Higher Dose Starting Protocols In Coronary Artery Disease Patients With Aspirin Hypersensitivity.

Introduction Aspirin is a cornerstone of atherosclerosis therapy, but 1.5% of coronary artery disease (CAD) patients report aspirin allergy. Past protocols of challenge and/or desensitization for aspirin allergy excluded acute coronary syndrome (ACS) patients and/or started at low doses. Recent studies propose higher starting doses with fewer steps. The safety and efficacy of these newer protocols are not established, especially in the acute setting where the ability to tolerate aspirin is time-sensitive. Methods A retrospective chart review was conducted for all inpatient allergy consults for patients with suspected CAD and aspirin allergy. Three categories of aspirin protocols were evaluated for patient characteristics, safety, and efficacy: challenge (graded or direct without premedication), challenge-desensitization (starting dose 20.25-40.5 mg with premedication), and slow desensitization (starting dose 0.1 mg with premedication). Results From 2007 to 2017, 144 aspirin challenges or challenge-desensitizations in patients without a history of anaphylaxis to aspirin were done with 98.9% success. A total of 126 procedures were done prior to cardiac intervention, and though 107 presented with ACS, none had direct cardiovascular complications from the aspirin protocol. There were 18 reactions (12.5%): 14 mild and 4 moderate, with 1 requiring epinephrine. Three were AERD patients with expected reactions, 4 were challenges who then underwent successful challenge-desensitization. There was no difference in the number of reactions between the challenge-desensitization versus the slow desensitization group (p=0.10). Conclusions Higher dose starting protocols for CAD patients with self-reported aspirin allergy are safe and effective, with similar success rate to protocols starting at lower doses.