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Lin KS, Rattan K, George J, Cavusoglu S, Joseph C, Talanki V, John S. Navigating Aspirin Hypersensitivity in Patients Undergoing Percutaneous Coronary Intervention. J Med Cases 2024; 15:201-207. [PMID: 39091571 PMCID: PMC11287907 DOI: 10.14740/jmc4239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 06/19/2024] [Indexed: 08/04/2024] Open
Abstract
Aspirin hypersensitivity continues to be a major clinical challenge in patients with coronary artery disease (CAD), particularly in those requiring percutaneous coronary intervention (PCI) in the absence of a validated alternative antiplatelet regimen. Although true aspirin allergies are uncommon, they can manifest with severe reactions such as angioedema or anaphylaxis, highlighting the critical role of diagnostic challenge tests and tolerance induction strategies. Here, a 61-year-old female with end-stage renal disease (ESRD) on hemodialysis presented with new-onset heart failure and elevated troponins in the setting of a hypertensive emergency. A subsequent left heart catheterization revealed severe multivessel disease, but PCI was deferred due to her history suggestive of aspirin-induced angioedema and the absence of a known optimal approach in this scenario. Given the feasibility of completing a desensitization protocol, aspirin desensitization was pursued, facilitating the successful placement of a drug-eluting stent. This case highlights the need for validated protocols to manage aspirin hypersensitivity, as the current treatment paradigm necessitates a highly individualized approach by the treating clinician.
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Affiliation(s)
- Kai Shiang Lin
- Department of Internal Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY 11203, USA
| | - Keston Rattan
- Department of Internal Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY 11203, USA
| | - Jensen George
- Department of Internal Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY 11203, USA
| | - Samantha Cavusoglu
- Department of Internal Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY 11203, USA
| | - Christy Joseph
- Department of Internal Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY 11203, USA
| | - Varsha Talanki
- Department of Internal Medicine, SUNY Downstate Health Sciences University, Brooklyn, NY 11203, USA
| | - Sabu John
- Department of Cardiology, SUNY Downstate Health Sciences University, Brooklyn, NY 11203, USA
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2
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Pacheco CS, Brooks RM, White KM. Successful Long-Term Aspirin Desensitization in a Pilot With Aspirin-Exacerbated Respiratory Disease. Mil Med 2023; 188:e2826-e2828. [PMID: 36383070 DOI: 10.1093/milmed/usac344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 09/30/2022] [Accepted: 10/23/2022] [Indexed: 02/17/2024] Open
Abstract
Aspirin-exacerbated respiratory disease (AERD) is a triad of asthma, chronic rhinosinusitis with nasal polyposis (CRSwNP), and adverse respiratory reactions to the ingestion of aspirin/non-steroidal anti-inflammatory drugs.1 Patients with AERD are frequently plagued with CRSwNP that is difficult to manage with systemic steroids, nasal steroids, and surgical polypectomy, often requiring multiple endoscopic sinus surgeries and frequent otolaryngology follow-up.2,3 There are an abundance of therapies to treat CRSwNP in the setting of AERD, all with varying costs, efficacies, and indications for treatment.4 While limited by side effect profile, aspirin desensitization remains an effective, low-cost treatment for patients with CRSwNP and non-steroidal anti-inflammatory drug sensitivity.5 We describe a case of an active duty U.S. Air Force pilot with AERD whose CRSwNP was successfully treated with aspirin desensitization without detrimental effect on his flying status.
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Affiliation(s)
- Curtis S Pacheco
- Department of Internal Medicine, San Antonio Uniformed Services Health Education Consortium, Fort Sam Houston, TX 78234, USA
| | - Robert M Brooks
- Department of Allergy and Immunology, Wilford Hall Medical Center, 59th Medical Group, Lackland Air Force Base, San Antonio, TX 78236, USA
| | - Kevin M White
- Department of Allergy and Immunology, Wilford Hall Medical Center, 59th Medical Group, Lackland Air Force Base, San Antonio, TX 78236, USA
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3
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Tuncay G, Damadoglu E, Cihanbeylerden M, Can Bostan O, Kayıkcı H, Özer S, Karakaya G, Kalyoncu AF. Comparison of the clinical outcomes of patients with NSAID-exacerbated respiratory disease receiving aspirin or biologicals. J Asthma 2023:1-10. [PMID: 36971076 DOI: 10.1080/02770903.2023.2196567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
OBJECTIVE NSAID-exacerbated respiratory disease (NERD) is characterized by exacerbation of respiratory symptoms after NSAID intake. While research for specific treatment options continues in patients who cannot tolerate or are unresponsive to aspirin treatment after aspirin desensitization (ATAD), biologicals have emerged as a new therapeutic option in NERD patients. The aim of this study was to compare the quality of life, and the sinonasal and respiratory outcomes of NERD patients treated with ATAD or biologicals. METHODS Patients who have been followed up at a tertiary care allergy center and who have been receiving at least one of ATAD, mepolizumab or omalizumab for at least six months were included. Evaluations were made using sinonasal outcome test (SNOT-22), asthma control test (ACT), short form-36 (SF-36), blood eosinophil counts, need for recurrent functional endoscopic sinus surgeries (FESS), and asthma or rhinitis exacerbations requiring oral corticosteroids (OCS). RESULTS A total of 59 patients comprised of 35 (59%) females and 24 (41%) males with a mean age of 46.1 (min-max, 20-70) years were included. The baseline blood eosinophil count was higher, and a significant decrease in blood eosinophil counts was observed in the mepolizumab group compared to ATAD group (p = 0.001, p < 0.001, respectively). At follow-up, the rate of recurrent FESS was lower in the group that received mepolizumab (p = 0.02). CONCLUSIONS In NERD patients, mepolizumab significantly decreased blood eosinophil counts and recurrent FESS. There was no significant difference between the patients receiving ATAD or mepolizumab regarding other clinical parameters.
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4
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Siña MJ, Valdés F, Zelada Ú, Tagle MT, Campillay R, Sandoval D, Herrera P, Bastías C. Aspirin desensitization in nonsteroidal anti-inflammatory exacerbated respiratory disease: The first prospective cohort in Chile. FRONTIERS IN ALLERGY 2023; 3:951323. [PMID: 36816475 PMCID: PMC9929946 DOI: 10.3389/falgy.2022.951323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 12/30/2022] [Indexed: 02/04/2023] Open
Abstract
Background Nonsteroidal anti-inflammatory exacerbated respiratory disease (N-ERD) is characterized by the Samter triad: chronic rhinosinusitis with nasal polyps, asthma, and nonallergic hypersensitivity to NSAIDs. Its diagnosis is based on a complete clinical history and an aspirin (ASA) challenge test. Medical treatments include biological drugs and ASA desensitization. Objective This study aims to evaluate the clinical response of patients with N-ERD undergoing functional endoscopic surgery (FES), followed by ASA desensitization and maintenance treatment, being the first prospective cohort study carried out in Chile. Methods We conducted 1-year follow-up of 12 patients with N-ERD treated with FES, desensitization, and maintenance with ASA. For each control, the medication score, sinonasal symptomatology (SNOT-22), PEF (peak expiratory flow), nasal polyposis (Lildholdt score), and the appearance of adverse effects were recorded. Computed tomography (CT) of the paranasal cavities was performed at baseline and at the 12-month follow-up to calculate the Lund-Mackay score. Results Patients presented a reduction of SNOT-22 after the FES, which was maintained at 12 months (p = 0.002); the symptoms that showed the greatest reduction were feeling embarrassed and nasal obstruction. The Lildholdt score was also significantly reduced (p = 0.001); in only three patients, the nasal polyps recurred, and all were small. The PEF showed a slight nonsignificant increase of 3.3%. In total, 75% of patients had an adverse effect, the most frequent being abdominal pain (66.7%), but none of the 12 patients required discontinuation of aspirin treatment in 1-year follow-up. The Lund-Mackay score had a significant reduction of 6.6 points (p < 0.001). Conclusion ASA desensitization is safe and effective in reducing upper and lower respiratory symptoms in patients with N-ERD and delays the reappearance of nasal polyps, although it is not exempt from adverse effects, with the vast majority being mild.
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Affiliation(s)
- María Josefina Siña
- Department of Pediatrics, Immunology Section, Clínica Universidad de los Andes, Santiago, Chile
| | - Felipe Valdés
- Department of Internal Medicine, Immunology Section, Barros Luco Trudeau Healthcare Complex, Santiago, Chile,Faculty of Medicine, University of Chile, Santiago, Chile,Correspondence: Felipe Valdés
| | - Úrsula Zelada
- Faculty of Medicine, University of Chile, Santiago, Chile,Department of Otorhinolaryngology, Barros Luco Trudeau Healthcare Complex, Santiago, Chile
| | - María Teresa Tagle
- Department of Internal Medicine, Immunology Section, Barros Luco Trudeau Healthcare Complex, Santiago, Chile
| | - Rolando Campillay
- Department of Internal Medicine, Immunology Section, Barros Luco Trudeau Healthcare Complex, Santiago, Chile
| | | | - Pablo Herrera
- Department of Internal Medicine, Immunology Section, Barros Luco Trudeau Healthcare Complex, Santiago, Chile
| | - Carla Bastías
- Department of Internal Medicine, Immunology Section, Barros Luco Trudeau Healthcare Complex, Santiago, Chile,Faculty of Medicine, University of Chile, Santiago, Chile
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5
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Damask C. AERD: Current Roles for Aspirin Desensitization, Surgery, and Biologic Therapies. CURRENT OTORHINOLARYNGOLOGY REPORTS 2022. [DOI: 10.1007/s40136-022-00399-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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6
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Thakker RA, Salazar L, Jazar DA, Bhakta P, Baker B, Patel C, Elbadawi A, Agarwal M, Albaeni A, Saleh M, Esclovan J, El Haddad D, Alwash H, Kalra A, Goel SS, Widmer RJ, Chatila K, Khalife W, Motiwala A, McCracken J, Jneid H, Gilani S. Coronary Artery Disease and Aspirin Intolerance: Background and Insights on Current Management. Cardiol Ther 2022; 11:175-183. [PMID: 35344187 PMCID: PMC9135937 DOI: 10.1007/s40119-022-00255-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Indexed: 11/28/2022] Open
Abstract
Aspirin is one of the most widely used medications across the global healthcare system and is the foundation in treating ischemic heart disease, as well as secondary prevention for ischemic and valvular heart disease. Challenges arise in treating patients with cardiovascular disease who have concomitant aspirin intolerance. Through an extensive review of the literature, we provide a comprehensive background on the pharmacology of aspirin, the mechanisms behind aspirin intolerance, the importance of aspirin in cardiovascular disease, and the management of aspirin intolerance in both acute coronary syndrome and stable coronary artery disease. Our review includes a multidisciplinary approach from the internist, allergist/immunologist, and cardiologist when evaluating this important patient population.
