In patients with stable CIHD and histories of nonsevere hypersensitivity reactions to ASA/NSAIDs, an ASA challenge is advisable. Patients with an ACS and histories of hypersensitivity reactions to ASA, especially following doses lower than 100 mg, should directly undergo desensitization.
Non-vitamin K antagonist oral anticoagulants (NOACs) are increasingly being used in hospital and outpatient settings as safe alternatives to warfarin. Hypersensitivity reactions have been described for NOACs and can be classified according to Gell and Coombs. We reviewed case reports of possible drug hypersensitivity reactions, noticing a predominance of delayed reactions (both mild and severe) and the absence of cross-reactions to warfarin and low molecular weight heparins. International experience on diagnostic tests is lacking. The vast majority of authors refer to probability scores and rely on biopsy to classify vasculitis and rule out differential diagnoses. We propose to adapt available tests to confirm the patient's reactivity to new anticoagulants. Among in vivo tests, patch testing revealed promising in delayed reactions.
We present tocilizumab desensitization of a 47-year-old woman affected by rheumatoid arthritis with full body delayed erythematous urticarial reaction. Skin test for tocilizumab gave cutaneous reaction after 6 h at 20 mg/mL. The schedule of desensitization was then adapted for non-immediate reaction. We prepared a desensitization procedure reaching the cumulative dose of 516 mg in 5 weeks. After 6 months, the repetition of skin tests had a negative result, with demonstration of tolerance induction. Today the patient has good control of the disease.
The current therapy with direct trombin inhibitors (DTI) is indicated for the prevention of stroke in non-valvular atrial fibrillation. Side effects are reported, particularly skin hypersensitivity, for this whole category of drugs as well as for other modern antiplatelet and anticoagulant drugs. For their clinical features, these reactions appear as delayed T-cell mediated drug hypersensitivity, but at present there are no diagnostic methods of investigation. We reported a case of delayed skin reaction to edoxaban and we found the non-irritant concentration for patch test in the whole category of drugs. The patch test resulted positive for edoxaban. A successive challenge with alternative DTIs and/or a switch to warfarin is proposed as alternative therapy.
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