Pathogenesis, diagnosis, and treatment of aspirin intolerance

Attitudes of dental implantologists in Spain to prescribing antibiotics, analgesics and anti-inflammatories in healthy patients

Background

The implantologists frequently prescribe antibiotics, analgesics and anti-inflammatories in dental implant surgery. The aims of this study were to evaluate the attitudes of implantologists in Murcia (Spain) to prescribing antibiotics, analgesics and anti-inflammatories in healthy patients during different implant dentistry procedures, and to see how these are influenced by individual dentist’s academic level, professional experience, and ongoing training (attending courses or reading scientific literature on medication use)

Material and Methods

This cross-sectional study included a total of 200 implantologists from the Murcia area (Spain), who each completed a two-page questionnaire consisting of 26 questions.

Results

The implant procedure in which most dentists (n=97) prescribed antibiotics was multiple implant surgery with flap raising, in which 55.6% of these 97 respondents used a prophylactic antibiotic regime for 7 days after implant placement. All subjects (n=200) prescribed analgesics for eight out of the eleven procedures included in the survey and anti-inflammatories in six. Dentists with higher academic levels or longer professional experience prescribed more antibiotics, but those who underwent continuous training (attending courses or reading scientific literature) reduced antibiotic prescription.

Conclusions

Dentists often prescribed antibiotics, analgesics and anti-inflammatories in almost all implant procedures in healthy patients, but ongoing training reduced the frequency of antibiotic prescription in some procedures.

Key words:Antibiotics, analgesics, anti-inflammatories, dental implant, oral surgery.

Gene Polymorphism of Aspirin-Induced Urticaria in Children With Kawasaki Disease

Objective: To investigate the distribution of the single nucleotide polymorphism (SNP) of LTC4S A-444C in children with Kawasaki disease in northern China and determine whether LTC4S A-444C SNP is associated with aspirin-induced urticaria (AIU). Methods: The clinical data of children with Kawasaki disease hospitalized in our center from April 2015 to November 2017 were collected, and fluorescence in situ hybridization was used to detect the LTC4S A-444C. According to the genotype, the subjects were divided into three groups: AA genotypes, AC genotypes, and CC genotypes. The incidence of AIU in the three groups was calculated and the relationship between LTC4S A-444C SNP and AIU was analyzed. Results: (1) A total of 574 children with Kawasaki disease were enrolled in the study. The allele frequencies for A, C were 980 (85.4%), 168 (14.6%). (2) Twenty-five cases of AIU in AA genotypes, with a positive rate of 6%, 11 cases of AIU in AC genotypes, with a positive rate of 7.5%, 2 cases of AIU in CC genotypes, with a positive rate of 18.2%. CC genotypes had higher incidence of AIU than that of AA and AC genotypes. However, there was no significant difference among the three groups (P > 0.05). Conclusion: The proportion of CC genotypes of LTC4S A-444C in children with Kawasaki disease in northern China is lower than that of AA genotypes and AC genotypes, and the incidence of AIU of CC genotypes is higher than that of AC genotypes and AA genotypes.

Characterization of Patients with Ibuprofen Hypersensitivity

BACKGROUND

Ibuprofen is the most frequently used over-the-counter nonsteroidal anti-inflammatory drug (NSAID) in North America. While it has been commonly implicated in drug-induced hypersensitivity reactions, there is limited literature specifically on ibuprofen hypersensitivity.

OBJECTIVES

To characterize the demographics and clinical course of hypersensitivity reactions in a cohort of patients with ibuprofen allergy.

METHODS

A retrospective chart review of patients diagnosed with ibuprofen allergy was conducted between 2008 and 2016 in an allergy clinic at a tertiary care academic institution. Demographics and clinical information were obtained, and severity of reactions was assessed by a standardized grading system.

RESULTS

A total of 41 patients were included of whom 27 were female. The mean age at first reaction to ibuprofen was 33 ± 13.9 years. The medi an time from the first reaction to the time of diagnosis was 1 year (0-3). The median time from ibuprofen exposure to the onset of symptoms was 30 min (16-101). The median duration of symptoms was 180 min (60-1,440). Urticaria and angioedema were seen in 90% of patients. The reactions were either mild (46%) or moderate (51%) in severity, but 1 patient had severe anaphylaxis. Cross-reactivity to other NSAIDs or acetaminophen was seen and presented with mostly mild reactions.

CONCLUSION

In our cohort of patients, ibuprofen hypersensitivity affected females more commonly than males, and presented with mainly cutaneous manifestations. Onset of symptoms was rapid (< 60 min). Reactions typically ranged in severity from mild to moderate although there was a risk of severe anaphylaxis. There was potential cross-reactivity with other NSAIDs or acetaminophen. The results of our study contribute to the understanding of the demographics and clinical course of ibuprofen hypersensitivity reactions.

Samter's Triad: State of the Art

Samter’s triad (ST) is a well-known disease characterized by the triad of bronchial asthma, nasal polyps, and aspirin intolerance. Over the past few years, a rapid development in the knowledge of the pathogenesis and clinical characteristics of ST has happened. The aim of this paper is to review the recent investigations on the pathophysiological mechanisms and genetic background, diagnosis, and different therapeutic options of ST to advance our understanding of the mechanism and the therapeutic control of ST. As concern for ST increase, more application of aspirin desensitization will be required to manage this disease successfully. There is also a need for continued research efforts in pathophysiology, treatment, and possible prevention.

