Desensitization Procedure: The 3-day desensitization protocol employed was obtained from a previous study.2 Over the 3 days of desensitization, a placebo dose was administered first followed by doses of mesalamine that were gradually increased over several hours. The maximum dosages administered were 570mg, 1g, and 3g on days 1, 2, and 3, respectively. The authors noted that, unlike other protocols published in the past, liquid and capsule formations were used to allow for easy dose titration. The authors also emphasized that it was important that the patient was treated as an inpatient due to the “severity of her reaction to aspirin (laryngeal angioedema), the patient’s anxiety, and the need to pursue alternative medical treatment for UC.” Arterial pressure measurements and peak expiratory flow rate were obtained after each administered dose during the protocol.

Patient Evaluation: The authors reported that the patient “tolerated desensitization well with no ill effects.”2 Additionally, arterial pressure and peak expiratory flow rate measurements obtained during the desensitization period were normal. Observations made during the desensitization protocol were as follows: right eye pain and fatigue after the placebo dose (day 2) and 1 episode of emesis after the first dose of mesalamine (day 2). Additionally, the patient complained of mild pruritus one day after completion of the desensitization protocol. The authors stated that the patient was “discharged from the hospital with oral and rectal mesalamine for treatment of UC” and was “tolerating both formulations well.”

Discussion: This single-blind, placebo-controlled case study found that desensitization to oral mesalamine produced minimal adverse effects.2 The authors noted that one major limitation of this study was the lack of oral challenge with aspirin or NSAIDs, which was not pursued due to the patient’s history of severe reactions to these medications. The authors concluded that desensitization should be considered after alternative therapies have failed and that “this case suggests that reactions to multiple NSAIDs do not preclude use of mesalamine for patients who require this treatment in the correct setting.” The authors did emphasize, however, the importance of considering “the risk of anaphylaxis and even patient preference regarding appropriate therapy interventions.”

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References

1.      What Is Ulcerative Colitis? Crohn’s and Colitis Foundation Web site. http://www.crohnscolitisfoundation.org/what-are-crohns-and-colitis/what-is-ulcerative-colitis/ Accessed March 13, 2017.

2.      Heath JL, Heath RD, Tamboli C, et al. Mesalamine desensitization in a patient with treatment refractory ulcerative colitis and aspirin and nonsteroidal anti-inflammatory drug hypersensitivity. Ann Allergy Asthma Immunol. 2017 Mar 8; DOI: 10.1016/j.anai.2017.01.026.