Protamine allergy

Vincent GM, Janowski M, Menlove R. Protamine allergy reactions during cardiac catheterization and cardiac surgery risk in patients taking protamine-insulin preparations. Cathet Cardiovasc Diagn 1991 23(3) 164-8. 

About 28% of patients develop IgG or IgE antibodies after a single exposure to protamine, but fortunately few develop a catastrophic allergic reaction on subsequent exposure to the drug. Nonetheless, prior exposure does increase the risk for an anaphylactic reaction. Other risk factors are fish allergy and patients with diabetes mellitus treated with neutral protamine Flagedorn (NPFI) insulin. After vasectomy, 22%... 

Insulin allergy is quite common (SEDA-7, 403 124—126). Allergy has been reported to human insulin and protamine (127) and to human insulin (128,129). 

Yoshino K, Takeda N, Muramatsu M, Morita H, Mune T, Ishizuka T, Yasuda K. [A case of generalized allergy to both human insulin and protamine in insulin preparation]. J Jpn Diabetes Soc 1999 42 927-30. 

Bruni S, Barolo P, Gamba S, Grassi G, Blatto A. Case of generalized allergy due to zinc and protamine in insulin preparation. Diabetes Care 1986 9(5) 552. 

Too rapid of an administration of protamine can have serious side effects, including hypotension and anaphylaxis. Pulmonary hypertension, shortness of breath, flushing, and urticaria have all been associated with rapid administration. Patients with allergies to fish products may be allergic to protamine. 

Allergy still occurs to additives (protamine), to the preservative, e.g. phenol, cresol, or to insulin itself. It may take the form of local reactions (inflammatory or fat atrophy) or of insulin resistance. 

Gottschlich GM, Gravlee GP, Georgitis JW. Adverse reactions to protamine sulfate during cardiac snrgery in diabetic and non-diabetic patients. Ann Allergy 1988 61(4) 277-81. 

Pfohler C, Muller CSL, Hasselmann DO, Tilgen W. Successful desensitization with human insulin in a patient with an insulin allergy and hypersensitivity to protamine a case report J Med Case Rep 2008 2 283-7. 

Questions of specific anesthetic interest in a patient s history should address allergies [e.g. to local anesthetics (LA), antibiotics, disinfectants, radiocontrast, protamine]. Previous experiences with general and LRA, the risk of postoperative nausea and vomiting, chronic steroid medication and relevant substance abuse should be explored. Substitution therapy may be necessary. 

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