Reviewer: S. Randhawa, M.D., Allergist/Immunologist and Assistant Professor at NSU
A 59-year-old Caucasian woman was referred to the clinic for evaluation of aspirin hypersensitivity. She had a severe reaction to aspirin which compromised of shortness of breath, "throat closing" and urticaria 5 years ago that required emergency room treatment with epinephrine, IV corticosteroids, and admission to the hospital overnight. Since then she has not taken any NSAIDs.
Approximately 7 years ago, she had a heart attack and underwent a CABG. Since then, her cardiac condition has been stable.
She has gradually developed worsening osteoarthritis affecting her knees she needs pain medications. She is on Tylenol PRN but she is reluctant to take any pain medications due to her significant history of adverse reaction to aspirin in the past.
Past medical history
Coronary artery disease and CABG surgery, hypertension, hyperlipidema, GERD, aspirin hypersensitivity.
Medications
Plavix, furosemide, Nexium, Benadryl, Toprol XL, lisinopril, simvastatin, Tylenol.
Physical examination
An old scar from the CABG, otherwise unremarkable.
What is the diagnosis?
This is a patient with aspirin hypersensitivity with a severe reaction 5 years ago.
Would you recommend aspirin "desensitization"?
Her PMH is complicated due to a history of coronary artery disease followed by CABG, she is on an ACE inhibitor and beta-blocker. There is a significant cross-reactivity between aspirin and the other NSAIDs which makes the use of almost all of them contraindicated.
What alternative approach would you recommend?
The safest and best approach for this patient, who requires pain medications for her osteoarthritis, is to prescribe Celebrex and Tylenol daily and PRN. Celebrex is a COX-2 inhibitor and there is no cross reactivity with the other NSAIDS in terms of allergic reactions.
She should also continue all cardiac medications. She can return to clinic PRN.
Summary
An alternative to the graded drug challenge is to administer a highly selective COX-2 inhibitor. Highly selective COX-2 inhibitors (eg, celecoxib) are tolerated by patients with pseudoallergic reactions. These agents demonstrate at least a 200 to 300-fold selectivity for inhibition of COX-2 over COX-1 at the defined therapeutic doses.
It is generally safe for patient with a pseudoallergic NSAID reaction to take a highly selective COX-2 inhibitor, such as celecoxib. Some allergists prefer to give an initial dose in a medically supervised setting (eg, a clinic), although there are no reported cases of pseudoallergic reactions who subsequently reacted to celecoxib.
However, selective COX-2 inhibitors may be unsafe in subjects with urticaria and/or angioedema caused by hypersensitivity reactions to NSAIDs with cross-intolerance if they are intolerant to paracetamol. Allergy, 2011.
However, selective COX-2 inhibitors may be unsafe in subjects with urticaria and/or angioedema caused by hypersensitivity reactions to NSAIDs with cross-intolerance if they are intolerant to paracetamol. Allergy, 2011.
Classification of adverse reactions to drugs: "SOAP III" mnemonic (click to enlarge the image):
Adverse drug reactions (ADRs) affect 10–20% of hospitalized patients and 25% of outpatients.
Rule of 10s in ADR
10% of patients develop ADR
10% of these are due to allergy
10% of these lead to anaphylaxis
10% of these lead to death
References
UpToDate, 2010.
NSAIDs are responsible for 21-25% of reported adverse drug events http://goo.gl/m6vMK
Selective COX-2 inhibitors may be unsafe in subjects with urticaria and/or angioedema caused by hypersensitivity reactions to NSAIDs with cross-intolerance if they are intolerant to paracetamol. Allergy, 2011.
How Can We Better Classify NSAID Hypersensitivity Reactions – Validation from a Large Database http://goo.gl/sal36
Selective COX-2 inhibitors may be unsafe in subjects with urticaria and/or angioedema caused by hypersensitivity reactions to NSAIDs with cross-intolerance if they are intolerant to paracetamol. Allergy, 2011.
How Can We Better Classify NSAID Hypersensitivity Reactions – Validation from a Large Database http://goo.gl/sal36
Published: 05/12/2010
Updated: 07/24/2012
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