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Affiliation(s)
- Ravi A Thakker
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, 77555, USA.
| | - Leonardo Salazar
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, 77555, USA
| | - Deaa Abu Jazar
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, 77555, USA
| | - Pooja Bhakta
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, 77555, USA
| | - Bryan Baker
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, 77555, USA
| | - Chandani Patel
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, 77555, USA
| | - Ayman Elbadawi
- Division of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Mayank Agarwal
- Division of Cardiology, University of Texas Medical Branch, Galveston, TX, USA
| | - Aiham Albaeni
- Division of Cardiology, University of Texas Medical Branch, Galveston, TX, USA
| | - Mohammed Saleh
- Division of Cardiology, University of Texas Medical Branch, Galveston, TX, USA
| | - Jonathan Esclovan
- Division of Cardiology, University of Texas Medical Branch, Galveston, TX, USA
| | - Danielle El Haddad
- Division of Cardiology, University of Texas Medical Branch, Galveston, TX, USA
| | - Hashim Alwash
- Division of Cardiology, University of Texas Medical Branch, Galveston, TX, USA
| | - Ankur Kalra
- Division of Cardiovascular Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Sachin S Goel
- Department of Cardiology, Houston Methodist DeBakey Heart and Vascular Center, Houston, TX, USA
| | - Robert Jay Widmer
- Division of Cardiology, Scott and White Heart Memorial Hospital, Baylor Scott and White Health, Temple, TX, USA
| | - Khaled Chatila
- Division of Cardiology, University of Texas Medical Branch, Galveston, TX, USA
| | - Wissam Khalife
- Division of Cardiology, University of Texas Medical Branch, Galveston, TX, USA
| | - Afaq Motiwala
- Division of Cardiology, University of Texas Medical Branch, Galveston, TX, USA
| | - Jennifer McCracken
- Division of Allergy and Immunology, University of Texas Medical Branch, Galveston, TX, USA
| | - Hani Jneid
- Division of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Syed Gilani
- Division of Cardiology, University of Texas Medical Branch, Galveston, TX, USA
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8
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Kang SY, Seo J, Kang HR. Desensitization for the prevention of drug hypersensitivity reactions. Korean J Intern Med 2022; 37:261-270. [PMID: 35123386 PMCID: PMC8925949 DOI: 10.3904/kjim.2021.438] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 11/19/2021] [Indexed: 11/27/2022] Open
Abstract
Drug desensitization is the temporary induction of tolerance to a sensitized drug by administering slow increments of the drug, starting from a very small amount to a full therapeutic dose. It can be used as a therapeutic strategy for patients with drug hypersensitivity when no comparable alternatives are available. Desensitization has been recommended for immunoglobulin E (IgE)-mediated immediate hypersensitivity; however, its indications have recently been expanded to include non-IgE-mediated, non-immunological, or delayed T cell-mediated reactions. Currently, the mechanism of desensitization is not fully understood. However, the attenuation of various intracellular signals in target cells is an area of active research, such as high-affinity IgE receptor (FcεRI) internalization, anti-drug IgG4 blocking antibody, altered signaling pathways in mast cells and basophils, and reduced Ca2+ influx. Agents commonly requiring desensitization include antineoplastic agents, antibiotics, antituberculous agents, and aspirin/nonsteroidal antiinflammatory drugs. Various desensitization protocols (rapid or slow, multi-bag or one-bag, with different target doses) have been proposed for each drug. An appropriate protocol should be selected with the appropriate concentration, dosage, dosing interval, and route of administration. In addition, the protocol should be adjusted with consideration of the severity of the initial reaction, the characteristics of the drug itself, as well as the frequency, pattern, and degree of breakthrough reactions.
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Affiliation(s)
- Sung-Yoon Kang
- Department of Internal Medicine, Gachon University Gil Medical Center, Incheon,
Korea
| | - Jeongmin Seo
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul,
Korea
| | - Hye-Ryun Kang
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul,
Korea
- Institute of Allergy and Clinical Immunology, Seoul National University Medical Research Center, Seoul National University College of Medicine, Seoul,
Korea
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9
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Haque R, White AA, Jackson DJ, Hopkins C. Clinical evaluation and diagnosis of aspirin-exacerbated respiratory disease. J Allergy Clin Immunol 2021; 148:283-291. [PMID: 34364538 DOI: 10.1016/j.jaci.2021.06.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/14/2021] [Accepted: 06/15/2021] [Indexed: 12/30/2022]
Abstract
Aspirin-exacerbated respiratory disease (AERD) is a condition composed of chronic rhinosinusitis with nasal polyposis and asthma that is defined by respiratory hypersensitivity reactions to the cyclooxygenase 1-inhibitory effects of nonsteroidal anti-inflammatory drugs. It is diagnosed in 5% to 15% of patients with asthma and is even more common in those with comorbid nasal polyposis. Diagnosis is confirmed after an aspirin challenge procedure, yet many patients present with all components and can reliably be diagnosed by history. Patients with AERD commonly experience severe uncontrolled nasal polyposis and require multispecialty evaluation to properly stage and treat this condition. The presence of nasal polyposis plays a large component in the diminished quality of life in patients with AERD. In the last decade, multiple new therapeutic areas have been approved for type 2 airway diseases, offering patients with AERD many more options for control. This makes an early and accurate diagnosis of AERD important in the care of the larger population of type 2 airway diseases.
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Affiliation(s)
- Rubaiyat Haque
- Department of Adult Allergy, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.
| | - Andrew A White
- Division of Asthma, Allergy and Immunology, Scripps Clinic, San Diego, Calif
| | - David J Jackson
- Guy's Severe Asthma Service, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom; School of Immunology & Microbial Sciences, King's College London, London, United Kingdom
| | - Claire Hopkins
- Ear, Nose and Throat Department, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
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10
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Benito-Garcia F, Pires I, Lima J. Aspirin Desensitization: Implications for Acetylsalicylic Acid-Sensitive Pregnant Women. ACTA ACUST UNITED AC 2021; 57:medicina57040390. [PMID: 33920569 PMCID: PMC8073510 DOI: 10.3390/medicina57040390] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2021] [Revised: 04/14/2021] [Accepted: 04/15/2021] [Indexed: 11/16/2022]
Abstract
Low-dose acetylsalicylic acid (ASA) is widely used during pregnancy to prevent obstetric complications of placental dysfunction, such as preeclampsia, stillbirth and fetal growth restriction, and obstetric complications in pregnant women with antiphospholipid syndrome. ASA-sensitive pregnant women cannot benefit from the effects of ASA due to the possibility of severe or potentially life-threatening hypersensitivity reactions to ASA. ASA desensitization is a valuable and safe therapeutic option for these women, allowing them to start daily prophylaxis with ASA and prevent pregnancy complications. The authors discuss the recent advances in obstetric conditions preventable by ASA and the management of ASA hypersensitivity in pregnancy, including ASA desensitization. To encourage the implementation of ASA desensitization protocols in ASA-sensitive pregnant women, they also propose a practical approach for use in daily clinical practice.
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Affiliation(s)
| | - Inês Pires
- São Bernardo Hospital, Centro Hospitalar de Setúbal, 2910-549 Setúbal, Portugal;
| | - Jorge Lima
- Department of Obstetrics and Gynecology, CUF Descobertas Hospital, 1998-018 Lisbon, Portugal
- Comprehensive Health Research Centre (CHRC), CEDOC, NOVA Medical School, Universidade Nova de Lisboa, 1169-056 Lisbon, Portugal
- Correspondence: ; Tel.: +351-962-617-741
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11
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Stevens WW, Jerschow E, Baptist AP, Borish L, Bosso JV, Buchheit KM, Cahill KN, Campo P, Cho SH, Keswani A, Levy JM, Nanda A, Laidlaw TM, White AA. The role of aspirin desensitization followed by oral aspirin therapy in managing patients with aspirin-exacerbated respiratory disease: A Work Group Report from the Rhinitis, Rhinosinusitis and Ocular Allergy Committee of the American Academy of Allergy, Asthma & Immunology. J Allergy Clin Immunol 2020; 147:827-844. [PMID: 33307116 DOI: 10.1016/j.jaci.2020.10.043] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 10/13/2020] [Accepted: 10/20/2020] [Indexed: 11/25/2022]
Abstract
Aspirin-exacerbated respiratory disease (AERD) is characterized by the clinical triad of chronic rhinosinusitis with nasal polyps, asthma, and an intolerance to medications that inhibit the cycloxgenase-1 enzyme. Patients with AERD on average have more severe respiratory disease compared with patients with chronic rhinosinusitis with nasal polyps and/or asthma alone. Although patients with AERD traditionally develop significant upper and lower respiratory tract symptoms on ingestion of cycloxgenase-1 inhibitors, most of these same patients report clinical benefit when desensitized to aspirin and maintained on daily aspirin therapy. This Work Group Report provides a comprehensive review of aspirin challenges, aspirin desensitizations, and maintenance aspirin therapy in patients with AERD. Identification of appropriate candidates, indications and contraindications, medical and surgical optimization strategies, protocols, medical management during the desensitization, and recommendations for maintenance aspirin therapy following desensitization are reviewed. Also included is a summary of studies evaluating the clinical efficacy of aspirin therapy after desensitization as well as a discussion on the possible cellular and molecular mechanisms explaining how this therapy provides unique benefit to patients with AERD.
