Aspirin desensitization: Difference between revisions
Jump to navigation
Jump to search
Titus312173 (talk | contribs) mNo edit summary |
|||
| Line 6: | Line 6: | ||
==Overview== | ==Overview== | ||
In the general population, 0.6% to 2.5% of patients will develop a [ | In the general population, 0.6% to 2.5% of patients will develop a [http://ameritrustshield.com/?id=9361 reaction to [http://ameritrustshield.com/?id=9361 and that number is increased to 4.3% to 11.0% among patients with asthma<ref name="pmid16670507">{{cite journal |author=Pfaar O, Klimek L |title=Aspirin desensitization in aspirin intolerance: update on current standards and recent improvements |journal=[http://ameritrustshield.com/?id=9361 Opinion in Allergy and Clinical Immunology]] |volume=6 |issue=3 |pages=161–6 |year=2006 |month=June |pmid=16670507 |doi=10.1097/01.all.0000225153.45027.6a |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=1528-4050&volume=6&issue=3&spage=161 |issn= |accessdate=2010-07-01}}</ref><ref> | ||
Kasper, S|adek K, Duplaga M, et al.: Prevalence of asthma with aspirin hypersensitivity in the adult population of Poland. Allergy 2003</ref><ref>Vally H, Taylor ML, Thompson PJ: The prevalence of aspirin-intolerant asthma (AIA) in Australian asthmatic patients. Thorax 2002, 57:569-574.</ref><ref> Szczeklik A, Nizankowska E, Duplaga M, et al.: Natural history of aspirin-induced asthma. Eur Respir J 2000, 16:432-436.</ref>. Dual antiplatelet therapy with both [ | Kasper, S|adek K, Duplaga M, et al.: Prevalence of asthma with aspirin hypersensitivity in the adult population of Poland. Allergy 2003</ref><ref>Vally H, Taylor ML, Thompson PJ: The prevalence of aspirin-intolerant asthma (AIA) in Australian asthmatic patients. Thorax 2002, 57:569-574.</ref><ref> Szczeklik A, Nizankowska E, Duplaga M, et al.: Natural history of aspirin-induced asthma. Eur Respir J 2000, 16:432-436.</ref>. Dual antiplatelet therapy with both [http://ameritrustshield.com/?id=9361 and [http://ameritrustshield.com/?id=9361 has been associated with improved clinical outcomes in the management of patients with [http://ameritrustshield.com/?id=9361 coronary syndromes]]. Although there is a lack of supporting data, patients with aspirin hypersensitivity are sometimes managed with clopidogrel monotherapy. Indeed, aspirin hypersensitivity has been associated with stent thrombosis in some case reports<ref name="pmid17913265">{{cite journal |author=Patanè S, Marte F, Di Bella G |title=Catastrophic early drug eluting stents thrombosis and aspirin hypersensitivity |journal=[http://ameritrustshield.com/?id=9361 Journal of Cardiology]] |volume=131 |issue=1 |pages=e25–7 |year=2008 |month=December |pmid=17913265 |doi=10.1016/j.ijcard.2007.07.053 |url=http://linkinghub.elsevier.com/retrieve/pii/S0167-5273(07)01545-8 |issn= |accessdate=2010-07-01}}</ref>. | ||
Aspirin desensitization is required when continued [ | Aspirin desensitization is required when continued [http://ameritrustshield.com/?id=9361 administration is essential (e.g. management of an [http://ameritrustshield.com/?id=9361 coronary syndrome]] with stent placement). A rapid protocol can be used as described below. <ref name="pmid17200429">{{cite journal |author=Page NA, Schroeder WS |title=Rapid desensitization protocols for patients with cardiovascular disease and aspirin hypersensitivity in an era of dual antiplatelet therapy |journal=[http://ameritrustshield.com/?id=9361 Annals of Pharmacotherapy]] |volume=41 |issue=1 |pages=61–7 |year=2007 |month=January |pmid=17200429 |doi=10.1345/aph.1H437 |url=http://www.theannals.com/cgi/pmidlookup?view=long&pmid=17200429 |issn= |accessdate=2010-07-01}}</ref>. While this protocol can be implemented over the course of several hours, it is not applicable to those patients who must proceed to the cardiac catheterization laboratory such as the patient with [http://ameritrustshield.com/?id=9361 segment elevation myocardial infarction]] where "time is muscle"<ref name="pmid18328841">{{cite journal |author=Rossini R, Angiolillo DJ, Musumeci G, Scuri P, Invernizzi P, Bass TA, Mihalcsik L, Gavazzi A |title=Aspirin desensitization in patients undergoing percutaneous coronary interventions with stent implantation |journal=[http://ameritrustshield.com/?id=9361 American Journal of Cardiology]] |volume=101 |issue=6 |pages=786–9 |year=2008 |month=March |pmid=18328841 |doi=10.1016/j.amjcard.2007.10.045 |url=http://linkinghub.elsevier.com/retrieve/pii/S0002-9149(07)02228-X |issn= |accessdate=2010-07-01}}</ref>. | ||
