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Douglas JE, Bosso JV. What's New in the Diagnosis and Treatment of Aspirin-Exacerbated Respiratory Disease: A Brief Review. Am J Rhinol Allergy 2023. [DOI: 10.1177/19458924221145254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
Background Aspirin-exacerbated respiratory disease (AERD) is a chronic condition characterized by the presence of asthma, chronic rhinosinusitis with nasal polyposis, and sensitivity to aspirin and other non-steroidal anti-inflammatory drugs. Diagnosis is based on careful clinical history and physical examination, characteristic laboratory and radiographic findings, and, in unclear cases, aspirin challenge. Established treatment is founded on comprehensive endoscopic sinus surgery followed by topical steroids and aspirin desensitization. T2 biologics are now available for refractory cases. Objective To summarize the historic literature on AERD, its diagnosis and treatment options, as well as to review the most current publications on the topic and explore areas for future research. Methods A literature review utilizing the PubMed database was performed. Results Seminal journal articles regarding the diagnosis and treatment of AERD were reviewed with close attention to evidence-based protocols and knowledge gaps in the field as areas for future research. Conclusion AERD is a complex disease which requires careful diagnostic work-up and coordinated care between the allergist and rhinologist to facilitate optimal treatment outcomes.
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Affiliation(s)
- Jennifer E. Douglas
- Department of Otorhinolaryngology – Head & Neck Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
- Monell Chemical Senses Center, Philadelphia, Pennsylvania, USA
| | - John V. Bosso
- Department of Otorhinolaryngology – Head & Neck Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
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2
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Merrill T, Kanaan A. Managing Chronic Rhinosinusitis with Nasal Polyps in the Elderly: Challenges and Solutions. Clin Interv Aging 2022; 17:685-698. [PMID: 35535364 PMCID: PMC9077011 DOI: 10.2147/cia.s279765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 04/20/2022] [Indexed: 11/23/2022] Open
Abstract
The proportion of the population over 65 years old continues to grow. Chronic rhinosinusitis is common in this population and causes a reduction in quality of life and an increase in health care utilization. Diagnosis of chronic rhinosinusitis with nasal polyps follows the same principles for elderly patients as in the general population, but the elderly population presents some diagnostic challenges worth considering. Presbynasalis, the anatomic and functional changes of the nose and paranasal sinuses associated with aging must be accounted for when caring for these patients. In addition, polypharmacy and other medical issues that can cause similar symptoms must be considered. Medical therapy is generally similar to the general population but with additional concerns given the propensity for geriatric patients to be on multiple medications and to suffer from multiple medical issues. Sinus surgery should be considered following the same indications as in the general population. While some authors have found higher complication rates in endoscopic sinus surgery, others have found higher rates of success. As always, the risks of surgery must be considered with the possible benefits on a patient-to-patient basis.
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Affiliation(s)
- Tyler Merrill
- University of Arkansas for Medical Sciences, Department of Otolaryngology – Head and Neck Surgery, Little Rock, AR, USA
- Correspondence: Tyler Merrill, University of Arkansas for Medical Sciences, Department of Otolaryngology – Head and Neck Surgery, 4301 W. Markham Street, #543, Little Rock, AR, 72205, USA, Tel +1 (501) 686 5140; +1 (330) 285 1750, Fax +1 (501) 686 8029, Email
| | - Alissa Kanaan
- University of Arkansas for Medical Sciences, Department of Otolaryngology – Head and Neck Surgery, Little Rock, AR, USA
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3
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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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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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5
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Nguyen A, Zuraw BL, Wu C, Kim A, Christiansen SC. Intranasal ketorolac, diagnosis, and desensitization for aspirin-exacerbated respiratory disease. Ann Allergy Asthma Immunol 2021; 126:674-680. [PMID: 33476718 DOI: 10.1016/j.anai.2021.01.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 12/30/2020] [Accepted: 01/10/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Intranasal ketorolac has been proposed as a diagnostic test for aspirin-exacerbated respiratory disease (AERD) and a faster, safer, and reliable addition to facilitating aspirin (ASA) desensitization. OBJECTIVE We conducted the first prospective study to dissect the impact of intranasal ketorolac incorporation during ASA desensitization vs standard oral protocols in concert with evaluating its diagnostic use for AERD. METHODS Patients with AERD were enrolled in a prospective open-label observational study between November 2006 and August 2013. Participants selected either one of the following desensitization protocols: intranasal ketorolac 1 day before oral ASA (group 1, combined) or ketorolac challenge with greater than 2 weeks elapsing until oral ASA (group 2, washout). All patients were on a leukotriene-modifying drug (montelukast) for at least 1 week before the challenge. RESULTS A total of 20 patients were enrolled: 13 in group 1 and 7 in group 2. No significant differences were seen for baseline symptom scores or forced expiratory volume in 1 second. Group 1 exhibited significant increases for the threshold dose of ASA (P = .009), the likelihood of having silent ASA desensitization (P = .01), and decreased reaction severity to oral ASA (P = .04). There were no significant differences in reaction forced expiratory volume in 1 second, the incidence of extrapulmonary symptoms, limited nasoocular reactions, rescue treatment requirements, or time to symptom resolution. There was 100% concordance between reactions to intranasal ketorolac and oral ASA for group 2, supporting its use as a diagnostic test for AERD. CONCLUSION Intranasal ketorolac is a useful diagnostic test and adjunct within the combined ketorolac/ASA protocol to achieve effective, efficient, and perhaps safer desensitization to ASA for patients with AERD.
