# Sulfa Allergies & Morphine



## ResTech

I wanted to post this because I am surprised at how many providers, both novice and experienced of all levels, have the misconception over sulfa allergy and morphine. 

Sulfa allergy relates to medications know as sulfonamides which are largely a group of antibiotics (Bactrim). Furosimide (Lasix) is also in this class as well. Morphine Sulfate is NOT a sulfonamide so if a patient say's they have a sulfa allergy, they CAN have Morphine.  

I was with a preceptor one time and we had a fall patient having some pain who said she had a sulfa allergy. My preceptor then went on to tell the patient that the only med we had for pain was morphine of which the patient couldn't have due to her sulfa allergy. As a student I didnt want to correct my preceptor.


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## medic417

Actually you are not entirely correct.  Some people are allergic to anything that contains the "sul" in its name.  So you need to discuss this with the patient and not rush to give something that can cause harm to many patients.


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## JB42

> Actually you are not entirely correct. Some people are allergic to anything that contains the "sul" in its name. So you need to discuss this with the patient and not rush to give something that can cause harm to many patients.



medic417, is it still a "Sulfa" allergy then, or is it something different? Not second guessing you, just trying to understand more about it. If it is still considered a sulfa allergy, what is the cause for the difference in allergy? Again, curiosity.


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## ResTech

> Some people are allergic to anything that contains the "sul" in its name



By chance they could be.... the same as they could be allergic to any drug with the letter "A" in it. But the point is there is no relation between sulfonamides and morphine sulfate as they are completely different chemically. They only sound similar. It's the same comparison as water and gasoline... both liquids but both totally different in their effects. 

Sulfates are naturally occurring and we take them in daily in water and foods as they are largely salts.

Don't automatically withhold morphine just because your patient may have an allergy to sulfonamides. That's the point.


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## medic417

JB42 said:


> medic417, is it still a "Sulfa" allergy then, or is it something different? Not second guessing you, just trying to understand more about it. If it is still considered a sulfa allergy, what is the cause for the difference in allergy? Again, curiosity.



W/o doing the research for you, yes at least per the patient.  In other words the patient will usually just say sulfa allergy, or just have the sulfa allergy medical bracelet/necklace.  To presume it only refers to the antibiotics as the OP suggests is a road you do not want to be on. 

 I suggest an in depth research of this subject by anyone that thinks as the OP does.  Yes the majority still only react to the antibiotics, but a large number still can and do react to anything with "sul" in its name.  Many cannot even chew most regular gum or eat most store bought breads as they are so sensitive.  If they react to such small concentrations as that you will risk killing them with the amount in our drug solutions.


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## VentMedic

http://www.druginformation.co.nz/Bulletins/SulphurAllergy.pdf


Yes there is confusion with these allergies and if we were overly cautious, Albuterol Sulfate would also be avoided. 

Always ask what med, what happened and under what circumstances.


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## silver

medic417 said:


> Actually you are not entirely correct.  Some people are allergic to anything that contains the "sul" in its name.  So you need to discuss this with the patient and not rush to give something that can cause harm to many patients.



thats impossible. Sulfur is the 8th most common element found in the human body. It is essential to human life and is found in many amino acids.

However the sulfa category is huge. But there are many other "Sul" drugs given not in that category and aren't related.

Besides the sulfonamide allergy, people do have hypersensitivity to sulfites which gets metabolized to sulfur dioxide. It is now being classified by some as an allergy.
Some asthmatics also are sensitive to sulfur dioxide, but its not because of the "sul," but because of the interaction of sulfur and two oxygens.


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## ResTech

> In other words the patient will usually just say sulfa allergy, or just have the sulfa allergy medical bracelet/necklace. To presume it only refers to the antibiotics as the OP suggests is a road you do not want to be on.



Who said anything about "presuming". The point was clear that sulfonamides ARE NOT related to morphine sulfate, albuterol sulfate, atropine sulfate, etc, etc. And not to ASSUME that they are the same thing... this is the road you do not want to go down as you could withhold a beneficial medication by not knowing the difference. 

This post was made with the assumption that providers can do the elementary task of ascertaining an allergy history.


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## medic417

ResTech said:


> By chance they could be.... the same as they could be allergic to any drug with the letter "A" in it. But the point is there is no relation between sulfonamides and morphine sulfate as they are completely different chemically. They only sound similar. It's the same comparison as water and gasoline... both liquids but both totally different in their effects.
> 
> Sulfates are naturally occurring and we take them in daily in water and foods as they are largely salts.
> 
> Don't automatically withhold morphine just because your patient may have an allergy to sulfonamides. That's the point.