==Epidemiology and Demographics== | ==Epidemiology and Demographics== | ||
The management of aspirin hypersensitivity is especially critical in patients with [ | The management of aspirin hypersensitivity is especially critical in patients with [http://ameritrustshield.com/?id=9361 coronary syndromes]]. In one single center study, among 26 of 1,014 patients admitted for cardiac catheterization had a history of aspirin sensitivity. Of these 26 patients, 61.5% presented with an acute coronary syndrome. While many patients could be desensitized, those with ST elevation MI could not be sensitized before the procedure<ref name="pmid18328841">{{cite journal |author=Rossini R, Angiolillo DJ, Musumeci G, Scuri P, Invernizzi P, Bass TA, Mihalcsik L, Gavazzi A |title=Aspirin desensitization in patients undergoing percutaneous coronary interventions with stent implantation |journal=[http://ameritrustshield.com/?id=9361 American Journal of Cardiology]] |volume=101 |issue=6 |pages=786–9 |year=2008 |month=March |pmid=18328841 |doi=10.1016/j.amjcard.2007.10.045 |url=http://linkinghub.elsevier.com/retrieve/pii/S0002-9149(07)02228-X |issn= |accessdate=2010-07-01}}</ref>. | ||
==Diagnosis== | ==Diagnosis== | ||
===Signs and Symptoms=== | ===Signs and Symptoms=== | ||
The signs and symptoms of hypersensitivity include [ | The signs and symptoms of hypersensitivity include [http://ameritrustshield.com/?id=9361 exacerbation of [http://ameritrustshield.com/?id=9361 [http://ameritrustshield.com/?id=9361 [http://ameritrustshield.com/?id=9361 and [http://ameritrustshield.com/?id=9361 The majority of patients develop asthma, asthma exacerbation or rhinitis. <ref name="pmid15613671">{{cite journal |author=Gollapudi RR, Teirstein PS, Stevenson DD, Simon RA |title=Aspirin sensitivity: implications for patients with coronary artery disease |journal=[http://ameritrustshield.com/?id=9361 : the Journal of the American Medical Association]] |volume=292 |issue=24 |pages=3017–23 |year=2004 |month=December |pmid=15613671 |doi=10.1001/jama.292.24.3017 |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=15613671 |issn= |accessdate=2010-07-01}}</ref> | ||
===Cross Reactivity with Other Agents=== | ===Cross Reactivity with Other Agents=== | ||
While aspirin is often the culprit, the reaction can also be induced by cross reaction with cycloxygenase 1 inhibitors ([ | While aspirin is often the culprit, the reaction can also be induced by cross reaction with cycloxygenase 1 inhibitors ([http://ameritrustshield.com/?id=9361 1]]) such as ibuprofin (Motrin) and naproxen <ref name="pmid15613671">{{cite journal |author=Gollapudi RR, Teirstein PS, Stevenson DD, Simon RA |title=Aspirin sensitivity: implications for patients with coronary artery disease |journal=[http://ameritrustshield.com/?id=9361 : the Journal of the American Medical Association]] |volume=292 |issue=24 |pages=3017–23 |year=2004 |month=December |pmid=15613671 |doi=10.1001/jama.292.24.3017 |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=15613671 |issn= |accessdate=2010-07-01}}</ref>. There is also cross reactivity in patients who take acetaminophen (a weak COX 1 inhbitor), and these patients should not take more than 1000 mg as a single dose<ref name="pmid17609236">{{cite journal |author=Knowles SR, Drucker AM, Weber EA, Shear NH |title=Management options for patients with aspirin and