Estimated reductions in provider-initiated preterm births and hospital length of stay under a universal acetylsalicylic acid prophylaxis strategy: a retrospective cohort study

BACKGROUND

Hypertensive disorders, especially preeclampsia, are the leading reason for provider-initiated preterm birth. We estimated how universal acetylsalicylic acid (ASA) prophylaxis might reduce rates of provider-initiated preterm birth associated with preeclampsia and intrauterine growth restriction, which are related conditions.

METHODS

We performed a cohort study of singleton hospital births in 2013 in Canada, excluding Quebec. We estimated the proportion of term births and provider-initiated preterm births affected by preeclampsia and/or intrauterine growth restriction, and the corresponding mean maternal and newborn hospital length of stay. We projected the potential number of cases reduced and corresponding hospital length of stay if ASA prophylaxis lowered cases of preeclampsia and intrauterine growth restriction by a relative risk reduction (RRR) of 10% (lowest) or 53% (highest), as suggested by randomized clinical trials.

RESULTS

Of the 269 303 singleton live births and stillbirths in our cohort, 4495 (1.7%) were provider-initiated preterm births. Of the 4495, 1512 (33.6%) had a diagnosis of preeclampsia and/or intrauterine growth restriction. The mean maternal length of stay was 2.0 (95% confidence interval [CI] 2.0-2.0) days among term births unaffected by either condition and 7.3 (95% CI 6.1-8.6) days among provider-initiated preterm births with both conditions. The corresponding values for mean newborn length of stay were 1.9 (95% CI 1.8-1.9) days and 21.8 (95% CI 17.4-26.2) days. If ASA conferred a 53% RRR against preeclampsia and/or intrauterine growth restriction, 3365 maternal and 11 591 newborn days in hospital would be averted. If ASA conferred a 10% RRR, 635 maternal and 2187 newborn days in hospital would be averted.

INTERPRETATION

A universal ASA prophylaxis strategy could substantially reduce the burden of long maternal and newborn hospital stays associated with provider-initiated preterm birth. However, until there is compelling evidence that administration of ASA to all, or most, pregnant women reduces the risk of preeclampsia and/or intrauterine growth restriction, clinicians should continue to follow current clinical practice guidelines.

Cyclooxygenase 2: its regulation, role and impact in airway inflammation

Cyclooxygenase 2 (COX-2: official gene symbol - PTGS2) has long been regarded as playing a pivotal role in the pathogenesis of airway inflammation in respiratory diseases including asthma. COX-2 can be rapidly and robustly expressed in response to a diverse range of pro-inflammatory cytokines and mediators. Thus, increased levels of COX-2 protein and prostanoid metabolites serve as key contributors to pathobiology in respiratory diseases typified by dysregulated inflammation. But COX-2 products may not be all bad: prostanoids can exert anti-inflammatory/bronchoprotective functions in airways in addition to their pro-inflammatory actions. Herein, we outline COX-2 regulation and review the diverse stimuli known to induce COX-2 in the context of airway inflammation. We discuss some of the positive and negative effects that COX-2/prostanoids can exert in in vitro and in vivo models of airway inflammation, and suggest that inhibiting COX-2 expression to repress airway inflammation may be too blunt an approach; because although it might reduce the unwanted effects of COX-2 activation, it may also negate the positive effects. Evidence suggests that prostanoids produced via COX-2 upregulation show diverse actions (and herein we focus on prostaglandin E2 as a key example); these can be either beneficial or deleterious and their impact on respiratory disease can be dictated by local concentration and specific interaction with individual receptors. We propose that understanding the regulation of COX-2 expression and associated receptor-mediated functional outcomes may reveal number of critical steps amenable to pharmacological intervention. These may prove invaluable in our quest towards future development of novel anti-inflammatory pharmacotherapeutic strategies for the treatment of airway diseases.

Contemporary management of chronic rhinosinusitis with nasal polyposis in aspirin-exacerbated respiratory disease: an evidence-based review with recommendations

BACKGROUND

Chronic rhinosinusitis (CRS) in aspirin-exacerbated respiratory disease (AERD) represents a recalcitrant form of sinonasal inflammation for which a multidisciplinary consensus on patient management has not been reached. Several medical interventions have been investigated, but a formal comprehensive evaluation of the evidence has never been performed. The purpose of this article is to provide an evidence-based approach for the multidisciplinary management of CRS in AERD.

METHODS

A systematic review of the literature was performed and the guidelines for development of an evidence-based review with recommendations were followed. Study inclusion criteria included: adult population >18 years old; CRS based on published diagnostic criteria, and a presumptive diagnosis of AERD. We focused on reporting higher-quality studies (level 2 or higher) when available, but reported lower-quality studies if the topic contained insufficient evidence. Treatment recommendations were based on American Academy of Otolaryngology (AAO) guidelines, with defined grades of evidence and evaluation of research quality and risk/benefits associated with each treatment.

RESULTS

This review identified and evaluated the literature on 3 treatment strategies for CRS in AERD: dietary salicylate avoidance, leukotriene modification, and desensitization with daily aspirin therapy.

CONCLUSION

Based on the available evidence, dietary salicylate avoidance and leukotriene-modifying drugs are options following appropriate treatment with nasal corticosteroids and saline irrigation. Desensitization with daily aspirin therapy is recommended following revision endoscopic sinus surgery (ESS).

