Benzylpenicilloyl Polylysine

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# Overview
Benzylpenicilloyl Polylysine is a Diagnostic Agent that is FDA approved for the diagnosis of sensitization to penicillin (benzylpenicillin or penicillin G) in patients suspected to have clinical penicillin hypersensitivity.   Common adverse reactions include allergic reaction, local inflammatory response.

# Adult Indications and Dosage

## FDA-Labeled Indications and Dosage (Adult)

### Indications
- PREPEN is indicated for the assessment of sensitization to penicillin (benzylpenicillin or penicillin G) in patients suspected to have clinical penicillin hypersensitivity. A negative skin test to PREPEN is associated with an incidence of immediate allergic reactions of less than 5% after the administration of therapeutic penicillin, whereas the incidence may be more than 50% in a history-positive patient with a positive skin test to PREPEN. These allergic reactions are predominantly dermatologic. Whether a negative skin test to PREPEN predicts a lower risk of anaphylaxis is not established. Similarly, when deciding the risk of proposed penicillin treatment, there are not enough data at present to permit relative weighing in individual cases of a history of clinical penicillin hypersensitivity as compared to positive skin tests to PREPEN and/or minor penicillin determinants.

### Dosage
- Skin testing responses can be attenuated by interfering drugs (e.g. H1antihistamines and vasopressors). Skin testing should be delayed until the effects of such drugs have dissipated, or a separate skin test with histamine can be used to evaluate persistent antihistaminic effects in vivo. Due to the risk of potential systemic allergic reactions, skin testing should be performed in an appropriate healthcare setting under direct medical supervision.
- Skin testing is usually performed on the inner volar aspect of the forearm. The skin test antigen should always be applied first by the puncture technique. After preparing the skin surface, apply a small drop of PREPEN solution using a sterile 2228 gauge needle. The same needle can then be used to make a single shallow puncture of the epidermis through the drop of PREPEN. Very little pressure is required to break the epidermal continuity. Observe for the appearance of a wheal, erythema, and the occurrence of itching at the test site during the succeeding 15 minutes at which time the solution over the puncture site is wiped off. A positive reaction consists of the development within 10 minutes of a pale wheal, sometimes with pseudopods, surrounding the puncture site and varying in diameter from 5 to 15 mm (or more). This wheal may be surrounded by a variable diameter of erythema, and accompanied by a variable degree of itching. The most sensitive individuals develop itching quickly, and the wheal and erythema are prompt in their appearance. As soon as a positive response as defined above is clearly evident, the solution over the scratch should be immediately wiped off. If the puncture test is either negative or equivocally positive (less than 5 mm wheal with little or no erythema and no itching), an intradermal test may be performed.
- Using a 0.5 to 1.0 cc syringe with a 3/8 to 5/8long, 26 to 30 gauge, short bevel needle, withdraw the contents of the ampule. Prepare with an alcohol swab a skin test area on the upper, outer arm, sufficiently below the deltoid muscle to permit proximal application of a tourniquet later, if necessary. Be sure to eject all air from the syringe through the needle, then insert the needle, bevel up immediately below the skin surface. Inject an amount of PREPEN sufficient to raise a small intradermal bleb of about 3 mm in diameter, in duplicate at least 2 cm apart. Using a separate syringe and needle, inject a like amount of saline or allergen diluting solution as a control at least 5 cm removed from the antigen test sites. Most skin reactions will develop within 5-15 minutes and response to the skin test is read at 20 minutes as follows:
- Negative response  no increase in size of original bleb and no greater reaction than the control site.
- Ambiguous response  wheal only slightly larger than initial injection bleb, with or without accompanying erythematous flare and slightly larger than the control site; OR discordance between duplicates.
- Positive response  itching and significant increase in size of original blebs to at least 5 mm. Wheal may exceed 20 mm in diameter and exhibit pseudopods.
- If the control site exhibits a wheal greater than 23 mm, repeat the test, and if the same reaction is observed, a physician experienced with allergy skin testing should be consulted.

## Off-Label Use and Dosage (Adult)

### Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Benzylpenicilloyl Polylysine in adult patients.

### NonGuideline-Supported Use
There is limited information regarding Off-Label NonGuideline-Supported Use of Benzylpenicilloyl Polylysine in adult patients.

# Pediatric Indications and Dosage

## FDA-Labeled Indications and Dosage (Pediatric)
There is limited information regarding FDA-Labeled Use of Benzylpenicilloyl Polylysine in pediatric patients.