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Affiliation(s)
- Amie Nguyen
- Department of Allergy and Immunology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California; Department of Medicine, University of California San Diego, La Jolla, California
| | - Bruce L Zuraw
- Department of Medicine, University of California San Diego, La Jolla, California; Section of Rheumatology and Allergy Medicine Service, Veterans Affairs San Diego Healthcare System, San Diego, California
| | - Christina Wu
- Department of Medicine, University of California San Diego, La Jolla, California
| | - Alexander Kim
- Department of Medicine, University of California San Diego, La Jolla, California
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6
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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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Bergmark RW, Palumbo M, Rahman S, Maurer R, Dominas C, Roditi R, Bhattacharyya N, Maxfield A, Buchheit KM, Laidlaw TM. Aspirin-Exacerbated Respiratory Disease: Association Between Patient-Reported Sinus and Asthma Morbidity. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:1604-1611. [PMID: 33307278 DOI: 10.1016/j.jaip.2020.11.051] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 11/11/2020] [Accepted: 11/17/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND The association between sinonasal and pulmonary symptoms in aspirin-exacerbated respiratory disease is not fully established. OBJECTIVE To characterize sinonasal and asthma symptomatology, and to determine whether reported sinonasal symptoms predict asthma severity. METHODS Prospectively collected data from an aspirin-exacerbated respiratory disease registry cohort were included from 2013 to 2018. Sinonasal symptomatology measured by Sino-Nasal Outcomes Test (SNOT) 22-item total scores was used as the predictor variable, with Asthma Control Test (ACT) scores and percent predicted FEV1 (FEV1% predicted) as primary outcomes. All instances of paired data on the same date were used. ACT score was also evaluated with FEV1% predicted as the outcome. Mixed effects regression was completed. RESULTS From 1065 aspirin-exacerbated respiratory disease registry subjects (mean age, 48.1 ± 12.8 years; 68.0% females, 29.8% males), mean SNOT-22 score was 42.3 ± 24.12 (n = 1307 observations from 869 subjects), mean ACT score was 19.4 ± 5.2 (n = 1511 observations from 931 subjects), and mean FEV1% predicted was 82.8 ± 19.6 (n = 777 observations from 307 subjects). SNOT-22 score significantly predicted ACT scores (P < .0001, 1185 paired observations from 845 subjects) and FEV1% predicted (P = .018, 485 observations from 246 subjects). Any 10-point increase in SNOT-22 score was associated with a 0.87-point decrease in ACT score and a 0.75% decrease in FEV1% predicted. Any 1-point increase in ACT score was associated with a 1.0% increase in FEV1% predicted (P < .0001, 616 observations from 269 subjects). The most severe SNOT-22 symptoms were sense of smell/taste and blockage/congestion of nose. CONCLUSIONS SNOT-22 scores significantly predict ACT scores and FEV1% predicted, and ACT scores significantly predict FEV1% predicted. This study demonstrates an association between patient-reported rhinosinusitis and asthma symptom severity and subjective and objective measures of asthma severity.
