Drug provocation tests in the diagnosis of hypersensitivity reactions to non-steroidal anti-inflammatory drugs in children

Variants of CEP68 gene are associated with acute urticaria/angioedema induced by multiple non-steroidal anti-inflammatory drugs

Non-steroidal anti-inflammatory drugs (NSAIDs) are the most consumed drugs worldwide because of their efficacy and utility in the treatment of pain and inflammatory diseases. However, they are also responsible for an important number of adverse effects including hypersensitivity reactions. The most important group of these reactions is triggered by non-immunological, pharmacological mechanisms catalogued under the denomination of cross-intolerance (CRI), with acute urticaria/angioedema induced by multiple NSAIDs (MNSAID-UA) the most frequently associated clinical entity. A recent genome-wide association study identified the gene encoding the centrosomal protein of 68 KDa (CEP68) as the major locus associated with aspirin intolerance susceptibility in asthmatics. In this study, we aimed to assess the role of this locus in susceptibility to CRI to NSAIDs by examining 53 common gene variants in a total of 635 patients that were classified as MNSAID-UA (n = 399), airway exacerbations (n = 110) or blended pattern (n = 126), and 425 controls. We found in the MNSAID-UA group a number of variants (17) associated (lowest p-value = 1.13×10⁻⁶), including the non-synonymous Gly74Ser variant (rs7572857) previously associated with aspirin intolerance susceptibility in asthmatics. Although not being significant in the context of multiple testing, eight of these variants were also associated with exacerbated respiratory disease or blended reactions. Our results suggest that CEP68 gene variants may play an important role in MNSAID-UA susceptibility and, despite the different regulatory mechanisms involved depending on the specific affected organ, in the development of hypersensitivity reactions to NSAIDs.

Challenge-proven nonsteroidal anti-inflammatory drug hypersensitivity in children

BACKGROUND

Few studies investigated hypersensitivity to nonsteroidal anti-inflammatory drugs (NSAIDs) in children. The objective was to determine the frequency of true NSAID hypersensitivity (NSAID-H) and whether there were any parameters in the history of children that would predict NSAID-H. Secondly, an investigation was conducted into whether NSAID-hypersensitive children could tolerate safe alternatives. Differing from previous studies, the researchers followed the recent diagnostic algorithm proposed for acute reactions in NSAID-H.

METHODS

Children with a history suggesting NSAID-H were evaluated by an allergist. The patients with a single NSAID in history were tested first with a skin prick test and if negative challenged with the culprit NSAID. The patients who had reactions with multiple NSAIDs were directly challenged with their culprit drugs. Safe alternatives in children with a confirmed NSAID-H were found by oral provocation tests (OPTs).

RESULTS

Fifty-eight of 61 patients participated in the study. Thirty-eight patients (65.5%) described a reaction to a single NSAID and 20 mentioned reactions with ≥2 different NSAIDs. Single-drug-induced and cross-reactive NSAID-Hs were proven in 5 of 36 (14%) and 8 of 18 (44%) of patients, respectively. Acetaminophen and nimesulide were tolerated in 60% and 88.8% of the study patients as safe alternatives, respectively. Family history of NSAID-H was found as the only significant predictor of OPT (OR: 5.4; 95% CI: 1.02-28.6).

CONCLUSION

Histories of both single and multiple NSAID-Hs are poor predictors of actual drug hypersensitivity. Therefore, diagnostic tests should be performed in all children if no contraindication exits. Family history of NSAID-H is the only significant parameter predicting OPT results.