NERD history, three-step protocol enable aspirin allergy challenges

Key takeaways:

• A history of NERD was the only significant predictor of increased risk for hypersensitivity to aspirin.
• The three-step challenge protocol guides patients through 30 mg, 81 mg and 325 mg doses.

BOSTON — A history of NSAID-exacerbated respiratory disease may indicate increased risks for aspirin hypersensitivity, according to an abstract presented at the American College of Allergy, Asthma & Immunology Annual Scientific Meeting.

A three-step protocol for aspirin challenges also may help physicians safely and efficiently triage patients in outpatient clinic settings, researchers reported in a second abstract presented at the conference.

In the first abstract by Tufts Medical Center internal medicine resident Maria Slater, MD, and colleagues, 41 of 48 patients (85.4%) with a documented NSAID allergy passed an aspirin challenge, defined as tolerating a total dose of 365.5 mg of aspirin 120 minutes after final ingestion, at a large academic allergy center between January 2015 and July 2024.

Physicians recorded a history of NSAID-exacerbated respiratory disease (NERD) among 10 of the 53 patients who initially met the study’s inclusion criteria (18.9%). Three (30%) of the patients with NERD needed empiric aspirin desensitization because of their clinical risk, and three (30%) failed a direct aspirin challenge.

The researchers said that the association between a history of NERD and increased risk for hypersensitivity to aspirin was significant (P = .005). Also, they said, there was a strong trend toward decreased risk for hypersensitivity to aspirin with a history of hives and angioedema.

But in the multivariate analysis, the researchers said the only significant predictor of increased risk for hypersensitivity to aspirin was NERD (OR = 6.5; 95% CI, 1.44-33.4).

Further, the researchers said additional research that prospectively enrolls incoming patients for aspiring drug allergy evaluations will be needed to validate this clinical screening algorithm.

In the second abstract by University of Pennsylvania otorhinolaryngology-head and neck surgery resident Alexandria Irace, MD, MS, and colleagues, researchers administered three-step in-clinic aspirin challenges to 145 patients with chronic rhinosinusitis with nasal polyps and asthma between 2016 and 2023.

Dosages increased from 30 mg to 81 mg to 325 mg, with a 30-minute observation after the 30 mg dose, a 90-minute observation after the 81 mg dose and a 3-hour observation after the 325 mg dose.

Sixty-seven patients (46.2%) had positive reactions, defined as symptom scores that increased by 5 points or more from baseline, FEV₁ scores that decreased by 15% or more, or peak nasal inspiratory flow rate scores that decreased by 20% or more.

Reactions followed the 30 mg dose for 47.8% of patients and the 81 mg dose for 43.3% of patients. Also, symptoms usually presented an hour (n = 26; 38.8%) or 2 hours (n = 18; 26.9%) after the challenge began.

The researchers reported an 8.9% mean decrease in FEV₁ and a 24.5% mean decrease in peak nasal inspiratory flow rate. Also, 51 patients (76.1%) experienced nasal congestion, and 23 patients (34.3%) had rhinorrhea.

Nine patients (13.4%) needed epinephrine, but nobody needed transfer to an ED or hospitalization. Challenges had a mean duration of 4.76 hours.

Based on these findings, the researchers called their three-step protocol efficient and safe for conducting aspiring challenges in outpatient clinic settings.

Reference:

• Irace A, et al. Abstract AA05. Presented at: ACAAI Annual Scientific Meeting; Oct. 24-28, 2024; Boston.