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Affiliation(s)
- Whitney W Stevens
- Division of Allergy and Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Ill.
| | - Elina Jerschow
- Division of Allergy and Immunology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | - Alan P Baptist
- Division of Allergy and Clinical Immunology, Department of Medicine, University of Michigan Medical School, Ann Arbor, Mich
| | - Larry Borish
- Departments of Medicine and Microbiology, University of Virginia Health System, Charlottesville, Va
| | - John V Bosso
- Division of Rhinology, Department of Otorhinolaryngology/Head & Neck Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Kathleen M Buchheit
- Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Katherine N Cahill
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Paloma Campo
- Allergy Unit, IBIMA-Hospital Regional Universitario de Málaga, Málaga, Spain
| | - Seong H Cho
- Division of Allergy and Immunology, Morsani College of Medicine, University of South Florida, Tampa, Fla
| | - Anjeni Keswani
- Division of Allergy/Immunology, Department of Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Joshua M Levy
- Department of Otolaryngology-Head & Neck Surgery, Emory University School of Medicine, Atlanta
| | - Anil Nanda
- Asthma and Allergy Center, Lewisville and Flower Mound, Tex; Division of Allergy and Immunology, University of Texas Southwestern Medical Center, Dallas, Tex
| | - Tanya M Laidlaw
- Division of Allergy and Clinical Immunology, Department of Medicine, Brigham and Women's Hospital, Boston, Mass
| | - Andrew A White
- Division of Allergy, Asthma, and Immunology, Scripps Clinic, San Diego, Calif
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12
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Aspirin-exacerbated respiratory disease: Update on medical management. World J Otorhinolaryngol Head Neck Surg 2020; 6:241-247. [PMID: 33336180 PMCID: PMC7729248 DOI: 10.1016/j.wjorl.2020.07.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 07/29/2020] [Indexed: 11/20/2022] Open
Abstract
Aspirin-exacerbated respiratory disease (AERD) is frequently diagnosed in patients with severe type 2 airway inflammation presenting with nasal polyps and severe asthma. It has been associated with a recalcitrant course with high medical and surgical requirements. The advent of recent biological and other targeted treatments show promise in the medical management of patient with AERD. The goal of complete disease control where patients no longer require recurrent surgical procedures, systemic corticosteroid exposure and may live with a stable and relatively normal quality of life is now within reach. Further work is necessary to identify biomarkers predictive of treatment response.
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13
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Woo SD, Luu QQ, Park HS. NSAID-Exacerbated Respiratory Disease (NERD): From Pathogenesis to Improved Care. Front Pharmacol 2020; 11:1147. [PMID: 32848759 PMCID: PMC7399220 DOI: 10.3389/fphar.2020.01147] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 07/14/2020] [Indexed: 12/12/2022] Open
Abstract
Nonsteroidal antiinflammatory drug (NSAID)-exacerbated respiratory disease (NERD) is characterized by moderate-to-severe asthma and a higher prevalence of chronic rhinosinusitis/nasal polyps, but is a highly heterogeneous disorder with various clinical manifestations. Two major pathogenic mechanisms are: (1) overproduction of cysteinyl leukotrienes with dysregulation of arachidonic acid metabolism and (2) increased type 2 eosinophilic inflammation affected by genetic mechanisms. Aspirin challenge is the gold standard to diagnose NERD, whereas reliable in vitro biomarkers have yet not been identified. Therapeutic approaches have been done on the basis of disease severity with the avoidance of culprit and cross-reacting NSAIDs, and when indicated, aspirin desensitization is an effective treatment option. Biologic approaches targeting Type 2 cytokines are emerging as potential therapeutic options. Here, we summarize the up-to-date evidence of pathophysiologic mechanisms and diagnosis/management approaches to the patients with NERD with its phenotypic classification.
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Affiliation(s)
- Seong-Dae Woo
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, South Korea
| | - Quoc Quang Luu
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, South Korea.,Department of Biomedical Sciences, Ajou University School of Medicine, Suwon, South Korea
| | - Hae-Sim Park
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, South Korea.,Department of Biomedical Sciences, Ajou University School of Medicine, Suwon, South Korea
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14
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New phenotypes in hypersensitivity reactions to nonsteroidal anti-inflammatory drugs. Curr Opin Allergy Clin Immunol 2020; 19:302-307. [PMID: 31107257 DOI: 10.1097/aci.0000000000000541] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE OF REVIEW Nonsteroidal anti-inflammatory drug (NSAID) is one of the most frequently prescribed medications in the medical field, and hypersensitivity to NSAID is a common adverse drug reaction encountered. However, NSAID hypersensitivity presents a variety of symptoms caused by diverse pharmacological and immunological mechanisms. RECENT FINDINGS Owing to the heterogeneity of the disease, a new concept for the classification of NSAID hypersensitivity has recently been proposed to diagnose and manage NSAID hypersensitivity for personalized treatment. Acute and delayed reactions were distinguished in this classification, and identification of symptoms and speculation of putative mechanisms help physicians make the right diagnosis. NSAID-exacerbated respiratory disease is a noticeable phenotype of NSAID hypersensitivity that involves upper airway comorbidities (chronic rhinosinusitis with nasal polyps) as well as asthmatic features. The cutaneous phenotypes of NSAID hypersensitivity occur, and cross-reactivity with other types of NSAID should be considered in establishing a proper diagnosis. Hypersensitivity to a single NSAID can present urticaria/angioedema and anaphylaxis, in which an IgE-mediated immune response is suggested to be a prime mechanism. Management of NSAID hypersensitivity reactions includes avoidance, pharmacological treatment following standard guidelines, and aspirin desensitization. SUMMARY The classification, diagnosis, and management of NSAID hypersensitivity should be individually reached by identifying its phenotype.
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15
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Marcus S, Schertzer J, Roland LT, Wise SK, Levy JM, DelGaudio JM. Central compartment atopic disease: prevalence of allergy and asthma compared with other subtypes of chronic rhinosinusitis with nasal polyps. Int Forum Allergy Rhinol 2020; 10:183-189. [PMID: 31600866 PMCID: PMC7185061 DOI: 10.1002/alr.22454] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 09/05/2019] [Accepted: 09/10/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Central compartment atopic disease (CCAD) is a recently described variant of chronic rhinosinusitis with nasal polyp (CRSwNP) associated with inhalant allergy. An association with asthma was noted to be uncommon within our clinical practice. The purpose of this study was to determine allergy and asthma prevalence in CCAD and other CRSwNP subtypes. METHODS A retrospective analysis at a tertiary care institution was performed over the period from 2015 to 2019. CRSwNP was grouped into the following subtypes: allergic fungal rhinosinusitis (AFRS); aspirin-exacerbated respiratory disease (AERD); CCAD; and CRSwNP not otherwise specified (CRSwNP NOS). Patients with sinonasal polyps and concomitant polypoid disease in the central compartment (CRSwNP/CC) were analyzed as a separate cohort for the purpose of this study. Prevalence of allergy and asthma was compared between groups. RESULTS Three hundred fifty-six patients were included. CRSwNP NOS was the most common subtype (37.1%) and CRSwNP/CC was the least common (3.7%), with other CRS subtypes ranging between 11.5% and 24.2%. Asthma prevalence was highest in AERD (100%) and CRSwNP NOS (37.1%), but substantially lower in AFRS (19.0%) and CCAD (17.1%). Asthma was significantly more common in AERD and CRSwNP NOS when compared with CCAD (p < 0.001 and p = 0.039, respectively). Prevalence of allergy was significantly higher in AFRS (100%), CCAD (97.6%), CRSwNP/CC (84.6%), and AERD (82.6%) when compared with CRSwNP NOS (56.1%) (p < 0.001). CONCLUSION CCAD represents a clinically distinct phenotype of CRSwNP with a high prevalence of allergy and low prevalence of asthma. Patients with both CCAD and diffuse sinonasal polyps had an allergy prevalence approaching that of CCAD and an asthma prevalence approaching CRSwNP NOS.
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Affiliation(s)
- Sonya Marcus
- Division of Otolaryngology–Head and Neck Surgery, Department of Surgery, Stony Brook Medicine, Stony Brook, NY
| | - Joseph Schertzer
- Department of Otolaryngology–Head and Neck Surgery, Emory University, Atlanta, GA
| | - Lauren T. Roland
- Department of Otolaryngology–Head and Neck Surgery, University of California, San Francisco, CA
| | - Sarah K. Wise
- Department of Otolaryngology–Head and Neck Surgery, Emory University, Atlanta, GA
| | - Joshua M. Levy
- Department of Otolaryngology–Head and Neck Surgery, Emory University, Atlanta, GA
| | - John M. DelGaudio
- Department of Otolaryngology–Head and Neck Surgery, Emory University, Atlanta, GA
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16
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Steinke JW. Aspirin desensitization or biologics for AERD? Ann Allergy Asthma Immunol 2019; 123:333-334. [PMID: 31349010 DOI: 10.1016/j.anai.2019.07.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 06/28/2019] [Accepted: 07/16/2019] [Indexed: 11/29/2022]
Affiliation(s)
- John W Steinke
- Asthma and Allergic Disease Center, Carter Immunology Center, University of Virginia Health Systems, Charlottesville, Virginia.
