Aspirin Desensitization in Patients With Coronary Artery Disease

Abstract

A spirin (ASA) is the cornerstone of antithrombotic therapy in patients with coronary artery disease (CAD), both in the acute and the chronic phase of treatment.1-3 However, ≈2% of patients have hypersensitivity to ASA. 4 Although See Editorial by Tantry and Gurbelclopidogrel is recommended in practice guidelines as the antiplatelet agent of choice for patients who are unable toBackground-There are limited data on aspirin (ASA) desensitization for patients with coronary artery disease. The aim of the present study was to assess the safety and efficacy of a standard rapid desensitization protocol in patients with ASA sensitivity undergoing coronary angiography. Methods and Results-This is a prospective, multicenter, observational study including 7 Italian centers including patients with a history of ASA sensitivity undergoing coronary angiography with intent to undergo percutaneous coronary intervention. A total of 330 patients with history of ASA sensitivity with known/suspected stable coronary artery disease or presenting with an acute coronary syndrome, including ST-segment-elevation myocardial infarction were enrolled. Adverse effects to aspirin included urticaria (n=177, 53.6%), angioedema (n=69, 20.9%), asthma (n=65, 19.7%), and anaphylactic reaction (n=19, 5.8%). Among patients with urticaria/angioedema, 13 patients (3.9%) had a history of idiopathic chronic urticaria. All patients underwent a rapid ASA (5.5 hours) desensitization procedure. The desensitization procedure was performed before cardiac catheterization in all patients, except for those (n=78, 23.6%) presenting with ST-segment-elevation myocardial infarction who underwent the desensitization after primary percutaneous coronary intervention. Percutaneous coronary intervention was performed in 235 patients (71%) of the overall study population. The desensitization procedure was successful in 315 patients (95.4%) and in all patients with a history of anaphylactic reaction. Among the 15 patients (4.6%) who did not successfully respond to the desensitization protocol, adverse reactions were minor and responded to treatment with corticosteroids and antihistamines. Among patients with successful in-hospital ASA desensitization, 253 patients (80.3%) continued ASA for at least 12 months. Discontinuation of ASA in the 62 patients (19.7%) who had responded to the desensitization protocol was because of medical decision and not because of hypersensitivity reactions. Conclusions-A standard rapid desensitization protocol is safe and effective across a broad spectrum of patients, irrespective of the type of aspirin sensitivity manifestation, with indications to undergo coronary angiography with intent to perform percutaneous coronary intervention. Rossini et al Antiplatelet Desensitization Registrytake aspirin because of hypersensitivity or intolerance, ASA desensitization also represents an alternative approach. 5 This is particularly relevant for patients requiring dual antiplatelet therapy, including ASA and a P2Y 12 receptor, such as in patients experien...

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

“…Several protocols for ASA challenge or desensitization in patients with cardiovascular diseases were published prior to our study [12-24] and are summarized in Table 1. A European expert panel of the ENDA group has recently agreed on guidelines on this topic [23], but no position paper has been published so far.…”

“…A European expert panel of the ENDA group has recently agreed on guidelines on this topic [23], but no position paper has been published so far. All previous studies did not specifically exclude patients who tolerated NSAIDs after the initial reaction, and in most cases did not assess the patterns of response, including reactions to other NSAIDs and the presence of previous CSU [12-24]. 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]. With our approach, the time required for challenge or desensitization can be shortened and, hence, all the direct and indirect medical costs for patient care can be reduced significantly (Table 1).…”

“…The aim of this study was to evaluate the short- and long-term outcomes of a risk-stratified, dynamic protocol developed in our center. This approach is shorter than those previously published protocols for challenge and/or desensitization to NSAID hypersensitivity for coronary artery disease [12-24]. …”

Is Aspirin Still the Cornerstone of Antiplatelet Therapy in Patients With Coronary Artery Disease? An Historical and Practical Narrative Review

“…Results showed that a 6-step oral protocol carried out over 5.5 hours was safe, as no severe hypersensitivity reaction occurred, and effective in a wide cohort of non-selected patients with a success rate of 95.4%. 46 Focusing on other drug interactions, there could be an increased sensitivity to allergens associated with therapy with beta-blockers, which could culminate in a dangerous hypersensitivity reaction. [47][48][49] In addition, beta-blockers may cause a reduction in the adrenaline effect, which represents a fundamental drug in the treatment of serious hypersensitivity responses.…”