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Grimaldi S, Migliorini P, Puxeddu I, Rossini R, De Caterina R. Aspirin hypersensitivity: a practical guide for cardiologists. Eur Heart J 2024; 45:1716-1726. [PMID: 38666370 DOI: 10.1093/eurheartj/ehae128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 02/08/2024] [Accepted: 02/15/2024] [Indexed: 05/22/2024] Open
Abstract
Aspirin has been known for a long time and currently stays as a cornerstone of antithrombotic therapy in cardiovascular disease. In patients with either acute or chronic coronary syndromes undergoing percutaneous coronary intervention aspirin is mandatory in a dual antiplatelet therapy regimen for prevention of stent thrombosis and/or new ischaemic events. Aspirin is also currently a first-option antithrombotic therapy after an aortic prosthetic valve replacement and is occasionally required in addition to oral anticoagulants after implantation of a mechanical valve. Presumed or demonstrated aspirin hypersensitivity is a main clinical problem, limiting the use of a life-saving medication. In the general population, aspirin hypersensitivity has a prevalence of 0.6%-2.5% and has a plethora of clinical presentations, ranging from aspirin-exacerbated respiratory disease to anaphylaxis. Although infrequent, when encountered in clinical practice aspirin hypersensitivity poses for cardiologists a clinical dilemma, which should never be trivialized, avoiding-as much as possible-omission of the drug. We here review the epidemiology of aspirin hypersensitivity, provide an outline of pathophysiological mechanisms and clinical presentations, and review management options, starting from a characterization of true aspirin allergy-in contrast to intolerance-to suggestion of desensitization protocols.
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Affiliation(s)
- Silvia Grimaldi
- Postgraduate School of Cardiology, University of Pisa and Cardiovascular Division, Pisa University Hospital, Via Paradisa 2, 56124 Pisa, Italy
| | - Paola Migliorini
- Postgraduate School of Clinical Immunology, University of Pisa, Pisa, Italy
| | - Ilaria Puxeddu
- Postgraduate School of Clinical Immunology, University of Pisa, Pisa, Italy
| | - Roberta Rossini
- Cardiology Division, S. Croce e Carle Hospital, Cuneo, Italy
| | - Raffaele De Caterina
- Postgraduate School of Cardiology, University of Pisa and Cardiovascular Division, Pisa University Hospital, Via Paradisa 2, 56124 Pisa, Italy
- Fondazione VillaSerena per la Ricerca, Viale L. Petruzzi 42, 65013 Città S. Angelo, Pescara, Italy
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Laidlaw TM, White AA. Should Biologics Be Used Before Aspirin Desensitization in Aspirin-Exacerbated Respiratory Disease? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:79-84. [PMID: 37778627 PMCID: PMC10842409 DOI: 10.1016/j.jaip.2023.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 09/13/2023] [Accepted: 09/14/2023] [Indexed: 10/03/2023]
Abstract
There has been a paradigm shift in the management of aspirin-exacerbated respiratory disease (AERD). It started in 2015 when the first biologic was Food and Drug Administration (FDA) approved for severe eosinophilic asthma. Thus, there emerged a new era in the treatment of patients with type 2-mediated airway diseases. This has led to an increasing number of options for patients, undoubtably a great thing, but has left clinicians without a clear answer for how to balance the therapies that exist for AERD, what to recommend for treatment, and how to best assess the benefits and risks of each therapy. This paper aims to explore these benefits and risks, and to provide a roadmap for future studies.
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Affiliation(s)
- Tanya M Laidlaw
- Division of Allergy and Clinical Immunology, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
| | - Andrew A White
- Division of Allergy, Asthma, and Immunology, Scripps Clinic, San Diego, Calif
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Landa E, Javaid S, Vigandt E, Campos F, Mercado L. Aspirin-Exacerbated Respiratory Disease Requiring Desensitization Prior to Planned Percutaneous Catheterization Intervention. Cureus 2022; 14:e26686. [PMID: 35949785 PMCID: PMC9359106 DOI: 10.7759/cureus.26686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2022] [Indexed: 11/18/2022] Open
Abstract
Aspirin-exacerbated respiratory disease (AERD) consists of a triad of asthma, chronic rhinosinusitis with nasal polyposis, and a hypersensitivity reaction to aspirin consisting of nasal congestion and broncho-constriction. This disease presents a conundrum in cardiac patients undergoing percutaneous catheterization intervention (PCI) who might require stent deployment due to the need for aspirin as part of the dual antiplatelet therapy required if a stent is placed. Here, we present the case of a patient who underwent a coronary angiogram showing two-vessel disease but had to undergo aspirin desensitization first before planned PCI as he had a history of severe aspirin allergy in the past.