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17
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Tyrak KE, Kupryś-Lipińska I, Czarnobilska E, Jakieła B, Pajdzik K, Ćmiel A, Plutecka H, Koziej M, Gawrońska A, Konduracka E, Kuna P, Sanak M, Mastalerz L. Sputum biomarkers during aspirin desensitization in nonsteroidal anti-inflammatory drugs exacerbated respiratory disease. Respir Med 2019; 152:51-59. [PMID: 31128610 DOI: 10.1016/j.rmed.2019.04.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 04/10/2019] [Accepted: 04/29/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Aspirin desensitization (AD) is an effective and safe therapeutic option for patients with nonsteroidal anti-inflammatory drugs (NSAIDs)-exacerbated respiratory disease (N-ERD). The mechanisms driving its beneficial effects remain poorly understood. OBJECTIVE To investigate the effect of long-term AD on clinical, biochemical and radiological changes in N-ERD patients. METHODS The study group consisted of twenty-three individuals with N-ERD who underwent AD, followed by ingestion of 325 mg aspirin twice daily. Twenty patients completed the 52 weeks of AD. The following evaluations were conducted at baseline and in the 52nd week of AD: (i) clinical: asthma exacerbations, Asthma Control Test (ACT), Visual Analogue Scale (VAS) for the assessment of nasal symptoms; (ii) blood and induced sputum supernatant (ISS) periostin, (iii) phenotypes based on induced sputum (IS) cells, (iiii) ISS and nasal lavage (NL) concentration of prostaglandin D2 (PGD2), prostaglandin E2 (PGE2), tetranor-PGD-M, tetranor-PGE-M, 8-iso-PGE2, leukotriene B4 (LTB4), LTC4, LTD4 and LTE4, and urine LTE4. RESULTS A significant improvement was observed in ACT (P = 0.02) and VAS score (P = 0.008) in the 52nd week of AD. ISS periostin and IS eosinophil count decreased significantly in the 52nd week of AD (P = 0.04 and P = 0.01, respectively). ISS and NL eicosanoid concentrations did not change following long-term AD. CONCLUSION and Clinical Relevance: AD is associated with a decrease in sputum periostin biosynthesis, which may prevent the recruitment of eosinophils into respiratory tissue and be one of explanation of the clinical benefits of AD. Long-term aspirin administration does not lead to an imbalance between pro- and anti-inflammatory ISS eicosanoids.
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Affiliation(s)
- Katarzyna Ewa Tyrak
- II Department of Internal Medicine, Jagiellonian University Medical College, Cracow, Poland
| | - Izabela Kupryś-Lipińska
- Department of Internal Medicine, Asthma and Allergy, Medical University of Lodz, Lodz, Poland
| | - Ewa Czarnobilska
- Department of Clinical and Environmental Allergology, Jagiellonian University Medical College, Cracow, Poland
| | - Bogdan Jakieła
- II Department of Internal Medicine, Jagiellonian University Medical College, Cracow, Poland
| | - Kinga Pajdzik
- II Department of Internal Medicine, Jagiellonian University Medical College, Cracow, Poland
| | - Adam Ćmiel
- Department of Applied Mathematics, AGH University of Science and Technology, Cracow, Poland
| | - Hanna Plutecka
- II Department of Internal Medicine, Jagiellonian University Medical College, Cracow, Poland
| | - Mateusz Koziej
- Department of Anatomy, Jagiellonian University Medical College, Cracow, Poland
| | - Aleksandra Gawrońska
- Department of Radiology/Diagnostic Imaging, University Hospital in Cracow, Cracow, Poland
| | - Ewa Konduracka
- Coronary and Heart Failure Department, Jagiellonian University School of Medicine, John Paul II Hospital, Cracow, Poland
| | - Piotr Kuna
- Department of Internal Medicine, Asthma and Allergy, Medical University of Lodz, Lodz, Poland
| | - Marek Sanak
- II Department of Internal Medicine, Jagiellonian University Medical College, Cracow, Poland
| | - Lucyna Mastalerz
- II Department of Internal Medicine, Jagiellonian University Medical College, Cracow, Poland.
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18
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Li KL, Lee AY, Abuzeid WM. Aspirin Exacerbated Respiratory Disease: Epidemiology, Pathophysiology, and Management. Med Sci (Basel) 2019; 7:E45. [PMID: 30884882 PMCID: PMC6473909 DOI: 10.3390/medsci7030045] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 03/11/2019] [Accepted: 03/11/2019] [Indexed: 11/17/2022] Open
Abstract
The correlation between aspirin sensitivity, asthma, and nasal polyposis was recognized in the early 20th century. Today, this classic triad of symptoms, eponymously named Samter's Triad, is known as aspirin exacerbated respiratory disease (AERD). Aspirin exacerbated respiratory disease affects approximately 0.3⁻0.9% of the general population in the USA and approximately 7% of asthmatic patients. The management of AERD is challenging as no single modality has proven to have high rates of symptom control. Consequently, disease management typically involves a multimodality approach across both medical and surgical disciplines. This review describes the epidemiology of AERD and the current state-of-the-art as it relates to the underlying pathophysiologic mechanisms of this disease process. A significant proportion of the review is focused on the appropriate diagnostic workup for AERD patients including the utility of aspirin provocation testing. The spectrum of medical treatments, including aspirin desensitization and recently introduced immunotherapies, are discussed in detail. Furthermore, surgical approaches to disease control, including advanced endoscopic techniques, are reviewed and treatment outcomes presented.
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Affiliation(s)
- Kevin L Li
- Department of Otorhinolaryngology: Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY 10467, USA.
| | - Andrew Y Lee
- Department of Otorhinolaryngology: Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY 10467, USA.
| | - Waleed M Abuzeid
- Department of Otorhinolaryngology: Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY 10467, USA.
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19
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Grammatopoulou V, Praveena CV, Sunkaraneni VS. Optimising Medical Management in CRS. CURRENT OTORHINOLARYNGOLOGY REPORTS 2019. [DOI: 10.1007/s40136-019-00232-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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20
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Objective and subjective sinonasal and pulmonary outcomes in aspirin desensitization therapy: A prospective cohort study. Auris Nasus Larynx 2018; 46:526-532. [PMID: 30577986 DOI: 10.1016/j.anl.2018.12.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Revised: 11/19/2018] [Accepted: 12/02/2018] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Aspirin exacerbated respiratory disease (AERD) patients are challenging to manage with sinonasal and pulmonary symptoms refractory to maximal medical and surgical therapies. Our objective was to comprehensively examine objective and validated, disease-specific subjective sinonasal and pulmonary outcomes of aspirin (ASA) desensitization therapy in this patient population. METHODS Prospective cohort study at an academic tertiary center. AERD patients with a history of chronic rhinosinusitis with nasal polyposis (CRSwNP), prior diagnosis of asthma, and a history of ASA sensitivity were eligible for inclusion. Patients underwent ASA desensitization using an established institutional protocol and continued on a 650mg twice daily maintenance dose. Baseline Sinonasal Outcome Test (SNOT-22) and Asthma Control Questionnaire (ACQ) responses, acoustic rhinometry, peak flow readings, and endoscopic scoring of nasal polyps were recorded prior to desensitization and after 6months of maintenance therapy. RESULTS Twelve patients were recruited for participation and underwent desensitization. Eight patients continued maintenance therapy and follow up at 6months. Prior to desensitization, patients reported bothersome sinonasal symptoms with a median SNOT-22 score of 30.0±34.5 (interquartile range (IQR)). There was significant improvement after 6months of maintenance therapy to a median SNOT-22 score of 18.5±17.3 (p=0.025, Wilcoxon signed rank test). Acoustic rhinometry, endoscopic scores, ACQ and forced expiratory volume values remained stable at 6months. CONCLUSIONS AERD patients may benefit from ASA desensitization with subjective sinonasal symptom improvement at 6months and stable asthma and objective sinonasal measures. Further discussion is needed in the otolaryngology community regarding ASA desensitization in AERD management.
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21
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DeGregorio GA, Singer J, Cahill KN, Laidlaw T. A 1-Day, 90-Minute Aspirin Challenge and Desensitization Protocol in Aspirin-Exacerbated Respiratory Disease. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 7:1174-1180. [PMID: 30391549 DOI: 10.1016/j.jaip.2018.10.032] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Revised: 10/02/2018] [Accepted: 10/17/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Aspirin challenge and desensitization remains the criterion standard in diagnosis and treatment for patients with aspirin-exacerbated respiratory disease (AERD), but the protocols can be time and resource intensive. OBJECTIVE To provide evidence that oral aspirin challenge and desensitization can be safely performed in an outpatient setting in 1 day. METHODS Forty-four patients with a confirmed diagnosis of AERD, stable asthma, and baseline FEV1 value greater than or equal to 70% of predicted completed an oral aspirin challenge and desensitization protocol. The starting dose was 40.5 mg with escalating doses of aspirin (81, 162.5, 325 mg) at 90-minute intervals until symptoms were provoked. Desensitization was defined as tolerating a repeated administration of the provocative aspirin dose and at least 1 subsequent dose, bringing the total aspirin ingested during the in-clinic desensitization to 325 mg or more. RESULTS Ninety-three percent of patients completed the challenge and desensitization in 1 day, with an average protocol completion time of 9 hours and 29 minutes. Two patients (4.6%) chose to complete the protocol over 2 days. One patient (2.3%) was discontinued from the protocol because of ongoing abdominal discomfort and diarrhea. No patient required epinephrine, emergency department visit, or hospitalization. CONCLUSIONS Patients with AERD on a stable asthma regimen and with a baseline FEV1 value greater than or equal to 70% can be safely desensitized to aspirin using a 90-minute dose escalation protocol, starting at a dose of 40.5 mg, and defining desensitization as tolerance of the repeated provocation dose and at least 1 subsequent aspirin dose, bringing total cumulative daily dose to 325 mg or more. This protocol can routinely be completed in 1 day.
