Intermittent NSAID intolerance with underlying chronic urticaria
Question:
3/4/2021
I have 62 year-old female with history of allergic rhinitis (on SCIT) and chronic idiopathic urticaria (last urticaria over a year ago, currently not on any medicines) interested in evaluation of lip angioedema and throat irritation about two hours after taking ibuprofen and naproxen. Her reactions to NSAIDs occurred around the same time as CIU flare but does not recall if she was having urticaria on the day she took NSAID. She was tolerating NSAIDs before CIU onset but has been avoiding them since her reactions.
I have discussed with her Summary Statement 157 from AAAAI practice parameters which says: A second reaction type to aspirin and NSAIDs is exacerbation of urticaria and angioedema in approximately 20% to 40% of patients with underlying chronic idiopathic urticaria. (C) Drugs that inhibit COX-1cross-react to cause this reaction, whereas selective COX-2inhibitors typically are better tolerated by these patients. (C).
However, she is inquiring about a possible drug challenge since urticaria has not been a problem for over a year now. Is there any evidence of drug challenge in such patients? Is she always considered high risk for NSAIDs related exacerbation of urticaria and angioedema given the history of CIU? Is it wise to do such a challenge or recommend continued COX-1 inhibitors and use acetaminophen or COX-2 inhibitors for her general aches and pains?
Answer:
Intermittent NSAID intolerance is not uncommon in the setting of chronic urticaria as noted above. The intolerance is often only noted when the underlying urticaria is active. Other co-factors that can make angioedema worse in this setting are exposure to heat and ingestion of alcohol, which both can worsen blood vessel dilation.
Cox-2 inhibitors are generally well tolerated, even if the chronic urticaria is active or recently active.
COX-1 inhibitors are generally well tolerated in these patients if there has been no active itching, swelling or hives in the preceding 6 weeks, off all therapy from chronic urticaria.
This patient could be safely challenged with ibuprofen 200 mg and observed in the office for three hours to confirm current tolerance.
I hope this information is helpful for you and your patient.
Eric Macy MD MS FAAAAI