as well as allergy to cow's milk proteins and nuts. In the last year, he reported daily exacerbations with the need for frequent rescue with salbutamol and several visits to the emergency room due to bronchospasm.

An allergy study was performed (Tables 1 and 2) and, given the poor asthma control, treatment was started with a fluticasone furoate/vilanterol dry powder inhaler. The next day, after the first use of the inhaler, the patient presented intense dyspnea with wheezing, generalized itching and diffuse erythema, requiring treatment with corticosteroids, antihistamines, and inhaled therapy.

Given the suspicion of a systemic reaction secondary to exposure to traces of milk proteins through inhalation, the manufacturer's laboratory was contacted to confirm the animal origin of the lactose and a skin test was performed with the device involved, which was positive. Subsequently, a controlled exposure test was performed with a pressurized budesonide/formoterol inhaler, which was well tolerated.

Conclusions

1.⁠ ⁠We present the case of a man with milk allergy who suffered a systemic reaction after using a dry powder inhaler with lactose of animal origin.

2.⁠ ⁠There is no synthetic lactose in the pharmaceutical industry, it is of animal origin, generally from the cow. The lactose used in dry powder inhalers is usually highly purified, but may contain traces of milk proteins, which poses a risk to allergic people.

4.⁠ ⁠This case highlights the importance of considering excipients in medications, especially in people with severe food allergies.