• Aurélie Gouel-Chéron, Catherine Neukirch, Sylvie Chollet-Martin, Arnaud Valent, Benoit Plaud, Dan Longrois, Pascale Nicaise-Roland, Philippe Montravers, and Luc de Chaisemartin.
• From the Anaesthesiology and Critical Care Medicine Department, DMU PARABOL, Bichat Hospital, AP-HP (AG-C, DL, PM), Antibody in Therapy and Pathology, Pasteur Institute, UMR 1222 INSERM (AG-C, LdC), Paris Cité University (AG-C, BP, DL, PM, LdC), C2A: WAO Centre of Excellence for Allergy and Asthma (AG-C, CN, SC-M, DL, PN-R, LdC), Pulmonology Department, Bichat Hospital, AP-HP, Paris Cité University (CN), Université Paris Cité, Inserm, PHERE (CN), Immunology department, 'autoimmunity, hypersensitivities, and biologics', DMU BIOGEM, Bichat Hospital, AP-HP, Paris (SC-M, PN-R, LdC), Université Paris-Saclay, Inflammation, Microbiome and Immunosurveillance, INSERM, Orsay (SC-M, PN-R, LdC), Anaesthesiology, Critical Care and Burn Unit Department, DMU PARABOL, Saint-Louis Hospital, AP-HP, Paris (AV, BP) and INSERM UMR-S942, Lariboisière Hospital and INI-CRCT network, France (BP).
• Eur J Anaesthesiol. 2024 Oct 1; 41 (10): 722727722-727.

BackgroundDrug challenge is the gold standard for identifying causative agents of drug allergies. Although clinical guidelines have recently been published, they do not recommend neuromuscular blocking agent (NMBA) drug challenges. NMBA challenges are rendered difficult by the lack of homogeneity of routine allergy work-ups and the necessity of a specialised setting. Several scenarios support NMBA challenges, such as an ambiguous allergy work-up, a high suspicion of a false-positive skin test or identification of a well tolerated alternative NMBA strategy. Furthermore, routine allergy work-ups may not recognise non-IgE mechanisms, such as IgG or MRGPRX2, whereas drug challenges may reveal them. Finally, if the culprit NMBA is not identified, subsequent anaesthesia regimens will be challenging to implement, resulting in increased risk.ObjectivesThis literature review discusses the indications, strategies, doses, monitoring methods, limitations, and unresolved issues related to drug challenges for NMBAs.DesignThe literature review included randomised controlled trials, observational studies, reviews, case reports, series, and comments on humans.Data SourcesStudies were retrieved from databases (PubMed) and electronic libraries (OVID, EMBASE, Scopus, etc.).Eligibility CriteriaAll studies that referred to the NMBA challenge were included without publication date limitations.ResultsNMBA challenge may be considered in NMBA anaphylaxis patients with inconclusive or ambivalent IgE diagnostic work-up under controlled conditions (presence of anaesthetists and allergists with continuous monitoring in a secured environment). To illustrate its utility, a case report of a double NMBA challenge in a patient with NMBA cross-reactivity is presented, along with biological explorations to detect subclinical cellular activation, a novel aspect of this procedure.ConclusionDrug challenges could be implemented during the NMBA allergy work-up under strict safety conditions at specialised centres with close collaboration between anaesthetists and allergists. This could decrease uncertainty and contribute to defining a safer strategy for subsequent anaesthetic drug regimens.Copyright © 2024 European Society of Anaesthesiology and Intensive Care. Unauthorized reproduction of this article is prohibited.

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