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Affiliation(s)
- Regan W Bergmark
- Division of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital, Boston, Mass; Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Mass; Patient Reported Outcomes, Value and Experience (PROVE) Center, Brigham and Women's Hospital, Boston, Mass; Center for Surgery and Public Health, Harvard Medical School, Boston, Mass.
| | - Marina Palumbo
- Division of Rheumatology, Immunology, and Allergy, Brigham and Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Sarah Rahman
- Center for Surgery and Public Health, Harvard Medical School, Boston, Mass; Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Rie Maurer
- Center for Clinical Investigation, Brigham and Women's Hospital, Boston, Mass
| | - Christine Dominas
- Division of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital, Boston, Mass
| | - Rachel Roditi
- Division of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital, Boston, Mass; Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Mass
| | - Neil Bhattacharyya
- Division of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital, Boston, Mass; Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Mass
| | - Alice Maxfield
- Division of Otolaryngology-Head and Neck Surgery, Brigham and Women's Hospital, Boston, Mass; Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Mass
| | - Kathleen M Buchheit
- Division of Rheumatology, Immunology, and Allergy, Brigham and Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
| | - Tanya M Laidlaw
- Division of Rheumatology, Immunology, and Allergy, Brigham and Women's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass
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The importance of timely diagnosis of aspirin-exacerbated respiratory disease for patient health and safety. World J Otorhinolaryngol Head Neck Surg 2020; 6:203-206. [PMID: 33336174 PMCID: PMC7729250 DOI: 10.1016/j.wjorl.2020.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 07/29/2020] [Indexed: 11/28/2022] Open
Abstract
Backgroud Aspirin-exacerbated respiratory disease (AERD) is a difficult-to-treat syndrome where timely diagnosis and initiation of disease-specific therapies are pertinent to improved patient outcomes. Objective To characterize the most common timeline for development of the clinical triad [asthma, nasal polyposis, and reactions to nonsteroidal anti-inflammatory drugs (NSAIDs)], identify barriers to prompt diagnosis of AERD, and describe indications for an aspirin challenge to facilitate accurate diagnosis. Methods Six hundred ninety-seven patients with diagnosed AERD and history of at least one sinus surgery to remove nasal polyps were identified in the Brigham and Women's Hospital AERD registry. Patient reported age at disease onset of asthma, nasal polyposis, and age of first NSAID reaction were obtained from 2013 to 2019 at enrollment. Results Of the 697 patients identified, diagnosis of asthma preceded diagnosis of nasal polyposis and first NSAID reaction, although there was considerable variability between patients. Conclusions Prompt diagnosis of AERD is important for patient and provider education and improved care of this difficult-to-treat population of patients. Consider diagnostic aspirin challenge in patients without historical reactions to NSAIDs who have an otherwise compatible clinical history, specifically in patients who take daily low-dose aspirin, leukotriene modifiers, avoid NSAIDs, or who are severely symptomatic at baseline where it would be difficult to identify an acute worsening of symptoms.
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Dominas C, Gadkaree S, Maxfield AZ, Gray ST, Bergmark RW. Aspirin-exacerbated respiratory disease: A review. Laryngoscope Investig Otolaryngol 2020; 5:360-367. [PMID: 32596477 PMCID: PMC7314471 DOI: 10.1002/lio2.387] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 03/09/2020] [Accepted: 03/16/2020] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES Aspirin-exacerbated respiratory disease (AERD) is a chronic respiratory condition characterized by a triad of symptoms: asthma, chronic rhinosinusitis with nasal polyposis, and a respiratory reaction to aspirin and other cyclooxygenase-1 inhibitors, also known as nonsteroidal anti-inflammatory drugs. The objective of this review is to provide otolaryngologists with an overview of the pathophysiology, diagnosis, and treatment of this under-recognized condition. DATA SOURCES AND METHODS Foundational papers on AERD were reviewed, focusing on the clinical otolaryngology and allergy/immunology literature and other high impact journals or trials. RESULTS AERD results from increased production of pro-inflammatory leukotrienes and a decrease in production of anti-inflammatory prostaglandins associated with the dysregulation of multiple enzymes influencing eicosanoid metabolism. Diagnosis hinges on a high index of suspicion, careful history, and confirmatory testing for all three elements. Treatments include endoscopic sinus surgery; topical, inhaled, or oral corticosteroids; aspirin desensitization; leukotriene modifying drugs; and the new class of biologics such as dupilumab. CONCLUSION AERD is an under-recognized disease associated with substantial patient-reported morbidity. We expect rapid progress in the pathophysiological understanding of this disease and available treatments in the coming decades. LEVEL OF EVIDENCE 5.