Rapid Aspirin Challenge in Patients with Aspirin Allergy and Acute Coronary Syndromes

Aspirin allergy in a patient with acute coronary syndrome represents one of the more urgent challenges an allergist may face. Adverse reactions to aspirin are reported in 1.5% of patients with coronary artery disease. A history of adverse reaction to aspirin often leads to unnecessary withholding of this medication or use of alternative antiplatelet therapy which may be inferior or more costly. Aspirin therapy has been shown to reduce morbidity and mortality in patients with coronary artery disease. Rapid aspirin challenge/desensitization in the aspirin allergic patient has been consistently shown to be both safe and successful in patients with acute coronary syndromes.

HLA-DRB and HLA-DQ genetic variability in patients with aspirin-exacerbated respiratory disease

BACKGROUND

Major histocompatibility complex (MHC) class II is involved in T-cell activation, cytokine secretion, and induction of immune responses. Cytokines, staphylococcus super antigens, and eosinophil activation are proposed to play important roles in aspirin-exacerbated respiratory disease (AERD).

OBJECTIVES

This study is aimed at investigating the association of HLA-DRB and DQ genetic variabilities in patients with AERD.

METHODS

A genetic association analysis in three different groups, including 33 patients with AERD, 17 patients with aspirin-tolerant asthma (ATA), and 100 healthy controls was performed. Oral aspirin challenge (OAC) test was performed to identify aspirin hypersensitivity. Pulmonary function test (PFT) was performed for all patients. Eosinophil percentage in nasal smear and peripheral blood and serum immunoglobin (Ig)E were investigated. HLA-DRB, HLA-DQA1, and HLA-DQB1 were genotyped using polymerase chain reaction.

RESULTS

HLA-DQB1*0302 (OR, 5.49, 95% confidence interval [CI],(2.40-12.59)), HLA-DQA1*0301 (OR, 2.90, 95% CI, (1.49-5.67)), HLA-DRB4 (OR, 2.94, 95% CI, (1.61-5.36)), and HLA-DRB1*04 (OR, 3.19, 95% CI, (1.57-6.47)) were higher in patients with AERD compared with controls. In patients with AERD, HLA-DQB1*0301 (OR,0.22, 95% CI, (0.09-0.54)), HLA-DQA1*0501 (OR, 0.42, 95% CI, (0.21-0.81)), HLA-DRB1*11 (OR, 0.30, 95% CI, (0.12-0.73)), and HLA-DRB3 (OR, 0.38, 95% CI, (0.21-0.70)) were significantly lower compared with healthy controls. Patients with AERD had lower frequencies of HLA-DQB1*0301 (OR, 0.27, 95% CI, (0.08-0.86)), and HLA-DRB1*011 (OR, 0.27, 95% CI, (0.08-0.86)) compared with ATA. Haplotypes of HLA-DRB1*04/ DQA1*0301/ DQB1*0302 (OR, 4.25, 95% CI, (1.94-9.29)) and HLA-DRB1*07 /DQA1*0201/ DQB1*0201 (OR, 3.52, 95% CI, (1.54-8.06)) were higher in patients with AERD compared with controls (all p < 0.05).

CONCLUSIONS

Results of this study suggest that HLA-DQB1*0302 and HLA-DRB1*04 and their related haplotypes are genes involved in predisposing patients to AERD, whereas HLA-DQB1*0301 and HLA-DRB1*011 have negative association with AERD.

Efficacy and Safety of Available Protocols for Aspirin Hypersensitivity for Patients Undergoing Percutaneous Coronary Intervention: A Survey and Systematic Review

BACKGROUND

The most suitable approach for patients with aspirin hypersensitivity undergoing percutaneous coronary intervention remains to be assessed.

METHODS AND RESULTS

Pubmed, Google Scholar, and Cochrane were systematically searched for papers describing protocols about aspirin hypersensitivity in the percutaneous coronary intervention setting. Discharge from hospital with aspirin was the primary end point, whereas rates of adverse reactions being a secondary outcome. An online international survey was performed to critically analyze rates of aspirin hypersensitivity and its medical and interventional management. Eleven studies with 283 patients were included. An endovenous desensitization protocol was performed on one of them, with high efficacy rate (98%) and a low adverse reaction rate when compared with oral administration. No significant differences were reported among the oral protocols in terms of efficacy (less versus more fractionated [95.8% {95.4%-96.2%} versus 95.9% {95.2-96.5%}]), whereas higher incidence of rash and angioedema were reported for protocols with <6 doses escalation (2.6% [1.1%-4.1%] versus 2.6% [1.9%-3.2%]). In the survey, we collected answer from 86 physician of the 100 interviewed. Fifty-six percent of them managed aspirin hypersensitivity changing the therapeutic regimen (eg, clopidogrel monotherapy and indobufen). Despite the previous safety data, desensitization protocols were adopted by only 42% of surveyed cardiologist.

CONCLUSIONS

Available protocols for aspirin hypersensitivity are effective and safe, representing a feasible approach for patients needing dual antiplatelet therapy.

Aspirin desensitization for patients with aspirin-exacerbated respiratory disease: A randomized double-blind placebo-controlled trial

The effect of aspirin desensitization (AD) on immunologic profile of patients with AERD has been poorly understood. This study is aimed at investigating the effect of AD on clinical and immunological markers of patients with AERD. This randomized double-blind placebo-controlled trial comprised 34 adult patients (67.6% female) with chronic rhinosinusitis, nasal polyps, and aspirin-intolerant asthma. The active group underwent AD over a 2-day period with increasing doses of aspirin (60, 125, 325, and 625 mg), followed by receiving aspirin 625 mg twice daily for 6 months. Symptom scores and medication needs of patients with AERD who have undergone AD were significantly lower compared to the placebo group after 6 months (7.5 ± 3.5 vs. 10.6 ± 3.8 and 9.3 ± 2.0 vs. 11.0 ± 3.1, respectively, all p < 0.05). However, no significant difference was observed in serum concentration of IL-10, IFN-γ, and TGF-β between two groups neither at baseline nor at the end of study.

