Telemedicine-supported penicillin allergy delabeling in low-risk patients

The advancement of telemedicine (TM) practices has enabled greater access for allergists to assess suspected drug allergies. While penicillin allergy delabeling by drug challenges may not seem suitable for TM due to the need for close patient observation and rapid access to emergency care, it is important not to shy away from discussing the potential for initial drug hypersensitivity assessments and even direct amoxicillin oral provocation in low-risk patients under TM conditions. Through an extensive literature analysis, this narrative review discusses clinical practices, eligibility criteria, and safety considerations regarding virtual care for safe penicillin allergy delabeling in such patients. Emphasis is placed on risk stratification using recently validated clinical tools and expert opinion strategies, such as PEN-FAST [penicillin (PEN) allergy, an occurrence of five or fewer years ago (F), anaphylaxis or angioedema (A), severe cutaneous adverse reaction/SCAR (S), and treatment required for allergic reaction (T)] score and European Academy of Allergy and Clinical Immunology (EAACI)/European Network on Drug Allergy (ENDA) practical recommendations, to identify the low-risk patients suitable for remote assessment and TM-supported amoxicillin challenges, if necessary, which may be performed in outpatient departments, long-term care facilities or other remote settings, including the patient's home. The clinical practice review summarizes initial evaluation protocols, virtual monitoring procedures in case of low-risk oral provocations, and post-challenge follow-up, underlining the importance of informed consent, patient education, and caregiver presence. Oral H1 antihistamines are recommended for symptomatic relief if needed, and the benefits of acquiring an epinephrine autoinjector solely for the challenge represent a juncture for shared decision-making. While TM offers promising avenues to expand access to penicillin allergy delabeling in low-risk individuals, it is not a substitute for in-person evaluation in high- or intermediate-risk cases. The review also highlights technological, ethical, and legal challenges, serving only as an informational resource.