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Affiliation(s)
- Christine Dominas
- Division of Otolaryngology‐Head and Neck SurgeryBrigham and Women's HospitalBostonMassachusettsUSA
| | - Shekhar Gadkaree
- Division of Otolaryngology‐Head and Neck SurgeryBrigham and Women's HospitalBostonMassachusettsUSA
- Department of Otolaryngology‐Head and Neck SurgeryHarvard Medical SchoolBostonMassachusettsUSA
- Department of Otolaryngology‐Head and Neck SurgeryMassachusetts Eye and Ear InfirmaryBostonMassachusettsUSA
| | - Alice Z. Maxfield
- Division of Otolaryngology‐Head and Neck SurgeryBrigham and Women's HospitalBostonMassachusettsUSA
- Department of Otolaryngology‐Head and Neck SurgeryHarvard Medical SchoolBostonMassachusettsUSA
| | - Stacey T. Gray
- Department of Otolaryngology‐Head and Neck SurgeryHarvard Medical SchoolBostonMassachusettsUSA
- Department of Otolaryngology‐Head and Neck SurgeryMassachusetts Eye and Ear InfirmaryBostonMassachusettsUSA
| | - Regan W. Bergmark
- Division of Otolaryngology‐Head and Neck SurgeryBrigham and Women's HospitalBostonMassachusettsUSA
- Department of Otolaryngology‐Head and Neck SurgeryHarvard Medical SchoolBostonMassachusettsUSA
- Center for Surgery and Public HealthBrigham and Women's HospitalBostonMassachusettsUSA
- Patient Reported Outcomes, Value and Experience (PROVE) CenterBrigham and Women's HospitalBostonMassachusettsUSA
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10
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Wangberg H, White AA. Aspirin-exacerbated respiratory disease. Curr Opin Immunol 2020; 66:9-13. [PMID: 32299015 DOI: 10.1016/j.coi.2020.02.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 02/28/2020] [Indexed: 02/06/2023]
Abstract
Aspirin-exacerbated respiratory disease (AERD) classically presents with severe asthma, nasal polyposis, and respiratory exacerbations in response to cyclooxygenase (COX)-1 inhibition. Recent advances in our understanding of AERD have revealed multiple facets of immune dysregulation, including diminished prostaglandin E2 (PGE2) function and elevated levels of both cysteinyl leukotrienes (CysLTs) and innate cytokines such as interleukin 33 (IL-33). Inflammatory mediators in AERD heighten the recruitment and activation of innate lymphoid cells type 2 (ILC2), mast cells, eosinophils, and platelet-adherent leukocytes. This contributes to a cyclical pattern of type 2 inflammation. Here, we highlight current understanding of the immunopathogenesis of AERD.
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Affiliation(s)
- Hannah Wangberg
- Division of Allergy, Asthma, and Immunology, Scripps Clinic, San Diego, CA, United States
| | - Andrew A White
- Division of Allergy, Asthma, and Immunology, Scripps Clinic, San Diego, CA, United States.
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Luskin K, Thakrar H, White A. Nasal Polyposis and Aspirin-Exacerbated Respiratory Disease. Immunol Allergy Clin North Am 2020; 40:329-343. [PMID: 32278455 DOI: 10.1016/j.iac.2019.12.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Aspirin-exacerbated respiratory disease (AERD) is characterized by eosinophilic chronic rhinosinusitis with nasal polyps, asthma, and upper-/lower-respiratory tract reactions to nonsteroidal antiinflammatory drugs. Persistent, severe disease, anosmia, and alcohol sensitivity is typical. AERD is mediated by multiple pathways, including aberrant arachidonic acid metabolism leading to elevated leukotriene E4 and decreased prostaglandin E2. Mast cell mediators (prostaglandin D2) and unique properties of eosinophils and type 2 innate lymphoid cells, along with receptor-mediated signaling, also contribute to AERD pathogenesis. Pharmacologic therapies are a cornerstone of AERD treatment and include leukotriene modifiers, corticosteroids, biologics, and aspirin.
