Aspirin Desensitization: Faster Protocols for Busy Patients

Aspirin hypersensitivity: a practical guide for cardiologists

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.

Meta-analysis Exploring Sinopulmonary Outcomes of Aspirin Desensitization in Aspirin-Exacerbated Respiratory Disease

OBJECTIVE

The objective of this study is to explore the sinopulmonary outcomes of aspirin desensitization through a systematic review and meta-analysis.

DATA SOURCES

Embase and OVID Medline databases.

REVIEW METHODS

A systematic review of published articles on outcomes following aspirin desensitization in any language for relevant articles was performed in February 2019. Outcomes included sinonasal quality-of-life assessment, sense-of-smell scores, FEV-1 (forced expiratory volume in 1 second), and medication/steroid use.

RESULTS

Thirteen studies met the inclusion criteria out of 6055 articles screened. Aspirin desensitization resulted in significant improvement in FEV-1 and reduction in asthma medication/steroid use (P < .05). There was no significant improvement in the sinonasal quality of life of patients who underwent aspirin desensitization (P = .098).

CONCLUSION

Aspirin desensitization appears to be effective in improving pulmonary outcomes and should be considered in the treatment of patients with aspirin-exacerbated respiratory disease. However, good-quality studies are still needed to determine the ideal protocol tailored to individual patients.

Nasal Polyposis and Aspirin-Exacerbated Respiratory Disease

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.

Update on the Management of Nonsteroidal Anti-Inflammatory Drug Hypersensitivity

The clinical phenotypes of nonsteroidal anti-inflammatory drug (NSAID) hypersensitivity are heterogeneous with various presentations including time of symptom onset, organ involvements, and underlying pathophysiology. Having a correct diagnosis can be challenging. Understanding their respective mechanisms as well as developing a comprehensive classification and diagnostic algorithm are pivotal for appropriate management strategy. Treatment modalities are based on the subtypes and severity of hypersensitivity reactions. Insights into the phenotypes and endotypes of hypersensitivity reactions enable personalized management in patients with suboptimal control of disease. This review updated the recent evidence of pathophysiology, classification, diagnostic algorithm, and management of NSAID hypersensitivity reactions.

Treatment practices for aspirin-exacerbated respiratory disease: analysis of a national insurance claims database

BACKGROUND

Aspirin-exacerbated respiratory disease (AERD) is the triad of asthma, nasal polyposis, and sensitivity to cyclooxygenase-1 inhibitors. Treatment options include medical management, surgical intervention, and aspirin desensitization (AsaD).

METHODS

AERD patients were identified using the MarketScan Database from 2009 to 2015. Patients were included using International Classification of Diseases, 9th edition (ICD-9) codes for asthma, nasal polyposis, and drug allergy. Treatments were determined by Current Procedural Terminology (CPT) codes for drug desensitization and endonasal procedures. Geographic trends and timing of interventions between those exposed and not exposed to desensitization were explored.

RESULTS

A total of 5628 patients met inclusion criteria for AERD, with mean age 46 years, 60% female; 395 (7%) underwent AsaD and 2171 (39%) underwent sinus surgery. Among patients who were desensitized, 229 (58%) underwent surgery, of whom 201 (88%) had surgery prior to AsaD (median [quartile 1, quartile 3]; 61 days [30, 208] prior to desensitization). For patients undergoing surgery following AsaD (n = 46), surgery was performed a median of 302 (163, 758) days after AsaD. Nineteen patients had multiple surgeries post-AsaD with median time between surgeries being 734 days (312, 1484); 261 patients were not desensitized to aspirin but did undergo multiple surgeries, with the median of the median time between surgeries being 287 days (15, 617), which is shorter than for patients post-AsaD (p < 0.001).

CONCLUSION

A very small percentage of AERD patients undergo AsaD. Patients who had AsaD underwent surgery approximately 2 months prior to AsaD. Patients who underwent AsaD experienced an increased time between surgeries compared to patients who did not undergo AsaD.