Human Leukocyte Antigens and Sulfamethoxazole/Cotrimoxazole-Induced Severe Cutaneous Adverse Reactions: A Systematic Review and Meta-Analysis

Wu PC, Chen WT, Huang IH, Chen CB, Wang CW, Tai CC, Chung WH, Chi CC. JAMA Dermatol. 2024 Apr 3. doi: 10.1001/jamadermatol.2024.0210. 

Key Points

Question  Is there an association between human leukocyte antigen (HLA) and sulfamethoxazole (SMX)/cotrimoxazole (CTX)–induced severe cutaneous adverse reactions (SCARs)?

Findings  In this systematic review and meta-analysis of 6 studies involving 322 patients with SCARs, significant associations were identified between the HLA-A*11:01, HLA-B*13:01, HLA-B*15:02, HLA-B*38:02, and HLA-C*08:01 genotypes and SMX/CTX-induced SCARs. The HLA-B*15:02 and HLA-B*38:02 genotypes were significantly associated with SMX/CTX-induced Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN), while the HLA-A*68:01 and HLA-B*39:01 genotypes were associated with SMX/CTX-induced drug reaction with eosinophilia and systemic symptoms; the HLA-B*13:01 allele showed an association with SMX/CTX-induced SJS/TEN and drug reaction with eosinophilia and systemic symptoms.

Meaning  The results of this review suggest that multiple HLA alleles were associated with SMX/CTX-induced SCARs.

Abstract

Importance  Sulfamethoxazole (SMX) and cotrimoxazole (CTX), a fixed-dose combination of SMX and trimethoprim in a 5:1 ratio, are antibacterial sulfonamides commonly used for treating various diseases.

A substantial prevalence of severe cutaneous adverse reactions (SCARs) following the administration of these drugs has been reported. However, the association between human leukocyte antigen (HLA) genotypes and SMX/CTX-induced SCARs has remained unclear.

Objective  To investigate the association between HLA genotypes and SMX/CTX-induced SCARs.

Data sources  A comprehensive search was conducted in CENTRAL (Cochrane Library), MEDLINE, and Embase from inception to January 17, 2023.

Study Selection  Case-control studies that recruited patients who had experienced SCARs following SMX or CTX were included, and HLA alleles were analyzed.

Data Extraction and Synthesis  Two independent authors extracted data on study characteristics and outcome data. The Meta-analysis of Observational Studies in Epidemiology (MOOSE) reporting guideline and the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines were followed. The Newcastle-Ottawa Scale for case-control studies was used to assess study quality. Odds ratios (ORs) were calculated using a random-effects model for meta-analysis.

Main Outcomes and Measures  The prespecified outcome was the OR comparing SMX/CTX-induced SCARs with healthy or SMX/CTX-tolerant controls based on different HLA alleles.

Prevalence of Severe Cutaneous Adverse Reactions (SCARs) in Individuals Carrying
Different Human Leukocyte Antigen (HLA) Alleles Compared With Tolerant Controls

Results  Six studies involving 322 patients with SCAR were included, including 236 patients with Stevens-Johnson syndrome/toxic epidermal necrolysis, 86 with drug reaction with eosinophilia and systemic symptoms, 8448 healthy controls, and 229 tolerant controls. Significant associations were found in HLA-A*11:01 (OR, 2.10; 95% CI, 1.11-4.00), HLA-B*13:01 (OR, 5.96; 95% CI, 1.58-22.56), HLA-B*15:02 (OR, 2.23; 95% CI, 1.20-4.14), HLA-B*38:02 (OR, 3.47; 95% CI, 1.42-8.48), and HLA-C*08:01 (OR, 2.63; 95% CI, 1.07-6.44) compared with tolerant controls. In the Stevens-Johnson syndrome/toxic epidermal necrolysis subgroup, significant associations were found in HLA-B*15:02 (OR, 3.01; 95% CI, 1.56-5.80) and HLA-B*38:02 (OR, 5.13; 95% CI, 1.96-13.47). In the drug reaction with eosinophilia and systemic symptoms subgroup, significant associations were found in HLA-A*68:01 (OR, 12.86; 95% CI, 1.09-151.34), HLA-B*13:01 (OR, 23.09; 95% CI, 3.31-161.00), HLA-B*39:01 (OR, 4.56; 95% CI, 1.31-15.82).

Conclusions and Relevance  The results of this systematic review and meta-analysis suggest that multiple HLA alleles (HLA-A*11:01, HLA-B*13:01, HLA-B*15:02, HLA-B*38:02, and HLA-C*0801) are associated with SMX/CTX-induced SCARs.

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