Aspirin desensitization in NSAID-exacerbated respiratory disease and its outcomes in the clinical course of asthma: A systematic review of the literature and meta-analysis

Updates on the Natural History and Clinical Characteristics of NSAID-ERD

Nonsteroidal anti-inflammatory drug-exacerbated respiratory disease (NSAID-ERD) is a distinct clinical syndrome characterized by nonsteroidal anti-inflammatory drug (NSAID) hypersensitivity, asthma, and nasal polyposis. Its diagnosis is challenging owing to variable presentations and a lack of simple tests, leading to diagnostic delays. Recent research has revealed its genetic predispositions, environmental triggers, and associations with atopy and second-hand tobacco smoke exposure or smoking cessation. Despite its severity, diagnostic awareness remains low, leading to the delay in effective management. Therapeutically, NSAID-ERD necessitates multidisciplinary approaches, often combining surgical interventions with medical management, including aspirin desensitization and biologic agents. However, predictive biomarkers for treatment response remain elusive. Understanding the underlying mechanisms driving NSAID-ERD pathogenesis and identifying reliable biomarkers are crucial for enhancing diagnostic accuracy and refining targeted therapeutic strategies for this debilitating condition. This review aims to provide a thorough understanding of NSAID-ERD, covering its history, clinical features, epidemiology, diagnosis, systemic and molecular biomarkers, available treatment options, and avenues for future research.

Pre-asthma: a useful concept? A EUFOREA paper. Part 2-late onset eosinophilic asthma

The concept of pre-diabetes has led to provision of measures to reduce disease progression through identification of subjects at risk of diabetes. We previously considered the idea of pre-asthma in relation to allergic asthma and considered that, in addition to the need to improve population health via multiple measures, including reduction of exposure to allergens and pollutants and avoidance of obesity, there are several possible specific means to reduce asthma development in those most at risk (pre- asthma). The most obvious is allergen immunotherapy (AIT), which when given for allergic rhinitis (AR) has reasonable evidence to support asthma prevention in children (2) but also needs further study as primary prevention. In this second paper we explore the possibilities for similar actions in late onset eosinophilic asthma.

Nonsteroidal Anti-inflammatory Drug (NSAID) Tolerance After Biological Therapy in Patients With NSAID-Exacerbated Respiratory Disease: A Randomized Comparative Trial

BACKGROUND

There are no prospective studies comparing how biological therapies affect nonsteroidal anti-inflammatory drug (NSAID) tolerance in NSAID-exacerbated respiratory disease.

OBJECTIVE

To study the induction of NSAID tolerance after biological therapy in patients with NSAID-exacerbated respiratory disease.

METHODS

A prospective pilot study in a real-world clinic setting was conducted among subjects with severe asthma and type 2 inflammation. A random allocation of therapy was carried out: benralizumab, dupilumab, mepolizumab, or omalizumab. NSAID intolerance was confirmed by an oral challenge test (OCT) using acetyl-salicylic acid (ASA-OCT). The principal outcome was NSAID tolerance according to OCT before and after 6 months of each biological therapy (intragroup comparisons). As exploratory outcomes, we compared NSAID tolerance between biological therapies (intergroup comparisons).

RESULTS

A total of 38 subjects were included; 9 received benralizumab, 10 dupilumab, 9 mepolizumab, and 10 omalizumab. There was an increase in the concentration needed to produce a reaction during ASA-OCT with omalizumab (P < .001) and dupilumab (P = .004) but not with mepolizumab and benralizumab. Omalizumab and dupilumab achieved the highest frequency of NSAID tolerance (omalizumab 60%, dupilumab 40%, mepolizumab 22%, and benralizumab 22%).

CONCLUSIONS

Biological therapies for asthma are useful for inducing NSAID tolerance; however, in patients with type 2 inflammation and high levels of total IgE, atopy, and eosinophils, anti-IgE or anti-IL4/13 seem to be more effective than antieosinophilic therapies. Omalizumab and dupilumab increased ASA tolerance, whereas mepolizumab and benralizumab did not. Future trials will be able to clarify this finding.

Allergen immunotherapy: progress and future outlook

INTRODUCTION

Allergy, the immunological hypersensitivity to innocuous environmental compounds, is a global health problem. The disease triggers, allergens, are mostly proteins contained in various natural sources such as plant pollen, animal dander, dust mites, foods, fungi and insect venoms. Allergies can manifest with a wide range of symptoms in various organs, and be anything from just tedious to life-threatening. A majority of all allergy patients are self-treated with symptom-relieving medicines, while allergen immunotherapy (AIT) is the only causative treatment option.

AREAS COVERED

This review will aim to give an overview of the state-of-the-art allergy management, including the use of new biologics and the application of biomarkers, and a special emphasis and discussion on current research trends in the field of AIT.

EXPERT OPINION

Conventional AIT has proven effective, but the years-long treatment compromises patient compliance. Moreover, AIT is typically not offered in food allergy. Hence, there is a need for new, effective and safe AIT methods. Novel routes of administration (e.g. oral and intralymphatic), hypoallergenic AIT products and more effective adjuvants holds great promise. Most recently, the development of allergen-specific monoclonal antibodies for passive immunotherapy may also allow treatment of patients currently not treated or treatable.

Controversies in Allergy: Aspirin Desensitization or Biologics for Aspirin-Exacerbated Respiratory Disease-How to Choose

Aspirin-exacerbated respiratory disease (AERD) can be a frustratingly complex syndrome to treat. Until recently, standard medical and surgical therapies for patients' asthma and chronic rhinosinusitis with nasal polyposis were the primary treatment modalities available, combined with either complete avoidance of all aspirin and nonsteroidal anti-inflammatory medications, or aspirin desensitization and initiation of high-dose aspirin therapy. There are now several targeted respiratory biologics added to the available armament for patients with AERD and choosing between this ever-growing list of options can be daunting for both patients and their clinicians. This review includes our understanding and interpretation of the existing data for each option, along with our own approach to weighing the pros and cons of each treatment for individual patients.