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Affiliation(s)
- Kathleen Luskin
- Allergy-Immunology, Scripps Health, San Diego, CA, USA; Scripps Clinic Carmel Valley, 3811 Valley Centre Drive, San Diego, CA 92130, USA.
| | - Hiral Thakrar
- Allergy-Immunology, Scripps Health, San Diego, CA, USA; Scripps Clinic Carmel Valley, 3811 Valley Centre Drive, San Diego, CA 92130, USA
| | - Andrew White
- Allergy-Immunology, Scripps Health, San Diego, CA, USA; Scripps Clinic Carmel Valley, 3811 Valley Centre Drive, San Diego, CA 92130, USA
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12
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Abstract
Background: Aspirin-exacerbated respiratory disease (AERD), a syndrome that includes asthma, recurrent nasal polyps, and pathognomonic reactions to aspirin and other nonselective cyclooxygenase inhibitors, is still not fully understood and lacks specific disease-modifying therapeutic options. Objective: To review the most recent clinical updates in the evaluation and treatment of patients with AERD. Methods: Recent clinical research studies relevant to patients with AERD were reviewed. Results: Multiple new biologics are available for the treatment of severe asthma, several of which have been specifically studied and determined to be efficacious in the subset of patients with asthma who are also aspirin sensitive. Zileuton continues to be underprescribed for AERD and is considered to be very effective by many patients with AERD. Dietary modifications toward a diet that is high in omega-3 fatty acids and low in omega-6 fatty acids can reduce the production of the inflammatory leukotriene and prostaglandin D₂ lipids and help improve symptoms for patients with AERD. Conclusion: A lack of definitive understanding of the causative mechanisms of AERD and the absence of an AERD-specific patient-reported outcome measure are obstacles that remain in this field, but much progress has been made over the past decade.
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13
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Jerschow E, Edin ML, Chi Y, Hurst B, Abuzeid WM, Akbar NA, Gibber M, Fried MP, Han W, Pelletier T, Ren Z, Keskin T, Roizen G, Lih FB, Gruzdev A, Bradbury JA, Schuster V, Spivack S, Rosenstreich D, Zeldin DC. Sinus Surgery Is Associated with a Decrease in Aspirin-Induced Reaction Severity in Patients with Aspirin Exacerbated Respiratory Disease. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 7:1580-1588. [PMID: 30580047 DOI: 10.1016/j.jaip.2018.12.014] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/12/2018] [Revised: 12/06/2018] [Accepted: 12/07/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND Nasal polyps influence the burden of aspirin-exacerbated respiratory disease (AERD) by contributing to eicosanoid production. AERD is diagnosed through graded aspirin challenges. It is not known how sinus surgery affects aspirin challenge outcomes. OBJECTIVE To investigate the effects of endoscopic sinus surgery (ESS) on aspirin-induced reaction severity and on the levels of eicosanoids associated with these reactions. METHODS Twenty-eight patients with AERD were challenged with aspirin before and 3 to 4 weeks after ESS. Respiratory parameters and plasma and urine levels of eicosanoids were compared before and after challenges. RESULTS Before ESS, AERD diagnosis was confirmed in all study patients by aspirin challenges that resulted in hypersensitivity reactions. After ESS, reactions to aspirin were less severe in all patients and 12 of 28 patients (43%, P < .001) had no detectable reaction. A lack of clinical reaction to aspirin was associated with lower peripheral blood eosinophilia (0.1 K/μL [interquartile range (IQR) 0.1-0.3] vs 0.4 K/μL [IQR 0.2-0.8]; P = .006), lower urinary leukotriene E4 levels after aspirin challenge (98 pg/mg creatinine [IQR 61-239] vs 459 pg/mg creatinine [IQR 141-1344]; P = .02), and lower plasma prostaglandin D2 to prostaglandin E2 ratio (0 [±0] vs 0.43 [±0.2]; P = .03), compared with those who reacted. CONCLUSIONS Sinus surgery results in decreased aspirin sensitivity and a decrease in several plasma and urine eicosanoid levels in patients with AERD. Diagnostic aspirin challenges should be offered to patients with suspected AERD before ESS to increase diagnostic accuracy. Patients with established AERD could undergo aspirin desensitizations after ESS as the severity of their aspirin-induced hypersensitivity reactions lessens.
