D2.393 - Aspirin hypersensitivity and desensitization-Sense and sensibility

Background: Aspirin (ASA) is essential in the acute treatment and secondary prevention of cardiovascular and cerebrovascular diseases. Expansion in the indication field led to a rise in both hypersensitivity reactions and ASA intolerance. Despite the development of numerous other antithrombotic drugs, the use of ASA remains irreplicable and inevitable in the management of coronary artery disease (CAD) for many patients.

Case report: A 73-year-old female patient was referred to the Clinic of Allergology and Immunology at the University Clinical Centre of Serbia due to suspected ASA hypersensitivity. Ten years ago, the patient had increased nasal discharge, tearing, and difficulty breathing upon taking an Aspirin. Due to the later development of the myocardial infarction with ST elevation (STEMI) of the antero-septal localization, a stent was implanted in the left anterior descending artery (LAD), and the alternative antithrombotic therapy was introduced (initially ticagrelor and later prasugrel). Coronarography revealed a triple-vessel CAD. Therefore, the patient was referred to an allergologist for the ASA drug provocation test in vivo, which was positive. A few hours after the test with 75mg ASA was completed, the patient developed bronchial obstruction with nasal and sinus discharge. Following the administration of the corticosteroids and antihistamines, the symptoms quickly resolved. The spirometry confirmed the aspirin-exacerbated respiratory disease (AERD), which was treated with inhalation therapy. Despite the chronic sinusitis without nasal polyposis, she well-tolerated other non-steroidal anti-inflammatory drugs (NSAIDs). Given the patient ́s history and need for dual antithrombotic treatment, the rapid desensitization protocol, recommended by Silberman for the dose of 75mg of ASA, was successfully performed (image 1). Since then, she continued an uneventful use of 75mg of ASA and received two more drug-eluting stents in the right coronary artery.

Conclusion: Aspirin desensitization is a life-saving procedure that enables a successful and less invasive coronary intervention than the alternative surgical approach, even with patients with AERD. It also provides optimal anti-aggregation following the procedure. Compliance and understanding that the established tolerance could be broken upon treatment discontinuation is of utmost importance; careful patient selection may determine the outcome.