Hypersensitivity to non-steroidal anti-inflammatory drugs (NSAIDs): classification of a Danish patient cohort according to EAACI/ENDA guidelines

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) are reported to be the second most common cause of drug hypersensitivity. In 2011, experts from the EAACI/ENDA group and GA(2)LEN proposed a new classification system for NSAID hypersensitivity. The aim of this study was to classify a patient cohort with a history of NSAID hypersensitivity according to this system.

METHODS

Patients with a clinical history of NSAID hypersensitivity referred to the Allergy Centre, Odense University Hospital between 2002 and 2011 and evaluated with oral provocation tests (OPTs) were included in the study. Medical records were retrospectively investigated with respect to the culprit NSAID(s), underlying diseases and symptoms at the primary reaction and during oral provocation tests (OPTs). Data was supplemented with a questionnaire. Classification according to EAACI guideline was based on these findings.

RESULTS

In total 149 patients were included. Of those, 39 patients (26.2%) had a positive OPT. Twenty-nine patients were classified as cross-reactive responders and 9 patients as single NSAID responders after positive OPTs with the culprit NSAID, but not to acetylsalicylic acid. All single NSAID responders reacted to non-pyrazolone drugs. Only one patient could not be classified according to the EAACI/ENDA system. An overlap between respiratory and cutaneous symptoms was found in 15/39 (38%) of patients.

CONCLUSIONS

All but one of our patients could be classified according to the EAACI classification system. Overlaps between different classes may occur much more commonly than expected.

Altered inhibitory function of the E-type prostanoid receptor 4 in eosinophils and monocytes from aspirin-intolerant patients

Prostaglandin (PG) E2 has been implicated in the pathogenesis of aspirin-exacerbated respiratory disease (AERD). E-type prostanoid (EP) receptor 4 is known to confer inhibitory signals to eosinophils and monocytes, amongst others. In this study, we investigated whether the responsiveness of eosinophils and monocytes to PGE2 and EP4 receptor activation is altered in AERD patients. While the expression of the EP4 receptor in eosinophils was unaltered in AERD patients, inhibition of eosinophil chemotaxis by PGE2 or the EP4 agonist CAY10598 was less pronounced in AERD patients as compared to healthy control subjects. In monocytes, we found no changes in basal or lipopolysaccharide (LPS)-stimulated PGE2 synthesis, but the response to EP4 receptor activation with respect to inhibition of LPS-induced tumor necrosis factor-α release was reduced in AERD patients, especially in the presence of aspirin (acetylsalicylic acid). Our data point towards a decreased sensitivity of inhibitory EP4 receptor that may play a role in AERD.

Management of angioedema without urticaria in the emergency department

Angioedema refers to a localized, transient swelling of the deep skin layers or the upper respiratory or gastrointestinal mucosa. It develops as a result of mainly two different vasoactive peptides, histamine or bradykinin. Pathophysiology, as well as treatment, is different in each case; nevertheless, the resulting signs and symptoms may be similar and difficult to distinguish. Angioedema may occur at any location. When the affected area involves the upper respiratory tract, both forms of angioedema can lead to an imminent upper airway obstruction and a life-threatening emergency. Emergency physicians must have a basic understanding of the pathophysiology underlying this process. Angioedema evaluation in the emergency department (ED) should aim to distinguish between histamine- and bradykinin-induced angioedema, in order to provide appropriate treatment to patients. However, diagnostic methods are not available at the ED setting, neither to confirm one mechanism or the other, nor to identify a cause. For this reason, the management of angioedema should rely on clinical data depending on the particular features of the episode and the patient in each case. The history-taking should be addressed to identify a possible etiology or triggering agent, recording complete information for an ulterior diagnostic study in the outpatient clinic. It is mandatory quickly to recognize and treat a potential life-threatening upper airway obstruction or anaphylaxis. This review focuses on the underlying mechanisms and management of histamine- and bradykinin-induced angioedema at the emergency department and provides an update on the currently available treatments.

Nasal lysine aspirin challenge in the diagnosis of aspirin - exacerbated respiratory disease: asthma and rhinitis

BACKGROUND

Aspirin-exacerbated respiratory disease is under-diagnosed and therefore effective and inexpensive therapy with aspirin desensitization is rarely performed.

METHODS

We present an audit of 150 patients with difficult to treat nasal polyposis, 132 of whom also had asthma, 131 of whom underwent challenge with the only soluble form of aspirin, lysine aspirin (LAS), to confirm or exclude the diagnosis of aspirin-exacerbated respiratory disease (AERD).

RESULTS

One hundred patients proved positive on nasal challenge, 31 who were negative went onto oral LAS challenge and a further 14 gave positive results, leaving 17 who were negative to a dose equivalent to over 375 mg of aspirin. Nineteen were not challenged because of contraindications. With the exception of one patient who developed facial angioedema and two patients with > 20% drop in FEV1 (following nasal plus oral challenge) no other severe adverse events occurred. No hospitalization was required for these three patients. Nasal inspiratory peak flow monitoring was less sensitive to obstruction caused by aspirin than was acoustic rhinometry - which should be employed when aspirin challenge is an outpatient procedure.