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Affiliation(s)
- Elina Jerschow
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY.
| | - Matthew L Edin
- National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle, NC
| | - Yuling Chi
- Albert Einstein College of Medicine, Bronx, NY
| | | | - Waleed M Abuzeid
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY
| | - Nadeem A Akbar
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY
| | - Marc Gibber
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY
| | - Marvin P Fried
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY
| | - Weiguo Han
- Albert Einstein College of Medicine, Bronx, NY
| | | | - Zhen Ren
- Washington University School of Medicine, St. Louis, Mo
| | - Taha Keskin
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY
| | - Gigia Roizen
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY
| | - Fred B Lih
- National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle, NC
| | - Artiom Gruzdev
- National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle, NC
| | - J Alyce Bradbury
- National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle, NC
| | - Victor Schuster
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY
| | - Simon Spivack
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY
| | - David Rosenstreich
- Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY
| | - Darryl C Zeldin
- National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle, NC
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14
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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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15
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Abstract
PURPOSE OF REVIEW The pathophysiology of aspirin-exacerbated respiratory disease (AERD) is not fully understood and diagnostic methods and so far, treatments for AERD have not been standardized. We summarize recent research into the pathological mechanisms of AERD, diagnostic methods, and treatments for AERD patients. RECENT FINDINGS In AERD pathophysiology, not only the reduced expression of E prostanoid 2 but also the dysfunction of its pathway could be involved. Moreover, eosinophils of AERD patients could be directly activated by aspirin to produce prostaglandin D2. Platelet activations are well known to be involved in AERD; however, plasma markers do not change during aspirin challenge tests. Additionally, novel genetic polymorphisms, such as P2RY12 and dipeptidyl peptidase 10 gene, and epigenetic predispositions of AERD were found. In AERD diagnosis, bronchial and nasal aspirin challenges have been applied in addition to oral challenge. Serum periostin has been suggested as a potential biomarker for AERD. Apart from standard pharmacological treatment and aspirin desensitization, biologics, including omalizumab and mepolizumab, as well as CRTH2 antagonists have been suggested as promising therapies for AERD treatment. SUMMARY AERD is usually associated with severe asthma phenotypes. AERD pathophysiology mainly involves the dysregulation of eicosanoid metabolisms, activations of effector cells, which could be influenced by genetic/epigenetic factors. Understanding the pathophysiology of AERD is key to improve the diagnostic methods and proper management of AERD patients.
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16
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Laidlaw TM, Cahill KN. Current Knowledge and Management of Hypersensitivity to Aspirin and NSAIDs. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 5:537-545. [PMID: 28483309 DOI: 10.1016/j.jaip.2016.10.021] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 10/21/2016] [Accepted: 10/28/2016] [Indexed: 11/15/2022]
Abstract
Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) are some of the most common culprits of drug-induced hypersensitivity reactions, and can lead to a wide array of adverse effects. The accurate and timely diagnosis of aspirin and NSAID-induced hypersensitivity reactions is important for both patient safety and for the initiation of appropriate disease-specific management and treatment. Because there are no reliably validated in vitro tests available, aspirin and NSAID challenges are considered to be the criterion standard for the diagnosis of these hypersensitivity reactions, though in some patients the diagnosis can be made on the basis of a clear clinical history.
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Affiliation(s)
- Tanya M Laidlaw
- Division of Rheumatology, Immunology, and Allergy, Brigham and Women's Hospital, Boston, Mass.
| | - Katherine N Cahill
- Division of Rheumatology, Immunology, and Allergy, Brigham and Women's Hospital, Boston, Mass
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17
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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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Abstract
Drug allergy affects a large percentage of the general population. A listed drug allergy can also have broad implications for many aspects of patient care. Here, we will review recent advances in the arena of drug allergies with a focus on antibiotics, monoclonals, NSAIDs, and chemotherapeutics.