And that is why some people have water filters that remove them and have to be very careful of the food they buy.  Many cannot even eat certain fruits and vegetables.  

But to avoid problems it is better to provide another pain relief med. If your service only has morphine it is time to join the 21st century.


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## ResTech

Medic 417... your being ridiculous... nothing posted was incorrect. Are you disagreeing that sulfonamides and sulfates are totally different?


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## silver

medic417 said:


> And that is why some people have water filters that remove them and have to be very careful of the food they buy.  Many cannot even eat certain fruits and vegetables.



they are sensitive to sulfites then.


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## medic417

ResTech said:


> Who said anything about "presuming". The point was clear that sulfonamides ARE NOT related to morphine sulfate, albuterol sulfate, atropine sulfate, etc, etc. And not to ASSUME that they are the same thing... this is the road you do not want to go down as you could withhold a beneficial medication by not knowing the difference.
> 
> This post was made with the assumption that providers can do the elementary task of ascertaining an allergy history.



No you said they can have morphine with a sulfa allergy.  Many would take you at your word sadly and fail to dig into the patients history.  Then wonder why the patient quit breathing.  

By now you should know that most are not educated well enough to do a proper HX.  

If you have other options why risk a reaction.


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## medic417

silver said:


> they are sensitive to sulfites then.



They are sensitive to sulfa, sulfate, sulfites, etc etc.  I am very familiar with the fact that some react very severly to anything with "sul" as I am one of the ones that it happens to.


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## ResTech

I posted to provide clarification on a common misconception and your keeping that misconception alive and providing confusion. Its not difficult. Again for the fifth time, SULFONAMIDES ARE TOTALLY CHEMICALLY DIFFERENT THAN SULFATES. YOU CAN BE ALLERGIC TO BACTRIM OR SEPTRA AND STILL RECEIVE MORPHINE WITHOUT CONTRAINDICATION. 

It's all over Google and I specifically recall my pharm instructor standing in front of class specifically going over this.



> They are sensitive to sulfa, sulfate, sulfites, etc etc



They are chemically different and from the research I have done, there is no cross reactivity. Basicly its the same as being allergic to tylenol and Zantac. Its just by chance... not because the drugs are related... thats the point.


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## medic417

ResTech said:


> Medic 417... your being ridiculous... nothing posted was incorrect. Are you disagreeing that sulfonamides and sulfates are totally different?



They are different yes, but it is surprising how often a severe reaction to one equals a severe reaction to the other.  To just say give them morphine when they say they are allergic to one w/o discussing in depth is asking for a bad outcome.  Had you said in most patients it is still safe to give that would have been correct.  But a large number react to all "sul" yet most only say sulfa unless drawn out.  

I bring this out so people remember to do a complete HX.


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## medic417

ResTech said:


> I posted to provide clarification on a common misconception and your keeping that misconception alive and providing confusion. Its not difficult. Again for the fifth time, SULFONAMIDES ARE TOTALLY CHEMICALLY DIFFERENT THAN SULFATES. YOU CAN BE ALLERGIC TO BACTRIM OR SEPTRA AND STILL RECEIVE MORPHINE WITHOUT CONTRAINDICATION.
> 
> It's all over Google and I specifically recall my pharm instructor standing in front of class specifically going over this.
> 
> 
> 
> They are chemically different and from the research I have done, there is no cross reactivity. Basicly its the same as being allergic to tylenol and Zantac. Its just by chance... not because the drugs are related... thats the point.



But to presume w/o doing a complete HX can bite you in the butt.  Do not presume when they say sulfa that it is just antibiotics.  Ask.


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## fma08

medic417 said:


> They are sensitive to *sulfa, sulfate, sulfites, etc etc*.  I am very familiar with the fact that some react very severly to anything with "sul" as *I am one of the ones that it happens to*.



How are your proteins still together?


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## rescue99

medic417 said:


> They are different yes, but it is surprising how often a severe reaction to one equals a severe reaction to the other.  To just say give them morphine when they say they are allergic to one w/o discussing in depth is asking for a bad outcome.  Had you said in most patients it is still safe to give that would have been correct.  But a large number react to all "sul" yet most only say sulfa unless drawn out.
> 
> I bring this out so people remember to do a complete HX.



Medic 417 may well be right on this subject. It is hit and miss as to which patients will react and it isn't a coincidence IMO. According to a board certified allergist, he claims multiple sulfa sensitivities/allergies isn't uncommon. Medication reactions are especially common among those with a HX of hypothyroidism. Perhaps there is a connection? 