CONCLUSIONS

Provided patients are carefully chosen and monitored LAS challenge is suitable for ENT day case practice where respiratory physician help with asthma is available and should reduce the under-diagnosis of this condition.

Low prevalence of hypersensitivity to nonsteroidal anti-inflammatory drugs in Chinese patients with chronic rhinosinusitis

The exact prevalence of hypersensitivity to nonsteroidal anti-inflammatory drugs (NSAIDs) remains unclear in patients with chronic rhinosinusitis (CRS) because many of these patients routinely avoid the use of NSAIDs. Since the diagnosis of aspirin hypersensitivity is based mainly on history, the aspirin challenge protocol is seldom used clinically in China. The objective of this study is to investigate the prevalence of NSAID hypersensitivity in Chinese patients diagnosed with CRS. In a unique cohort study, consecutive CRS patients received intramuscular diclofenac sodium injection or diclofenac sodium sustained-release tablets to relieve intraoperative and postoperative pain following nasal surgery. In addition, data on NSAID hypersensitivity in large-sample series of CRS patients were collected by searching relevant literature published in Chinese to determine the prevalence of NSAID hypersensitivity in Chinese patients with CRS. A total of 244 consecutive CRS patients were included in this study. Three (1.34%) patients experienced a severe asthmatic attack after intramuscular diclofenac sodium injection and were diagnosed with NSAID hypersensitivity. Despite the use of different methods to diagnose NSAID hypersensitivity, the prevalence of NSAID hypersensitivity in Chinese CRS patients was between 0.28 and 1.46%. The prevalence of NSAID hypersensitivity in Chinese patients with CRS is low, which is a distinct clinical characteristic of Chinese CRS patients. Despite the apparently low prevalence of the condition in this population, a large number of patients in China are affected by this disorder, which should not be overlooked or regarded with an indifferent attitude in medical research and clinical practices.

Aspirin allergy desensitization in cerebrovascular disease. A report of two cases, literature review and management guide for the neurointerventionalist

Aspirin (ASA) is the mainstay of treatment in cerebrovascular and systemic vascular disease. ASA hypersensitivity can pose a challenge to achieving optimum medical management prior to and after neurointerventional treatment. Desensitization to ASA is well described in the allergy and cardiovascular literature, but there are no similar discussions specific to neurointervention. The purpose of our study was to describe our experience with ASA hypersensitivity management and review the relevant literature. Two cases of patients with symptomatic cerebrovascular disease requiring neurointervention who were successfully desensitized to their ASA hypersensitivity prior to treatment are described. The subsequent literature is reviewed. Several ASA desensitization protocols exist and have been proven to successfully treat ASA hypersensitivity and allow for ASA therapy to be safely initiated. We describe several previously published protocols. ASA desensitization is a safe and simple way to manage ASA hypersensitivity. We provide comprehensive management guidelines for the neurointerventionalist engaging in ASA desensitization.

Eosinophil activation and novel mediators in the aspirin-induced nasal response in AERD

BACKGROUND

Eosinophil activation is the key feature of upper and lower airway inflammation in aspirin-exacerbated respiratory disease (AERD).

OBJECTIVE

To investigate the mechanism of eosinophil activation and identify novel inflammatory mediators using proteomics.

METHODS

Thirty-two asthmatic subjects were enrolled: 18 AERD patients who showed positive responses to the lysine-aspirin nasal provocation test (L-ASA NPT) and 14 aspirin-tolerant asthma (ATA) patients who showed negative responses to the L-ASA NPT (control group). Nasal lavage fluid (NLF) was collected before (baseline), at 10, 30 and 60 min (early response), and at 3 h (late response) after the L-ASA NPT. Eosinophil cationic protein (ECP) and cysteinyl leucotriene (CysLT) levels were measured using an ImmunoCAP system and ELISA respectively. To identify proteins involved in AERD, comparative proteomics was applied using NLFs collected before and after L-ASA NPTs in AERD patients. The clinical relevance of identified novel proteins was evaluated by ELISA using NLFs from the AERD and ATA groups.

RESULTS

Eosinophil cationic protein and CysLT levels both increased significantly during the early response in AERD. ECP levels increased until the late response in AERD, while CysLT levels were not significantly increased during the late response. Proteomic analysis showed up-regulation of apolipoprotein A1 (ApoA1), α2-macroglobulin (α2M) and ceruloplasmin (CP), with significant increases in NLF of AERD patients, which was significantly higher in AERD patients with chronic rhinosinusitis. Significant correlations were noted between ECP and CysLT, ApoA1, α2M and CP levels during the early response in AERD patients.

CONCLUSION

Eosinophil activation occurred in early and late responses after L-ASA NPT in upper airway mucosa of AERD patients, where ApoA1, α2M and CP as well as CysLT may be involved in eosinophilic inflammation.

An aspirin a day

The title of this article is also its punch line. The thesis that I will prove is that every adult, with a few exceptions, should take one 325 mg aspirin tablet each day. The drug is extraordinary and is beneficial in myriad ways. In this dosage the toxicity of the treatment is minimal. Since the drug is sold "over the counter", not requiring prescription, it is cheap and its benefits are easily underestimated. I do not use extensive reference citations; but just tell the story of aspirin.