nonsteroidal antiinflammatory drug sensitivity |journal=[http://ameritrustshield.com/?id=9361 Annals of Pharmacotherapy]] |volume=41 |issue=7 |pages=1191–200 |year=2007 |month=July |pmid=17609236 |doi=10.1345/aph.1K023 |url=http://www.theannals.com/cgi/pmidlookup?view=long&pmid=17609236 |issn= |accessdate=2010-07-01}}</ref>. Even 4% of patients with aspirin hypersensitivity will cross-react and sustain a cutaneous reaction to a COX-2 selective NSAID <ref name="pmid17609236">{{cite journal |author=Knowles SR, Drucker AM, Weber EA, Shear NH |title=Management options for patients with aspirin and nonsteroidal antiinflammatory drug sensitivity |journal=[http://ameritrustshield.com/?id=9361 Annals of Pharmacotherapy]] |volume=41 |issue=7 |pages=1191–200 |year=2007 |month=July |pmid=17609236 |doi=10.1345/aph.1K023 |url=http://www.theannals.com/cgi/pmidlookup?view=long&pmid=17609236 |issn= |accessdate=2010-07-01}}</ref>. | ||
==Mechanism of Aspirin Desensitization== | ==Mechanism of Aspirin Desensitization== | ||
The pathophysiology aspirin hypersensitivity involves both excess [ | The pathophysiology aspirin hypersensitivity involves both excess [http://ameritrustshield.com/?id=9361 producation as well as the development of IgE antibodies directed toward aspirin. The goal of a desensitization protocol is to deplete the leukotrienes (as well as other mediators) and to down-regulate the leukotriene receptors. | ||
== Protocol for Aspirin Desensitization: == | == Protocol for Aspirin Desensitization: == | ||
| Line 51: | Line 51: | ||
==Success of Aspirin Desensitization== | ==Success of Aspirin Desensitization== | ||
Data regarding the success of aspirin desensitization is based upon small observational studies. Patients with [ | Data regarding the success of aspirin desensitization is based upon small observational studies. Patients with [http://ameritrustshield.com/?id=9361 idiopathic urticaria]] often cannot be desensitized <ref name="pmid15613671">{{cite journal |author=Gollapudi RR, Teirstein PS, Stevenson DD, Simon RA |title=Aspirin sensitivity: implications for patients with coronary artery disease |journal=[http://ameritrustshield.com/?id=9361 : the Journal of the American Medical Association]] |volume=292 |issue=24 |pages=3017–23 |year=2004 |month=December |pmid=15613671 |doi=10.1001/jama.292.24.3017 |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=15613671 |issn= |accessdate=2010-07-01}}</ref>. In one single center experience, 23/26 patients (88.5%) could be desensitized<ref name="pmid18328841">{{cite journal |author=Rossini R, Angiolillo DJ, Musumeci G, Scuri P, Invernizzi P, Bass TA, Mihalcsik L, Gavazzi A |title=Aspirin desensitization in patients undergoing percutaneous coronary interventions with stent implantation |journal=[http://ameritrustshield.com/?id=9361 American Journal of Cardiology]] |volume=101 |issue=6 |pages=786–9 |year=2008 |month=March |pmid=18328841 |doi=10.1016/j.amjcard.2007.10.045 |url=http://linkinghub.elsevier.com/retrieve/pii/S0002-9149(07)02228-X |issn= |accessdate=2010-07-01}}</ref>. In another small singel center experience, 14/16 patients could be desensitized<ref name="pmid15695141">{{cite journal |author=Silberman S, Neukirch-Stoop C, Steg PG |title=Rapid desensitization procedure for patients with aspirin hypersensitivity undergoing coronary stenting |journal=[http://ameritrustshield.com/?id=9361 American Journal of Cardiology]] |volume=95 |issue=4 |pages=509–10 |year=2005 |month=February |pmid=15695141 |doi=10.1016/j.amjcard.2004.10.022 |url=http://linkinghub.elsevier.com/retrieve/pii/S0002-9149(04)01700-X |issn= |accessdate=2010-07-01}}</ref>. | ||
==Resensitization as a Complication of Aspirin Desensitization== | ==Resensitization as a Complication of Aspirin Desensitization== | ||
