The Australasian Society of Clinical Immunology and Allergy

ASCIA Education Resources patient information

Aspirin has long been used to reduce pain from inflammation (redness and swelling) and injury, as well as fever. Although it was originally isolated from plants in the early 1800's, aspirin is now made synthetically. A number of similar synthetic non-steroidal anti-inflammatory drugs (NSAIDS) have also been introduced.

How do aspirin and NSAIDS work?

Aspirin and NSAIDS work by inhibiting production of compounds in the body known as prostaglandins, which are involved in tissue inflammation, pain and fever. Aspirin also inhibits the activity of blood elements known as platelets (which help clotting). Therefore aspirin also thins the blood, thus reducing the risk of heart attacks and strokes. There is also recent evidence that aspirin may even reduce the risk of bowel cancer.

All drugs are potential poisons; aspirin is no exception

Common side effects of aspirin include bruising and stomach upset (or even ulcers or bleeding from the bowel), at high dose. Very high doses may cause confusion or ringing in the ears (tinnitus). It should also be avoided in children, as aspirin can trigger a condition as Reye's syndrome, where severe liver inflammation and damage occurs.

Aspirin and allergy

Mild to severe allergic reactions to aspirin may occur in some people. Symptoms include flushing, itchy rashes, blocked and runny noses and severe difficulty in breathing or asthma, usually within an hour of taking a tablet. If you have hives (urticaria), nose / sinus disease or asthma this can increase the likelihood of aspirin allergy to approximately 10-30% compared to 1% in people without these conditions.

The presence of aspirin is not always obvious

Aspirin is present in many over the counter painkillers and:

• medications for pain from headache, periods, sinus
• cold & flu tablets
• Alka-Seltzer
• Inflammatory Bowel Disease Drugs - Mesalazine, Salazopyrin
• Complementary Alternative Medicines - Willow Tree Bark extract, some herbal arthritis pills
• Topical salicylates such as teething gels (Bonjela, Oral-sed Gel)

If you are sensitive to aspirin, you will need to carefully read medicine labels and be cautious about taking any pain killer without talking to your doctor or pharmacist first.

There are many brands of NSAIDS

Because there are so many brand names of the same medication, and so many types of medications available, accidental exposure to aspirin or NSAIDS may occur. It is therefore important to tell your pharmacist or health professional about your sensitivity to these medicines.

Testing for drug sensitivity

The reason why allergic reactions to aspirin and related pain-killers occur is uncertain. There is no reliable blood or skin allergy test which has been proven to be useful for confirming or excluding sensitivity to these medicines. The only way to do so is a graded open challenge under strict medical supervision. Challenge testing is not always necessary, but may be advised in some circumstances: to prove that sensitivity exists, or to prove the safety of an unrelated medicine, so that you have another drug from which to choose if you need to use a pain killer.

What is aspirin desensitisation?

This is useful in some people with aspirin allergy, nasal polyps and asthma. It can be used to:

• improve asthma control
  
• reduce the severity of sinusitis/nasal polyposis
  
• reduce the rate at which polyps regrow
  
• enable people to use aspirin or similar medication for treatment of heart disease or arthritis.
  

Side effects can include:

• Stomach Irritation - ulceration and bleeding at high doses
  
• Easy bruising - common
  
• Tinnitus (ringing in the ears - rare).
  The decision to undertake aspirin desensitisation should be made in consultation with an allergy specialist.

Management of aspirin / NSAID sensitivity

Ongoing hives

If you have on-going hives or urticaria, you should avoid aspirin and NSAIDS unless you know that you can tolerate them without a problem. If you are already taking regular aspirin (for example, to thin the blood), or a regular arthritis tablet for treatment of pain, then you do not need to stop this medicine unless your hives clearly get much worse after taking a tablet.

Acute hives/severe allergic reactions after a pain-killer

Most people with aspirin/NSAID allergy are sensitive to only one drug. Unfortunately, up to 1 in 5 may have unpredictable cross-reactive allergic responses to similar medicines. Under these circumstances, an open challenge with a completely different drug can be considered if you need to take a pain killer for treatment of pain.

Aspirin sensitive people with asthma, nasal polyps and sinusitis/rhinitis

Leukotriene "blockers"/antagonists such as Singulair (montelukast) or aspirin desensitisation (see above) are useful treatment options.

Tolerability of new medications

A number of new medications have been introduced in the last few years such as Celebrex and Vioxx. Whilst they cause less stomach irritation than aspirin and traditional NSAIDS, around 5 - 20% of people with aspirin allergy may have allergic reactions to these as well.

Dietary salicylates in aspirin-sensitive patients

Occasionally people who are allergic to aspirin and have asthma, nasal polyps and sinusitis/rhinitis
willl suffer symptoms if they eat foods that have high levels of natural salicylates in some food. This affects the occasional person rather than the majority, so low salicylate diets are not considered a routine part of management.

© ASCIA 2003

The Australasian Society of Clinical Immunology and Allergy (ASCIA) is the peak professional body of Clinical Allergists and Immunologists in Australia and New Zealand.

