Rapid Desensitization Protocols for Patients with Cardiovascular Disease and Aspirin Hypersensitivity in an Era of Dual Antiplatelet Therapy

Abstract

To review the available protocols for rapid desensitization of patients with aspirin hypersensitivity and apply the data for use in patients with cardiovascular disease who would benefit from the dual antiplatelet therapy. A literature search was conducted via MEDLINE from 1966 to December 2006. Main search terms included: aspirin sensitivity, aspirin allergy, aspirin desensitization, aspirin-induced asthma, aspirin therapy, and aspirin intolerance syndrome. Articles describing rapid aspirin desensitization protocols were selected for review. Literature pertaining to aspirin hypersensitivity, drug desensitization, and the use of aspirin and dual antiplatelet therapy was also examined. Three rapid desensitization protocols were identified and evaluated. While landmark studies demonstrated that dual antiplatelet therapy with aspirin and clopidogrel significantly reduces mortality and morbidity in acute coronary syndromes and coronary stenting, patients with aspirin hypersensitivity are frequently managed with clopidogrel alone with no supporting data. Approximately 10% of the population experiences hypersensitivity to aspirin, which can manifest as asthma exacerbations, rhinorrhea, angioedema, urticaria, and anaphylaxis. The hypersensitivity reaction is mediated through aspirin-directed antibodies or by excessive leukotriene production. The desensitization process involved depletion of these mediators, as well as down-regulation of leukotriene receptors. Two groups of investigators developed rapid protocols to desensitize patients with aspirin hypersensitivity safely and effectively. The rapid protocol developed by Wong provides benefits over other protocols with its low starting dose and completion in less than 3 hours, low incidence of adverse effects, and high success rate in aspirin desensitization. The Wong protocol is an attractive option for the rapid desensitization of patients requiring dual antiplatelet therapy with aspirin and clopidogrel in the perimyocardial infarction period.