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Algorithm of drug causality for epidermal necrolysis (ALDEN)

Algorithm of drug causality for epidermal necrolysis (ALDEN)
Criterion Values Rules to apply
Delay from initial drug component intake to onset of reaction (index day) Suggestive: +3 From 5 to 28 days –3 to 3
Compatible: +2 From 29 to 56 days
Likely: +1 From 1 to 4 days
Unlikely: –1 >56 days
Excluded: –3 Drug started on or after the index day

In case of previous reaction to the same drug, only changes for:

Suggestive: +3: from 1 to 4 days

Likely: +1: from 5 to 56 days

Drug present in the body on index day Definite: 0 Drug continued up to index day or stopped at a time point less than five times the elimination half-life* before the index day –3 to 0
Doubtful: –1 Drug stopped at a time point prior to the index day by more than five times the elimination half-life* but liver or kidney function alterations or suspected drug interactions are present
Excluded: –3 Drug stopped at a time point prior to the index day by more than five times the elimination half-life*, without liver or kidney function alterations or suspected drug interactions
Prechallenge/rechallenge Positive specific for disease and drug: 4 SJS/TEN after use of same drug –2 to 4
Positive specific for disease or drug: 2 SJS/TEN after use of similarΔ drug or other reaction with same drug
Positive unspecific: 1 Other reaction after use of similarΔ drug
Not done/unknown: 0 No known previous exposure to this drug
Negative: –2 Exposure to this drug without any reaction (before or after reaction)
Dechallenge Neutral: 0 Drug stopped (or unknown) –2 or 0
Negative: –2 Drug continued without harm
Type of drug (notoriety) Strongly associated: 3 Drug of the "high-risk" list according to previous case-control studies –1 to 3
Associated: 2 Drug with definite but lower risk according to previous case-control studies
Suspected: 1 Several previous reports, ambiguous epidemiology results (drug "under surveillance")
Unknown: 0 All other drugs including newly released ones
Not suspected: –1 No evidence of association from previous epidemiology study with sufficient number of exposed controlsΔ
Intermediate score = total of all previous criteria
Other cause Possible: –1 Rank all drugs from highest to lowest intermediate score –1
If at least one has an intermediate score >3, subtract 1 point from the score of each of the other drugs taken by the patient (another cause is more likely)
Final score: –12 to 10
<0: very unlikely; 0 to 1: unlikely; 2 to 3: possible; 4 to 5: probable; ≥6: very probable.
SJS: Stevens-Johnson syndrome; TEN: toxic epidermal necrolysis; ATC: anatomical therapeutic chemical.
* Drug (or active metabolite) elimination half-life from serum and/or tissues (according to pharmacology textbooks), taking into account kidney function for drugs predominantly cleared by kidney and liver function for those with high hepatic clearance.
¶ Suspected interaction was considered when more than five drugs were present in a patient's body at the same time.
Δ Similar drug = same ATC code up to the fourth level (chemical subgroups).
Reprinted by permission from Macmillan Publishers Ltd: Clinical Pharmacology and Therapeutics. Sassolas B, Haddad C, Mockenhaupt M, et al. ALDEN, an algorithm for assessment of drug causality in Stevens-Johnson syndrome and toxic epidermal necrolysis: comparison with case-control analysis. Clin Pharmacol Ther 2010; 88:60. www.nature.com/cpt. Copyright © 2010.
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