Page 58 - RPIA_26-3

Inês Mota, Ângela Gaspar, Mário Morais-Almeida

Given the relatively increasing rate of positive chal- days) until the cumulative therapeutic dose is achieved
lenges with COX -2 inhibitors and multiple drug intoler- with tolerance and followed by daily intake. Desensitiza-
ance, it is necessary to perform an oral challenge under tion is a suitable option only in patients in whom alterna-
medical surveillance prior to a prescription of an alterna- tive drugs are less effective or unavailable. Hypersensitiv-
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tive drug . ity to involved drug must be clearly confirmed, as well as
Based on 13 studies (n=749) which addressed celecoxib the absence of an alternative drug.
tolerability, a 4% rate of positive reactions has been docu- Desensitization is not recommended in case of sys-
mented, being the majority urticaria and angioedema . temic vasculitis and severe cutaneous reactions.
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Regarding etoricoxib, tolerability was similar. Ten The main indications for aspirin desensitization are
studies (n=823) showed the same rate (4%) of positive anti -aggregative therapy with AAS in coronary disease
reactions, mainly described as non -severe, but there were with indication for chronic dual antiplatelet therapy, an-
4 subjects who had moderate to severe reactions . In a tiphospholipid syndrome, aspirin hypersensitivity associ-
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study performed in 104 aspirin -sensitive patients, 3 pa- ated to upper and/or lower airway disease despite mul-
tients (2.9%) developed a positive asthmatic reaction with tiple nasal/sinus surgical procedures and aggressive
etoricoxib (cumulative dose from 45 to 105mg) . In 118 anti -inflammatory treatment (inhaled and/or systemic
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patients with history of urticaria or angioedema triggered corticosteroids) 51, 52 . Moreover, for those needing chron-
by one or more NSAIDs, only 2 had positive challenges ic NSAIDs treatment due to osteoarticular diseases with-
with etoricoxib 60mg . out satisfactory alternative drug.
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Patients with hypersensitivity to non -selective Several desensitization protocols were proposed ac-
NSAIDs should be advised to avoid dosage higher than cording to different cumulative doses of aspirin to achieve
60mg daily of etoricoxib. control of the above -mentioned diseases.
The safety and efficacy of selective COX -2 inhibitors In patients with aspirin/NSAIDs hypersensitivity and
under 18 years have not been established. A recent coronary disease, the aspirin maintenance dose com-
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study performed in 41 children aged 9 -14 years with monly proposed is from 100 to 150mg.
hypersensitivity to NSAIDs confirmed by oral challenge Aspirin desensitization may be a safe alternative in
with the culprit drug and ASA, found that 100% toler- women with antiphospholipid syndrome who require
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ated acetaminophen and etoricoxib and only 2 (5%) re- treatment with ASA during pregnancy . Also, women
acted with meloxicam. According to these data, both with inherited thrombophilia and recurrent miscarriage
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etoricoxib and meloxicam seem to be suitable alterna- have been successfully desensitized before pregnancy .
tives in children over 8 years, even though these drugs The desensitization process can be done safely at the
are not recommended in this age group, which means an outpatient setting in less than 2 days in for the majority
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off -label use. of patients .
Regarding NERD, the maintenance dose ranges from
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325mg to 1300mg daily, depending on the protocol . The
DESENSITIZATION optimal dosage is still not clear, and the literature has
shown a similar benefit with different regimens, but some
The desensitization is reserved to exceptional situa- patients will need to adjust the dosage. Some authors rec-
tions. It is a high -risk procedure that should always be ommend to begin with higher dose (650 mg twice daily)
performed in hospital setting. Increasing doses are given and subsequently decrease to the lowest effective dos-
within a short period of time (from several hours to few age . Older studies preconized a dose of at least 650mg
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