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Mullol J, Laidlaw TM, Bachert C, Mannent LP, Canonica GW, Han J, Maspero JF, Picado C, Daizadeh N, Ortiz B, Li Y, Ruddy M, Laws E, Amin N. Efficacy and safety of dupilumab in patients with uncontrolled severe chronic rhinosinusitis with nasal polyps and a clinical diagnosis of NSAID-ERD: Results from two randomized placebo-controlled phase 3 trials. Allergy 2022; 77:1231-1244. [PMID: 34459002 PMCID: PMC9292324 DOI: 10.1111/all.15067] [Citation(s) in RCA: 49] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 08/12/2021] [Indexed: 12/19/2022]
Abstract
Background About one‐tenth of patients with difficult‐to‐treat chronic rhinosinusitis with nasal polyps (CRSwNP) have comorbid non‐steroidal anti‐inflammatory drug‐exacerbated respiratory disease (NSAID‐ERD). Dupilumab, a fully human monoclonal antibody that blocks the shared interleukin (IL)‐4/IL‐13 receptor component, is an approved add‐on treatment in severe CRSwNP. This post hoc analysis evaluated dupilumab efficacy and safety in patients with CRSwNP with/without NSAID‐ERD. Methods Data were pooled from the phase 3 SINUS‐24 and SINUS‐52 studies in adults with uncontrolled severe CRSwNP who received dupilumab 300 mg or placebo every 2 weeks. CRSwNP, nasal airflow, lung function, and asthma control outcomes at Week 24 were evaluated, and treatment–subgroup interactions were assessed for patients with and without NSAID‐ERD. Results Of 724 patients, 204 (28.2%) had a diagnosis of NSAID‐ERD. At Week 24, least squares mean treatment differences demonstrated significant improvements in nasal polyp score, nasal congestion (NC), Lund–Mackay computed tomography, 22‐item Sinonasal Outcome Test (SNOT‐22), Total Symptom Score (TSS), rhinosinusitis severity visual analog scale, peak nasal inspiratory flow (PNIF), six‐item Asthma Control Questionnaire score, and improvement in smell with dupilumab versus placebo (all p < .0001) in patients with NSAID‐ERD. Treatment comparisons demonstrated significantly greater improvements with dupilumab in patients with versus without NSAID‐ERD for NC (p = .0044), SNOT‐22 (p = .0313), TSS (p = .0425), and PNIF (p = .0123). Conclusions In patients with uncontrolled severe CRSwNP, dupilumab significantly improved objective measures and patient‐reported symptoms to a greater extent in the presence of comorbid NSAID‐ERD than without. Dupilumab was well tolerated in patients with/without NSAID‐ERD.
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Affiliation(s)
- Joaquim Mullol
- Rhinology Unit & Smell Clinic, ENT Department Hospital ClínicIDIBAPSUniversitat de BarcelonaCIBERES Barcelona Catalonia Spain
| | - Tanya M. Laidlaw
- Division of Allergy and Clinical Immunology Brigham and Women's Hospital, and Harvard Medical School Boston Massachusetts USA
| | - Claus Bachert
- Upper Airways Research Laboratory and Department of Otorhinolaryngology Ghent University Ghent Belgium
- Division of ENT Diseases, CLINTEX Karolinska Institutet Stockholm Sweden
- First Affiliated Hosptial Sun Yat‐sen University Guangzhou China
| | | | - G. Walter Canonica
- Department of Biomedical Sciences Humanitas University, Personalized Medicine Asthma & Allergy Unit‐IRCCS Humanitas Research Hospital, Rozzano Milan Italy
| | - Joseph K. Han
- Department of Otolaryngology & Head and Neck Surgery Eastern Virginia Medical School Norfolk Virginia USA
| | - Jorge F. Maspero
- Allergy and Respiratory Medicine Fundación CIDEA Buenos Aires Argentina
| | - Cesar Picado
- Clinical & Experimental Respiratory Immunoallergy IDIBAPS, Universitat de Barcelona, CIBERES Barcelona Catalonia Spain
| | | | - Benjamin Ortiz
- Immunology and Allergy Medical Affairs Regeneron Pharmaceuticals, Inc. New York USA
| | - Yongtao Li
- Global Medical Affairs Respiratory Sanofi Bridgewater New Jersey USA
| | - Marcella Ruddy
- Clinical Sciences Global Development Regeneron Pharmaceuticals, Inc. Tarrytown New Jersey USA
| | - Elizabeth Laws
- Immunology and Inflammation Sanofi Bridgewater New Jersey USA
| | - Nikhil Amin
- Clinical Sciences Global Development Regeneron Pharmaceuticals, Inc. Tarrytown New Jersey USA
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Corey KB, Cahill KN. Aspirin-Exacerbated Respiratory Disease: A Unique Case of Drug Hypersensitivity. Immunol Allergy Clin North Am 2022; 42:421-432. [DOI: 10.1016/j.iac.2021.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Pendolino AL, Scadding GK, Scarpa B, Andrews PJ. A retrospective study on long-term efficacy of intranasal lysine-aspirin in controlling NSAID-exacerbated respiratory disease. Eur Arch Otorhinolaryngol 2021; 279:2473-2484. [PMID: 34480600 PMCID: PMC8986745 DOI: 10.1007/s00405-021-07063-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 08/27/2021] [Indexed: 11/26/2022]
Abstract
Purpose Aspirin treatment after desensitization (ATAD) represents an effective therapeutic option suitable for NSAID-exacerbated respiratory disease (N-ERD) patients with recalcitrant disease. Intranasal administration of lysine-aspirin (LAS) has been suggested as a safer and faster route than oral ATAD but evidence for its use is less strong. We investigated nasal LAS therapy long-term efficacy based on objective outcomes, smell function, polyp recurrence and need for surgery or rescue therapy. Clinical biomarkers predicting response to intranasal LAS, long-term side effects and consequences of discontinuing treatment have been evaluated. Methods A retrospective analysis of a database of 60 N-ERD patients seen between 2012 and 2020 was performed in March 2021. They were followed up at 3-months, 1-, 2- and 3-years with upper and lower airway functions assessed at each follow-up. Results Higher nasal airflow and smell scores were found at each follow-up in patients taking LAS (p < 0.001 and p = 0.048 respectively). No influence of LAS on pulmonary function measurements was observed. Patient on intranasal LAS showed a lower rate of revision sinus surgery when compared to those who discontinued the treatment (p < 0.001). None of the variables studied was found to influence LAS treatment response. Conclusion Our study demonstrates the clinical effectiveness of long-term intranasal LAS in the management of N-ERD in terms of improved nasal airflow and olfaction and a reduced need for revision sinus surgery. Intranasal LAS is safe, being associated with a lower rate of side effects when compared to oral ATAD. However, discontinuation of the treatment at any stage is associated with a loss of clinical benefit.
