Correspondence
Anaphylactoid Reaction to a Cyclooxygenase-2 Inhibitor in a Patient Who Had a Reaction to a Cyclooxygenase-1 Inhibitor
N Engl J Med 2001; 345:1856December 20, 2001
- Article
To the Editor:
Recent studies1-3 have suggested that cyclooxygenase-2 (COX-2) inhibitors can be safely used in patients with asthma who have documented intolerance to COX-1 inhibitors such as aspirin and nonsteroidal antiinflammatory drugs. On the basis of these observations, we chose to treat a subject who had had an adverse reaction to a nonsteroidal antiinflammatory drug with the COX-2 inhibitor rofecoxib (Vioxx) in a supervised hospital setting.
A 63-year-old man with no history of asthma or allergic disease began treatment with diclofenac–misoprostol (Arthotec) in June 2001 for osteoarthritis. After one week of use, facial flushing and itching of the hands and feet developed within two hours of ingestion of the drug. These symptoms resolved with the oral administration of 25 mg of diphenhydramine. That evening, approximately 90 minutes after ingestion of another dose of diclofenac–misoprostol, these symptoms as well as dyspnea, lightheadedness, and profound shaking developed. Blood pressure was 60/40 mm Hg when evaluated by the paramedics, who administered 0.3 ml of subcutaneous epinephrine in a 1:1000 dilution, 50 mg of intravenous diphenhydramine, and a 250-ml bolus of saline on transfer to the emergency department. His condition stabilized rapidly. Since his reaction was attributed to seafood, he took diclofenac–misoprostol again two days later. One to two hours thereafter, while in his cardiologist's waiting room (for routine follow-up of an asymptomatic bicuspid aortic valve and right bundle-branch block), he became flushed and dyspneic and lost consciousness. Blood pressure was 70/50 mm Hg, and cardiopulmonary resuscitation was immediately instituted, leading to rapid recovery. There was no evidence of myocardial ischemia or other sequelae.
Because of persistent arthritic pain, the patient was admitted to the medical short-stay unit at St. Paul's Hospital two weeks after this reaction and given an oral challenge with 12.5 mg of rofecoxib. Within 40 minutes, there was a sudden onset of uncontrollable shaking (with the patient stating, “this is how it starts”), facial flushing, and a drop in blood pressure to 95/55 mm Hg. He was immediately given 0.5 ml of subcutaneous epinephrine at a 1:1000 dilution, 50 mg of intravenous diphenhydramine, 100 mg of intravenous methylprednisolone, and rapid administration of 1 liter of intravenous saline. His blood pressure quickly returned to normal, and dyspnea, stridor, and bronchospasm did not develop. Oxygen saturation was normal. He has subsequently remained symptom-free aside from his arthritis, for which he takes acetaminophen without problems.
This case emphasizes that COX-2 inhibitors are not safe in all persons who have adverse reactions to COX-1 inhibitors. It also suggests that different mechanisms may be involved in patients with asthma and in those with anaphylactoid reactions to nonsteroidal antiinflammatory drugs.
3 ReferencesR. Robert Schellenberg, M.D.
Saul H. Isserow, M.D.
University of British Columbia, Vancouver, BC V5Z 4E3, Canada1
Szczeklik A ,Nizankowska E ,Bochenek G ,Nagraba K ,Mejza F ,Swierczynska M . Safety of a specific COX-2 inhibitor in aspirin-induced asthma. Clin Exp Allergy 2001;31:219-225
CrossRef | Web of Science | Medline2
Stevenson DD ,Simon RA . Lack of cross-reactivity between rofecoxib and aspirin in aspirin-sensitive patients with asthma. J Allergy Clin Immunol 2001;108:47-51
CrossRef | Web of Science | Medline3
Dahlen B ,Szczeklik A ,Murray JJ . Celecoxib in patients with asthma and aspirin intolerance. N Engl J Med 2001;344:142-142
Full Text | Web of Science | Medline
- Citing Articles (19)
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1
S. L. Fernando, N. N. A. Assaad. (2010) BRIEF COMMUNICATION: Rapid and sequential desensitization to both aspirin and clopidogrel. Internal Medicine Journal 40:8, 596-599
CrossRef2
Maria Cristina Colanardi, Eustachio Nettis, Pierluigi Traetta, Carmela Daprile, Carmela Fitto, Anna Maria Aloia, Elisabetta Di Leo, Antonio Ferrannini, Angelo Vacca. (2008) Safety of parecoxib in patients with nonsteroidal anti-inflammatory drug-induced urticaria or angioedema. Annals of Allergy, Asthma & Immunology 100:1, 82-85
CrossRef3
Tobias Bernd Weberschock, Sylke-Monina Müller, Sandra Boehncke, Wolf-Henning Boehncke. (2007) Tolerance to coxibs in patients with intolerance to non-steroidal anti-inflammatory drugs (NSAIDs): a systematic structured review of the literature. Archives of Dermatological Research 299:4, 169-175
CrossRef4
Marek L Kowalski, Joanna Makowska. (2006) Use of Nonsteroidal Anti-Inflammatory Drugs in Patients with Aspirin Hypersensitivity. Treatments in Respiratory Medicine 5:6, 399-406
