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Acetylsalicylic acid challenge or desensitization in sensitive patients with cardiovascular disease

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Abstract

The use of acetylsalicylic acid (ASA) is problematic in subjects with histories of hypersensitivity reactions (HRs) to it or with cross-reactive types of nonsteroidal anti-inflammatory drug (NSAID) hypersensitivity. We sought to evaluate the efficacy of low-dose ASA challenge (LDAC) and desensitization to allow ASA therapy at an antiplatelet dose in patients with atherosclerotic cardiovascular disease (ASCVD) or multiple related risk factors and histories of HRs to ASA or ≥ 2 chemically unrelated NSAIDs. We studied prospectively all patients with such histories and ≥ 3 risk factors for ASCVD (group I), chronic coronary syndrome (CCS, group II), and acute coronary syndrome (ACS) with indication for ASA desensitization (group III). Patients from groups I and II underwent LDACs (cumulative dose of 110 mg), while those from group III were desensitized (cumulative dose of 100.1 mg). We evaluated 103 patients: 62 from group I, 24 from group II, and 17 from group III. Eighty-two of the 86 patients from the first two groups underwent LDACs and 2 reacted. Subsequently, 22 (27.5%) of the 80 patients with negative LDACs were administered dual antiplatelet therapy with ASA after successful percutaneous coronary interventions, thus sparing desensitizations. The remaining 4 patients with CCS and all 17 patients from group III were successfully desensitized. In this pragmatic study, LDAC proved to be a safe and reliable diagnostic tool for identifying patients with histories of HRs to ASA or ≥ 2 different NSAIDs who can tolerate ASA at antiplatelet doses. Routine LDAC is advisable in all patients at high risk for ASCVD or with CCS who report HRs to ASA or ≥ 2 NSAIDs. ASA desensitization remains a safe and effective option in patients with ACS.

Graphical Abstract

Study flow-chart. ASCVD atherosclerotic cardiovascular disease; CCS chronic coronary syndrome; ACS acute coronary syndrome; ASA acetylsalicylic acid; DAPT dual antiplatelet therapy; PCI percutaneous coronary intervention; NSAIDs nonsteroidal anti-inflammatory drugs; NERD NSAID-exacerbated respiratory disease; NECD NSAID-exacerbated cutaneous disease; NIUAA NSAID-induced urticaria-angioedema or anaphylaxis; SNIUAA single NSAID-induced urticaria-angioedema or anaphylaxis; SNIDHR single NSAID-induced delayed hypersensitivity reaction.

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Data availability

The data that support the findings of this study are available from the leading authors [GC, AR], upon reasonable request to the corresponding author.

Abbreviations

ACS:

Acute coronary syndrome

ASA:

Acetylsalicylic acid

ASCVD:

Atherosclerotic cardiovascular disease

CAD:

Coronary artery disease

CCS:

Chronic coronary syndrome

DAPT:

Dual antiplatelet therapy

HR:

Hypersensitivity reaction

LDAC:

Low-dose ASA challenge

NECD:

NSAID-exacerbated cutaneous disease

NERD:

NSAID-exacerbated respiratory disease

NIUAA:

NSAID-induced urticaria-angioedema or anaphylaxis

NSAID:

Nonsteroidal anti-inflammatory drug

PCI:

Percutaneous coronary intervention

SNIDHR:

Single NSAID-induced delayed hypersensitivity reaction

SNIUAA:

Single NSAID-induced urticaria-angioedema or anaphylaxis

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Acknowledgements

We are grateful to Giancarlo Piovaccari, Federica Baldazzi, Daniele Grosseto (Cardiology Unit of Rimini, Azienda Sanitaria della Romagna) for their collaboration.

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Author notes

  1. Gabriele Cortellini, Alberto Raiteri and Mattia Galli have contributed equally to this work.

Authors and Affiliations

  1. Allergy Unit, Azienda Sanitaria Della Romagna, Rimini, Italy

    Gabriele Cortellini

  2. Division of Internal Medicine, Hepatobiliary and Immunoallergic Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy

    Alberto Raiteri & Fabio Piscaglia

  3. Catholic University of the Sacred Heart, Largo Francesco Vito, 1, 00168, Rome, Italy

    Mattia Galli

  4. Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy

    Mattia Galli

  5. Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy

    Marzia Lotrionte

  6. Oasi Research Institute-IRCCS, Troina, Italy

    Antonino Romano

Authors
  1. Gabriele Cortellini
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  2. Alberto Raiteri
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Correspondence to Mattia Galli or Marzia Lotrionte.

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Cortellini, G., Raiteri, A., Galli, M. et al. Acetylsalicylic acid challenge or desensitization in sensitive patients with cardiovascular disease. J Thromb Thrombolysis 55, 762–769 (2023). https://doi.org/10.1007/s11239-023-02782-1

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