Real-Life Outcomes of Oral Provocation Testing with Alternative NSAIDs in NSAID Hypersensitivity

Background: Nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most common causes of drug hypersensitivity reactions. Identifying safe alternative NSAIDs through oral provocation testing (OPT) is essential for clinical management. The 2025 World Allergy Organization (WAO) classification introduced updated phenotypes, highlighting the need for real-life data on tolerated alternative agents.Materials and methods:This retrospective study included 824 adults evaluated for suspected NSAID hypersensitivity between January 2020 and September 2025. Patients were reclassified according to the 2025 WAO criteria. Demographic characteristics, comorbid allergic diseases, culprit drugs, laboratory parameters, and outcomes of OPT with alternative NSAIDs were analyzed.Results:The mean age was 44.7 ± 13.2 years, and 65.5% of patients were female. According to the 2025 WAO classification, 48.8% had NSAID-exacerbated cutaneous disease (NECD), 32.2% NSAID-induced urticaria/angioedema (NIUA), and 11.2% single NSAID-induced urticaria/angioedema/anaphylaxis (SNIUAA). Among 704 patients undergoing OPT, tolerance rates were high for meloxicam (96%), nimesulide (97%), and celecoxib (98.6%). The distribution of asthma, rhinitis, urticaria/angioedema, chronic sinusitis, and nasal polyps differed significantly among WAO phenotypes (p < 0.05), whereas tolerance to alternative NSAIDs did not differ between groups (p > 0.05).Conclusion:Meloxicam, nimesulide, and celecoxib are well tolerated in most patients with NSAID hypersensitivity. The 2025 WAO classification improves phenotypic stratification, while OPT remains a reliable method for identifying safe alternative NSAIDs in real-life practice.