CrossRef5
2006. COX-2 inhibitors. , 1000-1015.
CrossRef6
Eustachio Nettis, Maria Cristina Colanardi, Antonio Ferrannini, Angelo Vacca, Alfredo Tursi. (2005) Short-term tolerability of etoricoxib in patients with cutaneous hypersensitivity reactions to nonsteroidal anti-inflammatory drugs. Annals of Allergy, Asthma & Immunology 95:5, 438-442
CrossRef7
Ronina A. Covar, Beth A. Macomber, Stanley J. Szefler. (2005) Medications as asthma triggers. Immunology and Allergy Clinics of North America 25:1, 169-190
CrossRef8
Eustachio Nettis, Maria C. Colanardi, Antonio Ferrannini, Alfredo Tursi. (2005) Short-term and long-term tolerability of rofecoxib in patients with prior reactions to nonsteroidal anti-inflammatory drugs. Annals of Allergy, Asthma & Immunology 94:1, 29-33
CrossRef9
S.-E. Dahlen, E. Sundstrom, M. Gulliksson, P. Gyllfors, M. Kumlin, B. Dahlen. (2004) Leukotrienes and other mast cell mediators cause asthmatic airway obstruction. Clinical <html_ent glyph="@amp;" ascii="&"/> Experimental Allergy Reviews 4:s2, 212-218
CrossRef10
Mario S??nchez-Borges, Arnaldo Capriles-Hulett, Fernan Caballero-Fonseca. (2004) Adverse Reactions to Selective Cyclooxygenase-2 Inhibitors (Coxibs). American Journal of Therapeutics 11:6, 494-500
CrossRef11
Joaquín Quiralte, Julio Delgado, Blanca Sáenz de San Pedro, Esperanza López-Pascual, Maria A. Nieto, Nancy Ortega, Jose Fernando Florido, José Conde. (2004) Safety of the new selective cyclooxygenase type 2 inhibitors rofecoxib and celecoxib in patients with anaphylactoid reactions to nonsteroidal anti-inflammatory drugs. Annals of Allergy, Asthma & Immunology 93:4, 360-364
CrossRef12
Katharine M. Woessner, Ronald A. Simon, Donald D. Stevenson. (2004) Safety of high-dose rofecoxib in patients with aspirin-exacerbated respiratory disease. Annals of Allergy, Asthma & Immunology 93:4, 339-344
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Deborah Layton, Lynda V. Wilton, Saad A. W. Shakir. (2004) Safety profile of celecoxib as used in general practice in England: results of a prescription-event monitoring study. European Journal of Clinical Pharmacology 60:7, 489-501
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Tanya Wilton. (2004) Cyclooxygenase-2 inhibitors: Do they have a role in emergency department prescribing?. Emergency Medicine Australasia 16:1, 65-73
CrossRef15
F. J. Munoz-Bellido, M. Terron, A. Leon. (2003) Safety of rofecoxib in nonsteroidal anti-inflammatory drugs intolerance. Allergy 58:10, 1072-1075
CrossRef16
H. Brost, H. Ott, C. Pfannenstiel, T. G. Wenzl, G. Heimann. (2003) Aspirin intolerance in boy with primary ciliary dyskinesia. Allergy 58:2, 160-160
CrossRef17
Katharine M. Woessner, Ronald A. Simon, Donald D. Stevenson. (2002) The safety of celecoxib in patients with aspirin-sensitive asthma. Arthritis & Rheumatism 46:8, 2201-2206
CrossRef18
(2002) Current Awareness. Pharmacoepidemiology and Drug Safety 11:4, 345-360
CrossRef19
&NA;. (2002) Diclofenac/rofecoxib. Reactions Weekly &NA;:884, 8
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