What alternative can be given to a child allergic to Diclofenac (Klafenac)?

Alternative Medications for Children Allergic to Diclofenac (Klafenac)

For children allergic to diclofenac (Klafenac), paracetamol (acetaminophen) is the recommended first-line alternative due to its favorable safety profile and lack of cross-reactivity with NSAIDs.

Understanding NSAID Allergies in Children

• NSAID allergies can manifest as immediate hypersensitivity reactions, with angioedema being the most common clinical manifestation (60% of cases) 1
• Diclofenac is contraindicated in patients with known hypersensitivity reactions, including anaphylaxis and serious skin reactions 2
• Children with history of asthma, urticaria, or allergic reactions after taking aspirin or other NSAIDs should avoid diclofenac due to risk of severe, potentially fatal anaphylactic reactions 2

Recommended Alternatives

First-Line Alternative:

• Paracetamol (Acetaminophen)
  • Preferred first-line alternative for children allergic to diclofenac 1
  • Lacks anti-inflammatory properties but provides effective analgesia and antipyresis
  • Has been safely tolerated in children with proven NSAID allergies 1

Second-Line Alternatives (if no cross-reactivity):

• Naproxen

  • Recommended as the preferred NSAID for children with juvenile idiopathic arthritis due to its efficacy and safety profile 3
  • Should only be considered if the child doesn't have cross-reactivity with other NSAIDs
  • Available in various formulations suitable for children 3

• Selective COX-2 Inhibitors (e.g., celecoxib)

  • May be better tolerated in children with hypersensitivity to traditional NSAIDs 3
  • Consider only after confirming no cross-reactivity through appropriate testing

Cross-Reactivity Considerations

• Among children with confirmed ibuprofen allergy, approximately 41% (7 out of 17) demonstrated cross-intolerance to other NSAIDs 1
• Cross-intolerance reactions were classified as:
  • NSAID-exacerbated cutaneous disease (1 case)
  • NSAID-induced urticaria/angioedema/anaphylaxis (6 cases) 1
• When selecting an alternative NSAID, consider the chemical structure classification:
  • Diclofenac belongs to acetic acid derivatives
  • Consider medications from different chemical classes (e.g., propionic acids like naproxen) if NSAID therapy is essential 3

Testing and Confirmation

• Drug provocation tests (DPTs) should be performed to:
  • Confirm or exclude the allergy to diclofenac
  • Identify safe alternative medications 1
• Before testing:
  • Discontinue antihistamines (3-10 days depending on the specific antihistamine) 3
  • Ensure testing is conducted in a controlled setting with emergency equipment available

Risk Factors for NSAID Hypersensitivity

• Older age and male gender have been identified as independent risk factors for immediate-type NSAID allergies in children 1
• Children with a history of asthma or other allergic conditions may be at higher risk for NSAID hypersensitivity 2

Management Recommendations

• For mild pain or fever in children allergic to diclofenac:

  • Use paracetamol as first-line treatment 1
  • Consider non-pharmacological pain management strategies

• For moderate to severe pain requiring anti-inflammatory effects:

  • Refer to an allergist for comprehensive evaluation and testing
  • Consider drug provocation tests with alternative NSAIDs from different chemical classes under medical supervision 1

• For severe allergic reactions:

  • Immediate administration of epinephrine is the first-line treatment 3
  • Adjunctive treatments include H1 antihistamines (diphenhydramine), H2 antihistamines (ranitidine), and corticosteroids 3

Remember that the safety of the child is paramount, and any alternative medication should be introduced with caution, particularly in children with a history of severe allergic reactions to NSAIDs.