Correspondence

COX-2 Inhibitors in Patients with Sensitivity to Nonselective NSAIDs

N Engl J Med 2009; 361:2197-2198November 26, 2009

Article

To the Editor:

Controlled oral challenge is the only definitive way to detect sensitivity to nonsteroidal antiinflammatory drugs (NSAIDs) in patients with adverse reactions to these agents.1 Patients who have adverse reactions to nonselective NSAIDs have very limited analgesic and antiinflammatory therapeutic options, but several studies have shown that highly selective cyclooxygenase-2 (COX-2) inhibitors can be safely used.2-4 However, in a small percentage of cases, adverse reactions (respiratory or cutaneous) have been observed during challenge with a COX-2 inhibitor.5 When these occur, the next step to be taken is not clear. Can we use another highly selective COX-2 inhibitor as a safe alternative? We present two patients with skin reactions to highly selective COX-2 inhibitors (confirmed by oral challenge) who had no adverse reactions to another COX-2 inhibitor.

The first patient was a 69-year-old man with no history of asthma or atopic disorders who had several episodes of exanthema during treatment with nonselective NSAIDs (ibuprofen, aspirin, diclofenac, and dipyrone). A single-blind, placebo-controlled oral challenge with the highly selective COX-2 inhibitor etoricoxib was carried out in a supervised hospital setting. A nonpruritic exanthem limited to the patient's arms and internal thighs developed 145 minutes after he reached the 60-mg dose. Diphenhydramine and deflazacort were administered orally, with rapid clinical resolution. One week later, a similar oral challenge was performed with 200 mg of celecoxib; no adverse reaction occurred.

The second patient was a 32-year-old woman without asthma in whom a generalized cutaneous rash had previously developed when ibuprofen and dipyrone were administered. She underwent a single-blind, placebo-controlled oral challenge with celecoxib, and a non-itching exanthem on her upper limbs developed 60 minutes after she reached the 200-mg dose. A similar oral challenge confirmed that there were no adverse reactions to 60 mg of etoricoxib. Neither patient had an adverse reaction to acetaminophen.

These cases show that choosing another highly selective COX-2 inhibitor may be a safe alternative in patients who have adverse reactions to nonselective NSAIDs and who have previously had an adverse reaction to a first COX-2 inhibitor. They also show that not all persons with adverse reactions to nonselective NSAIDs will necessarily be free of adverse reactions to COX-2 inhibitors.

Stefan Cimbollek, M.D.
Joaquin Quiralte, M.D., Ph.D.
Robledo Avila, M.D.
Hospital Universitario Virgen del Rocio, Seville, Spain
scimbollek@gmail.com

5 References

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Citing Articles (3)

Citing Articles

1. 1

   I. Doña, N. Blanca-López, L. R. Jagemann, M. J. Torres, C. Rondón, P. Campo, A. I. Gómez, J. Fernández, J. J. Laguna, A. Rosado, M. Blanca, G. Canto. (2011) Response to a selective COX-2 inhibitor in patients with urticaria/angioedema induced by nonsteroidal anti-inflammatory drugs. Allergy 66:11, 1428-1433
   CrossRef

2. 2

   Antonio Valero, Jaime Sánchez-López, Joan Bartra, Carlos Serrano, Rosa Muñoz-Cano, Jordi Roca, Cesar Picado. (2011) Safety of Parecoxib in Asthmatic Patients with Aspirin-Exacerbated Respiratory Disease. International Archives of Allergy and Immunology 156:2, 221-223
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3. 3

   (2010) Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiology and Drug Safety 19:5, i-xiv
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