A strategy for addressing aspirin hypersensitivity in patients requiring urgent PCI

Aspirin is key to the treatment of acute myocardial infarction, particularly if stent implantation is considered. In patients with a history of hypersensitivity to aspirin, the optimal management of ST-segment elevation acute myocardial infarction is unclear. We suggest a strategy for addressing this problem by performing percutaneous coronary intervention with antiplatelet therapy by intravenous glycoprotein IIb/IIIa receptor blockers and performing rapid oral desensitization in the ensuing hours, once the patient has stabilized.

Nanosized aspirin-Arg-Gly-Asp-Val: delivery of aspirin to thrombus by the target carrier Arg-Gly-Asp-Val tetrapeptide

Resistance and nonresponse to aspirin dramatically decreases its therapeutic efficacy. To overcome this issue, a small-molecule thrombus-targeting drug delivery system, aspirin-Arg-Gly-Asp-Val (A-RGDV), is developed by covalently linking Arg-Gly-Asp-Val tetrapeptide with aspirin. The 2D ROESY NMR and ESI-MS spectra support a molecular model of an A-RGDV tetramer. Transmission electron microscopy images suggest that the tetramer spontaneously assembles to nanoparticles (ranging from 5 to 50 nm in diameter) in water. Scanning electron microscopy images and atomic force microscopy images indicate that the smaller nanoparticles of A-RGDV further assemble to bigger particles that are stable in rat blood. The delivery investigation implies that in rat blood A-RGDV is able to keep its molecular integrity, while in a thrombus it releases aspirin. The in vitro antiplatelet aggregation assay suggests that A-RGDV selectively inhibits arachidonic acid induced platelet aggregation. The mechanisms of action probably include releasing aspirin, modifying cyclic oxidase, and decreasing the expression of GPIIb/IIIa. The in vivo assay demonstrates that the effective antithrombotic dose of A-RGDV is 16700-fold lower than the nonresponsive dose of aspirin.

Characterization of aspirin allergies in patients with coronary artery disease

BACKGROUND

Aspirin prevents coronary thrombosis and is used extensively in cardiovascular prophylaxis. However, patients with a prior history of an aspirin "reaction" are routinely denied this medication.

OBJECTIVE

To characterize the clinical presentation of a cohort of patients with coronary artery disease (CAD) and aspirin reactions.

METHODS

Between 2009 and 2012, using a retrospective computer analysis, information was collected on all patients within a county-wide health care system presenting with CAD and a prior history of aspirin reactions.

RESULTS

Of 9,565 patients with CAD, a prior history of aspirin reactions was recorded in 142 patients. Of these 142 patients, 30 (21%) had histories compatible with cutaneous and/or respiratory reactions. The other patients described adverse effects to aspirin, mostly gastrointestinal intolerance and bleeding. Aspirin-induced anaphylaxis was recorded in patients but may have been misdiagnosed, describing instead respiratory hypersensitivity reactions. Of the 142 patients, only 34 (24%) were receiving daily cardiovascular prophylaxis with aspirin. Of 108 patients not receiving aspirin, 25 (17.6%) were prescribed clopidogrel.

CONCLUSION

Histories of aspirin reactions in patients with CAD are uncommon, occurring in only 1.5% of our study population. The 21% of patients with histories compatible with aspirin hypersensitivities can be challenged and, if the results are positive, successfully desensitized. Moreover, almost all patients with gastric intolerance to aspirin can be treated with aspirin and a proton pump inhibitor. However, both approaches, which result in restoration of cardiovascular prophylaxis, were seriously underused in our study population.

Definitions and mechanisms of drug hypersensitivity

Adverse drug reactions are a difficult problem faced by clinicians in everyday practice. The mechanisms of drug hypersensitivity are not well understood. This is reflected by difficulties in their classification, which is mainly based upon the current knowledge of immunologic and nonimmunologic mechanisms, onset of symptoms (immediate or nonimmediate) and morphology. For the individual patient, the correct diagnosis and classification is important because strict avoidance of the offending drug might be of vital importance. Considerable experience is required to guide management, to interpret results of investigations and to undertake drug challenges. This article summarizes the current knowledge regarding definitions and mechanisms. However, the field of drug hypersensitivity is rapidly expanding. Modern drugs such as biological agents bare hypersensitivity risks that are potentially mediated by, so far, unknown mechanisms.

[Aspirin desensitization: therapy options in patients with aspirin-exacerbated respiratory disease]

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.

Aspirin-exacerbated respiratory disease in China: a cohort investigation and literature review

BACKGROUND

Although the prevalence of aspirin-exacerbated respiratory disease (AERD) in western populations is high, AERD is rather rare in China, and few related studies have been published to date.

METHODS

We performed a prospective cohort investigation on the incidence of AERD in patients with chronic rhinosinusitis (CRS) in southern China. A literature search of the China Academic Journal Network Publishing Database was conducted to obtain an overview of the incidence of AERD in the Chinese population, and previous studies on the incidence of AERD were reviewed.

RESULTS

We found 2 patients with aspirin hypersensitivity among 351 consecutive CRS (309 with nasal polyps [NPs]) patients, suggesting a rate of 0.57% in the CRS population. Forty-five articles about AERD were obtained by Chinese-language literature searches. In total, 346 cases of AERD were reported during the past 30 years.

CONCLUSION

Given the large population of NPs in China, the prevalence of AERD is very low, and this may be related to the reduced levels of nasal tissue eosinophilia and subsequent low asthma comorbidity.

Is there an association between otitis media and nasal polyposis?