## Off-Label Use and Dosage (Pediatric)

### Guideline-Supported Use
There is limited information regarding Off-Label Guideline-Supported Use of Benzylpenicilloyl Polylysine in pediatric patients.

### NonGuideline-Supported Use
There is limited information regarding Off-Label NonGuideline-Supported Use of Benzylpenicilloyl Polylysine in pediatric patients.

# Contraindications
- PREPEN is contraindicated in those patients who have exhibited either a systemic or marked local reaction to its previous administration. Patients known to be extremely hypersensitive to penicillin should not be skin tested.

# Warnings
- The risk of sensitization to repeated skin testing with PREPEN is not established. Rarely, a systemic allergic reaction including anaphylaxis may follow a skin test with PREPEN. To decrease the risk of a systemic allergic reaction, puncture skin testing should be performed first. Intradermal skin testing should be performed only if the puncture test is entirely negative.

### Precautions
- No reagent, test, or combination of tests will completely assure that a reaction to penicillin therapy will not occur.
- The value of the PREPEN skin test alone as a means of assessing the risk of administering therapeutic penicillin (when penicillin is the preferred drug of choice) in the following situations is not established:
- Adult patients who give no history of clinical penicillin hypersensitivity.
Pediatric patients.
- In addition, the clinical value of PREPEN where exposure to penicillin is suspected as a cause of a current drug reaction or in patients who are undergoing routine allergy evaluation is not known. Likewise, the clinical value of PREPEN skin tests alone in determining the risk of administering semi-synthetic penicillins (phenoxymethyl penicillin, ampicillin, carbenicillin, dicloxacillin, methicillin, nafcillin, oxacillin, amoxicillin), cephalosporin-derived antibiotics, and penem antibiotics is not known.
- In addition to the results of the PREPEN skin test, the decision to administer or not administer penicillin should take into account individual patient factors. Healthcare professionals should keep in mind the following:
- A serious allergic reaction to therapeutic penicillin may occur in a patient with a negative skin test to PREPEN.
- It is possible for a patient to have an anaphylactic reaction to therapeutic penicillin in the presence of a negative PREPEN skin test and a negative history of clinical penicillin hypersensitivity.
- If penicillin is the drug of choice for a life-threatening infection, successful desensitization with therapeutic penicillin may be possible irrespective of a positive skin test and/or a positive history of clinical penicillin hypersensitivity.

# Adverse Reactions

## Clinical Trials Experience
- Occasionally, patients may develop an intense local inflammatory response at the skin test site. Rarely, patients will develop a systemic allergic reaction, manifested by generalized erythema, pruritus, angioedema, urticaria, dyspnea, hypotension, and anaphylaxis. The usual methods of treating a skin test antigen-induced reaction  the applications of a venous occlusion tourniquet proximal to the skin test site and administration of epinephrine are recommended. The patient should be kept under observation for several hours.

## Postmarketing Experience
There is limited information regarding Postmarketing Experience of Benzylpenicilloyl Polylysine in the drug label.

# Drug Interactions
There is limited information regarding Benzylpenicilloyl Polylysine Drug Interactions in the drug label.

# Use in Specific Populations

### Pregnancy
Pregnancy Category (FDA): C
- Animal reproduction studies have not been conducted with PREPEN. It is not known whether PREPEN can cause fetal harm when administered to a pregnant woman or can affect reproduction capacity. The hazards of skin testing in such patients should be weighed against the hazard of penicillin therapy without skin testing.
Pregnancy Category (AUS):
- Australian Drug Evaluation Committee (ADEC) Pregnancy Category
There is no Australian Drug Evaluation Committee (ADEC) guidance on usage of Benzylpenicilloyl Polylysine in women who are pregnant.

### Labor and Delivery
There is no FDA guidance on use of Benzylpenicilloyl Polylysine during labor and delivery.

### Nursing Mothers
There is no FDA guidance on the use of Benzylpenicilloyl Polylysine with respect to nursing mothers.

### Pediatric Use
There is no FDA guidance on the use of Benzylpenicilloyl Polylysine with respect to pediatric patients.

### Geriatic Use
There is no FDA guidance on the use of Benzylpenicilloyl Polylysine with respect to geriatric patients.

### Gender
There is no FDA guidance on the use of Benzylpenicilloyl Polylysine with respect to specific gender populations.

### Race
There is no FDA guidance on the use of Benzylpenicilloyl Polylysine with respect to specific racial populations.

### Renal Impairment
There is no FDA guidance on the use of Benzylpenicilloyl Polylysine in patients with renal impairment.

