Leukotriene receptor antagonists may prevent NSAID-induced exacerbations in patients with chronic urticaria

Background: About 30% of patients with chronic urticaria experience flares of hives and/or angioedema after ingesting either aspirin or nonsteroidal a nti-inflammatory drugs. In such patients, cross-reactivity to all NSAIDs se ems to occur suggesting a mechanism dependent on cyclooxygenase inhibition. Objective: To evaluate the preventive effect of leukotriene receptor antago nists on urticaria exacerbations induced by NSAIDs in a patient with chroni c urticaria. Methods: A 59-year-old woman with a 2-year history of recurrent urticaria e xacerbated by different NSAIDs including aspirin 500 mg (2 episodes), pirox icam 20 mg, and nimesulide 100 mg (1 episode each) was studied. Acetaminoph en 375 mg and floctafenine 50 mg induced a marked flare of urticaria/angioe dema in a single-blind, placebo-controlled challenge. Results: The patient was totally urticaria free during a 3-week course of m ontelukast 10 mg once a day. After montelukast withdrawal, a gradual relaps e of urticaria/angioedema occurred along with a further acute urticaria/ang ioedema episode after a single piroxicam, 20-mg tablet. Zafirlukast 20 mg t wice daily was started. After some days the patient was urticaria-free agai n, and after 3 weeks she tolerated a 6-day course of injective piroxicam (2 0 mg once a day) without any problem. To date the patient is still urticari a-free. Conclusion: Leukotriene receptor antagonists may prevent the severe urticar ia/angioedema exacerbations which follow the use of NSAIDs in some patients with chronic urticaria.