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Oral challenges to detect reactions induced by acetylsalicylic acid (ASA) and other nonsteroidal anti-inflammatory drugs (NSAIDs)

Suspected reaction type (based upon detailed history of past reactions and underlying conditions)	Symptoms of past reaction(s)	Starting dose for ASA, in mg	Increase per step	Interval between steps	Dose range in which reactions usually occur, in mg	Usual time between administration and onset of symptoms
Respiratory reaction induced by multiple NSAIDs (cross-reacting) in patient with underlying AERD (type 1) Also appropriate for type 4 reactions	Rhinitis/ocular symptoms, bronchospasm	40.5	Double	Three hours	60 to 100	One to three hours
Urticaria/angioedema induced by multiple NSAIDs (cross-reacting) in patient with chronic urticaria (type 2) Also appropriate for type 3 reactions	Urticaria/angioedema	81 to 162	Double	Three hours	162 to 650	One to three hours
Urticaria/angioedema induced by one NSAID (no underlying conditions) (type 5)*	Urticaria/angioedema	162	Double	Three hours	Not applicable^¶	Not applicable^¶
Anaphylaxis induced by one NSAID (no underlying conditions) (type 6)*	Anaphylaxis	81	Double	Three hours	Not applicable^¶	Not applicable^¶

The challenge is terminated when either the patient reacts or the desired therapeutic dose of ASA/NSAID is reached without a reaction. The challenge is continued beyond the reaction in order to desensitize patients with AERD.
Aspirin is most often used for these protocols, and the doses cited here apply to aspirin. Refer to the UpToDate topic for a discussion of performing challenges with other NSAIDs.

AERD: aspirin-exacerbated respiratory disease.
* These patients should avoid the suspected NSAID and be challenged with ASA or another NSAID (chemically different from the one that caused the reaction) to prove drug tolerance.
¶ Patients are challenged with aspirin to confirm that they do not have a pseudoallergic reaction, and symptoms during challenge are not anticipated.

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