Example: 
I am severely allergic to antibiotics containing sulfa but, not others that I know of. I am allergic to all fresh fruits and vegetables to a degree (some worse than others) and suffered an acute onset V-Tach within seconds of MS IVP. 

Advise: Be ready for any adverse reaction to any medication.


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## medic_texas

I get the feeling medic417 is arguing this point because...  he can.  You keep twisting the topic and throwing in things just to keep your argument alive.    

The OP has a good and valid point from a situation that they encountered.  Their paramedic preceptor was WRONG.  When someone says "I'm allergic to Sulfa drugs" and the medics response is "well you can't have morphine".  

WRONG!

True - not all sulfa medications are antibiotics.    

Also, good job not mentioning anything to your preceptor and especially in front of the patient.  An issue like that should be brought up subtle and later on, if necessary.  I'm glad people are researching this and not going off the "infinite wisdom" that some of the keyboard warriors have.

My question is, what Sulfa medications do you carry on the ambulance?


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## cm4short

ResTech said:


> Medic 417... your being ridiculous... nothing posted was incorrect. Are you disagreeing that sulfonamides and sulfates are totally different?



I researched this topic using multiple sources. SULFATES ans SULFONAMIDES are completely different. Allergies to sulfa are directly related to antibiotics. Do the research. It only take a few minutes on google.


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## medic417

rescue99 said:


> Medic 417 may well be right on this subject. It is hit and miss as to which patients will react and it isn't a coincidence IMO. According to a board certified allergist, he claims multiple sulfa sensitivities/allergies isn't uncommon. Medication reactions are especially common among those with a HX of hypothyroidism. Perhaps there is a connection?
> 
> Example:
> I am severely allergic to antibiotics containing sulfa but, not others that I know of. I am allergic to all fresh fruits and vegetables to a degree (some worse than others) and suffered an acute onset V-Tach within seconds of MS IVP.
> 
> Advise: Be ready for any adverse reaction to any medication.





cm4short said:


> I researched this topic using multiple sources. SULFATES ans SULFONAMIDES are completely different. Allergies to sulfa are directly related to antibiotics. Do the research. It only take a few minutes on google.



It is surprisingly common for people to be allergic to all sulfa, sulfates, sulfites, etc.  I know they are unrelated but seems to be some relationship that science has failed to find.  

And medic Texas the only thing wrong that the Parmedic did was not pursue the true level of allergy.  But to say people with sulfa allergys can have morphine is misleading.  Most can but that is why he should have asked questions.


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## silver

medic417 said:


> It is surprisingly common for people to be allergic to all sulfa, sulfates, sulfites, etc.  I know they are unrelated but seems to be some relationship that science has failed to find.




Science has also failed to find Bigfoot as well, yet people still believe.



Im sorry I couldn't help myself.



> But to say people with sulfa allergys can have morphine is misleading. Most can but that is why he should have asked questions.


Correct, because some can be allergic to the morphine itself.


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## medic_texas

cm4short said:


> I researched this topic using multiple sources. SULFATES ans SULFONAMIDES are completely different. Allergies to sulfa are directly related to antibiotics. Do the research. It only take a few minutes on google.



First off, I'm not sure why you quoted me.  The bulk of your post doesn't reflect my content.  

"Allergies to sulfa are directly related to antibiotics"  

Here is my source - 

http://www.mayoclinic.com/health/sulfa-allergy/AN01565

However, not ALL SULFA (short for sulfonamide) medications are antibiotics.  HCTZ and some anti-diabetic medications are in the "sulfa" class of medications.  

Another source and probably the best source I found. Everyone should read this regarding this topic.  I find it credible and very educational.   

http://www.itmonline.org/arts/sulfa.htm

You're welcome.


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## ResTech

> My question is, what Sulfa medications do you carry on the ambulance?



Furosemide (Lasix)... which again, I have observed a lot of providers are not aware of this either. They will withhold morphine yet give Lasix. 

I'm glad my post opened up some dialog and is raising some awareness.


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## Seaglass

medic417 said:


> It is surprisingly common for people to be allergic to all sulfa, sulfates, sulfites, etc.



That's me too, along with several family members. But my reaction to each type is different, and those are far from the only serious drug reactions that I have. My morphine reaction isn't an allergy, either. It gives me panic attacks. But if a healthcare provider I don't know asks, I'll claim it is. I've had too many mishaps in the past where someone assumed it was alright to administer something with a known bad reaction as long as it wasn't an actual allergy...


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## jedirye

ResTech, I received the point of this poist and appreciate the clarification. A pity I had sifted through all the replies, it wasted time though was midly entertaining... lol.

-rye


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