We have read with great interest the article by Vega Hernández et al.,1 who describe the rapid aspirin desensitization in patients with a history of reactions to this drug who are indicated treatment after acute coronary syndrome. In this respect, we would like to be several remarks.
As indicated by the authors, it is not clear whether a hypersensitivity reaction really occurred or whether some other type of adverse reaction was reported in some of the 12 patients studied. This is particularly pertinent in the 7 patients who either did not recall why they were considered hypersensitive to aspirin or had hives of unknown origin as part of their history of hypersensitivity. The fact that no patients were included with a serious reaction (edema of glottis, anaphylactic shock) means that the patients studied belong to a group with either doubtful manifestations or low risk ones. We should therefore perhaps ask whether desensitization really did occur in all patients studied and whether the findings can be extrapolated.
The use of lysine acetylsalicylate (C15H12N2O6) as a precursor for aspirin (C9H8O4) may confer advantages in the antiplatelet profile in a clinical trial setting, as recently demonstrated by the ECCLIPSE study,2 but it has at least 2 drawbacks in the setting described by the authors. First, it triples the rate of absorption of aspirin, which could be dangerous if an allergic reaction occurs during exposure. Second, the stock solution is stable for approximately 2hours at room temperature, and this may limit its use in practice.
On another level, exposure of an individual in an acute phase of myocardial infarction to a potential allergic reaction is something we believe should be assessed on a case-by-case basis.3 It may be that it is more appropriate in patients with the profile presented by the authors rather than in other cases.
An alternative for acute-phase patients could be the use of glycoprotein IIb/IIIa inhibitors from the outset as part of a dual antiplatelet strategy. However, such an approach is currently not supported by scientific evidence.
Finally, we believe a broad registry is necessary to gather data to enable decisions based on stronger evidence.