Hypersensitivities to non-steroidal anti-inflammatory drugs

Abstract

NSAIDs are the most commonly used medications worldwide and are responsible for almost 25% of adverse drug reactions. Such reactions can have different manifestations and can be immunologic or non-immunologic. The diagnosis is primarily based on the medical history, which can be difficult in patients receiving multiple medications. Because skin testing and blood tests are not valid for NSAIDs reactions, confirmation requires an appropriately-designed challenge. The latter could be avoided when the history is obvious and the reaction is life-threatening. The challenge route can be oral, nasal, or bronchial. Avoidance of the causative NSAID, often associated with the avoidance of the cross-reacting preparations, is the cornerstone of management. In most cases, a safe substitute can be used. When treatment with the causative NSAID is necessary, titrated desensitization can be performed. This review discusses the classes of NSAIDs, mechanisms of their adverse reactions, manifestations, diagnosis, and management.

Keywords::

• aspirin challenge
• aspirin desensitization
• aspirin exacerbated respiratory disease
• cyclooxygenase
• drug adverse reaction
• drug hypersensitivity
• NSAIDs

Acknowledgements

The authors thank Caleb Sheaffer for assisting in grammatical review of this manuscript.

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• There is an increase of adverse reactions to NSAIDs.

• NSAID adverse reactions are mediated by immunological (allergic) or non-immunological (non-allergic) mechanisms.

• AERD is the triad of asthma, chronic rhinosinusitis with nasal polyposis and NSAID sensitivity.

• The pathogenesis of AERD is based on the imbalance between PG and LT pathways toward increased LTs.

• NSAIDs can induce or exacerbate urticaria by a mechanism similar to AERD.

• The diagnosis is suspected by the medical history and may be confirmed by challenge testing.

• The immunologic hypersensitivity reactions to NSAIDs are mediated by any of the Gell and Coombs hypersensitivity mechanisms.

• Avoidance is the cornerstone of management; however, desensitization is indicated in some situations.