ContentsSynopsisCodesLook ForDiagnostic PearlsDifferential Diagnosis & PitfallsBest TestsManagement PearlsTherapyDrug Reaction DataReferences
Drug-induced flushing reaction
Print
Other Resources UpToDate PubMed

Drug-induced flushing reaction

Print Images (1)
Contributors: Jonathan Webster, Michael W. Winter MD, Benjamin L. Mazer MD, MBA, Susan Burgin MD
Other Resources UpToDate PubMed

Synopsis

Drug-induced flushing reaction is characterized by episodic erythema and warmth of the head, neck, and arms associated with the use of a medication or other drug. Flushing is an involuntary response of the central nervous system that increases cutaneous blood flow. Onset is hours to days after initiation of medication. Common medications that trigger a flushing reaction include nicotinic acid (niacin), vasodilators, calcium channel blockers, nitroglycerin, anti-inflammatories, cholinergics, beta blockers, and angiotensin-converting enzyme (ACE) inhibitors. Other drugs, including opiates, amyl nitrite, butyl nitrite, cocaine, heroin, alcohol, and amphetamines, as well as alcohol combined with drugs, can cause severe reactions with flushing.

Certain medications known to cause moderate drug-induced flushing reaction, such as infused vancomycin, may be treated by giving patients diphenhydramine and ranitidine, then restarting vancomycin at a reduced dosage.

Some medications, such as antiestrogen medications, can induce a pharmacologic menopause reaction. Withdrawal from hormone replacement therapy can also induce a flushing reaction.

Serotonin syndrome is a potentially life-threatening condition caused by excess serotonergic activation. Be sure to ask about medications that may have serotonergic effects within the central nervous system. These drugs include serotonin reuptake inhibitors, tricyclic antidepressants, monoamine oxidase inhibitors, and opiates. Other medications such as triptans, antibiotics, antiemetics, cough syrups, herbal remedies, or illicit drugs can cause serotonin syndrome in the setting of serotonergic medications listed previously. Serotonin syndrome is a clinical diagnosis and encompasses a spectrum of disease. Classically, serotonin syndrome is composed of a triad of mental status changes, autonomic hyperactivity, and neuromuscular abnormalities. The spectrum of disease ranges from benign to lethal and may be missed.

Alcohol is a common cause of "dry flushing" in patients with aldehyde dehydrogenase gene polymorphisms. A deficiency in aldehyde dehydrogenase causes an increase in acetaldehyde levels, which slows alcohol metabolism and causes a cutaneous flushing reaction. Patients may also report dizziness, lightheadedness, fatigue, anxiety, headache, weakness, nausea, or vomiting associated with alcohol intake. Even in the absence of an aldehyde dehydrogenase gene polymorphism, alcohol combined with medications can cause a flushing reaction. Those medications include disulfiram, chlorpropamide, metronidazole, ketoconazole, griseofulvin, cephalosporins, chloramphenicol, antimalarials, and topical tacrolimus.

Codes

ICD10CM:
R23.2 – Flushing

SNOMEDCT:
403618004 – Drug-induced flushing

Look For

Subscription Required

Diagnostic Pearls

Subscription Required

Differential Diagnosis & Pitfalls

The most common causes of flushing:
  • Benign cutaneous flushing – Caused by emotion, temperature, food, or beverages.
  • Fever
  • Alcohol – May cause flushing directly or via its metabolite acetaldehyde. More common among patients of Asian descent that may have aldehyde dehydrogenase-2 deficiency. Certain drugs combined with alcohol may cause flushing.
  • Menopause – Can be provoked by warmth, hot drinks, alcohol, and mental stress.
  • Rosacea
  • Cluster headache
Uncommon, serious, and malignant causes: Neurologic causes: Other causes:

Best Tests

Subscription Required

Management Pearls

Subscription Required

Therapy

Subscription Required

Drug Reaction Data

Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.

Subscription Required

References

Subscription Required

Last Reviewed: 02/06/2019
Last Updated: 03/01/2019
Copyright © 2019 VisualDx®. All rights reserved.
Drug-induced flushing reaction
Print 1 Images
Drug-induced flushing reaction : Flushing
Copyright © 2019 VisualDx®. All rights reserved.