Page 98 - Škrgat, Sabina, ed. 2022. Severe Asthma - Basic and Clinical Views. Koper: University of Primorska Press. Severe Asthma Forum, 1
P. 98
sensitivity of the provocation test is only 90%. other equivalent alternatives. It can be used
In these patients, it is reasonable to repeat test- for IgE-induced hypersensitivity (eg anaphy-
severe asthma forum 1: severe asthma - basic and clinical views ing with a higher cumulative dose of aspirin at laxis after antibiotics, monoclonal antibodies,
the time of discontinuation of antileukotriene or chemotherapeutics), for non-immune-me-
therapy and systemic steroids. diated hypersensitivity (eg aspirin angioede-
ma), or infusion reactions (eg chemotherapy
Management of AERD or monoclonal antibodies). Desensitization
is also possible for mild delayed reactions (eg
Cross reactivity between NSAIDs in AERD maculopapular rash after antibiotics)43,44.
is not associated with similarity of chemical
structure, as it is in IgE mediated hypersensi- The exact mechanism of action of de-
tivity, but it is associated with the strength of sensitization is not yet fully understood. In
COX-1 inhibitions. A patient must avoid all vitro studies have shown that during desen-
the other drugs which are strong COX-1 in- sitization both basophils and mast cells are
hibitors: acetylsalicylic acid, piroxicam, sulin- temporarily unresponsive to desensitized an-
dac, fenoprofen, oxazopirin, mefenamic acid tigen, while these cells may still respond to an-
indomethacin, ibuprofen, naproxen, ketopro- other antigen.
fen, diclofenac, ketorolac, etodolac, nabu-
metone. Metamizole (dipyrone) is considered It has been suggested that aspirin
as week COX-1 inhibitor8. But majority of pa- desesnitization followed by maintenance of a
tients with AERD develop respiratory exac- daily dose of aspirin improves deregulation of
erbation with metamizole38. Patients should arachidonic acid metabolism which leads to
carry with them information about their drug decreased airway inflammation and to clini-
hypersensitivity. cal improvement45. The state of anergy to an
antigen is temporary, the cells are responding
Weak COX-1 inhibitors such as par- after about two half-lives of the allergen. De-
acetamol, meloxicam, and selective COX- sensitization can be performed in all patients
2 inhibitors (celecoxib, etoricoxib, parecox- with immediate hypersensitivity to the drug
ib) are well tolerated by most AERD patients. that have no alternative choice. It can theoret-
Central analgetics such as tramadol and opi- ically be administered for any drug. The rela-
ates are also safe alternative12,39. Some patients tive contraindications for desensitization are:
also have respiratory symptoms after alco- unstable patient, uncontrolled asthma, severe
hol ingestion so alcohol avoidance should be heart failure, pregnancy. In these cases, it is
advised to AERD patients40. Some patients necessary to evaluate risks and benefits. De-
even report respiratory symptoms after us- sensitization is also not recommended when
ing spearmint flavored food like chewing gum proper patient supervision and safety cannot
or toothpaste, cows milk, and salicylate rich be ensured43,44.
diet41. Patients with AERD do benefit with
additional antileukotriens for asthma symp- Different protocols exist for performing
toms42. desensitization, but all include the adminis-
tration of ascending doses of aspirin at inter-
Aspirin Desensitization in AERD vals of 90-120 minutes until a reaction or the
target dose is reached within 1-3 days46. An
Drug desensitization is a method of induc- example of desensitization protocol used in
ing a temporary tolerance and safely admin- University Clinic Golnik is presented in Ta-
istering the drug to a patient who is allergic ble 2. Aspirin desensitization in AERD could
to it. The procedure is potentially danger- be performed for two purposes: aspirin toler-
ous and time-consuming and it is suitable ance in cardiovascular indication or symp-
for the selected patient in which there are no toms improvement in severe cases of chronic
In these patients, it is reasonable to repeat test- for IgE-induced hypersensitivity (eg anaphy-
severe asthma forum 1: severe asthma - basic and clinical views ing with a higher cumulative dose of aspirin at laxis after antibiotics, monoclonal antibodies,
the time of discontinuation of antileukotriene or chemotherapeutics), for non-immune-me-
therapy and systemic steroids. diated hypersensitivity (eg aspirin angioede-
ma), or infusion reactions (eg chemotherapy
Management of AERD or monoclonal antibodies). Desensitization
is also possible for mild delayed reactions (eg
Cross reactivity between NSAIDs in AERD maculopapular rash after antibiotics)43,44.
is not associated with similarity of chemical
structure, as it is in IgE mediated hypersensi- The exact mechanism of action of de-
tivity, but it is associated with the strength of sensitization is not yet fully understood. In
COX-1 inhibitions. A patient must avoid all vitro studies have shown that during desen-
the other drugs which are strong COX-1 in- sitization both basophils and mast cells are
hibitors: acetylsalicylic acid, piroxicam, sulin- temporarily unresponsive to desensitized an-
dac, fenoprofen, oxazopirin, mefenamic acid tigen, while these cells may still respond to an-
indomethacin, ibuprofen, naproxen, ketopro- other antigen.
fen, diclofenac, ketorolac, etodolac, nabu-
metone. Metamizole (dipyrone) is considered It has been suggested that aspirin
as week COX-1 inhibitor8. But majority of pa- desesnitization followed by maintenance of a
tients with AERD develop respiratory exac- daily dose of aspirin improves deregulation of
erbation with metamizole38. Patients should arachidonic acid metabolism which leads to
carry with them information about their drug decreased airway inflammation and to clini-
hypersensitivity. cal improvement45. The state of anergy to an
antigen is temporary, the cells are responding
Weak COX-1 inhibitors such as par- after about two half-lives of the allergen. De-
acetamol, meloxicam, and selective COX- sensitization can be performed in all patients
2 inhibitors (celecoxib, etoricoxib, parecox- with immediate hypersensitivity to the drug
ib) are well tolerated by most AERD patients. that have no alternative choice. It can theoret-
Central analgetics such as tramadol and opi- ically be administered for any drug. The rela-
ates are also safe alternative12,39. Some patients tive contraindications for desensitization are:
also have respiratory symptoms after alco- unstable patient, uncontrolled asthma, severe
hol ingestion so alcohol avoidance should be heart failure, pregnancy. In these cases, it is
advised to AERD patients40. Some patients necessary to evaluate risks and benefits. De-
even report respiratory symptoms after us- sensitization is also not recommended when
ing spearmint flavored food like chewing gum proper patient supervision and safety cannot
or toothpaste, cows milk, and salicylate rich be ensured43,44.
diet41. Patients with AERD do benefit with
additional antileukotriens for asthma symp- Different protocols exist for performing
toms42. desensitization, but all include the adminis-
tration of ascending doses of aspirin at inter-
Aspirin Desensitization in AERD vals of 90-120 minutes until a reaction or the
target dose is reached within 1-3 days46. An
Drug desensitization is a method of induc- example of desensitization protocol used in
ing a temporary tolerance and safely admin- University Clinic Golnik is presented in Ta-
istering the drug to a patient who is allergic ble 2. Aspirin desensitization in AERD could
to it. The procedure is potentially danger- be performed for two purposes: aspirin toler-
ous and time-consuming and it is suitable ance in cardiovascular indication or symp-
for the selected patient in which there are no toms improvement in severe cases of chronic
