Yonsei Med J.  2020 Jan;61(1):4-14. 10.3349/ymj.2020.61.1.4.

Update on the Management of Nonsteroidal Anti-Inflammatory Drug Hypersensitivity

• Yeung WY
• Park HS

• KMID: 2466330
• DOI: http://doi.org/10.3349/ymj.2020.61.1.4

Abstract

The clinical phenotypes of nonsteroidal anti-inflammatory drug (NSAID) hypersensitivity are heterogeneous with various presentations including time of symptom onset, organ involvements, and underlying pathophysiology. Having a correct diagnosis can be challenging. Understanding their respective mechanisms as well as developing a comprehensive classification and diagnostic algorithm are pivotal for appropriate management strategy. Treatment modalities are based on the subtypes and severity of hypersensitivity reactions. Insights into the phenotypes and endotypes of hypersensitivity reactions enable personalized management in patients with suboptimal control of disease. This review updated the recent evidence of pathophysiology, classification, diagnostic algorithm, and management of NSAID hypersensitivity reactions.

Keyword

NSAID; asthma; hypersensitivity; urticaria; angioedema; rhinitis

MeSH Terms

Angioedema
Asthma
Classification
Diagnosis
Drug Hypersensitivity*
Humans
Hypersensitivity
Phenotype
Rhinitis
Urticaria

Figure

• 

  Fig. 1 Classification of NSAID hypersensitivity reactions. NSAID, nonsteroidal anti-inflammatory drug; COX, cyclooxygenase; NERD, NSAID-exacerbated respiratory disease; NECD, NSAID-exacerbated cutaneous disease; NIUA, NSAID-induced urticaria/angioedema; SNIUAA, single NSAID-induced urticaria, angioedema or anaphylaxis; NIDHR, NSAID-induced delayed hypersensitivity reactions.

• 

  Fig. 2 Diagnostic algorithm of suspected NSAID hypersensitivity. NSAID, nonsteroidal anti-inflammatory drug; NERD, NSAID-exacerbated respiratory disease; NECD, NSAID-exacerbated cutaneous disease; NIUA, NSAID-induced urticaria/angioedema; SNIUAA, single NSAID-induced urticaria, angioedema or anaphylaxis; NIDHR, NSAID-induced delayed hypersensitivity reactions; SPT, skin prick test; IDT, intradermal skin test; OPT, oral provocation test; PT, provocation test; CU, chronic urticaria; PFT, pulmonary function test; CRS, chronic rhinosinusitis; UAS, Urticaria Assessment Score; AAS, Angioedema Assessment Score; M-test, airway hyper-responsiveness to methacholine.

• 

  Fig. 3 Summary of mechanisms, investigation and management of NSAID hypersensitivity reactions. NSAID, nonsteroidal anti-inflammatory drug; NERD, NSAID-exacerbated respiratory disease; NECD, NSAID-exacerbated cutaneous disease; NIUA, NSAID-induced urticaria/angioedema; SNIUAA, single NSAID-induced urticaria, angioedema or anaphylaxis; NIDHR, NSAID-induced delayed hypersensitivity reactions; SPT, skin prick test; IDT, intradermal skin test; SCAR, severe cutaneous adverse reaction; PFT, pulmonary function test; CRS, chronic rhinosinusitis; UAS, Urticaria Assessment Score; AAS, Angioedema Assessment Score; M-test, airway hyper-responsiveness to methacholine; ICS, inhaled corticosteroids; LABA, long-acting beta-agonists; LTRA, leukotriene receptor antagonists; INS, intranasal corticosteroids; AH, antihistamines; TSLP, thymic stromal lymphopoietin.

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