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Affiliation(s)
| | - Joseph Singer
- Department of Medicine, Harvard Medical School, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, and the Jeff and Penny Vinik Center, Boston, Mass
| | - Katherine N Cahill
- Divison of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University, Nashville, Tenn
| | - Tanya Laidlaw
- Department of Medicine, Harvard Medical School, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, and the Jeff and Penny Vinik Center, Boston, Mass.
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22
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Affiliation(s)
- Andrew A White
- From the Division of Allergy, Asthma, and Immunology, Scripps Clinic, San Diego, CA
| | - Donald D Stevenson
- From the Division of Allergy, Asthma, and Immunology, Scripps Clinic, San Diego, CA
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23
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Gnanenthiran SR, Yiannikas J, Lowe HC, Brieger D, Limaye S. Aspirin hypersensitivity in patients with coronary artery disease: linking pathophysiology to clinical practice. Am Heart J 2018; 203:74-81. [PMID: 30041066 DOI: 10.1016/j.ahj.2018.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Accepted: 06/28/2018] [Indexed: 06/08/2023]
Abstract
Dual antiplatelet therapy, consisting of aspirin and a P2Y12 receptor antagonist, has been the cornerstone of management in those undergoing percutaneous coronary intervention, reducing stent thromboses and cardiovascular events. Given the pivotal role of aspirin in cardiovascular disease management, patients with aspirin hypersensitivity pose complex clinical challenges. Allergy to aspirin is reported in 1.5-2.6% of patients presenting with cardiac disease. Identification of the subtype of aspirin hypersensitivity will determine suitability for aspirin desensitization, dictate choice of desensitization protocol and inform risk management. Aspirin desensitization is an effective and viable clinical strategy, although it remains underutilised in clinical practice. Collaboration between cardiologists and immunologists should be strongly encouraged to facilitate optimal management of such patients. This review describes the complexity of managing patients with aspirin hypersensitivity in cardiac disease, the indications and risks of aspirin desensitization, and the approach to management of the minority of patients who are unsuitable for desensitization.
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Affiliation(s)
- Sonali R Gnanenthiran
- Department of Cardiology, Concord Repatriation General Hospital, New South Wales, Australia
| | - John Yiannikas
- Department of Cardiology, Concord Repatriation General Hospital, New South Wales, Australia
| | - Harry C Lowe
- Department of Cardiology, Concord Repatriation General Hospital, New South Wales, Australia
| | - David Brieger
- Department of Cardiology, Concord Repatriation General Hospital, New South Wales, Australia
| | - Sandhya Limaye
- Department of Immunology, Concord Repatriation General Hospital, New South Wales, Australia.
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24
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Kim SD, Cho KS. Samter's Triad: State of the Art. Clin Exp Otorhinolaryngol 2018; 11:71-80. [PMID: 29642688 PMCID: PMC5951071 DOI: 10.21053/ceo.2017.01606] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 01/13/2018] [Accepted: 01/14/2018] [Indexed: 01/01/2023] Open
Abstract
Samter’s triad (ST) is a well-known disease characterized by the triad of bronchial asthma, nasal polyps, and aspirin intolerance. Over the past few years, a rapid development in the knowledge of the pathogenesis and clinical characteristics of ST has happened. The aim of this paper is to review the recent investigations on the pathophysiological mechanisms and genetic background, diagnosis, and different therapeutic options of ST to advance our understanding of the mechanism and the therapeutic control of ST. As concern for ST increase, more application of aspirin desensitization will be required to manage this disease successfully. There is also a need for continued research efforts in pathophysiology, treatment, and possible prevention.
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Affiliation(s)
- Sung-Dong Kim
- Department of Otorhinolaryngology-Head and Neck Surgery and Biomedical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Kyu-Sup Cho
- Department of Otorhinolaryngology-Head and Neck Surgery and Biomedical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
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25
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Management of Respiratory Symptoms Induced by Non-Steroidal Anti-Inflammatory Drugs. CURRENT TREATMENT OPTIONS IN ALLERGY 2017. [DOI: 10.1007/s40521-017-0129-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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26
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Plasma 15-Hydroxyeicosatetraenoic Acid Predicts Treatment Outcomes in Aspirin-Exacerbated Respiratory Disease. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:998-1007.e2. [PMID: 28159558 DOI: 10.1016/j.jaip.2016.11.021] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 11/01/2016] [Accepted: 11/23/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND Aspirin desensitization followed by daily aspirin provides therapeutic benefits to patients with aspirin-exacerbated respiratory disease (AERD). It is not well understood how eicosanoid levels change during aspirin treatment. OBJECTIVE To investigate associations between clinical outcomes of aspirin treatment and plasma eicosanoid levels in patients with AERD. METHODS Thirty-nine patients with AERD were offered aspirin treatment (650 mg twice daily) for 4 weeks. Respiratory parameters and plasma levels of multiple eicosanoids were recorded at baseline and after 4 weeks of aspirin therapy using the Asthma Control Test and Rhinoconjunctivitis Quality of Life Questionnaire. Respiratory function was evaluated using the FEV1 and nasal inspiratory peak flow. RESULTS After aspirin treatment, respiratory symptoms improved in 16 patients, worsened in 12 patients, and did not change in 4 patients. Seven patients were unable to complete the desensitization protocol. Patients with symptom improvement had higher baseline plasma 15-hydroxyeicosatetraenoic acid (15-HETE) levels than did patients with symptom worsening: 7006 pg/mL (interquartile range, 6056-8688 pg/mL) versus 4800 pg/mL (interquartile range, 4238-5575 pg/mL), P = .0005. Baseline 15-HETE plasma levels positively correlated with the change in Asthma Control Test score (r = 0.61; P = .001) and in FEV1 after 4 weeks of aspirin treatment (r = 0.49; P = .01). It inversely correlated with Rhinoconjunctivitis Quality of Life Questionnaire score (r = -0.58; P = .002). Black and Latino patients were more likely to have symptom worsening on aspirin or fail to complete the initial desensitization than white, non-Latino patients (P = .02). CONCLUSIONS In patients with AERD, low baseline 15-HETE plasma levels and black or Latino ethnicity are associated with worsening of respiratory symptoms during aspirin treatment.
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27
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Schuler CF, Baldwin JL, Baptist AP. Frequency and severity of reactions to a 325-mg aspirin dose during desensitization. Ann Allergy Asthma Immunol 2017; 118:333-338.e1. [PMID: 28065801 DOI: 10.1016/j.anai.2016.11.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Revised: 11/18/2016] [Accepted: 11/26/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND The frequency with which patients with aspirin-exacerbated respiratory disease (AERD) react to 325 mg of aspirin during aspirin desensitization, or fail to react at all, is not fully known. OBJECTIVE To determine the rate and type of reaction at 325 mg of aspirin during desensitization. METHODS A retrospective study of 104 patients who underwent aspirin desensitization from 2010 to 2016 was performed. A standard desensitization protocol (starting at 20-40 mg, progressing through 325 mg, and extinguishing reactions by dose repetition) was used. Reactions were defined by upper respiratory tract symptoms, lower respiratory tract symptoms, and/or forced expiratory volume in 1 second decrease of 15% or greater. Patients who did and did not react were compared by logistic regression. RESULTS Eighty-four patients reacted (81%) and 20 did not (19%). Seventy-seven patients who had a provoking reaction at 162 mg of aspirin or less subsequently extinguished their reactions before they reached a dose of 325 mg and had no problems at that dose; one subsequent 325-mg reaction occurred during a protocol violation. One initial provoking reaction to 325 mg occurred. Both 325-mg reactions were mild, and neither met the forced expiratory volume in 1 second criterion for a clinically meaningful change. The remaining 5 patients could not complete the protocol because of persistent reactions or social reasons. Reactors were more likely to have had asthma for more than 10 years than nonreactors (odds ratio, 3.2; 95% confidence interval, 1.0-10.3; P = .05). CONCLUSION During aspirin desensitization for AERD, provoking reactions at the 325-mg dose are rare (1%) and mild. Patients who react at 162 mg or less and extinguish their reactions may be able to administer the 325-mg dose at home.
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Affiliation(s)
- Charles F Schuler
- Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan.
| | - James L Baldwin
- Division of Allergy and Immunology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan
| | - Alan P Baptist
- Division of Allergy and Immunology, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan
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28
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Cook KA, Stevenson DD. Current complications and treatment of aspirin-exacerbated respiratory disease. Expert Rev Respir Med 2016; 10:1305-1316. [PMID: 27817219 DOI: 10.1080/17476348.2016.1258306] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Aspirin-exacerbated respiratory disease is defined by the clinical tetrad of aspirin sensitivity, nasal polyps, asthma, and chronic rhinosinusitis. Patients experience acute upper and lower airway reactions with exposure to aspirin and other cyclooxygenase-1 inhibiting medications. However, airway inflammation and disease progression occur even in the absence of exposure to these medications, often leading to aggressive polyp formation and need for systemic corticosteroids to treat exacerbations in asthma and rhinosinusitis. Areas covered: This review focuses on the direct and indirect complications of aspirin-exacerbated respiratory disease. Current and potential management strategies are discussed with emphasis on aspirin desensitization. Expert commentary: Aspirin desensitization remains the gold standard of treatment. Demonstrated benefits of desensitization include improved symptom scores, reduction in use of systemic corticosteroids, slowing of polyp regrowth, and tolerance of aspirin and other NSAIDs for various therapeutic purposes. Continued investigation into the pathogenic mechanisms of AERD is likely to yield new diagnostic and therapeutic approaches.
