Help for Patients with Respiratory or Skin Reactions to Aspirin

Daily aspirin can reduce the risk of cardiovascular events, but not everyone can safely take it. How do you proceed when a patient who might benefit from aspirin reports being “allergic” to it or has a history of worsening respiratory or cutaneous symptoms with aspirin exposure?

The first step, says David M. Lang, MD, Chair of Cleveland Clinic’s Allergy and Clinical Immunology Department, is evaluating the likelihood and nature of a patient’s aspirin sensitivity.

“Patients with a history of aspirin sensitivity can be categorized into three groups,” Dr. Lang says, “based on whether they have had (1) a respiratory reaction to aspirin, (2) exacerbation of chronic hives or swelling, or (3) a history of hives or rash with aspirin in the absence of a chronic respiratory or cutaneous condition.”

No skin or in vitro test exists to further evaluate a history of aspirin sensitivity. “An adverse skin or respiratory reaction to aspirin is not a true allergy but an exaggerated reaction to aspirin’s blocking of cyclooxygenase,” he explains. Aspirin sensitivity encompasses all of the nonsteroidal anti-inflammatory drugs (NSAIDs). The rate of cross-reaction is 100 percent.

Respiratory reaction to aspirin

For patients with aspirin-exacerbated respiratory disease (AERD), Cleveland Clinic offers an aspirin desensitization procedure. Typical AERD patients are women ages 35 to 60 who develop chronic rhinosinusitis in midlife. Over time, they develop nasal polyps and may require repeated sinus surgeries. Asthma frequently, but not always, becomes the dominant component of the syndrome. An estimated 5 to 10 percent of individuals with bronchial asthma have AERD. These individuals tend to have ongoing symptoms despite high reliance on medications, including steroids.

“The respiratory reaction to aspirin/NSAIDs in a patient with AERD may be serious or even life-threatening,” Dr. Lang says.

Tolerance to aspirin can be induced in patients with AERD by provoking a mild, semicontrolled respiratory reaction and then continuing to administer aspirin until no reaction occurs. Candidates for an aspirin challenge/desensitization procedure must have well-controlled asthma and adequate lung function. After a patient is successfully “desensitized,” daily doses of aspirin are taken to perpetuate the tolerant state. Sensitivity can recur if doses are missed for even a few days.

“Aspirin desensitization commonly provides benefit in AERD’s course, including reduced symptoms, lower medication reliance, improved quality of life, lower rates of healthcare utilization for asthma and reduced need for sinus surgery over time,” Dr. Lang reports.

Aspirin-exacerbated urticaria and angioedema is a worsening of cutaneous symptoms that may occur when affected individuals take aspirin. Because tolerance can’t be accomplished in patients with skin reactions to aspirin, those with chronic urticaria/angioedema don’t qualify for aspirin desensitization.

Cutaneous reaction to aspirin

Dr. Lang advises that patients without AERD or chronic urticaria/angioedema who have had skin reactions when taking aspirin or aspirin-type drugs should take acetaminophen “as an equally efficacious alternative.” If a situation arises for which aspirin is clearly indicated, then a graded-dose oral aspirin challenge may be performed.

“An aspirin challenge is not the same as aspirin desensitization for patients with AERD,” Dr. Lang emphasizes. When a patient is referred for an aspirin challenge, he compiles a careful history to judge the likelihood that an aspirin-type drug caused the previous reaction.

Because an aspirin challenge can provoke a serious reaction for some individuals, he assesses potential benefits and harm for each patient. For example, he describes a patient, age 80, with coronary artery disease who was a candidate for stent placement and aspirin therapy. Catheterization showed no left main or proximal left anterior descending occlusion.

“Fifty years ago she experienced postpartum hives an hour after taking two aspirin tablets. In my judgment, her risk of serious reaction to a graded-dose aspirin challenge was exceeded by the risk of withholding aspirin,” he explains.

Over a half-day, he gave her 20 mg, then 40 mg, then a full baby aspirin, and she experienced no reaction.

“This doesn’t imply that she can take full-dose aspirin safely, but we showed she could tolerate 81 mg without elevated risk for adverse reaction,” he says. Had she reacted to any dose, the challenge would have been stopped and the referring physician informed she could not safely take aspirin-type drugs.