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Affiliation(s)
- Alfonso Luca Pendolino
- Department of ENT, Royal National ENT & Eastman Dental Hospitals, 47-49 Huntley St, Bloomsbury, London, WC1E 6DG, UK.
- Ear Institute, University College London, London, UK.
| | - Glenis K Scadding
- Department of ENT, Royal National ENT & Eastman Dental Hospitals, 47-49 Huntley St, Bloomsbury, London, WC1E 6DG, UK
- Faculty of Medical Sciences, University College London, London, UK
| | - Bruno Scarpa
- Department of Statistical Sciences and Department of Mathematics Tullio Levi-Civita, University of Padua, Padua, Italy
| | - Peter J Andrews
- Department of ENT, Royal National ENT & Eastman Dental Hospitals, 47-49 Huntley St, Bloomsbury, London, WC1E 6DG, UK
- Ear Institute, University College London, London, UK
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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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Can nasal acetylsalicylic acid challenge predict the severity of non-steroidal anti-inflammatory drugs (NSAIDs)-exacerbated respiratory disease (N-ERD)?
. Allergol Select 2021; 4:135-143. [PMID: 33393939 PMCID: PMC7771579 DOI: 10.5414/alx01996e] [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: 09/04/2017] [Accepted: 12/05/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Non-steroidal anti-inflammatory drugs (NSAIDs)-exacerbated respiratory disease (N-ERD) complicates the clinical course of chronic rhinosinusitis with nasal polyps (CRSwNP) and severe asthma. We aimed to determine the detection rate of NERD in patients with CRSwNP, asthma, and history of NSAID intolerance using nasal challenge with acetylsalicylic acid (ASA) and the relationship between the severities of response to ASA challenges and the grade of N-ERD. MATERIALS AND METHODS Three groups of patients were included: CRSwNP with asthma and clinical history of analgesics intolerance (CRSwNP-AAI n = 18), CRSwNP with asthma but without a clinical history of analgesics intolerance (CRSwNP-A n = 20), and CRSwNP without asthma or analgesics intolerance (n = 18). All subjects were challenged nasally with 16 mg ASA and monitored with active anterior rhinomanometry. Rhinological (nasal polyp score), pulmonary (spirometry, Asthma Control Test (ACT), and asthma treatment), and psychometric questionnaire scores were recorded and correlated with rhinomanometric data following nasal challenges (flow depressions and symptom scores). RESULTS Nasal ASA challenge detected N-ERD in 96.7% of CRSwNP-AAI patients and 45% of CRSwNP-A patients. No N-ERD was seen in the CRSwNP group. The control grade of asthma measured with ACT scores was significantly lower in the groups CRSwNP-AAI (MV 18.22) and CRSwNP-A (MV 19.75) when compared to the CRSwNP group (MV 24.39) (p = 0.000). In the CRSwNP-AAI group, 11 patients had uncontrolled asthma (61%), and in the CRSwNP-A group, 9 patients had uncontrolled asthma (45%). No correlation was found between rhinology and pulmonary parameters, nasal symptoms, and the severity of nasal ASA challenges. Specific reactions were detectable under the therapy of prednisolone and omalizumab. CONCLUSION N-ERD might not always be detected by screening a patient's medical history. Nasal ASA challenges are recommended in patients with CRSwNP and asthma. The nasal challenge with ASA positively confirms the N-ERD diagnosis. Moreover, N-ERD is a differential diagnosis in patients with severe asthma with the need for prednisolone or omalizumab therapy. The severity of the reaction to the ASA challenge in controlled and uncontrolled asthma patients is independent of the grade of N-ERD.
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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: 68] [Impact Index Per Article: 17.0] [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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Aspirin Desensitization: Faster Protocols for Busy Patients. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 7:1181-1183. [PMID: 30961839 DOI: 10.1016/j.jaip.2018.10.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 10/08/2018] [Indexed: 11/20/2022]
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Luskin KT, Bosso JV, Simon RA. Intranasal ketorolac-induced pancreatitis as a complication of modified oral aspirin desensitization in a patient with aspirin-exacerbated respiratory disease. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 8:1147-1148. [PMID: 31678291 DOI: 10.1016/j.jaip.2019.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 09/24/2019] [Accepted: 10/10/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Kathleen T Luskin
- Division of Allergy, Asthma and Immunology, Scripps Clinic, San Diego, Calif
| | - John V Bosso
- Penn Medicine, Penn AERD Center, Philadelphia, Pa.
| | - Ronald A Simon
- Division of Allergy, Asthma and Immunology, Scripps Clinic, San Diego, Calif
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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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Pelletier T, Roizen G, Ren Z, Hudes G, Rosenstreich D, Jerschow E. Comparable safety of 2 aspirin desensitization protocols for aspirin exacerbated respiratory disease. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 7:1319-1321. [PMID: 30144584 DOI: 10.1016/j.jaip.2018.08.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 07/26/2018] [Accepted: 08/08/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Teresa Pelletier
- Division of Allergy & Immunology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, NY
| | - Gigia Roizen
- Division of Allergy & Immunology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, NY
| | - Zhen Ren
- Division of Allergy & Immunology, Washington University School of Medicine, Barnes Jewish Hospital, St Louis, Mo
| | - Golda Hudes
- Division of Allergy & Immunology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, NY
| | - David Rosenstreich
- Division of Allergy & Immunology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, NY
| | - Elina Jerschow
- Division of Allergy & Immunology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, NY.
