Dear all,

A request from EPPICC for some additional ART_RS codes:

70 – pregnancy – toxicity concerns 75 – pregnancy – switch to more appropriate regimen for PMTCT 76 – Post partum prophylaxis 77 – dose change for weight/height

Many thanks, Heather

Dear Casper

Prompted by Bev's question on how to code RASH I contacted Robert Zangerle from the Austrian Cohort. He is dermatologist and reminded me, that we had the discussion on the (sub-)coding of hypersensitivity already back in 2013 when the 1.70 release was imminent.

As suspected, things are more complicated when going beyond the general term and he suggested to just slightly modify the general term and avoid trying more detailed codes.

4. “Hypersensitivity reaction (skin eruption….etc.)”.

This is the specialists' suggestion in full text which, in my view, is convincing enough not to try to be more specific:

I would prefer a light modification, namely

4. “Hypersensitivity reaction (skin eruption….etc.)”.

Sub-coding is difficult, and the distinction between "Toxicity limited to skin" and "Systemic reaction" is prone to mistakes. A drug eruption might seem to be limited to skin, but without a differential blood count and measurement of the levels of transaminases you cannot rule out a systemic reaction. There are severe hypersensitivity reactions, namely Stevens Johnson Syndrome (SJS)* and Hypersensitivity Syndrome with the acronyms DRESS (drug rash with eosinophilia and systemic symptoms) or DIDMOHS (drug-induced delayed multiorgan hypersensitivity syndrome) and it might be important to capture these two entities. In high income countries these complications occur in recent years much less frequently (HLA B 5701 testing, rule based use of nevirapine, infrequent use of trimethoprim-sulfamethoxazole..). So one might also come up with

4 - “Hypersensitivity reaction (skin eruption….etc.)”.

4.1 - "Severe reactions (DRESS, SJS-TEN)"

4.2 - "Other or not specified”

Acute reactions with urticaria (with or without anaphylaxis) might the be classified as “other” as well as skin eruptions with normal differential blood count and normal transaminase levels whereas a drug eruption “limited to the skin” however, without any diagnostic procedures would classify as “not specified”. And a large proportion of drug eruptions may classify as “not specified” due to lack of ecpertise.

*SJS is defined as involving less than 30% of body surface area, whereas toxic epidermal necrolysis involves 30% or more.