TWO-STEP NONSTEROIDAL ANTI-INFLAMMATORY DRUG CHALLENGE DURING PREGNANCY: A CASE SERIES

Abstract

<h3>Introduction</h3> Preeclampsia is a multi-system disorder associated with serious maternal and fetal morbidity and mortality, and low-dose aspirin is recommended for prevention in high-risk women. However, up to 2.5% of women of childbearing age report allergy to nonsteroidal anti-inflammatory drugs (NSAIDs), which may preclude aspirin use. We have previously shown that 2-step NSAID challenges can be safely performed in the outpatient setting. <h3>Case Description</h3> Three pregnant women were referred for NSAID allergy evaluation between 2021-2022: a 33-year-old with twin pregnancy and history of skin flushing with aspirin use >30 years prior; a 34-year-old with twin pregnancy and history of delayed facial angioedema and rash after aspirin ingestion within the past year; a 40-year-old with elevated BMI and history of lip angioedema with ibuprofen use >10 years prior. Two patients had well-controlled asthma, and none had history of chronic spontaneous urticaria. After risk-benefit discussion of drug challenge versus desensitization, all three underwent outpatient 2-step oral graded challenge (aspirin, aspirin, and ibuprofen, respectively) in the second trimester. All challenges were negative with no subjective symptoms or objective signs of a reaction elicited. <h3>Discussion</h3> For pregnant women with history of NSAID hypersensitivity and an indication for aspirin use, empiric aspirin desensitization can be performed but is time and resource intensive and requires subsequent daily administration to prevent risk of re-sensitization. For women with history of a prior mild reaction, we propose that a 2-step drug challenge may be considered in select patients after a risk-benefit discussion with the patient and obstetrician.