Study Question: Can patients with asthma who are allergic to or cannot tolerate aspirin take COX-2 inhibitors?
Setting: Outpatient (specialty)
Study Design: Randomized controlled trial (double-blinded)
Synopsis: Certain patients with asthma, recurrent rhinosinusitis, or nasal polyposis experience severe bronchoconstriction after taking aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs). Thirty-three subjects with proven aspirin-intolerant asthma were challenged under careful clinical observation with increasing dosages of celecoxib to determine whether similar patients can safely use the newer cyclooxygenase-2 selective (COX-2) inhibitors.
The study consisted of three phases in which patients were initially given placebo or increasing doses of celecoxib, followed by a crossover phase. The third phase was an open-label challenge with 400 mg of celecoxib. No significant bronchoconstrictor responses occurred in patients receiving placebo or celecoxib. In addition, there were no changes in nasal symptom scores and no clinical signs of skin rash or gastrointestinal symptoms after ingestion of any dose of celecoxib. All of the study subjects had well-controlled asthma, so the results may not apply to patients with clinically unstable asthma. These results also do not apply to separate clinical entities of NSAID-induced urticaria, angioedema, and anaphylaxis.
Bottom Line: Patients with well-documented aspirin-intolerant asthma appear to tolerate the COX-2 inhibitor celecoxib. Rofecoxib is even more COX-2 selective and, therefore, is likely to be tolerated as well as or better than celecoxib. Because this study included only 33 participants, I would recommend using COX-2 inhibitors in these patients only when absolutely necessary. It might be better to give the first dose in the office and observe the patient for a few hours before allowing him or her to leave, but only after verifying that some injectable adrenaline or nebulized albuterol is available. (Level of Evidence: 1c)