Controversies in drug provocation tests: what can we learn?

Drug provocation tests (DPT) are considered the gold standard for diagnosing drug hypersensitivity reactions (DHRs) and can provide diagnostic clarity when other tests are limited. However, their use remains controversial due to safety concerns and lack of standardized test protocols.

Drawing upon literature published by major allergy societies and recent studies, this review explores the current controversies surrounding DPTs, including their use in patients with severe index reactions, potential risks, and challenges related to test protocol variability and result interpretation. Special considerations in vulnerable populations such as pregnant women and those with limited therapeutic options, and clinically important drugs, such as penicillin's and nonsteroid anti-inflammatory drugs (NSAID), are also discussed. Despite the controversies, reliance on DPTs is increasing and are invaluable in the evaluation of DHRs. Nonetheless, the application of DPTs must be guided by careful patient selection, individualized risk stratification and thorough risk-benefit assessment, especially in complex scenarios.

More collaborative studies are needed to enhance safety evaluation and develop reliable, standardized protocols to address current inconsistencies and improve clinical outcomes. A combination of improved testing algorithms will be key to maximize the potential of DPTs, optimize outcomes and improve patient care.