The association between otitis media with effusion (OME) and nasal polyposis (NP) is poorly described. However, two different approaches to this problem seem to come from the few studies concerning both otitis media and NP in the literature. One study was based on the assessment of a population of patients presenting with NP, with the authors interested in patients among the studied population who complained of ear-related symptoms and developed OME (rhinologic approach). Other studies were based on the assessment of a population of patients developing a particular OME, with the authors interested in characterizing this condition they named eosinophilic otitis media (otologic approach). The article reviews currents concepts in the relationship between OME and NP. It appears that regardless of the approach to the problem of interest (rhinologic or otologic approach), OME and NP seem to be closely related. Moreover, some striking similarities can be noted between the different entities described in the different studies reviewed, and all authors seem to agree that the middle ear has a central role in the concept of united airways inflammatory disease. Otologists and rhinologists should work together on a single approach that allows for better management of inflammatory disease leading to the formation of polyps, development of concurrent asthma, appearance of aspirin intolerance, and finally involvement of the middle ear.

Recognising the risk of aspirin-sensitive respiratory disease in a patient with asthma who has previously tolerated aspirin

Asthma is a common chronic condition composed of numerous different phenotypes. One clinically relevant phenotype is that of aspirin-sensitive respiratory disease (ASRD) which is more frequently seen in patients with difficult asthma. Reliance on a history of previous reaction to non-steroidal anti-inflammatory drugs (NSAIDs) in order to diagnose ASRD may give false reassurance. We describe the case of a 58-year old man with late onset asthma who was suspected to have ASRD on the basis of associated clinical features despite having taken aspirin safely in the past. The diagnosis of ASRD was subsequently confirmed by an inadvertent aspirin challenge which led to a serious adverse asthma outcome.

Arg16Gly β2-adrenergic receptor gene polymorphism in Japanese patients with aspirin-exacerbated respiratory disease

BACKGROUND

There has been no report that investigated β(2)-adrenergic receptor (ADRB2) gene polymorphism in patients with aspirin-exacerbated respiratory disease (AERD).

METHODS

DNA in the specimens in three groups of study subjects classified patients with AERD, patients with aspirin-tolerant asthma (ATA) and normal controls was extracted, and the target DNA sequence of the ADRB2 was amplified using a set of primers to generate an amplicon of 219 bp in length. Allelic discrimination assay for single nucleotide polymorphisms relating to the ADRB2 gene expression was carried out by using a previously described single nucleotide polymorphism detective system, sequence-specific thermal-elution chromatography.

RESULTS

The frequency of the Gly variant allele in patients with AERD was significantly lower than that in patients with ATA (p = 0.007), and the odds ratio (OR) of AERD to ATA associated with wild-type ArgArg homozygote was 3.300. Frequencies of wild-type ArgArg homozygote are significantly higher than those of variant-type ArgGly/GlyGly genotype in patients with AERD compared with those with ATA (p < 0.001, OR = 3.153). In patients with AERD, frequencies of wild-type ArgArg homozygote in both female and male patients are significantly higher than those of variant-type ArgGly/GlyGly genotype in male patients compared with those with ATA (p < 0.001, OR = 5.128 and p = 0.007, OR = 4.367, respectively). Also, in patients with AERD, frequencies of wild-type ArgArg homozygote in female patients are significantly higher than those of variant-type ArgGly/GlyGly genotype in female patients compared with those with ATA (p = 0.002, OR = 2.825).

CONCLUSIONS

We were the first to analyze Arg16Gly ADRB2 gene polymorphism in Japanese patients with AERD, and showed that Arg16Gly ADRB2 gene polymorphism in Japanese patients with AERD is different from that in the patients with ATA.

Rhinosinusitis and comorbidities

A variety of systemic conditions impact the incidence, severity, prognosis, and treatment approach in patients with chronic rhinosinusitis (CRS). The controversy surrounding the impact of allergic rhinitis on CRS continues, but it is reasonable to consider and treat allergic sources of inflammation in any patient with CRS. CRS is more severe in patients with aspirin sensitivity but improves--at least temporarily--to the same degree as in non-aspirin-sensitive patients, given appropriate therapy. Polypoid rhinosinusitis in cystic fibrosis patients is characterized by compromised mucociliary clearance and infection with staphylococcal and pseudomonal organisms. Affected individuals require frequent antibiotic treatment, saline lavage, and repeated surgeries. Rhinosinusitis is among the most common infectious complications of humoral immunodeficiency, which is not uncommon in patients with refractory CRS. The treatment approach in immunodeficiency includes aggressive antibiotic treatment and intravenous immunoglobulin. Specific diagnosis of comorbid systemic conditions with CRS will facilitate appropriate management.

Perioperative anaphylaxis

The incidence of immune-mediated anaphylaxis during anesthesia ranges from 1 in 10,000 to 1 in 20,000. Neuromuscular blocking agents are most frequently incriminated, followed by latex and antibiotics, although any drug or substance used may be a culprit. Diagnosis relies on tryptase measurements at the time of the reaction and skin tests, specific immunoglobulin E, or basophil activation assays. Treatment consists of rapid volume expansion and epinephrine administration titrated to symptom severity.