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Al-Ahmad M, Rodriguez-Bouza T, Nurkic M. Establishing a Safe Administration of ASA in Cardiovascular Patients with Nonsteroidal Anti-Inflammatory Drug Hypersensitivity with Skin and/or Respiratory Involvement. Int Arch Allergy Immunol 2018; 175:237-245. [DOI: 10.1159/000486415] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 12/18/2017] [Indexed: 01/02/2023] Open
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15
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Aspirin and Nonsteroidal Antiinflammatory Drugs Hypersensitivity and Management. Immunol Allergy Clin North Am 2017; 37:727-749. [PMID: 28965637 DOI: 10.1016/j.iac.2017.07.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Aspirin and nonsteroidal antiinflammatory drugs (NSAIDs) are widely used in the United States and throughout the world for a variety of indications. Several unique hypersensitivity syndromes exist to this class of medications, making them one of the common reasons for consultation to the allergist. The lack of any laboratory-based diagnostic studies to assist in identifying the culprits in these reactions make evaluation of aspirin and NSAID hypersensitivity challenging. Identifying patients appropriate for oral challenge and/or desensitization protocols is the standard pragmatic approach to this issue when it arises.
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Cook KA, Modena BD, Wineinger NE, Woessner KM, Simon RA, White AA. Use of a composite symptom score during challenge in patients with suspected aspirin-exacerbated respiratory disease. Ann Allergy Asthma Immunol 2017; 118:597-602. [PMID: 28477789 DOI: 10.1016/j.anai.2017.02.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 02/08/2017] [Accepted: 02/16/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Aspirin-exacerbated respiratory disease is characterized by asthma, chronic rhinosinusitis, nasal polyposis, and sensitivity to aspirin and other nonsteroidal anti-inflammatory drugs. Confirmation of the diagnosis requires provocation challenge with resulting upper and/or lower airways reactivity. Currently, determination of a positive challenge result is based solely on clinical judgment that synthesizes subjective symptoms and objective measures, as a concomitant increase in nasal or bronchial airways resistance is measured in only half of patients. OBJECTIVE To describe a quantitative scoring system, based on symptoms typically reported during provocation challenge, used to identify a positive challenge result. METHODS A total of 115 patients were asked to record 10 symptoms, rated on a scale from 1 (mild) to 10 (most severe), at regular intervals during intranasal ketorolac with modified oral aspirin challenge performed in our office. Composite scores, a simple sum of all individual scores, were calculated at each time point and compared with baseline, prechallenge values. RESULTS One hundred of the 115 patients were determined to have a positive challenge result. A statistically significant difference in composite scores was observed in reactors vs nonreactors. All nonreactors recorded an increase in composite score of less than 5, whereas 69% of reactors recorded an increase of 5 or more. CONCLUSION Our 10-symptom composite score provides a quantitative and comparable measure of symptoms that typically present during a challenge with a positive result. Although an external validation is needed to confirm its diagnostic performance characteristics, a change in composite score of 5 or more appears to be specific to reactors.
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Affiliation(s)
- Kevin A Cook
- Division of Allergy, Asthma and Immunology, Scripps Clinic, San Diego, California.
| | - Brian D Modena
- Division of Allergy, Asthma and Immunology, Scripps Clinic, San Diego, California
| | | | - Katharine M Woessner
- Division of Allergy, Asthma and Immunology, Scripps Clinic, San Diego, California
| | - Ronald A Simon
- Division of Allergy, Asthma and Immunology, Scripps Clinic, San Diego, California
| | - Andrew A White
- Division of Allergy, Asthma and Immunology, Scripps Clinic, San Diego, California
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Abstract
Aspirin-exacerbated respiratory disease (AERD) is an acquired disease characterized by chronic eosinophilic airway inflammation with underlying dysregulation of arachidonic acid metabolism. The purpose of this paper is to review the latest developments in our understanding of the underlying pathophysiology including the role of eosinophils, mast cells, innate lymphoid cells (ILC2), and platelets. Clinical features such as respiratory reactions induced by alcohol, aggressive nasal polyposis, and anosmia will allow for earlier recognition of these patients in clinical practice. The current state of the art management of AERD will be addressed including the ongoing central role for aspirin desensitization and high-dose aspirin therapy.
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Affiliation(s)
- Katharine M Woessner
- Allergy, Asthma, and Immunology Division, Scripps Clinic Medical Group, 3811 Valley Centre Drive, San Diego, CA, 92130, USA.
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18
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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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19
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Borgeat Kaeser A, Ribi C. [Not Available]. PRAXIS 2017; 106:1243-1249. [PMID: 29088964 DOI: 10.1024/1661-8157/a002830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Zusammenfassung. Das Widal-Syndrom umfasst eine klinische Trias mit chroniquer Rhinosinusitis und nasalen Polypen, Asthma bronchiale und eine Unverträglichkeit auf Acetylsalicylsäure (Aspirin) und anderen nichtsteroidalen Entzündungshemmern (NSAID). Etwa 7 % der Asthmatiker und 10 % der Patienten mit chronischer Rhinosinusitis leiden darunter. Asthma und NSAID-Unverträglichkeit treten häufig mehrere Jahre nach Beginn der Rhinosinusitis auf, was zur Verzögerung der Diagnose führt. Zurzeit gibt es keine spezifischen Biomarker. Der Provokationstest mit Aspirin bleibt der Gold-Standard für die Diagnose, sollte aber wegen des Risikos eines schweren Asthmaanfalls nur durch den Spezialisten durchgeführt werden. Die Grundbehandlung beruht auf der Kombination topischer Kortikosteroide und Montelukast, sowie der Vermeidung von Hemmern der Zyklooxygenase-1. Therapierefraktäre Fälle können auf eine Desensibilisierung mit Aspirin oder neuerdings auf Biologika wie Mepolizumab ansprechen.