Disclaimer:

ASCIA Education Resources (AER) information bulletins have been peer reviewed by ASCIA members and represent the available published literature at the time of review .
It is important to note that information contained in this bulletin is not intended to replace professional medical advice. Any questions regarding a medical diagnosis or treatment should be directed to a medical practitioner.

References

1. Settipane RA, Schrank PJ, Simon RA, Mathison DA, Christiansen SC, Stevenson DD: Prevalence of cross-sensitivity with acetaminophen in aspirin-sensitive asthmatic subjects. J ALLERGY CLIN IMMUNOL 1995; 96: 480-5

2. Stevenson DD: Diagnosis, prevention, and treatment of adverse reactions to aspirin and nonsteroidal anti-inflammatory drugs. J ALLERGY CLIN IMMUNOL 74:4 1984, 617-622

3. Juergens UR, Christiansen SC, Stevenson DD, Zuraw BL: Inhibition of monocyte leukotriene B4 production after aspirin desensitization: J ALLERGY CLIN IMMUNOL 96:2 1995, 148-156

4. Stevenson DD, Pleskow WW, Simon RA, Mathison DA, Lumry WR, Schatz M, Zeiger RS: Aspirin-sensitive rhinosinusitis astshma: A double-blind crossover study of treatment with aspirin. J ALLERGY CLIN IMMUNOL 73:4 1984, 500-507

5. Stevenson DD, Hankammer MA, Mathison DA, Christiansen SC, Simon RA: Aspirin desensitization treatment of aspirin-sensitive patients with rhinosinusitis-asthma: Long-term outcomes. J ALLERGY CLIN IMMUNOL 98:4 1996, 751-758

6. Sweet JM, Stevenson DD, Simon RA, Mathison DA: Long-term effects of aspirin desensitization - Treatment of aspirin-sensitive rhinosinusitis-asthma. J.ALLERGY CLIN IMMUNOL 85:1 1990, 59-64

7. Stevenson DD, Sanchez-Borges M, Szczeklik A: Classifciation of allergic and pseudoallergic reactions to drugs that inhibit cyclooxygenase enzymes. ANNALS OF ALLERGY, ASTHMA & IMMUNOLOGY 87 2001, 177-180

8. Arm JP, Austen K: Leukotriene Receptors and Aspirin Sensitivity. N ENGL J MED 347:19 2002, 1524-1526

9. Sousa AR, Parikh A, Scadding G, Corrigan CJ, Lee TH: Leukotriene-Receptor Expression on Nasal Mucosal Inflammatory Cells in Aspirin-Sensitive Rhinosinusitis. N ENGL J MED 347:19 2002, 1493-1499

10. Quiralte J, Blanco C, Castillo R, Ortega N, Carillo T: Anaphylactoid reactions due to nonsteroidal anti-inflammatory drugs: clinical and cross-reactivity studies. ANN ALLERGY 78 1997, 293-296

11. Vidal C, Perez-Carral C, Gonzalez-Quintela A: Paracetamol (acetaminophen) hypersensitivity. ANN ALLERGY 79 1997, 320-321

12. Asero R: Risk factors for acetaminophen and nimesulide intolerance in patients with NSAID-induced skin disorders. ANN ALLERGY 82 1999, 554-557

13. Stelze, RC, Squire EN: Oral desensitization to 5-aminosalicylic acid medications. ANN ALLERGY 83 1999, 23-24

14. Asero, R: Multiple sensitivity to NSAID. ALLERGYNET 2000, 893-894

15. Quiralte, J, de San Pedro BS, Florido JJF: Safety of selective cyclooxygenase-2 inhibitor rofecoxib in patients with NSAID-induced cutaneous reactions. ANN ALLERGY ASTHMA IMMUNOL 2002; 89: 63-6

16. Christie, PE: Aspirin-sensitive asthma. ROYAL SOC MED - CURRENT MED LIT 63-73

17. Szczeklik A, Stevenson DD: Aspirin-induced asthma: Advances in pathogenesis and management. J ALLERGY CLIN IMMUNOL 104:1 1999, 5-13

18. Dahlen B, Dalen SE: leucotrienes as mediators of airway obstruction and inflammation in asthma. CLIN EXP ALLERGY 25:2 1995, 50-54

19. Moneret-Varutrin, DA, Kanny G (1995): Food induced anaphylaxis. A new French multicenter study. BULL ACAD NATL MED 179:1. 161-72, 178-84; discussion 173-7.

20. Castells MC, Horan RF, et al. (1999): Exercise-induced anaphylaxis (EIA). CLIN REV ALLERGY IMMUNOL 17:4, 413-24.

21. Dohi M, Suko M et al. (1990): 3 Cases of food-dependent exercise-induced anaphylaxis in which aspirin intake exacerbated anaphylactic symptoms". ARERUGI 39:12, 1598-604.

22. Borges MS, Capriles-Hulett A, Caballero-Fonseca F, Perez CR: Tolerability to new COX-2 inhibitors in NSAID-sensitive patients with cutaneous reactions. ANN ALLERGY 87 2001, 201-203. 

Content Updated 1 April 2003