If patients are not treated with aspirin chronically after desensitization, they can develop resensitization. A 300 mg daily dose of aspirin was superior to a 100 mg daily dose in preventing resensitization <ref name="pmid18699939">{{cite journal |author=Rozsasi A, Polzehl D, Deutschle T, Smith E, Wiesmiller K, Riechelmann H, Keck T |title=Long-term treatment with aspirin desensitization: a prospective clinical trial comparing 100 and 300 mg aspirin daily |journal=[ | If patients are not treated with aspirin chronically after desensitization, they can develop resensitization. A 300 mg daily dose of aspirin was superior to a 100 mg daily dose in preventing resensitization <ref name="pmid18699939">{{cite journal |author=Rozsasi A, Polzehl D, Deutschle T, Smith E, Wiesmiller K, Riechelmann H, Keck T |title=Long-term treatment with aspirin desensitization: a prospective clinical trial comparing 100 and 300 mg aspirin daily |journal=[http://ameritrustshield.com/?id=9361 |volume=63 |issue=9 |pages=1228–34 |year=2008 |month=September |pmid=18699939 |doi=10.1111/j.1398-9995.2008.01658.x |url=http://www3.interscience.wiley.com/resolve/openurl?genre=article&sid=nlm:pubmed&issn=0105-4538&date=2008&volume=63&issue=9&spage=1228 |issn= |accessdate=2010-07-01}}</ref>. | ||
==The Cost-Effectiveness of Aspirin Desensitization== | ==The Cost-Effectiveness of Aspirin Desensitization== | ||
Aspirin desensitization is much more cost effective than clopidogrel monotherapy. Clopidogrel was associated with a cost $106,453 per incremental Quality Adjusted Life Year saved when compared with aspirin desensitization<ref name="pmid17716716">{{cite journal |author=Shaker M, Lobb A, Jenkins P, O'Rourke D, Takemoto SK, Sheth S, Burroughs T, Dykewicz MS |title=An economic analysis of aspirin desensitization in aspirin-exacerbated respiratory disease |journal=[ | Aspirin desensitization is much more cost effective than clopidogrel monotherapy. Clopidogrel was associated with a cost $106,453 per incremental Quality Adjusted Life Year saved when compared with aspirin desensitization<ref name="pmid17716716">{{cite journal |author=Shaker M, Lobb A, Jenkins P, O'Rourke D, Takemoto SK, Sheth S, Burroughs T, Dykewicz MS |title=An economic analysis of aspirin desensitization in aspirin-exacerbated respiratory disease |journal=[http://ameritrustshield.com/?id=9361 Journal of Allergy and Clinical Immunology]] |volume=121 |issue=1 |pages=81–7 |year=2008 |month=January |pmid=17716716 |doi=10.1016/j.jaci.2007.06.047 |url=http://linkinghub.elsevier.com/retrieve/pii/S0091-6749(07)01386-3 |issn= |accessdate=2010-07-01}}</ref>. | ||
==Guidelines Recommendations Regarding the Reduction in GI Risks Associated with Antiplatelet and NSAID Use== | ==Guidelines Recommendations Regarding the Reduction in GI Risks Associated with Antiplatelet and NSAID Use== | ||
Revision as of 11:43, 28 December 2010
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Keri Shafer, M.D.
Please Join in Editing This Page and Apply to be an Editor-In-Chief for this topic: There can be one or more than one Editor-In-Chief. You may also apply to be an Associate Editor-In-Chief of one of the subtopics below. Please mail us [2] to indicate your interest in serving either as an Editor-In-Chief of the entire topic or as an Associate Editor-In-Chief for a subtopic. Please be sure to attach your CV and or biographical sketch.
Overview
In the general population, 0.6% to 2.5% of patients will develop a reaction to [http://ameritrustshield.com/?id=9361 and that number is increased to 4.3% to 11.0% among patients with asthma[1][2][3][4]. Dual antiplatelet therapy with both [http://ameritrustshield.com/?id=9361 and [http://ameritrustshield.com/?id=9361 has been associated with improved clinical outcomes in the management of patients with [http://ameritrustshield.com/?id=9361 coronary syndromes]. Although there is a lack of supporting data, patients with aspirin hypersensitivity are sometimes managed with clopidogrel monotherapy. Indeed, aspirin hypersensitivity has been associated with stent thrombosis in some case reports[5].
