Page 52 - RPIA_26-3

Inês Mota, Ângela Gaspar, Mário Morais-Almeida

CLASSIFICATION by aspirin or other NSAIDs (urticaria and/or angioedema)
occurring in patients with underlying chronic spontaneous
Hypersensitivity reactions to NSAIDs can be classified urticaria. Symptoms usually appear from 0.5 to 6 hours
in different clinical phenotypes, according to clinical mani- after NSAID intake, although both immediate (within 15
festations, the presence of an underlying allergic disease, minutes) and late (within several hours) reactions can oc-
cross -reactivity pattern with other COX -1 inhibitors and cur. Skin lesions may last from few hours to several days.
distinct immunological or pharmacological mechanisms. The severity of symptoms is dose -dependent and greater
According to the last proposed classification , there when chronic urticaria is active; being less frequent and
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are three types of nonimmunological reactions (NSAIDs- less intense when chronic urticaria is in remission or un-
-exacerbated respiratory disease; NSAIDs -exacerbated der control. Chronic spontaneous urticaria in patients
cutaneous disease; NSAIDs -induced urticaria/angioede- with NECD can also be exacerbated by other triggers
ma) and two types of immunological mediated reactions (infections, antibiotics, physical factors, and stress), fur-
4
(Single -NSAID -induced urticaria/angioedema or anaphy- ther complicating the clinical picture and diagnosis .
laxis; Single -NSAID -induced delayed reactions).
NSAIDs -induced urticaria/angioedema (NIUA):
NSAIDs -exacerbated respiratory disease (NERD): Hypersensitivity reactions induced by aspirin or other
Hypersensitivity reactions induced by aspirin or other NSAIDs NSAIDs with cutaneous manifestations as urticaria and/
with predominant respiratory manifestations (bronchial ob- or angioedema, occurring in otherwise healthy subjects
struction, dyspnea, and nasal congestion/rhinorrhea), occur- (symptoms induced by at least two NSAIDs belonging to
ring in patients with an underlying chronic airway respiratory different chemical groups).
disease (asthma/ rhinosinusitis/ nasal polyps). This clinical as- Regarding immunological mediated reactions, they
sociation was previously known as the aspirin triad or Widal can assume two different clinical patterns:
syndrome. It is more prevalent in female gender (more than
2 to 1) and at least one third of patients are atopic. Typically, 1. Single -NSAID -induced urticaria/angioedema
these patients develop chronic rhinitis during the third or or anaphylaxis (SNIUAA) consists of an immediate
fourth decade of life, refractory to medical management. The hypersensitivity reaction (usually IgE -mediated) to a
chronic rhinitis evolves into chronic eosinophilic rhinosinusitis single NSAID (or to a similar one belonging to the
with nasal polyposis. Multiple sinus surgeries result in only same chemical group), with tolerance to other
limited temporary benefit. During the evolution of the sinus chemically nonrelated NSAIDs. It occurs in subjects
disease, asthma appears and persists. Lastly, NSAID -induced without history of asthma or chronic urticaria.
respiratory reactions appear, after exposure to these med- 2. Single -NSAID -induced delayed reactions
ications. Despite subsequent avoidance of NSAIDs, the (SNIDR) consists of hypersensitivity reactions
disease persists, and often requires therapy with systemic (usually T -cell mediated) to a single NSAID (or to
corticosteroids. Adequate asthma control can only be ac- a similar belonging to the same chemical group)
complished with the simultaneous control of the associated that appear usually within 24 to 48 hours after drug
rhinosinusitis. With few exceptions, there is a progressive administration. They can assume cutaneous mani-
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worsening of the clinical manifestations over time . festations (maculopapular exanthema, fixed drug
eruption), organ -specific symptoms (as renal and
NSAIDs -exacerbated cutaneous disease pulmonary involvement) or severe cutaneous ad-
(NECD): Cutaneous hypersensitivity reactions induced verse reaction (SCAR).

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