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Affiliation(s)
- Amélie Borgeat Kaeser
- 1 Service d'Immunologie et d'Allergie, Centre Hospitalier Universitaire Vaudois, Lausanne
| | - Camillo Ribi
- 1 Service d'Immunologie et d'Allergie, Centre Hospitalier Universitaire Vaudois, Lausanne
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20
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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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Stevenson DD, White AA. Clinical Characteristics of Aspirin-Exacerbated Respiratory Disease. Immunol Allergy Clin North Am 2016; 36:643-655. [PMID: 27712760 DOI: 10.1016/j.iac.2016.06.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Aspirin-exacerbated respiratory disease is a significant endotype of both asthma and chronic rhinosinusitis with nasal polyps. The disease demonstrates what seems to be a unified inflammatory mechanism culminating in highly eosinophilic nasal polyp disease and asthma. The rate of polyp recurrence and morbidity from asthma exacerbations are significant and warrant separating this group diagnostically from aspirin-tolerant peers. Given the unique anti-inflammatory effects of aspirin and the evolving landscape of new, targeted biologic treatments, it is even more incumbent to consider this diagnosis and offer patients treatment specific for the disease.
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Affiliation(s)
- Donald D Stevenson
- Scripps Clinic, Division of Allergy, Asthma and Immunology, 3811 Valley Centre Drive S99, San Diego, CA 92130, USA
| | - Andrew A White
- Scripps Clinic, Division of Allergy, Asthma and Immunology, 3811 Valley Centre Drive S99, San Diego, CA 92130, USA.
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22
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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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23
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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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24
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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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25
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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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26
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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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27
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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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Abstract
Asthma has many triggers including rhinosinusitis; allergy; irritants; medications (aspirin in aspirin-exacerbated respiratory disease); and obesity. Paradoxic vocal fold dysfunction mimics asthma and may be present along with asthma. This article reviews each of these triggers, outlining methods of recognizing the trigger and then its management. In many patients more than one trigger may be present. Full appreciation of the complexity of these relationships and targeted therapy to the trigger is needed to best care for the patient with asthma.
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Affiliation(s)
- Justin C. McCarty
- Lake Erie of Osteopathic Medicine, 5000 Lakewood Ranch Boulevard, Bradenton, FL 34211–4909, USA
| | - Berrylin J. Ferguson
- UPMC Mercy, University of Pittsburgh School of Medicine, 1400 Locust Street, Suite B11500, Pittsburgh, PA 15219, USA
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29
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Elevation of Eosinophil-Derived Neurotoxin in Plasma of the Subjects with Aspirin-Exacerbated Respiratory Disease: A Possible Peripheral Blood Protein Biomarker. PLoS One 2013; 8:e66644. [PMID: 23805255 PMCID: PMC3689668 DOI: 10.1371/journal.pone.0066644] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Accepted: 05/08/2013] [Indexed: 11/19/2022] Open
Abstract
Aspirin-exacerbated respiratory disease (AERD) remains widely underdiagnosed in asthmatics, primarily due to insufficient awareness of the relationship between aspirin ingestion and asthma exacerbation. The identification of aspirin hypersensitivity is therefore essential to avoid serious aspirin complications. The goal of the study was to develop plasma biomarkers to predict AERD. We identified differentially expressed genes in peripheral blood mononuclear cells (PBMC) between subjects with AERD and those with aspirin-tolerant asthma (ATA). The genes were matched with the secreted protein database (http://spd.cbi.pku.edu.cn/) to select candidate proteins in the plasma. Plasma levels of the candidate proteins were then measured in AERD (n = 40) and ATA (n = 40) subjects using an enzyme-linked immunosorbent assay (ELISA). Target genes were validated as AERD biomarkers using an ROC curve analysis. From 175 differentially expressed genes (p-value <0.0001) that were queried to the secreted protein database, 11 secreted proteins were retrieved. The gene expression patterns were predicted as elevated for 7 genes and decreased for 4 genes in AERD as compared with ATA subjects. Among these genes, significantly higher levels of plasma eosinophil-derived neurotoxin (RNASE2) were observed in AERD as compared with ATA subjects (70(14.62∼311.92) µg/ml vs. 12(2.55∼272.84) µg/ml, p-value <0.0003). Based on the ROC curve analysis, the AUC was 0.74 (p-value = 0.0001, asymptotic 95% confidence interval [lower bound: 0.62, upper bound: 0.83]) with 95% sensitivity, 60% specificity, and a cut-off value of 27.15 µg/ml. Eosinophil-derived neurotoxin represents a novel biomarker to distinguish AERD from ATA.
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Poulos LM, Ampon RD, Marks GB, Reddel HK. Inappropriate prescribing of inhaled corticosteroids: are they being prescribed for respiratory tract infections? A retrospective cohort study. PRIMARY CARE RESPIRATORY JOURNAL : JOURNAL OF THE GENERAL PRACTICE AIRWAYS GROUP 2013; 22:201-8. [PMID: 23616052 PMCID: PMC6442784 DOI: 10.4104/pcrj.2013.00036] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Revised: 01/02/2013] [Accepted: 01/07/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND Guidelines recommend regular use of inhaled corticosteroid (ICS)-containing medications for all patients with persistent asthma and those with moderate to severe chronic obstructive pulmonary disease. It is important to identify indicators of inappropriate prescribing. AIMS To test the hypothesis that ICS are prescribed for the management of respiratory infections in some patients lacking evidence of chronic airways disease. METHODS Medication dispensing data were obtained from the Australian national Pharmaceutical Benefits Scheme (PBS) for concessional patients dispensed any respiratory medications during 2008. We identified people dispensed only one ICS-containing medication and no other respiratory medications in a year, who were therefore unlikely to have chronic airways disease, and calculated the proportion who were co-dispensed oral antibiotics. RESULTS In 2008, 43.6% of the 115,763 patients who were dispensed one-off ICS were co-dispensed oral antibiotics. Co-dispensing was seasonal, with a large peak in winter months. The most commonly co-dispensed ICS among adults were moderate/high doses of combination therapy, while lower doses of ICS alone were co-dispensed among children. In this cohort, one-off ICS co-dispensed with oral antibiotics cost the government $2.7 million in 2008. CONCLUSIONS In Australia, many people who receive one-off prescriptions for ICS-containing medications do not appear to have airways disease. In this context, the high rate of co-dispensing with antibiotics suggests that ICS are often inappropriately prescribed for the management of symptoms of respiratory infection. Interventions are required to improve the quality of prescribing of ICS and the management of respiratory infections in clinical practice.