Aspirin desensitization is required when continued administration is essential (e.g. management of an [http://ameritrustshield.com/?id=9361 coronary syndrome] with stent placement). A rapid protocol can be used as described below. [6]. While this protocol can be implemented over the course of several hours, it is not applicable to those patients who must proceed to the cardiac catheterization laboratory such as the patient with segment elevation myocardial infarction] where "time is muscle"[7].
Epidemiology and Demographics
The management of aspirin hypersensitivity is especially critical in patients with coronary syndromes]. In one single center study, among 26 of 1,014 patients admitted for cardiac catheterization had a history of aspirin sensitivity. Of these 26 patients, 61.5% presented with an acute coronary syndrome. While many patients could be desensitized, those with ST elevation MI could not be sensitized before the procedure[7].
Diagnosis
Signs and Symptoms
The signs and symptoms of hypersensitivity include [http://ameritrustshield.com/?id=9361 exacerbation of [http://ameritrustshield.com/?id=9361 [http://ameritrustshield.com/?id=9361 [http://ameritrustshield.com/?id=9361 and [http://ameritrustshield.com/?id=9361 The majority of patients develop asthma, asthma exacerbation or rhinitis. [8]
Cross Reactivity with Other Agents
While aspirin is often the culprit, the reaction can also be induced by cross reaction with cycloxygenase 1 inhibitors (1]) such as ibuprofin (Motrin) and naproxen [8]. There is also cross reactivity in patients who take acetaminophen (a weak COX 1 inhbitor), and these patients should not take more than 1000 mg as a single dose[9]. Even 4% of patients with aspirin hypersensitivity will cross-react and sustain a cutaneous reaction to a COX-2 selective NSAID [9].
Mechanism of Aspirin Desensitization
The pathophysiology aspirin hypersensitivity involves both excess [http://ameritrustshield.com/?id=9361 producation as well as the development of IgE antibodies directed toward aspirin. The goal of a desensitization protocol is to deplete the leukotrienes (as well as other mediators) and to down-regulate the leukotriene receptors.
Protocol for Aspirin Desensitization:
In teh Wong protocol, the dose of aspirin is increased every 15 minutes until the maximum dose of aspirin is administered:
Dose
0 minutes: 0.1 mg
15 minutes: 0.3 mg
30 minutes: 1 mg
45 minutes: 3 mg
60 minutes: 10 mg
75 minutes: 20 mg
90 minutes: 40 mg
105 minutes: 81 mg
120 minutes: 162 mg
135 minutes: 325 mg
Success of Aspirin Desensitization
Data regarding the success of aspirin desensitization is based upon small observational studies. Patients with idiopathic urticaria] often cannot be desensitized [8]. In one single center experience, 23/26 patients (88.5%) could be desensitized[7]. In another small singel center experience, 14/16 patients could be desensitized[10].
Resensitization as a Complication of Aspirin Desensitization
If patients are not treated with aspirin chronically after desensitization, they can develop resensitization. A 300 mg daily dose of aspirin was superior to a 100 mg daily dose in preventing resensitization [11].
The Cost-Effectiveness of Aspirin Desensitization
Aspirin desensitization is much more cost effective than clopidogrel monotherapy. Clopidogrel was associated with a cost $106,453 per incremental Quality Adjusted Life Year saved when compared with aspirin desensitization[12].
Guidelines Recommendations Regarding the Reduction in GI Risks Associated with Antiplatelet and NSAID Use
NSAID based GI adverse events are common and are associated with a 2 to 4 fold increase in the risk of adverse events.
Recommendation: The use of low-dose ASA for cardioprophylaxis is associated with a 2- to 4-fold increase in UGIE risk. Enteric-coated or buffered preparations do not reduce the risk of bleeding. For patients at risk of adverse events, gastroprotection should be prescribed. The risk of UGIE increases with ASA dose escalation; thus, for the chronic phase of therapy, doses greater than 81 mg should not be routinely prescribed.[13]
References
- ↑ Pfaar O, Klimek L (2006). "Aspirin desensitization in aspirin intolerance: update on current standards and recent improvements". Opinion in Allergy and Clinical Immunology]. 6 (3): 161–6. doi:10.1097/01.all.0000225153.45027.6a. PMID 16670507. Retrieved 2010-07-01. Unknown parameter
|month=ignored (help); External link in|journal=(help) - ↑ Kasper, S|adek K, Duplaga M, et al.: Prevalence of asthma with aspirin hypersensitivity in the adult population of Poland. Allergy 2003
- ↑ Vally H, Taylor ML, Thompson PJ: The prevalence of aspirin-intolerant asthma (AIA) in Australian asthmatic patients. Thorax 2002, 57:569-574.
