A novel phenotype of nonsteroidal anti-inflammatory drug hypersensitivity: the high-risk patient

Aspirin Hypersensitivity in Patients with Coronary Artery Disease: An Updated Review and Practical Recommendations

Acetylsalicylic acid (ASA) represents a cornerstone of antiplatelet therapy for the treatment of atherosclerotic coronary artery disease (CAD). ASA is in fact indicated in case of an acute coronary syndrome or after a percutaneous coronary intervention with stent implantation. Aspirin hypersensitivity is frequently reported by patients, and this challenging situation requires a careful evaluation of the true nature of the presumed sensitivity and of its mechanisms, as well as to differentiate it from a more frequent (and more easily manageable) aspirin intolerance. Two main strategies are available to allow ASA administration for patients with CAD and suspected ASA hypersensitivity: a low-dose ASA challenge, aimed at assessing the tolerability of ASA at the antiplatelet dose of 100 mg, and desensitization, a therapeutic procedure which aims to induce tolerance to ASA. For those patients who cannot undergo ASA challenge and desensitization due to previous serious adverse reactions, or for those in whom desensitization was unsuccessful, a number of further alternative strategies are available, even if these have not been validated and approved by guidelines. The aim of this state-of-the-art review is therefore to summarize the established evidence regarding pathophysiology, clinical presentation, diagnosis, and management of aspirin hypersensitivity and to provide a practical guide for cardiologists (and clinicians) who have to face the not uncommon situation of a patient with concomitant coronary artery disease and aspirin hypersensitivity.

Aspirin-exacerbated cutaneous disease (AECD) is a distinct subphenotype of chronic spontaneous urticaria

BACKGROUND

A subset of patients with chronic spontaneous urticaria (CSU) experience disease exacerbations after receiving non-steroidal anti-inflammatory drugs (NSAIDs). This condition has been designated as Aspirin-Exacerbated Cutaneous Disease (AECD).

OBJECTIVES

The purpose of this study was twofold: (i) Investigate the demographic and clinical features of patients affected by AECD; (ii) To compare patients with AECD and NSAID-tolerant CSU patients for those characteristics.

METHODS

Patients with AECD and a group of unselected CSU patients tolerant to NSAIDs were studied. Demographic and clinical data were obtained by direct questioning and physical examination. Laboratory investigations and allergen skin prick tests were performed only in selected patients, as guided by the medical history.

RESULTS

Of 423 CSU patients admitted in the clinics, 52 (12.2%) had AECD. Compared with NSAID-tolerant CSU patients, AECD patients had significantly longer disease duration (57.7 ± 118.4 vs. 24.4 ± 36.6 months, P < 0.05), higher prevalence of angio-oedema (72.7 vs. 30.9%, P < 0.05) and atopy (83.8% vs. 58.4%, P < 0.05) and more frequent involvement of the face and upper respiratory tract (54.5% vs. 29.6%, P < 0.05).

CONCLUSIONS

AECD is a distinct phenotype that should be considered for inclusion as a separate subtype of chronic spontaneous urticaria.