From the Guidelines
For patients with an aspirin allergy requiring a stent, the most appropriate management option is to use either clopidogrel or ticagrelor alone indefinitely, or to attempt aspirin desensitization, as recommended by the 2012 ACCF/AHA focused update 1. When considering alternative antiplatelet therapy, it's essential to weigh the risks and benefits of each option.
- Clopidogrel (Plavix) 75mg daily is a suitable alternative, with a recommended duration of at least 12 months for drug-eluting stents and up to 12 months for bare-metal stents 1.
- Ticagrelor (Brilinta) 90mg twice daily is another option, with benefits observed irrespective of prior therapy with clopidogrel 1.
- Prasugrel (Effient) 10mg daily may also be considered, although its use is generally not recommended in patients aged 75 years or those with a history of TIA or stroke due to increased bleeding risk 1. Aspirin desensitization is also an option for patients with an aspirin allergy, involving gradual introduction of tiny amounts of aspirin in a controlled setting to overcome the allergic response 1. It's crucial to inform the cardiologist about the aspirin allergy before the procedure to plan accordingly and minimize potential complications. The alternative antiplatelet medications work by different mechanisms than aspirin but still prevent platelets from sticking together and forming clots that could block the stent. Ultimately, the choice of management option depends on individual patient factors, including the type of stent, location, and overall health status, and should be made in consultation with a healthcare professional.
From the Research
Management Options for Aspirin Allergy
- Aspirin desensitization is a viable option for patients with aspirin allergy who require a stent, as it has been shown to be effective and safe in several studies 2, 3.
- The desensitization protocol typically involves administering increasing doses of aspirin over a short period, allowing patients to tolerate the medication without adverse effects.
- Alternative antiplatelet therapies, such as cilostazol, may be considered for patients with aspirin intolerance, as they have been shown to be efficacious and safe in certain populations 4.
- Mono-antiplatelet therapy with P2Y12 inhibitors, such as clopidogrel, may also be an option for patients with aspirin intolerance, although further studies are needed to evaluate its efficacy and safety in this clinical scenario 5.
- Prasugrel may be considered as an alternative to clopidogrel in patients with a history of clopidogrel allergy, although the risk of cross-reactivity remains largely unknown 6.
Considerations for Management
- The choice of management option should be individualized based on the patient's specific clinical characteristics and medical history.
- Careful consideration of patient- and drug-specific factors is crucial in selecting the most appropriate antiplatelet dual therapy for patients with a history of allergic reactions to aspirin or other antiplatelet medications 6.
- The potential benefits and risks of each management option should be weighed, taking into account the patient's risk of adverse cardiac events and bleeding complications.