Rapid Desensitization Protocols for Patients with Cardiovascular Disease and Aspirin Hypersensitivity in an Era of Dual Antiplatelet Therapy

Abstract

Spanish

French

Objective:

To review the available protocols for rapid desensitization of patients with aspirin hypersensitivity and apply the data for use in patients with cardiovascular disease who would benefit from the dual antiplatelet therapy.

Data Sources:

A literature search was conducted via MEDLINE from 1966 to December 2006. Main search terms included: aspirin sensitivity, aspirin allergy, aspirin desensitization, aspirin-induced asthma, aspirin therapy, and aspirin intolerance syndrome.

Study Selection And Data Extraction:

Articles describing rapid aspirin desensitization protocols were selected for review. Literature pertaining to aspirin hypersensitivity, drug desensitization, and the use of aspirin and dual antiplatelet therapy was also examined. Three rapid desensitization protocols were identified and evaluated.

Data Synthesis:

While landmark studies demonstrated that dual antiplatelet therapy with aspirin and clopidogrel significantly reduces mortality and morbidity in acute coronary syndromes and coronary stenting, patients with aspirin hypersensitivity are frequently managed with clopidogrel alone with no supporting data. Approximately 10% of the population experiences hypersensitivity to aspirin, which can manifest as asthma exacerbations, rhinorrhea, angioedema, urticaria, and anaphylaxis. The hypersensitivity reaction is mediated through aspirin-directed antibodies or by excessive leukotriene production. The desensitization process involved depletion of these mediators, as well as down-regulation of leukotriene receptors. Two groups of investigators developed rapid protocols to desensitize patients with aspirin hypersensitivity safely and effectively. The rapid protocol developed by Wong provides benefits over other protocols with its low starting dose and completion in less than 3 hours, low incidence of adverse effects, and high success rate in aspirin desensitization.

Conclusions:

The Wong protocol is an attractive option for the rapid desensitization of patients requiring dual antiplatelet therapy with aspirin and clopidogrel in the perimyocardial infarction period.

Keywords

aspirin desensitization myocardial infarction

Get full access to this article

View all access options for this article.

References

Mehta

, Yusuf

, Peters

RJG

. Effects of pretreatment with clopidogrel and aspirin followed by long-term therapy in patients undergoing percutaneous coronary intervention: the PCI-CURE study. Lancet 2001;358:527–33.

Sabatine

, Cannon

, Gibson

. Addition of clopidogrel to aspirin and fibrinolytic therapy for myocardial infarction with ST-segment elevation. N Engl J Med 2005;352:1179–89.

Steinhubl

, Berger

, Mann

. Early and sustained dual oral antiplatelet therapy following percutaneous coronary intervention: a randomized controlled trial. JAMA 2002;288:2411–20.

Yusuf

, Zhao

, Mehta

, Chrolavicius

, Tognoni

, Fox

; Clopidogrel in Unstable Angina to Prevent Recurrent Events Trial Investigators. Effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation. N Engl J Med 2001; 345: 494–502.

Morice

, Serruys

, Sousa

. A randomized comparison of a sirolimus-eluting stent with a standard stent for coronary revascularization. N Engl J Med 2002;346:1773–80.

Moses

, Leon

, Popma

. Sirolimus-eluting stents versus standard stents in patients with stenosis in a native coronary artery. N Engl J Med 2003;349:1315–23.

Stone

, Ellis

, Cox

. A polymer-based, paclitaxel-eluting stent in patients with coronary artery disease. N Engl J Med 2004;350:221–31.

Smith

, Feldman

, Hirshfeld

. ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. American College of Cardiology. www.acc.org/clinical/guidelines/percutaneous/update/index.pdf (accessed 2006 Jul 11).

Jenkins

, Costello

, Hodge

Systematic review of prevalence of aspirin induced asthma and its implications for clinical practice. BMJ 2004;328:434–40.

10.

Gollapudi

, Teirstein

, Stevenson

, Simon

. Aspirin sensitivity: implications for patients with coronary artery disease. JAMA 2004;292:3017–23.

11.

Berges-Gimeno

, Stevenson

. Nonsteroidal anti-inflammatory drug–induced reactions and desensitization. J Asthma 2004;41:375–84.

12.

Ramanuja

, Breall

, Kalaria

. Approach to “aspirin allergy” in cardiovascular patients. Circulation 2004;110:e1–4.

13.

Kowalski

, Grzelewska-Rzymowksa

, Rozniecki

, Szmidt

Aspirin tolerance induced in aspirin-sensitive asthmatics. Allergy 1984;39:171–8.

14.

Cormican

, Farooque

, Altmann

, Lee

. Improvements in an oral aspirin challenge protocol for the diagnosis of aspirin hypersensitivity. Clin Exp Allergy 2005;35:717–22.

15.

Dahlen

, Szczeklik

, Murray

. Celecoxib in patients with asthma and aspirin intolerance (letter). N Engl J Med 2001;344:142.

16.

Schellenberg

, Isserow

. Anaphylactoid reaction to a cyclooxygenase-2 inhibitor in a patient who had a reaction to a cyclooxygenase-1 inhibitor (letter). N Engl J Med 2001;345:1856.

17.

Brophy

, Levesques

, Zhang

The coronary risk of cyclooxygenase-2 (COX-2) inhibitors in subjects with a previous myocardial infarction. Heart 2006 (in press).

18.

Gislason

, Jacobsen

, Rasmussen

. Risk of death or reinfarction associated with the use of selective cyclooxygenase-2 inhibitors and nonselective nonsteroidal antiinflammatory drugs after acute myocardial infarction. Circulation 2006;113:2906–13.

19.

Solomon

, Avorn

, Stürmer

Cardiovascular outcomes in new users of coxibs and nonsteroidal antiinflammatory drugs: high-risk subgroups and time course of risk. Arthritis Rheum 2006;54:1378–89.

20.

Szczeklik

, Stevenson

. Aspirin-induced asthma: advances in pathogenesis, diagnosis, and management. J Allergy Clin Immunol 2003;111:913–21.

21.

Stevenson

. Desensitization of aspirin-sensitive asthmatics: a therapeutic alternative? J Asthma 1983;20:31–8.

22.

Wong

, Nagy

, Krinzman

. Rapid oral challenge-desensitization for patients with aspirin-related urticaria-angioedema. J Allergy Clin Immunol 2000;105:997–1001.

23.

Manning

, Stevenson

. Aspirin sensitivity: a distressing reaction that is now often treatable. Postgrad Med 1991;90:227–33.

24.

Alijotas-Reig

, Miguel-Moncin

, Cistero-Bahima

Aspirin desensitization in the treatment of antiphospholipid syndrome during pregnancy in ASA-sensitive patients. Am J Reprod Immunol 2006;55:45–50.

25.

Schaefer

, Gore

. Aspirin sensitivity: the role for aspirin challenge and desensitization in postmyocardial infarction patients. Cardiology 1999;91:8–13.

26.

Steg

, Neukirch-Stoop

Reply to response to “Rapid desensitization for patients with aspirin sensitivity” (letter). Am J Cardiol 2006;97:294.

27.

Silberman

, Neukirch-Stoop

, Steg

. Rapid desensitization procedure for patients with aspirin hypersensitivity undergoing coronary stenting. Am J Cardiol 2005;95:509–10.

28.

Honsinger

. Response to “Rapid desensitization for patients with aspirin sensitivity” (letter). Am J Cardiol 2006;97:294.