From the Guidelines
For patients with an allergy to NSAIDs, clopidogrel (75 mg/day) is the recommended alternative for cardiovascular disease prevention, particularly in those with a history of atherosclerotic cardiovascular disease. This recommendation is based on the standards of medical care in diabetes-2020, which suggests the use of clopidogrel in patients with documented aspirin allergy and atherosclerotic cardiovascular disease 1. Clopidogrel works by inhibiting platelet aggregation, providing an effective alternative to aspirin for preventing cardiovascular events in patients who cannot tolerate NSAIDs.
When considering alternatives to NSAIDs for CV disease prevention, it's essential to weigh the risks and benefits of each option. In patients with an allergy to NSAIDs, the primary concern is finding an effective replacement that minimizes the risk of adverse reactions.
- Clopidogrel (75 mg/day) is a well-established alternative, with a strong recommendation from the standards of medical care in diabetes-2020 1.
- Other antiplatelet medications, such as ticagrelor (60-90 mg twice daily) or prasugrel (10 mg daily), may be considered in specific situations, but they are not the primary recommendation for patients with NSAID allergies.
- Lifestyle modifications, including maintaining healthy blood pressure, LDL cholesterol levels, and weight, as well as regular exercise and a balanced diet, are crucial for reducing cardiovascular risk when antiplatelet therapy is not an option.
In real-life clinical practice, it's essential to consult with a cardiologist or allergist before starting any new medication regimen, especially in patients with a history of allergies or adverse reactions. They may recommend desensitization to aspirin in some cases where the cardiovascular benefits outweigh the risks. However, clopidogrel (75 mg/day) remains the preferred alternative to NSAIDs for CV disease prevention in patients with an allergy to NSAIDs, based on the most recent and highest-quality evidence available 1.
From the Research
Alternatives to NSAIDs for CV Disease Prevention
In patients with an allergy to NSAIDs, several alternatives can be considered for cardiovascular disease prevention.
- Aspirin desensitization is a viable option for patients with a history of hypersensitivity reactions to aspirin or other NSAIDs 2, 3.
- A graded challenge or desensitization protocol can be used to safely administer aspirin to patients with a history of 'aspirin/NSAID allergy' who need ASA for cardiovascular issues 2.
- Patients with aspirin hypersensitivity can be safely challenged with aspirin, and those with NSAID-induced gastritis or other side effects can be started on aspirin without the need for special challenge 3.
- A desensitization protocol developed based on the guidelines proposed by the EAACI drug allergy expert recommendations can be effective in establishing a safe administration of ASA in cardiovascular patients with NSAID hypersensitivity 4.
Considerations for Aspirin Desensitization
When considering aspirin desensitization, the following factors should be taken into account:
- Patient characteristics and onset of reaction after NSAIDs 4.
- Premedication with a leukotriene antagonist and the H1-antagonist antihistamine 4.
- The clinical entities of NSAID-induced urticaria and/or angioedema and NSAID-exacerbated respiratory disease 4.
Risks Associated with NSAID Use
The use of NSAIDs is associated with an increased risk of adverse cardiovascular effects, including myocardial infarction, stroke, hypertension, heart failure, and atrial fibrillation 5, 6.