Safety of Aspirin Desensitization in Patients With Reported Aspirin Allergy and Cardiovascular Disease

Abstract

Background: Aspirin (ASA) is the drug of choice in patients with coronary artery disease for primary and secondary prevention. This poses a problem for those patients reporting hypersensitivity to this drug or class of drugs. Hypothesis: Desensitization to ASA may be carried out safely and effectively in patients with reported ASA or nonsteroidal anti-inflammatory drug (NSAID) hypersensitivity needing ASA for cardiac indications. Our 7-step protocol is one choice for a rapid desensitization protocol. Methods: A retrospective chart review was conducted evaluating ASA desensitization in patients with reported ASA or NSAID hypersensitivity and a cardiac indication for ASA. Results: In 160 evaluations over 15 years, 89 desensitizations were performed in both the inpatient and outpatient setting with only 16 reactions (18%). Eleven of these 16 patients (68.7%) were able to take daily ASA. Twenty-six desensitization procedures were performed with our 7-step rapid desensitization protocol in 10 inpatients and 16 outpatients with 3 reactions (18.75% of reactions). Initial reaction to ASA involving angioedema and reacting to ASA within the past year increased the risk of having a reaction to desensitization. Conclusions: Desensitization may be safely performed in patients with reported ASA or NSAID hypersensitivity and a cardiac indication for ASA. Our 7-step rapid protocol may be used in both the inpatient and outpatient setting to desensitize these patients. Patients who had angioedema with ASA ingestion or a reaction to ASA within the past year are at higher risk for reaction during the desensitization protocol.

Approaches to the diagnosis and management of patients with a history of nonsteroidal anti-inflammatory drug–related urticaria and angioedema

“…However, if chronic intake of aspirin (eg, for cardiovascular disease) or other strong COX-1 inhibitors (eg, for osteoarthritis) is necessary, desensitization to aspirin can be performed because several protocols for desensitization are available. 61,70,71 SNIUAA In a patient with hypersensitivity to a single NSAID (eg, diclofenac, ibuprofen, or ketoprofen), when the culprit drug has been identified, it can be replaced easily by another NSAID with an unrelated chemical structure but similar anti-inflammatory potency (Table II). Desensitization is not recommended.…”

“…A single-blind, placebo-controlled 2-day aspirin challenge can be performed after the patient has been without any skin eruptions for 1 to 2 weeks. 30 On day 1, the patient receives a placebo to determine baseline activity, and on day 2, the patient receives escalating doses of ASA (71,117,312, and 500 mg) at 1.5-to 2-hour intervals. 31 Most patients will react to a single dose of aspirin between 325 and 650 mg, with at least 1 hour to react after ingestion of aspirin.…”

Establishing a Safe Administration of ASA in Cardiovascular Patients with Nonsteroidal Anti-Inflammatory Drug Hypersensitivity with Skin and/or Respiratory Involvement

“…The most commonly used protocol starts with 0.1–1 mg of ASA with 30-min intervals between doses, and is performed after allergy consultation in only 47% of cases [32]. In previously published studies, most of the patients presenting with unsuccessful desensitization belonged to the group with chronic urticaria, although no severe reactions were reported [12-16, 18, 20, 21, 23]. With exception of the studies by Cortellini et al [18, 23], most previously published protocols did not include risk stratification and all patients were managed equally, disregarding their individual characteristics [12-17, 19-22, 24].…”

Rapid Desensitization in Immediate Hypersensitivity Reaction to Drugs

“…It is still controversial if ACE inhibitors and beta-blockers should be withheld before the ASA-DST, because of their benefits in vascular diseases. Thus, the use of antihistamines and corticosteroids as premedication is controversial, oppositely to NERD/AERD, for which patients must be treated with leukotriene modifiers and with asthma/rhinosinusitis drugs [66][67][68]. Finally, once the final therapeutic ASA antiplatelet dose is reached, it should not be interrupted in order to maintain aspirin tolerance.…”