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Affiliation(s)
- Leanne M Poulos
- Woolcock Institute of Medical Research, University of Sydney, New South Wales, Australia
| | - Rosario D Ampon
- Woolcock Institute of Medical Research, University of Sydney, New South Wales, Australia
| | - Guy B Marks
- Woolcock Institute of Medical Research, University of Sydney, New South Wales, Australia
- Department of Respiratory Medicine, Liverpool Hospital, Liverpool, New South Wales, Australia
| | - Helen K Reddel
- Woolcock Institute of Medical Research, University of Sydney, New South Wales, Australia
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31
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Aspirin Desensitization in Aspirin-Exacerbated Respiratory Disease. Immunol Allergy Clin North Am 2013; 33:211-22. [DOI: 10.1016/j.iac.2012.10.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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33
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Reply. J Allergy Clin Immunol 2013; 131:246-7. [DOI: 10.1016/j.jaci.2012.09.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Accepted: 09/27/2012] [Indexed: 11/22/2022]
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34
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[Aspirin desensitization: therapy options in patients with aspirin-exacerbated respiratory disease]. HNO 2012; 60:369-83. [PMID: 22491884 DOI: 10.1007/s00106-011-2444-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Aspirin desensitization has established itself as an additional therapy option in the treatment of aspirin- exacerbated respiratory disease, recurrent chronic rhinosinusitis and nasal polyps. Inpatient treatment is strongly recommended due to the risk of life-threatening side effects. In addition, the necessary requirements, indications and contraindications should be carefully considered from a medicolegal perspective. A maintenance dose of 300 (-500) mg ASS is currently recommended. Indications include persisting symptoms despite intensive medical care and/or recurrent nasal polyps, leading to recurrent sinus operations and/or the need to take systemic corticosteroids in order to control nasal symptoms or asthma. If ASS intake is interrupted for more than 48 h, aspirin desensitization should be resumed to prevent renewed intolerance reactions.
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35
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Chang JE, Chin W, Simon R. Aspirin-sensitive asthma and upper airway diseases. Am J Rhinol Allergy 2012; 26:27-30. [PMID: 22391075 DOI: 10.2500/ajra.2012.26.3721] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Aspirin exacerbated respiratory disease (AERD) consists of nasal polyposis, rhinosinusitis, asthma, and aspirin (ASA) sensitivity. OBJECTIVE This article details how to diagnose and treat AERD and describes the procedures associated with ASA challenge and desensitization, benefits associated with ASA desensitization, and appropriate doses for treatment. METHODS Criteria for diagnosis of AERD as well as desensitization protocols for oral ASA challenge and combined intranasal ketorolac and oral ASA challenge, are detailed in this article based on literature review. RESULTS AERD requires a multidimensional approach to treat the disease given the multiple conditions. With successful ASA desensitization and maintenance of ASA administration, all patients are able to achieve ASA tolerance and select patients are able to achieve improvement in clinical markers such as global scores and reduction in use of topical and systemic corticosteroids.
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Affiliation(s)
- Jinny E Chang
- Scripps Clinic, 3811 Valley Center Drive, San Diego, CA 92126, USA.
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36
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Stevenson DD, White AA, Simon RA. Aspirin as a cause of pancreatitis in patients with aspirin-exacerbated respiratory disease. J Allergy Clin Immunol 2012; 129:1687-8. [PMID: 22554703 DOI: 10.1016/j.jaci.2012.04.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2012] [Revised: 04/02/2012] [Accepted: 04/10/2012] [Indexed: 10/28/2022]
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Role of aspirin desensitization in the management of chronic rhinosinusitis. Curr Opin Otolaryngol Head Neck Surg 2011; 19:210-7. [PMID: 21372715 DOI: 10.1097/moo.0b013e3283450102] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW This review is set to revisit the pathogenesis of aspirin-exacerbated respiratory disease (AERD), the diagnostic method used, and finally the real impact of aspirin desensitization on chronic sinusitis with nasal polyposis (CRSwNP) in aspirin intolerant patients. RECENT FINDINGS In AERD, increased baseline production of cysteinyl-leukotriene (Cys-LT) is associated with upregulation of Cys-LT receptors on nasal inflammatory cells. This is further aggravated by inhibition of cyclooxygenase-1 by aspirin and other NSAIDs. New-found genetic markers need further study. Oral aspirin challenge is still the gold standard of diagnosis and can be safely conducted in a specialized outpatient clinic. Oral and endonasal aspirin desensitization show positive impact on CRSwNP course with decreased polyp recurrence, decreased number of hospitalizations, and decreased need for corticosteroids. Modulation of arachidonic acid metabolism and inhibition of intracellular biochemical pathways in key inflammatory cells involving anti-inflammatory cytokines interleukin (IL)-4 and IL-13 explain the clinical outcomes. SUMMARY Future studies should focus on establishing the lowest possible dose to maintain disease under check, allowing more widespread use of this underutilized and underrecognized treatment modality.
