This is a tough question. There’s no question that some patients use “drug allergy” as a rationale for drug-seeking. And yet there are a number who really do experience adverse events from NSAIDs. It should be emphasized that these adverse events are not true allergy, in that there is no NSAID-specific IgE.

The mechanism(s) for these events vary considerably, which is no surprise as the NSAIDs are a somewhat unique drug class, class membership being predicated on the ability to inhibit prostaglandin synthesis rather than on a common chemical structure. Thus, if an adverse event is related to prostaglandin inhibition, it’s likely to be cross-class. In many cases, however, patients have adverse reactions to one specific NSAID and can tolerate others.

The conventional wisdom has been to challenge the patient with a less potent NSAID in order to evaluate whether they can tolerate another agent, but in the experience of myself and others, analgesic potency is not a determinant of adverse event potential above and beyond dose-related adverse events. When patients have had an adverse event such as a rash to one NSAID, my usual practice is to conduct an observed challenge, starting with a low dose, with another NSAID. As the offending drug is often ibuprofen, I have lately been challenging patients with naproxen with good success. It should be emphasized that this challenge should be conducted by someone familiar with administering drug challenges, with observation of the patient.

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