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19
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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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20
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Cahill KN, Johns CB, Cui J, Wickner P, Bates DW, Laidlaw TM, Beeler PE. Automated identification of an aspirin-exacerbated respiratory disease cohort. J Allergy Clin Immunol 2016; 139:819-825.e6. [PMID: 27567328 DOI: 10.1016/j.jaci.2016.05.048] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 05/23/2016] [Accepted: 05/31/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Aspirin-exacerbated respiratory disease (AERD) is characterized by 3 clinical features: asthma, nasal polyposis, and respiratory reactions to cyclooxygenase-1 inhibitors (nonsteroidal anti-inflammatory drugs). Electronic health records (EHRs) contain information on each feature of this triad. OBJECTIVE We sought to determine whether an informatics algorithm applied to the EHR could electronically identify patients with AERD. METHODS We developed an informatics algorithm to search the EHRs of patients aged 18 years and older from the Partners Healthcare system over a 10-year period (2004-2014). Charts with search terms for asthma, nasal polyps, and record of respiratory (cohort A) or unspecified (cohort B) reactions to nonsteroidal anti-inflammatory drugs were identified as "possible AERD." Two clinical experts reviewed all charts to confirm a diagnosis of "clinical AERD" and classify cases as "diagnosed AERD" or "undiagnosed AERD" on the basis of physician-documented AERD-specific terms in patient notes. RESULTS Our algorithm identified 731 "possible AERD" cases, of which 638 were not in our AERD patient registry. Chart review of cohorts A (n = 511) and B (n = 127) demonstrated a positive predictive value of 78.4% for "clinical AERD," which rose to 88.7% when unspecified reactions were excluded. Of those with clinical AERD, 12.4% had no mention of AERD by any treating caregiver and were classified as "undiagnosed AERD." "Undiagnosed AERD" cases were less likely than "diagnosed AERD" cases to have been seen by an allergist/immunologist (38.7% vs 93.2%; P < .0001). CONCLUSIONS An informatics algorithm can successfully identify both known and previously undiagnosed cases of AERD with a high positive predictive value. Involvement of an allergist/immunologist significantly increases the likelihood of an AERD diagnosis.
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Affiliation(s)
- Katherine N Cahill
- Department of Medicine, Harvard Medical School, Boston, Mass; Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, Mass.
| | - Christina B Johns
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, Mass
| | - Jing Cui
- Department of Medicine, Harvard Medical School, Boston, Mass; Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, Mass
| | - Paige Wickner
- Department of Medicine, Harvard Medical School, Boston, Mass; Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, Mass
| | - David W Bates
- Department of Medicine, Harvard Medical School, Boston, Mass; Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Mass
| | - Tanya M Laidlaw
- Department of Medicine, Harvard Medical School, Boston, Mass; Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, Mass
| | - Patrick E Beeler
- Department of Medicine, Harvard Medical School, Boston, Mass; Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Mass; Research Center for Medical Informatics, University Hospital Zurich and University of Zurich, Zurich, Switzerland
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21
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Stevens W, Buchheit K, Cahill KN. Aspirin-Exacerbated Diseases: Advances in Asthma with Nasal Polyposis, Urticaria, Angioedema, and Anaphylaxis. Curr Allergy Asthma Rep 2016; 15:69. [PMID: 26475526 DOI: 10.1007/s11882-015-0569-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Aspirin-exacerbated diseases are important examples of drug hypersensitivities and include aspirin-exacerbated respiratory disease (AERD), aspirin- or non-steroidal anti-inflammatory drug (NSAID)-induced urticaria/angioedema, and aspirin- or NSAID-induced anaphylaxis. While each disease subtype may be distinguished by unique clinical features, the underlying mechanisms that contribute to these phenotypes are not fully understood. However, the inhibition of the cyclooxygenase-1 enzyme is thought to play a significant role. Additionally, eosinophils, mast cells, and their products, prostaglandins and leukotrienes, have been identified in the pathogenesis of AERD. Current diagnostic and treatment strategies for aspirin-exacerbated diseases remain limited, and continued research focusing on each of the unique hypersensitivity reactions to aspirin is essential. This will not only advance the understanding of these disease processes, but also lead to the subsequent development of novel therapeutics that patients who suffer from aspirin-induced reactions desperately need.
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Affiliation(s)
- Whitney Stevens
- Division of Allergy-Immunology, Department of Medicine, Northwestern University Feinberg School of Medicine, 211 East Ontario Street, Suite 1000, Chicago, IL, 60611, USA.
| | - Kathleen Buchheit
- Division of Rhematology, Immunology, and Allergy, Department of Medicine, Brigham and Women's Hospital/Harvard Medical School, 1 Jimmy Fund Way, Smith Building Room 638, Boston, MA, 02115, USA.
| | - Katherine N Cahill
- Division of Rhematology, Immunology, and Allergy, Department of Medicine, Brigham and Women's Hospital/Harvard Medical School, 1 Jimmy Fund Way, Smith Building Room 638, Boston, MA, 02115, USA.
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