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Pando S, Lemière C, Beauchesne MF, Perreault S, Forget A, Blais L. Suboptimal use of inhaled corticosteroids in children with persistent asthma: inadequate prescription, poor drug adherence, or both? Pharmacotherapy 2011; 30:1109-16. [PMID: 20973684 DOI: 10.1592/phco.30.11.1109] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE To assess the use of inhaled corticosteroids in children with persistent asthma, including patients' adherence to these drugs and physicians' prescribing patterns, by using a novel drug adherence measure, the Proportion of Prescribed Days Covered (PPDC). DESIGN Retrospective analysis. DATA SOURCE Two administrative claims databases in Quebec, Canada. PATIENTS Two thousand three hundred fifty-five children aged 5-15 years with persistent asthma who used more than 3 doses/week on average of a short-acting β-agonist during a 12-month period before beginning treatment with inhaled corticosteroids between 1997 and 2005. MEASUREMENTS AND MAIN RESULTS The PPDC measure was defined as the total days' supply dispensed divided by the total days' supply prescribed. During the 12-month follow-up period, 20% of the children received only one prescription for inhaled corticosteroids with no prescribed renewals. The mean number of prescriptions (including prescribed renewals) was 5.0, corresponding to only 152 days' supply prescribed. Mean PPDC (drug adherence) was 62.4%. Only 25% of the patients had controlled asthma, based on the use of 3 or fewer doses/week of short-acting β(2)-agonists and absence of moderate-to-severe exacerbations. CONCLUSION A large percentage of children with persistent asthma were prescribed intermittent rather than daily inhaled corticosteroids, and patient adherence to these drugs was suboptimal even though children had free access to their drugs. Many of these patients continued to experience poor asthma control. The PPDC adherence measure developed for this study allowed a better understanding of the gap between treatment goals and asthma control.
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Affiliation(s)
- Silvia Pando
- Faculty of Pharmacy, University of Montreal, Montreal, Quebec, Canada
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The time delay between drug intake and bronchospasm for nonsteroidal antiinflammatory drugs sensitive patients. World Allergy Organ J 2010; 3:266-70. [PMID: 23282984 PMCID: PMC3651119 DOI: 10.1097/wox.0b013e3181fdfc5f] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
A study was performed to assess the time between drug intake and drug induced
hypersensitivity reaction for patients sensitive to nonsteroidal
antiinflammatory drugs (NSAID) in clinical patient history and after oral
provocation tests. Drug hypersensitivity ENDA questionnaires were filled for the
patients with suspected sensitivity to NSAID. Oral provocation tests were
performed with suspected NSAID according to the ENDA/EAACI recommendations.
There were 76 patients with history of hypersensitivity reactions after use of
NSAID enrolled in the study. Recorded were 154 hypersensitivity reactions to
NSAID in the clinical history. In the clinical history median time of immediate
reactions (76 cases, 81%) between drug intake and bronchospasm was 20 minutes
[15-30 minutes]. Median time of nonimmediate reactions (18 cases, 19%) was 120
minutes [120-390 minutes]. There were 50 oral provocation tests performed, 14 of
them (28%) were positive. Median time between drug intake and immediate
reactions (8; 57% of cases) was 22.5 minutes [20-30 minutes] and median time of
nonimmediate reactions (6; 43% of cases) was 167.5 minutes [125-206.25 minutes].
Time delay between drug intake and bronchospasm in the clinical history and
after oral provocation test was not statistically different.
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Lee RU, Stevenson DD. Aspirin-exacerbated respiratory disease: evaluation and management. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2010; 3:3-10. [PMID: 21217919 PMCID: PMC3005316 DOI: 10.4168/aair.2011.3.1.3] [Citation(s) in RCA: 151] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/18/2010] [Accepted: 07/23/2010] [Indexed: 12/01/2022]
Abstract
The clinical syndrome of aspirin-exacerbated respiratory disease (AERD) is a condition where inhibition of cyclooxygenase-1 (COX-1) induces attacks of upper and lower airway reactions, including rhinorrhea and varying degrees of bronchospasm and laryngospasm. Although the reaction is not IgE-mediated, patients can also present with anaphylactic hypersensitivity reactions, including hypotension, after exposure to COX-1 inhibiting drugs. All patients with AERD have underlying nasal polyps and intractable sinus disease which may be difficult to treat with standard medical and surgical interventions. This review article focuses on the management of AERD patients with a particular emphasis on aspirin desensitization and continuous treatment with aspirin.
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Affiliation(s)
- Rachel U Lee
- Division of Allergy, Asthma & Immunology, Naval Medical Center Portsmouth, Portsmouth, VA, USA
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Use of intranasal ketorolac and modified oral aspirin challenge for desensitization of aspirin-exacerbated respiratory disease. Ann Allergy Asthma Immunol 2010; 105:130-5. [PMID: 20674823 DOI: 10.1016/j.anai.2010.05.020] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2010] [Revised: 05/24/2010] [Accepted: 05/25/2010] [Indexed: 11/21/2022]
Abstract
BACKGROUND Intranasal ketorolac challenges can induce respiratory reactions in patients with aspirin-exacerbated respiratory disease (AERD). OBJECTIVE To determine whether intranasal ketorolac challenges might be used for aspirin desensitization. METHODS One hundred patients with suspected AERD who were referred to Scripps Clinic from May 1, 2007 to December 31, 2009 were challenged with 4 increasing doses of ketorolac intranasally at 30-minute intervals. Symptoms, objective changes in the results of their nasal examination, peak nasal inspiratory flow rates, and forced expiratory volume in 1 second (FEV(1)) values were recorded. After nasal ketorolac dosing, patients were given oral aspirin as part of the challenge and desensitization. A control group consisted of 100 patients who had previously undergone our standard oral aspirin challenges and desensitization. Both groups were consecutively enrolled and had similar clinical characteristics. RESULTS Compared with the standard oral aspirin challenge and desensitization, intranasal ketorolac and modified aspirin challenge significantly attenuated the mean percentage decrease in FEV(1) values (8.5% vs 13.4%; P = .01) and decreased the percentage of extrapulmonary reactions (23% vs 45%; P = .002), particularly laryngospasm (7% vs19%; P = .02) and gastrointestinal reactions (12% vs 33%; P = .001). This new protocol was significantly shorter, lasting an average of 1.9 vs 2.6 days (P = <.001). In fact, 83% of the patients completed the new protocol in less than 48 hours compared with only 20% in the oral challenge control group (P < .001). CONCLUSIONS Intranasal ketorolac challenge and desensitization followed by rapid oral aspirin challenges is effective, safe, and less time-consuming than our standard oral aspirin desensitization protocol.