### Hepatic Impairment
There is no FDA guidance on the use of Benzylpenicilloyl Polylysine in patients with hepatic impairment.

### Females of Reproductive Potential and Males
There is no FDA guidance on the use of Benzylpenicilloyl Polylysine in women of reproductive potentials and males.

### Immunocompromised Patients
There is no FDA guidance one the use of Benzylpenicilloyl Polylysine in patients who are immunocompromised.

# Administration and Monitoring

### Administration
- Intradermal
- Intraepidermal

### Monitoring
There is limited information regarding Monitoring of Benzylpenicilloyl Polylysine in the drug label.

# IV Compatibility
There is limited information regarding IV Compatibility of Benzylpenicilloyl Polylysine in the drug label.

# Overdosage
There is limited information regarding Overdose of Benzylpenicilloyl Polylysine in the drug label.

# Pharmacology

## Mechanism of Action
- PRE-PEN is a skin test antigen reagent that reacts specifically with benzylpenicilloyl IgE antibodies initiating the release of chemical mediators which produce an immediate wheal and flare reaction at a skin test site. All individuals exhibiting a positive skin test to PRE-PEN possess IgE against the benzylpenicilloyl structural group which is a hapten. A hapten is a low molecular weight chemical that conjugates with a carrier (e.g. poly-l-lysine) resulting in the formation of an antigen with the haptens specificity. The benzylpenicilloyl hapten is the major antigenic determinant in penicillin-allergic individuals. However, many individuals reacting positively to PRE-PEN will not develop a systemic allergic reaction on subsequent exposure to therapeutic penicillin, especially among those who have not reacted to penicillins in the past. Thus, the PRE-PEN skin test determines the presence of penicilloyl IgE antibodies which are necessary but not sufficient for acute allergic reactions due to the major penicilloyl determinant.
- Non-benzylpenicilloyl haptens are designated as minor determinants, since they less frequently elicit an immune response in penicillin treated individuals. The minor determinants may nevertheless be associated with significant clinical hypersensitivity. PRE-PEN does not react with IgE antibodies directed against non-benzylpenicilloyl haptens.

## Structure
- PRE-PEN (benzylpenicilloyl polylysine injection USP) is a sterile solution of benzylpenicilloyl polylysine in a concentration of 6.0X10-5M (benzylpenicilloyl) in 0.01 M phosphate buffer and 0.15 M sodium chloride. The benzylpenicilloyl polylysine in PRE-PEN is a derivative of poly-l-lysine, where the epsilon amino groups are substituted with benzylpenicilloyl groups (50-70%) forming benzylpenicilloyl alpha amide. Each single dose ampule contains 0.25 mL of PRE-PEN.
- PRE-PEN has the following structure:

## Pharmacodynamics
There is limited information regarding Pharmacodynamics of Benzylpenicilloyl Polylysine in the drug label.

## Pharmacokinetics
There is limited information regarding Pharmacokinetics of Benzylpenicilloyl Polylysine in the drug label.

## Nonclinical Toxicology
There is limited information regarding Nonclinical Toxicology of Benzylpenicilloyl Polylysine in the drug label.

# Clinical Studies
There is limited information regarding Clinical Studies of Benzylpenicilloyl Polylysine in the drug label.

# How Supplied
- PREPEN (benzylpenicilloyl polylysine injection USP) is a clear, colorless, sterile solution supplied in ampules containing 0.25 mL.
- Box of 5 single dose ampules. Ampules are opened by snapping the neck of the ampule using two forefingers of each hand. Visually inspect for glass chards before use. Each ampule is for single patient use only. Discard any unused portion.

## Storage
- PREPEN is optimally stored under refrigeration (28 C). PREPEN subjected to ambient temperatures for more than 24 hours should be discarded. As with all parenteral drug products, PREPEN should be inspected visually for particulate matter and discoloration prior to administration.

# Images

## Drug Images

## Package and Label Display Panel

### PACKAGE/LABEL PRINCIPAL DISPLAY PANEL

### Ingredients and Appearance

# Patient Counseling Information
There is limited information regarding Patient Counseling Information of Benzylpenicilloyl Polylysine in the drug label.

# Precautions with Alcohol
Alcohol-Benzylpenicilloyl Polylysine interaction has not been established. Talk to your doctor about the effects of taking alcohol with this medication.

# Brand Names
- PRE-PEN

# Look-Alike Drug Names
There is limited information regarding Benzylpenicilloyl Polylysine Look-Alike Drug Names in the drug label.

# Drug Shortage Status

# Price