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Celecoxib-Associated Anaphylaxis

Assistant Clinical Professor of Pharmacy Practice, School of Pharmacy, University of Connecticut and Department of Pharmacy, University of Connecticut Health Center, Farmington, CT

Adam R Silverman, MD FACP

Chief, Division of General Internal Medicine, University of Connecticut Health Center; Associate Professor of Medicine, School of Medicine, University of Connecticut

Reprints: Dr. Chamberlin, Department of Pharmacy, MC2205, University of Connecticut Health Center, 263 Farmington Ave., Farmington, CT 06030, fax 860/679-1231, chamberlin{at}uchc.edu

OBJECTIVE: To report and discuss a case of anaphylaxis in a young, healthy white male taking celecoxib for intermittent lower back pain.

CASE SUMMARY: A healthy 27-year-old man with a documented history of anaphylaxis to penicillins and macrolides presented to the emergency department (ED) in anaphylactic shock after ingesting a 200-mg capsule of celecoxib and a cup of orange juice. The patient had been taking celecoxib over the past 6 months, for 1-2 weeks at a time, for low back pain secondary to a pilonidal cyst and an L5/S1 bulging disc. The day of admission was the seventh day of the most recent course of twice-daily celecoxib. The patient initially self-treated the reaction with diphenhydramine and subcutaneous epinephrine that he had at home due to his history of drug- and bee sting-induced anaphylaxis; neither intervention improved his symptoms. He became profoundly diaphoretic and developed systemic swelling, shortness of breath, bradycardia, and hypotension. Emergency medical services transported the patient to the ED, where he was treated appropriately and the symptoms resolved. However, 4 hours later, at time of discharge from the ED, the symptoms recurred. He was admitted to the intensive care unit and monitored for 3 days. Supportive care, steroids, and histamine blockade provided resolution of the symptoms. Cardiac workup was initiated because of the recurrence and severity of bradycardia and hypotension; results of the workup were unremarkable. The patient was discharged in stable condition.

DISCUSSION: This case demonstrates rare anaphylaxis to celecoxib in a patient who had previously taken the drug and who had documented tolerance to sulfonamide antibiotics. Despite this history, our patient developed type V immunoglobulin E-mediated anaphylaxis secondary to the sulfonamide component of celecoxib. This reaction was considered probable according to the Naranjo probability scale. A review of published case reports and related allergy literature for celecoxib allergenicity revealed that such reactions are rare. This is the first case report with great detail of a patient with anaphylaxis to celecoxib after having previously tolerated the medication.

CONCLUSIONS: Celecoxib can produce an anaphylactic reaction in patients who have previously tolerated sulfonamide antibiotics and who have previously tolerated celecoxib. This case also reviews the potentially biphasic presentation of anaphylaxis. Clinicians need to be aware of this biphasic anaphylactic response to ensure optimal duration of evaluation.

Key Words: anaphylaxis, celecoxib, cyclooxygenase-2 inhibitor

Published Online, March 18, 2009. www.theannals.com, DOI 10.1345/aph.1L593