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Fieldston ES, Puig A, Shea JA, Metlay JP, Pati S. Physicians’ Views on Incentives for Adherence in Childhood Asthma. ACTA ACUST UNITED AC 2009. [DOI: 10.1089/pai.2009.0026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Stevenson DD. Aspirin sensitivity and desensitization for asthma and sinusitis. Curr Allergy Asthma Rep 2009; 9:155-63. [PMID: 19210906 DOI: 10.1007/s11882-009-0023-4] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
NSAIDs-including aspirin (ASA)-that inhibit cyclooxygenase (COX)-1 induce nonallergic hypersensitivity reactions consisting of attacks of rhinitis and asthma. Such reactions occur exclusively in a subset of asthmatic patients who also have underlying nasal polyps and chronic hyperplastic eosinophilic sinusitis. We now refer to their underlying inflammatory disease of the entire respiratory tract as aspirin-exacerbated respiratory disease. This review focuses on descriptions of these patients; methods available to diagnose ASA-exacerbated respiratory disease; the unique ability of all NSAIDs that inhibit COX-1 to cross-react with ASA; lack of cross-reactivity with selective COX-2 inhibitors; an update on pathogenesis; and current thoughts about treatment, including ASA desensitization and daily ingestion of ASA itself.
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Slowik SM, Slavin RG. Aspirin desensitization in a patient with aspirin sensitivity and chronic idiopathic urticaria. Ann Allergy Asthma Immunol 2009; 102:171-2. [PMID: 19230473 DOI: 10.1016/s1081-1206(10)60252-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Rational approach to aspirin dosing during oral challenges and desensitization of patients with aspirin-exacerbated respiratory disease. J Allergy Clin Immunol 2008; 123:406-10. [PMID: 19056109 DOI: 10.1016/j.jaci.2008.09.048] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2008] [Revised: 09/24/2008] [Accepted: 09/29/2008] [Indexed: 12/30/2022]
Abstract
BACKGROUND Aspirin desensitization improves clinical outcomes in most patients with aspirin-exacerbated respiratory disease. Most protocols for desensitization are time-consuming. OBJECTIVE Our objective was to use historical information about the course of aspirin desensitization to enhance the efficiency of the desensitization protocol. METHODS Four hundred twenty subjects with suspected aspirin-exacerbated respiratory disease underwent oral aspirin challenges. Their clinical characteristics were analyzed in relation to features of reactions during aspirin challenges. RESULTS Large (FEV(1) decrease >30%) and moderate (FEV(1) decrease 21% to 30%) bronchial reactions occurred in 9% and 20% of subjects, respectively. Multivariate analysis identified risk factors associated with these larger reactions, including lack of leukotriene modifier use, baseline FEV(1) of less than 80% of predicted value, and previous asthma-related emergency department visits. Seventy-five percent of patients reacted to a provoking dose of either 45 or 60 mg. Only 3% of initial reactions occurred after 150- or 325-mg provoking doses, and none occurred after the 650-mg dose. CONCLUSIONS Most bronchial and naso-ocular reactions during oral aspirin challenges occurred within a narrow dosing range (45-100 mg). Only 1 of 26 patients without risk factors had a moderate reaction.
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Jones BL, Kelly KJ. The adolescent with asthma: fostering adherence to optimize therapy. Clin Pharmacol Ther 2008; 84:749-53. [PMID: 18946465 DOI: 10.1038/clpt.2008.189] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- B L Jones
- Children's Mercy Hospital and Clinics, Kansas City, Missouri, USA.
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The clinical effectiveness of aspirin desensitization in chronic rhinosinusitis. Curr Allergy Asthma Rep 2008; 8:245-52. [PMID: 18589844 DOI: 10.1007/s11882-008-0041-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Aspirin-exacerbated respiratory disease (AERD) is a chronic inflammatory disease characterized by chronic rhinosinusitis, nasal polyposis, asthma, and airway reactivity to aspirin and other nonsteroidal antiinflammatory drugs (NSAIDs). For patients who have inadequately controlled rhinosinusitis and/or asthma despite treatment with topical corticosteroids and leukotriene-modifying drugs, aspirin desensitization is an important therapeutic option. This review examines the evidence supporting the effectiveness of aspirin desensitization for the treatment of chronic rhinosinusitis in patients with AERD. Practical aspects of conducting safe aspirin desensitization procedures and optimizing therapeutic benefits are also reviewed. When conducted in accordance with current guidelines, aspirin desensitization is a safe procedure that allows patients with AERD who have an indication for aspirin or other NSAIDs to safely ingest these medications. There is now strong evidence that aspirin desensitization and daily aspirin therapy is effective for treatment of the chronic inflammatory disease of the upper airway and lower airways in AERD.
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