NSAID allergy
Question:
8/30/2018
I have a 30 year-old female who has had 3 episodes of left eye swelling in the past 6 months which she reports are associated with anti-inflammatory drugs. She reports the first two episodes occurred within 30 min of using eye drops in both eyes. She used Fluorometholone with first episode and Loteprednol with second episode. Both of which are corticosteroids. She then took ibuprofen about one month ago and had eye swelling and shortness of breath within 30 minutes. Interestingly, she reports both father and paternal cousin also have eye swelling with ibuprofen and aspirin. She has no other symptoms with her reactions. She denies chronic urticaria symptoms or previous angioedema episodes. She has environmental allergies with past positive testing as well as frequent dry eyes and states she is often prescribed eye drops. Since her reactions occurred to both corticosteroids and NSAID, I am curious what next steps should be undertaken.
Answer:
From the history is seems reasonable to infer that she is having reactions to these medicines. The next steps to take would depend upon the need for the medications. Does the patient have an ongoing need for topical ophthalmic steroids? What is the diagnosis for which she is using these medications? Is this class of medication the only class that can be used? There may be some value in considering skin testing to the topical preparation but as you know there is no standardized ST available for these medicines. So how to proceed will depend upon the patient’s diagnosis and the need to use the medicines.
As for the ibuprofen reaction, again having a reaction within 30 minutes of consuming the medicine seems the appropriate time frame to consider the ibuprofen as the culprit. There is no ST to NSAIDs as you know and whether to proceed with an oral challenge will be a decision that needs to be made locally (is one in a practice location that can have the appropriate resources immediately available if there were a severe reaction). If the patient is using Ibuprofen for occasional HA or similar minor condition then I would recommend lower dose acetaminophen as alternative agent. If there is a more complex medical problem that requires ongoing NSAID use then one may need to consider oral challenges or the use of COX 2 inhibitions if appropriate.
This article was a nice review of NSAID allergy. I would also suggest looking back at past Ask the Expert question on this topic.
I hope this has been helpful
Andrew Murphy, MD, FAAAAI