Two-step test de-labels pregnant women with reported NSAID allergy
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LOUISVILLE, Ky. — Physicians who treat pregnant patients should refer those with NSAID allergy labels for possible de-labeling, according to a presentation at the American College of Allergy, Asthma & Immunology Annual Scientific Meeting.
“Two-step NSAID challenges can be safely completed in an outpatient setting, allowing for the use of the desired NSAID in over 85% of challenges performed for patients in a general population,” Lily Li, MD, allergist and immunologist at Mass General Brigham, said during the presentation.
Low doses of aspirin after 12 weeks of gestation can be used to prevent preeclampsia in women at high risk for the disease, Li said, but up to 2.5% of women of childbearing age report allergy to NSAIDs, contraindicating their use.
“Pregnancy has historically been considered a contraindication for allergy drug testing, which can result in limited and suboptimal management options of complete drug avoidance or empiric drug desensitization,” Li said.
Also, Li said, previous literature has not reported on drug allergy testing for NSAIDs during pregnancy.
Four pregnant women with a history of NSAID hypersensitivity who needed aspirin to prevent preeclampsia were referred to the researchers’ outpatient allergy clinic for evaluation between March 2021 and July 2022.
The patients were aged 33, 34, 35 and 40 years. Three had a history of a single previous reaction to aspirin — including one 25 years prior, one 30 years prior and one less than 1 year prior — and the fourth had a history of 10 previous reactions to ibuprofen, the most recent 25 years prior. Reactions included flushing, delayed facial or lip angioedema, rash and throat swelling.
“No patient had a history of chronic spontaneous urticaria or aspirin-exacerbated respiratory disease,” Li said.
The researchers discussed the risks and benefits of drug challenges, desensitization and medication avoidance with the patients, who all chose to begin the two-step oral graded drug challenge during their second trimester.
The first step involved a dose followed by a 60-minute observation and then a second dose with a 120-minute observation. Doses varied by patient, ranging from 20 mg to 325 mg for aspirin and 60 mg to 600 mg for ibuprofen. The drug challenge was conducted at 14, 15, 22 or 23 weeks of gestation, depending on the patient.
“All NSAID challenges were negative with no subjective symptoms or objective signs of an immediate or delayed reaction, and all four patients were cleared for aspirin use in pregnancy,” Li said.
Also, none of the patients had reported any recurrent reactions due to NSAIDs as of the completion of the study.
“We propose that NSAID allergy evaluation with drug challenge is feasible and can be considered in collaboration with obstetricians for appropriate low-risk pregnant candidates to help optimize the use of aspirin and other NSAIDs during pregnancy and in the postpartum period,” Li said.
However, Li cautioned, further studies are necessary to better characterize the risk factors for NSAID hypersensitivity and to ensure the safety of allergy testing during pregnancy.