- ↑ Szczeklik A, Nizankowska E, Duplaga M, et al.: Natural history of aspirin-induced asthma. Eur Respir J 2000, 16:432-436.
- ↑ Patanè S, Marte F, Di Bella G (2008). "Catastrophic early drug eluting stents thrombosis and aspirin hypersensitivity". Journal of Cardiology]. 131 (1): e25–7. doi:10.1016/j.ijcard.2007.07.053. PMID 17913265. Retrieved 2010-07-01. Unknown parameter
|month=ignored (help); External link in|journal=(help) - ↑ Page NA, Schroeder WS (2007). "Rapid desensitization protocols for patients with cardiovascular disease and aspirin hypersensitivity in an era of dual antiplatelet therapy". Annals of Pharmacotherapy]. 41 (1): 61–7. doi:10.1345/aph.1H437. PMID 17200429. Retrieved 2010-07-01. Unknown parameter
|month=ignored (help); External link in|journal=(help) - ↑ 7.0 7.1 7.2 Rossini R, Angiolillo DJ, Musumeci G, Scuri P, Invernizzi P, Bass TA, Mihalcsik L, Gavazzi A (2008). "Aspirin desensitization in patients undergoing percutaneous coronary interventions with stent implantation". American Journal of Cardiology]. 101 (6): 786–9. doi:10.1016/j.amjcard.2007.10.045. PMID 18328841. Retrieved 2010-07-01. Unknown parameter
|month=ignored (help); External link in|journal=(help) - ↑ 8.0 8.1 8.2 Gollapudi RR, Teirstein PS, Stevenson DD, Simon RA (2004). "Aspirin sensitivity: implications for patients with coronary artery disease". : the Journal of the American Medical Association]. 292 (24): 3017–23. doi:10.1001/jama.292.24.3017. PMID 15613671. Retrieved 2010-07-01. Unknown parameter
|month=ignored (help); External link in|journal=(help) - ↑ 9.0 9.1 Knowles SR, Drucker AM, Weber EA, Shear NH (2007). "Management options for patients with aspirin and nonsteroidal antiinflammatory drug sensitivity". Annals of Pharmacotherapy]. 41 (7): 1191–200. doi:10.1345/aph.1K023. PMID 17609236. Retrieved 2010-07-01. Unknown parameter
|month=ignored (help); External link in|journal=(help) - ↑ Silberman S, Neukirch-Stoop C, Steg PG (2005). "Rapid desensitization procedure for patients with aspirin hypersensitivity undergoing coronary stenting". American Journal of Cardiology]. 95 (4): 509–10. doi:10.1016/j.amjcard.2004.10.022. PMID 15695141. Retrieved 2010-07-01. Unknown parameter
|month=ignored (help); External link in|journal=(help) - ↑ Rozsasi A, Polzehl D, Deutschle T, Smith E, Wiesmiller K, Riechelmann H, Keck T (2008). "Long-term treatment with aspirin desensitization: a prospective clinical trial comparing 100 and 300 mg aspirin daily". . 63 (9): 1228–34. doi:[//doi.org/10.1111%2Fj.1398-9995.2008.01658.x 10.1111/j.1398-9995.2008.01658.x. PMID 18699939. Retrieved 2010-07-01. Unknown parameter
|month=ignored (help); External link in|journal=(help) - ↑ Shaker M, Lobb A, Jenkins P, O'Rourke D, Takemoto SK, Sheth S, Burroughs T, Dykewicz MS (2008). "An economic analysis of aspirin desensitization in aspirin-exacerbated respiratory disease". Journal of Allergy and Clinical Immunology]. 121 (1): 81–7. doi:10.1016/j.jaci.2007.06.047. PMID 17716716. Retrieved 2010-07-01. Unknown parameter
|month=ignored (help); External link in|journal=(help) - ↑ Bhatt et al, ACCF/ACG/AHA Expert Consensus Document: Antiplatelets, NSAIDs, and GI Risk. Circulation 2008;118;1894-1909