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

Abstract

Nonsteroidal anti-inflammatory drug (NSAID)-induced urticarial and angioedema reactions are among the most commonly encountered drug hypersensitivity reactions in clinical practice. Three major clinical phenotypes of NSAID-induced acute skin reactions manifesting with angioedema, urticaria, or both have been distinguished: NSAID-exacerbated cutaneous disease, nonsteroidal anti-inflammatory drug-induced urticaria/angioedema (NIUA), and single NSAID-induced urticaria and angioedema. In some patients clinical history alone might be sufficient to establish the diagnosis of a specific type of NSAID hypersensitivity, whereas in other cases oral provocation challenges are necessary to confirm the diagnosis. Moreover, classification of the type of cutaneous reaction is critical for proper management. For example, in patients with single NSAID-induced reactions, chemically nonrelated COX-1 inhibitors can be safely used. However, there is cross-reactivity between the NSAIDs in patients with NSAID-exacerbated cutaneous disease and NIUA, and thus only use of selective COX-2 inhibitors can replace the culprit drug if the chronic treatment is necessary, although aspirin desensitization will allow for chronic treatment with NSAIDs in some patients with NIUA. In this review we present a practical clinical approach to the patient with NSAID-induced urticaria and angioedema.

Immediate Reactions to More Than 1 NSAID Must Not Be Considered Cross-Hypersensitivity Unless Tolerance to ASA Is Verified

“…According to recent guidelines, these reactions fall within the category of single NSAIDinduced urticaria/angioedema or anaphylaxis, for which all patients must tolerate ASA [7,30]. From a total of 203 patients with immediate SRs to NSAIDs, we identified 16 who reacted to 2 or 3 chemically unrelated NSAIDs and were tolerant to ASA.…”

“…Concentrations were used as previously reported [29][30][31]. The basophil activation test (BAT) was performed exclusively for pyrazolone derivatives as described elsewhere [27].…”

The Genetics of Drug Hypersensitivity Reactions

“…Despite growing interest in the genetics of NIUA [81][82][83][84], most available data are on NERD [85,86]. However, many studies have included limited numbers of individuals, often without replication, and largely in populations of Asian descent [85][86][87].…”

Effective Ibuprofen Desensitization in a Patient with Myopericarditis

“…There are not desensitization schemes in the literature for ibuprofen, but the analogy of metabolic drug effect cox 1 inhibitor is known [3] for all unrelated NSAIDs and equivalent pharmacological power, as well as the possibility, in the literature verified with ketorolac [4], of switching between 1 drug and the other in the process of desensitization Many data exist on aspirin desensitization on NSAIDs exacerbated respiratory diseases [5][6][7][8][9][10][11][12], particularly in asthma and rhinosinusitis, and NIUA [13]. Aspirin desensitization is also indicated in patients who need chronic antiplatelet treatment with aspirin for artery coronary disease [14][15][16][17][18][19][20][21][22][23][24][25] or chronic anti-inflammatory treatment with NSAIDs.…”