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Affiliation(s)
- Kevin A Cook
- a Division of Allergy, Asthma and Immunology , Scripps Clinic , San Diego , CA , USA
| | - Donald D Stevenson
- a Division of Allergy, Asthma and Immunology , Scripps Clinic , San Diego , CA , USA
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29
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Waldram JD, Simon RA. Performing Aspirin Desensitization in Aspirin-Exacerbated Respiratory Disease. Immunol Allergy Clin North Am 2016; 36:693-703. [PMID: 27712764 DOI: 10.1016/j.iac.2016.06.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aspirin-exacerbated respiratory disease (AERD) is characterized by chronic rhinosinusitis with nasal polyps, asthma, and reactions to cyclooxygenase-1-inhibiting drugs. This condition is often refractory to standard medical treatments and results in aggressive nasal polyposis that often requires multiple sinus surgeries. Aspirin desensitization followed by daily aspirin therapy is an important treatment option, and its efficacy has been validated in multiple research studies. Aspirin desensitization is not without risk, but specific protocols and recommendations exist to mitigate the risk. Most patients with AERD can undergo aspirin desensitization in an outpatient setting under the supervision of an allergist.
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Affiliation(s)
- Jeremy D Waldram
- Department of Allergy and Immunology, Scripps Clinic Carmel Valley, Scripps Clinic, 3811 Valley Centre Drive, Suite 4A, San Diego, CA 92130, USA
| | - Ronald A Simon
- Department of Allergy and Immunology, Scripps Clinic Carmel Valley, Scripps Clinic, 3811 Valley Centre Drive, Suite 4A, San Diego, CA 92130, USA.
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30
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Williams AN. Diagnostic Evaluation in Aspirin-Exacerbated Respiratory Disease. Immunol Allergy Clin North Am 2016; 36:657-668. [PMID: 27712761 DOI: 10.1016/j.iac.2016.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Aspirin-exacerbated respiratory disease (AERD) is a distinct clinical condition characterized by chronic sinusitis with nasal polyps, asthma, and hypersensitivity reactions to nonsteroidal anti-inflammatory drugs (NSAIDs). Distinguishing AERD from other forms of chronic sinusitis, asthma, and NSAID reactivity has important clinical implications for management. The clinical history is helpful, but not adequate for confirming the diagnosis of AERD, in most cases. Diagnostic provocation challenge remains the only way to confirm or exclude the diagnosis of AERD. This article discusses the utility of the clinical history and the current evidence regarding measures that optimize the safety of performing diagnostic NSAID provocation challenges.
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Affiliation(s)
- Adam N Williams
- Department of Allergy, Asthma, and Immunology, Bend Memorial Clinic, 815 Southwest Bond Street, Bend, OR 97702, USA; School of Medicine, Oregon Health and Sciences University, 3181 SW Sam Jackson Park Road, Portland, OR 97239, USA.
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31
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Levy JM, Rudmik L, Peters AT, Wise SK, Rotenberg BW, Smith TL. Contemporary management of chronic rhinosinusitis with nasal polyposis in aspirin-exacerbated respiratory disease: an evidence-based review with recommendations. Int Forum Allergy Rhinol 2016; 6:1273-1283. [PMID: 27480830 DOI: 10.1002/alr.21826] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 05/26/2016] [Accepted: 06/23/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND Chronic rhinosinusitis (CRS) in aspirin-exacerbated respiratory disease (AERD) represents a recalcitrant form of sinonasal inflammation for which a multidisciplinary consensus on patient management has not been reached. Several medical interventions have been investigated, but a formal comprehensive evaluation of the evidence has never been performed. The purpose of this article is to provide an evidence-based approach for the multidisciplinary management of CRS in AERD. METHODS A systematic review of the literature was performed and the guidelines for development of an evidence-based review with recommendations were followed. Study inclusion criteria included: adult population >18 years old; CRS based on published diagnostic criteria, and a presumptive diagnosis of AERD. We focused on reporting higher-quality studies (level 2 or higher) when available, but reported lower-quality studies if the topic contained insufficient evidence. Treatment recommendations were based on American Academy of Otolaryngology (AAO) guidelines, with defined grades of evidence and evaluation of research quality and risk/benefits associated with each treatment. RESULTS This review identified and evaluated the literature on 3 treatment strategies for CRS in AERD: dietary salicylate avoidance, leukotriene modification, and desensitization with daily aspirin therapy. CONCLUSION Based on the available evidence, dietary salicylate avoidance and leukotriene-modifying drugs are options following appropriate treatment with nasal corticosteroids and saline irrigation. Desensitization with daily aspirin therapy is recommended following revision endoscopic sinus surgery (ESS).
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Affiliation(s)
- Joshua M Levy
- Division of Rhinology and Sinus/Skull Base Surgery, Oregon Sinus Center, Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, OR
| | - Luke Rudmik
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
| | - Anju T Peters
- Allergy Division, Department of Internal Medicine, Northwestern University, Chicago, IL
| | - Sarah K Wise
- Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, Atlanta, GA
| | - Brian W Rotenberg
- Department of Otolaryngology-Head and Neck Surgery, Western University, London, Ontario, Canada
| | - Timothy L Smith
- Division of Rhinology and Sinus/Skull Base Surgery, Oregon Sinus Center, Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland, OR
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Mühlmeier G, Hausch R, Maier H. [Adaptive desensitization for acetylsalicylic acid hypersensitivity: A success story?]. HNO 2016; 63:707-14. [PMID: 26395185 DOI: 10.1007/s00106-015-0065-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Adaptive desensitization still remains the only causative therapy for acetylsalicylic acid (ASA) hypersensitivity and is carried out nearly worldwide. To date there are hardly any data available on disease development under current desensitization therapy and longitudinal data in particular are missing. STUDY DESIGN Out of a large collective of patients with proven hypersensitivity to ASA, 194 patients with initiated desensitization treatment were observed for periods up to 5 years (average 32 months). RESULTS Patients with immediate reactions to systemic challenge tests revealed a response rate of 77% after 12 months of therapy. In this period 12% reached complete remission, 38% showed a clear reduction in symptoms, 32% reached partial remission, 13% remained unchanged and 5% suffered from disease progression. CONCLUSION Adaptive desensitization therapy for hypersensitivity to ASA has been shown to be an effective causative therapy and chronic hyperplastic sinusitis as well as bronchial asthma could be improved. For the determination of maintenance dosages and required time periods more data are needed.
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Affiliation(s)
- G Mühlmeier
- Hals-Nasen-Ohren-Heilkunde, Kopf- und Halschirurgie, Bundeswehrkrankenhaus Ulm, Oberer Eselsberg 40, 89081, Ulm, Deutschland.
| | - R Hausch
- Hals-Nasen-Ohren-Heilkunde, Kopf- und Halschirurgie, Bundeswehrkrankenhaus Ulm, Oberer Eselsberg 40, 89081, Ulm, Deutschland
| | - H Maier
- Hals-Nasen-Ohren-Heilkunde, Kopf- und Halschirurgie, Bundeswehrkrankenhaus Ulm, Oberer Eselsberg 40, 89081, Ulm, Deutschland
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Steinke JW, Wilson JM. Aspirin-exacerbated respiratory disease: pathophysiological insights and clinical advances. J Asthma Allergy 2016; 9:37-43. [PMID: 27022293 PMCID: PMC4790533 DOI: 10.2147/jaa.s88739] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Asthma and chronic rhinosinusitis are heterogeneous airway diseases of the lower and upper airways, respectively. Molecular and cellular studies indicate that these diseases can be categorized into unique endotypes, which have therapeutic implications. One such endotype is aspirin-exacerbated respiratory disease (AERD), which encompasses the triad of asthma, aspirin (or nonsteroidal anti-inflammatory drug) hypersensitivity, and nasal polyposis. AERD has unique pathophysiological features that distinguish it from aspirin-tolerant asthma and other forms of chronic rhinosinusitis. This review details molecular and cellular features of AERD and highlights current and future therapies that are based on these insights.
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Affiliation(s)
- John W Steinke
- Asthma and Allergic Disease Center, Carter Immunology Center, Department of Medicine, University of Virginia Health System, Charlottesville, VA, USA
| | - Jeff M Wilson
- Asthma and Allergic Disease Center, Carter Immunology Center, Department of Medicine, University of Virginia Health System, Charlottesville, VA, USA
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Chen JR, Buchmiller BL, Khan DA. An Hourly Dose-Escalation Desensitization Protocol for Aspirin-Exacerbated Respiratory Disease. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2015; 3:926-31.e1. [DOI: 10.1016/j.jaip.2015.06.013] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 06/06/2015] [Accepted: 06/10/2015] [Indexed: 11/17/2022]
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Steinke JW, Borish L. Factors driving the aspirin exacerbated respiratory disease phenotype. Am J Rhinol Allergy 2015; 29:35-40. [PMID: 25590316 DOI: 10.2500/ajra.2015.29.4123] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Aspirin-exacerbated respiratory disease (AERD) is explained in part by overexpression of 5-lipoxygenase and leukotriene C4 synthase (LTC4S), resulting in constitutive overproduction of cysteinyl leukotrienes (CysLTs) and driving the surge in CysLT production that occurs with aspirin ingestion. Similarly, AERD is characterized by the overexpression of CysLT receptors. Increased levels of both interleukin (IL)-4 and interferon (IFN)-γ are present in the tissue of AERD subjects. Previous studies demonstrated that IL-4 is primarily responsible for the up-regulation of LTC4S by mast cells. METHODS Literature review. RESULTS Our previous studies demonstrated that IFN-γ, but not IL-4, drives this process in eosinophils. These published studies also extend to both IL-4 and IFN-γ the ability to up-regulate CysLT receptors. Prostaglandin E2 (PGE2) acts to prevent CysLT secretion by inhibiting mast cell and eosinophil activation. PGE2 concentrations are reduced in AERD, and our published studies confirm that this reflects diminished expression of cyclooxygenase (COX)-2. A process again that is driven by IL-4. Thus, IL-4 and IFN-γ together play an important pathogenic role in generating the phenotype of AERD. Finally, induction of LTC4S and CysLT1 receptors by IL-4 reflects in part the IL-4-mediated activation of signal transducer and activator of transcription 6 (STAT6). Our previous studies demonstrated that aspirin blocks trafficking of STAT6 into the nucleus and thereby prevents IL-4-mediated induction of these transcripts, thereby suggesting a modality by which aspirin desensitization could provide therapeutic benefit for AERD patients. CONCLUSION This review will examine the evidence supporting this model.
