Aspirin-exacerbated respiratory disease: characteristics and management strategies

Abstract

Aspirin-exacerbated respiratory disease is a clinical entity comprising chronic rhinosinusitis with nasal polyposis, asthma and intolerance to COX-1 inhibiting drugs. The pathogenesis is not completely understood at this point, but abnormal arachidonic acid metabolism is a key feature in this syndrome. The diagnosis is confirmed only by direct drug challenge. Aspirin desensitization followed by daily aspirin therapy is a useful treatment option in these patients. In this review article are discussed the important characteristics and treatment of aspirin-exacerbated respiratory disease.

Keywords:

• aspirin desensitization
• aspirin sensitivity
• aspirin-exacerbated respiratory disease
• asthma
• nasal polyposis
• rhinosinusitis
• Samter’s triad

Financial & competing interests’ disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Aspirin-exacerbated respiratory disease (AERD) is characterized by chronic rhinosinusitis with nasal polyposis, asthma and intolerance to COX-1 inhibiting drugs.

• AERD patients tend to have more severe rhinosinusitis and asthma, as compared to patients without COX-1 inhibitor intolerance.

• The reaction to COX-1 inhibitors is not IgE mediated, and is thus a class effect related to arachidonic acid metabolism.

• The diagnosis of AERD is confirmed by drug challenge.

• Eosinophils and abnormal arachidonic acid metabolism play significant roles in AERD pathogenesis.

• Aspirin desensitization should be highly considered in patients with recalcitrant symptoms despite optimal medical therapy, recurrent nasal polyposis requiring frequent sinus surgery, those on daily or frequent systemic corticosteroids to control symptoms, and/or in those have other medical indications for aspirin.

• Aspirin desensitization may be conducted safely in an outpatient setting, although physicians should be prepared to handle the rare chance of a systemic reaction.

• The recommended starting dose of continuous aspirin therapy following desensitization is 1300 mg daily (650 mg twice daily) which may be tapered down to a goal of 325 mg twice daily, if tolerated.

• Aspirin desensitization has been shown to have a positive impact on nasal and asthma symptom scores, quality of life, systemic corticosteroid requirement and the need for sinus surgery. Some of these effects are seen in as little as 4 weeks, but most will achieve benefit within 6 months.

• Despite the known side effect profile of aspirin, the majority of AERD patients tolerate aspirin therapy without any significant adverse event.

Notes