Mediators of inflammation in nasal lavage from aspirin intolerant patients after aspirin challenge

The pathogenetic mechanisms underlying development of persistent inflammation in aspirin (ASA) intolerance are not fully understood. The aim of this study was to determine levels of MCP-3, RANTES, eotaxin, Il-5 and Il-3 in aspirin intolerant asthmatics (AIA) after nasal lysine-aspirin (Lys-ASA) challenge. Twenty AIA and 10 aspirin tolerant controls (ATC) were challenged with saline or 14.4mg of Lys-ASA. Lys-ASA challenge induced clinical symptoms and influx of eosinophils and basophils only in AIA group. Statistically significant higher levels of MCP-3 and RANTES were found in lavages from AIA as compared with ATC (p<0.05 in all time points). Before challenge the average level of MCP-3 was 86.95pg/ml in AIA and 47.61pg/ml in ATC, RANTES levels were 34.20pg/ml in AIA and 17.21pg/ml in ATC and did not change after the challenge in both group. The mean eotaxin's level was 11.01pg/ml in AIA and 8.03pg/ml in ATC before and increased to 20.06, 26.22pg/ml (4 and 24h in AIA) as compared to 10.51, 14.76pg/ml (4 and 24h in ATC) after the challenge (p<0.05). Interleukin-3 and Il-5 were not detectable. The highest inhibition of eosinophils' chemotaxis was induced by anti-eotaxin (47% of inhibition), followed by anti-RANTES (29%), anti-MCP-3 (19%) and anti-Il-5 (9%). In summary, we found that persistent inflammation in AIA patients is characterized by overproduction of MCP-3 and RANTES. Lack of increase in MCP-3 and RANTES levels after Lys-ASA challenge suggest that those mediators are involved in chronic rather than acute phase of ASA induced inflammation.

[Safety of reintroducing platelet-inhibitory doses of aspirin in patients with urticaria or angioedema induced by anti-inflammatory doses]

BACKGROUND

Aspirin is one of the most widely prescribed drugs in the world on account of its analgesic, antipyretic, and anti-inflammatory properties. Its effect on platelet aggregation makes it the first choice for prophylaxis in cardiovascular, neurological and obstetric diseases. However, a history of aspirin-induced urticaria and/or angioedema is usually a contraindication for further prescription of the drug. The aim of this article was to demonstrate that patients presenting aspirin-induced cutaneous reactions at anti-inflammatory doses can safely benefit from aspirin reintroduction at platelet-inhibitory doses.

PATIENTS AND METHODS

Patients with a history of aspirin-induced urticaria and/or angioedema referred to our department between January 2000 and June 2008 for double-blind placebo-controlled reintroduction at platelet-inhibitory doses for a medical indication were enrolled in this study.

RESULTS

Seventy patients with aspirin hypersensitivity as well as a medical indication for this therapy were referred to our department. Of these, 38 (54.3%) had a history of aspirin-induced urticaria and/or angioedema, including three laryngeal oedemas (7.9%). All subjects received platelet-inhibitory doses of aspirin (maximal total dose: 400mg/day) in double-blind placebo-controlled fashion during a one-day hospitalization period. None of the patients presented an immediate hypersensitivity reaction. Only one patient, who had received a cumulative dose of 200mg/day, reported diffuse urticaria and facial angioedema of no clinical significance the following day. He had a history of chronic urticaria.

CONCLUSION

This article demonstrates the safety of reintroducing platelet-inhibitory doses of aspirin in patients in whom it is indicated and reporting aspirin-induced urticaria and/or angioedema with anti-inflammatory doses. However, patients with a history of chronic urticaria should undergo a challenge with the lowest platelet-inhibitory dose (75mg/day) in order to minimize the risk of aggravating their condition.

Potential adverse effects of bronchodilators in the treatment of airways obstruction in older people: recommendations for prescribing

Asthma and chronic obstructive pulmonary disease (COPD) are common disorders that are associated with increasing morbidity and mortality in older people. Bronchodilators are used widely in patients with these conditions, but even when used in inhaled form can have systemic as well as local effects. Older people experience more adverse drug effects because of pharmacodynamic and pharmacokinetic changes and particularly drug-drug and drug-disease interactions. Cardiovascular disease is common in older people and beta-adrenoceptor agonists (beta-agonists) have inotropic and chronotropic effects that can increase arrhythmias and cardiomyopathy. They can also worsen or induce myocardial ischaemia and cause electrolyte disturbances that contribute to arrhythmias. Tremor is a well known distressing adverse effect of beta-agonist administration. Long-term beta-agonist use can be associated with tolerance, poor disease control, sudden life-threatening exacerbations and asthma-related deaths. Functional beta2-adrenoceptors are present in osteoblasts, and chronic use of beta-agonists has been implicated in osteoporosis. Inhaled anticholinergics are usually well tolerated but may cause dry mouth, which can be troublesome in older people. Pupillary dilatation, blurred vision and acute glaucoma can occur from escape of droplets from loosely fitting nebulizer masks. Although ECG changes have not been seen in randomized controlled trials of long-acting inhaled anticholinergics, supraventricular tachycardias have been observed in a 5-year randomized controlled trial of ipratropium bromide. Paradoxical bronchoconstriction can occur with inhaled anticholinergics as well as with beta-agonists, but tolerance has not been reported with anticholinergics. Anticholinergic drugs also cause central effects, most notably impairment of cognitive function, and these effects have been noted with inhaled agents. Use of theophylline is limited by its adverse effects, which range from commonly occurring gastrointestinal symptoms to palpitations, arrhythmias and reports of myocardial infarction. Seizures have been reported, but are rare. Theophylline is metabolized primarily by the liver, and commonly interacts with other medications. Its concentration in plasma should be monitored closely, especially in older people. Although many clinical trials have been conducted on bronchodilators in obstructive airways disease, the results of these clinical trials need to be interpreted with caution as older people are often under-represented and subjects with co-morbidities actively excluded from these trials.

The clinical effectiveness of aspirin desensitization in chronic rhinosinusitis

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.