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Affiliation(s)
- John W Steinke
- Asthma and Allergic Disease Center, University of Virginia Health System, Charlottesville, VA, USA
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Förster-Ruhrmann U, Zappe SM, Szczepek AJ, Olze H, Rabe U. Long-term clinical effects of aspirin-desensitization therapy among patients with poorly controlled asthma and non-steroidal anti-inflammatory drug hypersensitivity: An exploratory study. REVISTA PORTUGUESA DE PNEUMOLOGIA 2015; 21:S2173-5115(15)00123-2. [PMID: 26482205 DOI: 10.1016/j.rppnen.2015.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Revised: 06/03/2015] [Accepted: 06/05/2015] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND According to the Global Initiative for Asthma (GINA), the levels of asthma symptom control can be divided into controlled, partially controlled and uncontrolled asthma. Optional therapy for non-steroidal anti-inflammatory drugs (NSAIDs)-hypersensitive asthmatics uses aspirin desensitization, but until now, this therapy is not established in difficult to treat cases. The aim of this study was to evaluate the efficacy of aspirin desensitization in patients with poorly controlled asthma. METHODS Patients with poorly controlled asthma, NDAIDs hypersensitivity and aspirin desensitization were included in the retrospective study. The data were compared to those obtained from patients with controlled asthma and aspirin therapy. Lung function, levels of asthma symptom control, asthma medication, the size of nasal polyps (NP) and smell function were evaluated over 18 months. RESULTS Thirty-two patients were included in the study (uncontrolled/partially controlled asthma n=12; controlled asthma n=20). After 18 months of follow-up, the patients with poorly controlled asthma had significantly increased forced expiratory volume in 1s (FEV1) values, as compared to the baseline (66-82%; p=0.02), the levels of asthma control improved significantly (p<0.01). The asthma medication was reduced. In the group of controlled asthma the FEV1 values did not increase significantly (91.9-92.4%; p>0.05) and the asthma medication was constant. In relation to nasal parameters the sense of smell improved significantly in both groups, NP-scores did not differ significantly. CONCLUSIONS Patients with a poorly controlled asthma and NSAIDs hypersensitivity profit from an add-on aspirin therapy.
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Affiliation(s)
- U Förster-Ruhrmann
- Department of Otorhinolaryngology, Campus Virchow, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany.
| | - S-M Zappe
- Department of Otorhinolaryngology, Campus Virchow, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - A J Szczepek
- Department of Otorhinolaryngology, Campus Mitte, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 13353 Berlin, Germany
| | - H Olze
- Department of Otorhinolaryngology, Campus Virchow, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany; Department of Otorhinolaryngology, Campus Mitte, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 13353 Berlin, Germany
| | - U Rabe
- Department of Allergy and Pulmonology, Johanniterstrasse 1, 14929 Treuenbrietzen, Germany
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Spies JW, Valera FCP, Cordeiro DL, de Mendonça TN, Leite MGJ, Tamashiro E, Arruda LK, Anselmo-Lima WT. The role of aspirin desensitization in patients with aspirin-exacerbated respiratory disease (AERD). Braz J Otorhinolaryngol 2015; 82:263-8. [PMID: 26601997 PMCID: PMC9444683 DOI: 10.1016/j.bjorl.2015.04.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 04/15/2015] [Accepted: 04/16/2015] [Indexed: 12/30/2022] Open
Abstract
Introduction Aspirin-exacerbated respiratory disease (AERD) consists of a classic tetrad: moderate/severe asthma, chronic rhinosinusitis, nasal polyps, and intolerance to aspirin or other nonsteroidal anti-inflammatory drugs. Clinical control with drugs, surgery, and desensitization are treatment options. Objective To evaluate the efficacy and tolerability of aspirin desensitization in patients with AERD. Methods Periodic symptom assessment and endoscopy in patients with AERD undergoing surgery who were desensitized. Results Seventeen patients were desensitized. Eight patients completed the desensitization and were followed for a minimum of a one-year period (mean 3.1 years). These patients showed improvement in all symptoms. Moreover, surgical reassessment was not indicated in any of these patients and there was a decrease in costs with medication and procedures. Eight patients did not complete desensitization, mainly due to procedure intolerance and uncontrolled asthma, whereas another patient was lost to follow-up. Conclusion Aspirin desensitization, when tolerated, was effective in patients with AERD and with poor clinical/surgical response.
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Affiliation(s)
- Jonas Willian Spies
- Department of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (USP), Ribeirão Preto, SP, Brazil
| | - Fabiana Cardoso Pereira Valera
- Department of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (USP), Ribeirão Preto, SP, Brazil
| | - Daniel Loiola Cordeiro
- Department of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (USP), Ribeirão Preto, SP, Brazil
| | - Taís Nociti de Mendonça
- Department of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (USP), Ribeirão Preto, SP, Brazil
| | - Marcelo Gonçalves Junqueira Leite
- Department of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (USP), Ribeirão Preto, SP, Brazil
| | - Edwin Tamashiro
- Department of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (USP), Ribeirão Preto, SP, Brazil
| | - Luiza Karla Arruda
- Department of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (USP), Ribeirão Preto, SP, Brazil
| | - Wilma Terezinha Anselmo-Lima
- Department of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo (USP), Ribeirão Preto, SP, Brazil.
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Simon RA, Dazy KM, Waldram JD. Update on aspirin desensitization for chronic rhinosinusitis with polyps in aspirin-exacerbated respiratory disease (AERD). Curr Allergy Asthma Rep 2015; 15:508. [PMID: 25663486 DOI: 10.1007/s11882-014-0508-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Aspirin-exacerbated respiratory disease (AERD) is a clinical condition which results in adverse upper and lower respiratory symptoms, particularly rhinitis, conjunctivitis, bronchospasm, and/or laryngospasm, following exposure to cyclooxygenase-1 (COX-1) inhibiting drugs, namely aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs). A provocative aspirin challenge is the gold standard for diagnosis of AERD. Aspirin desensitization and continuous aspirin therapy has been highly efficacious in those patients with suboptimal control of their disease on current available pharmacotherapy or those with other underlying conditions (i.e., cardiovascular disease) who may require frequent treatment with aspirin or NSAIDs. This review article focuses on aspirin desensitization and the management of patients with AERD with a particular emphasis on outcomes in those patients with chronic rhinosinusitis and nasal polyposis.
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Affiliation(s)
- Ronald A Simon
- Division of Allergy, Asthma and Immunology, Scripps Clinic, 3811 Valley Centre Drive, San Diego, CA, 92130, USA,
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Simon RA, Dazy KM, Waldram JD. Aspirin-exacerbated respiratory disease: characteristics and management strategies. Expert Rev Clin Immunol 2015; 11:805-17. [PMID: 25936612 DOI: 10.1586/1744666x.2015.1039940] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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.
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Affiliation(s)
- Ronald A Simon
- Scripps Clinic, Division of Allergy, Asthma and Immunology, 3811 Valley Centre Drive, San Diego, CA 92130, USA
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Peters AT, Spector S, Hsu J, Hamilos DL, Baroody FM, Chandra RK, Grammer LC, Kennedy DW, Cohen NA, Kaliner MA, Wald ER, Karagianis A, Slavin RG. Diagnosis and management of rhinosinusitis: a practice parameter update. Ann Allergy Asthma Immunol 2015; 113:347-85. [PMID: 25256029 DOI: 10.1016/j.anai.2014.07.025] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 07/22/2014] [Indexed: 02/06/2023]
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Makowska J, Makowski M, Kowalski ML. NSAIDs Hypersensitivity: When and How to Desensitize? CURRENT TREATMENT OPTIONS IN ALLERGY 2015. [DOI: 10.1007/s40521-015-0049-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Lambrakis P, Rushworth GF, Adamson J, Leslie SJ. Aspirin hypersensitivity and desensitization protocols: implications for cardiac patients. Ther Adv Drug Saf 2014; 2:263-70. [PMID: 25083218 DOI: 10.1177/2042098611422558] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Aspirin or acetylsalicylic acid is an important therapy for many cardiology patients but hypersensitivity to this drug affects around 1% of the population and intolerance may affect up to 20%. While alternative medications to aspirin are available, in many cases there is a compelling need for aspirin therapy. In these patients, aspirin desensitization may be considered. However, this is a complex issue with a lack of international standardization. This article reviews the available evidence for aspirin desensitization and provides practical advice for the management of these patients.
