Hypersensitivity reactions to nonsteroidal anti-inflammatory drugs
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The document investigates hypersensitivity reactions (HSRs) to non-steroidal anti-inflammatory drugs (NSAIDs) in patients, finding that acetylsalicylic acid (ASA) is the most commonly implicated drug. It highlights that nearly half of the patients had HSRs to only one NSAID, with urticaria and angioedema being the predominant symptoms. Additionally, the study suggests a potential lesser role of COX-1 inhibition in those with cutaneous symptoms compared to those with aspirin-exacerbated respiratory disease.
Hypersensitivity reactions to nonsteroidal anti-inflammatory drugs
- 1. Hypersensitivity reactions to Non-Steroidal Anti-Inflammatory Drugs: Single versus multiple reactors Ana Reis Ferreira, Natacha Santos, Carmen Botelho , Eunice Castro, Josefina R. Cernadas Serviço de Imunoalergologia, Hospital de São João, EPE, Porto, Portugal
- 2. Background • Non-‐Steroidal Anti-‐Inflammatory Drugs (NSAIDs) COX-‐2 COX-‐1 Prostaglandins / Thromboxanes NSAIDs Non-‐selective COX inhibitors – Acetylsalicylic acid (ASA) – Diclofenac – Ibuprofen Weak COX-‐1 inhibitor – Paracetamol COX-‐2 preferencial inhibitors – Nimesulide – Meloxicam COX-‐2 selective inhibitors – Coxibes
- 3. Background • NSAID hypersensitivity reactions (HSR) prevalence in the general populaGon – 0.6% to 2.5% • COX-‐1 inhibition responsible for HSR to NSAIDs? Stevenson et al. Ann Allergy Asthma Immunol. 2001 Sep;87(3):177-‐80. Single vs Multiple reactors
- 4. Aim To characterize clinical data of the patients referred to our Drug Allergy Unit for NSAID hypersensitivity reactions: – Demographical data – Type of reaction – Suspected drug(s) • Single versus Multiple reactors • Tolerance to weak COX – 1 inhibitors
- 5. Methods • Clinical data from the records of the patients referred in the last 10 years for NSAID hypersensitivity • Patients grouped according to symptoms: – Cutaneous symptoms (Urticaria and/or angioedema) – Aspirin-‐Exacerbated Respiratory Disease (AERD) – Anaphylaxis • Fisher’s exact test was used to compare frequencies (significance level of 5%).
- 6. Results • 204 patients, 143♀:♂61 • 16-‐81 years-‐old (47.3±13.7) • 36.8% were atopic • 29.4% had a previous medical diagnosis of asthma • Mean age for 1st reaction was 37.4 ± 14.1 years • Symptoms occurred in the 1st hour after exposure in 45.6%
- 7. Results Number of implicated NSAIDs 46,6% 23,5% 19,1% 8,3% 2,5% 1 2 3 4 ≥5
- 8. Results Most implicated drugs: – Acetilsalicilic acid (ASA) – 63.2% of the patients – Ibuprofen – 30.9% of the patients – Paracetamol – 29.9% of the patients
- 9. Results Cutaneous symptoms (urticaria and/or angioedema) • 154 patients (75.5%) • Reaction to 1 NSAID in 42.2% of the patients. • Most implicated drugs: – ASA -‐ 63% – Paracetamol -‐ 35.1% – Ibuprofen -‐ 33.8%
- 10. Results Aspirin-‐Exacerbated Respiratory Disease (AERD) • 18 patients (8.8%) -‐ 4 without previous asthma diagnosis • Reaction to 1 NSAID in 44.4% of the patients. • Most implicated drugs – ASA -‐ 77.8% – Ibuprofen -‐ 38.9% – Diclofenac -‐ 27.8%
- 11. Results Anaphylaxis • 21 patients (10.3%) • All these patients referred HR to only 1 NSAID • 8 to ASA, 6 to diclofenac and the others to different NSAIDs Eleven patients presented different types of reactions to NSAIDs and were not included in the previous groups.
- 12. Results Suspected NSAIDs according to symptoms (single vs multiple) 0% 20% 40% 60% 80% 100% Cutaneous AERD Single Multiple Single Multiple Single Multiple Single Multiple ASA Paracetamol Ibuprofeno Diclofenac
- 13. Results Tolerance to ASA and weak COX-‐1 inhibitors when asked Cutaneous AERD 2% 0% 54% 93% 24% 75% ASA Paracetamol Nimesulide
- 14. Results Cutaneous AERD 52,6% 16,7% p=0.0051 HSR to weak COX-‐1 inhibitors (paracetamol and nimesulide)
- 15. Conclusion • ASA was the most frequently implicated drug. • Almost half the patients reported HR to only one NSAID. • Urticaria and/or angioedema were the most common symptoms, with AERD and anaphylaxis occurring each in approximately 10% of the patients. • HR to weak COX-‐1 inhibitors was more frequent in patients with cutaneous symptoms.
- 16. Comments • This may suggest that COX-‐1 inhibition plays a less important role in patients with cutaneous symptoms than in those with AERD. • Drug challenges with NSAIDs with different COX-‐1 inhibition patterns may provide a more accurate diagnosis of NSAID HRS and confirm this hypotesis.