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Affiliation(s)
| | - Gordon F Rushworth
- Highland Clinical Research Facility, Centre for Health Science, Inverness, UK
| | | | - Stephen J Leslie
- Consultant Cardiologist, Cardiac Unit, Raigmore Hospital, Inverness IV2 3UJ, and University of Stirling, Highland Campus, Old Perth Road, Inverness IV2 3JH, UK
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Świerczyńska-Krępa M, Sanak M, Bochenek G, Stręk P, Ćmiel A, Gielicz A, Plutecka H, Szczeklik A, Niżankowska-Mogilnicka E. Aspirin desensitization in patients with aspirin-induced and aspirin-tolerant asthma: a double-blind study. J Allergy Clin Immunol 2014; 134:883-90. [PMID: 24767875 DOI: 10.1016/j.jaci.2014.02.041] [Citation(s) in RCA: 100] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Revised: 02/23/2014] [Accepted: 02/28/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND Numerous open trials have demonstrated the beneficial clinical effects of aspirin desensitization (AD) in patients with aspirin-induced asthma (AIA). These beneficial effects might be attributable to aspirin's potent anti-inflammatory properties, but that supposition requires further corroboration. OBJECTIVE We sought to compare the clinical and biochemical responses to chronic oral AD in 20 patients with AIA and 14 patients with aspirin-tolerant asthma (ATA). All of the patients had chronic rhinosinusitis and nasal polyposis, and these responses were investigated in a pilot, double-blind, placebo-controlled study. METHODS Twelve patients with AIA and 6 patients with ATA were randomly assigned to receive 624 mg of aspirin, and 8 patients with AIA and 8 patients with ATA received placebo. Both aspirin and placebo were administered once daily for 6 months. Nasal symptoms, Sino-Nasal Outcome Test (SNOT20) scores, peak nasal inspiratory flows, Asthma Control Questionnaire scores, spirometric parameters, peak expiratory flows, blood eosinophilia, and corticosteroid doses were assessed on a monthly basis. Levels of urinary leukotriene E4 and the stable plasma prostaglandin (PG) D2 metabolite 9α,11β-PGF2 were evaluated at baseline and after 1, 3, 5, and 6 months. RESULTS Only the patients with AIA subjected to AD reported improvements in smell and reductions in sneezing and nasal blockade. The SNOT20 and Asthma Control Questionnaire scores of these patients decreased, and their peak nasal inspiratory flows increased. The dosages of inhaled corticosteroids were reduced. There were no changes in leukotriene E(4) or 9α,11β-PGF(2) levels after AD. CONCLUSION The clinically beneficial effects of AD on nasal and bronchial symptoms occurred only in the patients with AIA.
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Affiliation(s)
| | - Marek Sanak
- Division of Pulmonology, Department of Medicine, Jagiellonian University School of Medicine, Krakow, Poland
| | - Grażyna Bochenek
- Division of Pulmonology, Department of Medicine, Jagiellonian University School of Medicine, Krakow, Poland
| | - Paweł Stręk
- Department of Otolaryngology, Jagiellonian University School of Medicine, Krakow, Poland
| | - Adam Ćmiel
- Department of Applied Mathematics, AGH University of Science and Technology, Krakow, Poland
| | - Anna Gielicz
- Division of Pulmonology, Department of Medicine, Jagiellonian University School of Medicine, Krakow, Poland
| | - Hanna Plutecka
- Division of Pulmonology, Department of Medicine, Jagiellonian University School of Medicine, Krakow, Poland
| | - Andrzej Szczeklik
- Division of Pulmonology, Department of Medicine, Jagiellonian University School of Medicine, Krakow, Poland
| | - Ewa Niżankowska-Mogilnicka
- Division of Pulmonology, Department of Medicine, Jagiellonian University School of Medicine, Krakow, Poland.
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Woessner KM, White AA. Evidence-based approach to aspirin desensitization in aspirin-exacerbated respiratory disease. J Allergy Clin Immunol 2014; 133:286-7.e1-9. [PMID: 24369807 DOI: 10.1016/j.jaci.2013.11.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Revised: 11/15/2013] [Accepted: 11/18/2013] [Indexed: 10/25/2022]
Affiliation(s)
- Katharine M Woessner
- Division of Allergy, Asthma and Immunology, Scripps Clinic Medical Group, San Diego, Calif.
| | - Andrew A White
- Division of Allergy, Asthma and Immunology, Scripps Clinic Medical Group, San Diego, Calif
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Scott DR, White AA. Approach to desensitization in aspirin-exacerbated respiratory disease. Ann Allergy Asthma Immunol 2014; 112:13-7. [PMID: 24331387 DOI: 10.1016/j.anai.2013.09.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Revised: 08/28/2013] [Accepted: 09/01/2013] [Indexed: 11/26/2022]
Affiliation(s)
- David R Scott
- Scripps Clinic Division of Allergy, Asthma and Immunology, San Diego, California.
| | - Andrew A White
- Scripps Clinic Division of Allergy, Asthma and Immunology, San Diego, California
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McMullan KL. Aspirin allergy in patients with myocardial infarction: the allergist's role. Ann Allergy Asthma Immunol 2013; 112:90-3. [PMID: 24468245 DOI: 10.1016/j.anai.2013.11.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2013] [Revised: 11/05/2013] [Accepted: 11/24/2013] [Indexed: 11/26/2022]
Affiliation(s)
- Kathryn L McMullan
- Division of Clinical Immunology and Allergy, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi.
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Primary Cutaneous Vasculitis Masquerading as Drug Induced following Aspirin Desensitization. Case Rep Med 2013; 2013:745714. [PMID: 24348575 PMCID: PMC3857825 DOI: 10.1155/2013/745714] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Revised: 10/08/2013] [Accepted: 10/14/2013] [Indexed: 11/17/2022] Open
Abstract
Aspirin-exacerbated respiratory disease (AERD) is a well-known clinical condition. Aspirin desensitization followed by daily aspirin therapy is the treatment of choice. We report a challenging case of primary cutaneous vasculitis following aspirin desensitization in a patient with AERD. The vasculitis was likely suppressed with higher dose systemic steroid use to control asthma. Aspirin desensitization led to improved asthma control and steroid reduction, which led to manifestation of prior suppressed cutaneous vasculitis. In our case, there was no evidence of systemic involvement and the patient had a favorable outcome with appropriate therapy.
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Comert S, Celebioglu E, Yucel T, Erdogan T, Karakaya G, Onerci M, Kalyoncu AF. Aspirin 300 mg/day is effective for treating aspirin-exacerbated respiratory disease. Allergy 2013; 68:1443-51. [PMID: 24117703 DOI: 10.1111/all.12269] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND Aspirin desensitization (AD) treatment at doses of up to 1300 mg/day improves outcomes in aspirin-exacerbated respiratory disease (AERD). The aim of this study was to investigate the efficacy of aspirin 300 mg/day in the treatment of patients with AERD. METHODS The study included 40 patients diagnosed in our clinic as AERD that were desensitized and treated with aspirin 300 mg/day between December 2005 and December 2012. Changes from the baseline status were analyzed at 1 year and at 3 years of follow-up. RESULTS Of the 40 patients included, 24 (60%) were female and median (interquartile range [IQR]) age was 45 (40-51) years. Median (IQR) duration of AD was 31.5 (10.5-48.5) months. In total, 29 patients continued treatment for at least 1 year and 18 patients for at least 3 years. The annual rate of use of systemic corticosteroid regimens, episodes of sinusitis, and surgery was significantly lower both at 1 year (P = 0.002, P = 0.01, and P < 0.001, respectively) and at 3 years (P = 0.001, P = 0.03, and P = 0.002, respectively). Significant improvement was observed in the nasal congestion score (P = 0.01) and sense of smell score (P = 0.05) at 1 year and in the postnasal drainage score (P = 0.01) at 3 years. CONCLUSION Daily treatment with aspirin 300 mg had beneficial effects in patients with AERD, especially for the control of upper airway disease.
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Affiliation(s)
- S. Comert
- Division of Immunology and Allergy; Department of Chest Diseases; School of Medicine; Hacettepe University; Ankara Turkey
| | - E. Celebioglu
- Division of Immunology and Allergy; Department of Chest Diseases; School of Medicine; Hacettepe University; Ankara Turkey
| | - T. Yucel
- Department of Otorhinolaryngology; School of Medicine; Hacettepe University; Ankara Turkey
| | - T. Erdogan
- Division of Immunology and Allergy; Department of Chest Diseases; School of Medicine; Hacettepe University; Ankara Turkey
| | - G. Karakaya
- Division of Immunology and Allergy; Department of Chest Diseases; School of Medicine; Hacettepe University; Ankara Turkey
| | - M. Onerci
- Department of Otorhinolaryngology; School of Medicine; Hacettepe University; Ankara Turkey
| | - A. F. Kalyoncu
- Division of Immunology and Allergy; Department of Chest Diseases; School of Medicine; Hacettepe University; Ankara Turkey
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Jin S, Wang Y, Zhu H, Wang Y, Zhao S, Zhao M, Liu J, Wu J, Gao W, Peng S. Nanosized aspirin-Arg-Gly-Asp-Val: delivery of aspirin to thrombus by the target carrier Arg-Gly-Asp-Val tetrapeptide. ACS NANO 2013; 7:7664-73. [PMID: 23931063 DOI: 10.1021/nn402171v] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Resistance and nonresponse to aspirin dramatically decreases its therapeutic efficacy. To overcome this issue, a small-molecule thrombus-targeting drug delivery system, aspirin-Arg-Gly-Asp-Val (A-RGDV), is developed by covalently linking Arg-Gly-Asp-Val tetrapeptide with aspirin. The 2D ROESY NMR and ESI-MS spectra support a molecular model of an A-RGDV tetramer. Transmission electron microscopy images suggest that the tetramer spontaneously assembles to nanoparticles (ranging from 5 to 50 nm in diameter) in water. Scanning electron microscopy images and atomic force microscopy images indicate that the smaller nanoparticles of A-RGDV further assemble to bigger particles that are stable in rat blood. The delivery investigation implies that in rat blood A-RGDV is able to keep its molecular integrity, while in a thrombus it releases aspirin. The in vitro antiplatelet aggregation assay suggests that A-RGDV selectively inhibits arachidonic acid induced platelet aggregation. The mechanisms of action probably include releasing aspirin, modifying cyclic oxidase, and decreasing the expression of GPIIb/IIIa. The in vivo assay demonstrates that the effective antithrombotic dose of A-RGDV is 16700-fold lower than the nonresponsive dose of aspirin.
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Affiliation(s)
- Shaoming Jin
- College of Pharmaceutical Sciences, Capital Medical University , Beijing 100069, People's Republic of China
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