1
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Levin M, Chan Y, Sommer DD, Thamboo A, Lee JM. Quantifying surgical completeness in patients with aspirin exacerbated respiratory disease. J Otolaryngol Head Neck Surg 2023; 52:83. [PMID: 38105254 PMCID: PMC10726574 DOI: 10.1186/s40463-023-00682-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 11/17/2023] [Indexed: 12/19/2023] Open
Abstract
BACKGROUND Aspirin exacerbated respiratory disease (AERD) in patients who have had sinus surgery remains a management challenge. Aspirin desensitization and biologics are additional treatment options. It remains unclear if patients require a more comprehensive surgery prior to implementing such additional therapies. The purpose of this study was to quantify prior surgery completeness in AERD patients at a tertiary rhinology practice. METHODS Paranasal sinus CT scans were reviewed by four academic rhinologists to assess surgery completeness. Using a published CT grading system, each sinus was graded on the completeness of surgery and middle turbinate reduction. A score out of 14 was calculated for each patient (7 per side). RESULTS Sixty-one patients with AERD out of 141 available were included. Mean inter-rater agreement across all sinuses was moderate (k = 0.42). The mean completeness score was 6.7/14. The following procedures were rated as complete (means): uncinectomy (L: 84%, R: 82%, k = 0.44), maxillary (L: 83%, R: 77%, k = 0.32), middle turbinate reduction (L: 45%, R: 46%, k = 0.31), anterior ethmoid (L: 35%, R: 39%, k = 0.51), sphenoid (L: 36%, R: 35%, k = 0.4), posterior ethmoid (L: 30%, R: 30%, k = 0.48), frontal (L: 22%, R: 21%, k = 0.46). CONCLUSION Prior surgery in AERD patients were mostly deemed incomplete. Uncinectomy and maxillary antrostomy are the most common procedures previously performed. It remains toe seen whether this would be considered 'adequate' surgery or more 'complete' surgery is required to achieve greater disease control.
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Affiliation(s)
- Marc Levin
- Division of Rhinology, Department of Otolaryngology - Head and Neck Surgery, St. Michael's Hospital, Unity Health Toronto, University of Toronto, 30 Bond Street, 8 Cardinal Carter, Toronto, ON, M5B 1WB, Canada
| | - Yvonne Chan
- Division of Rhinology, Department of Otolaryngology - Head and Neck Surgery, St. Michael's Hospital, Unity Health Toronto, University of Toronto, 30 Bond Street, 8 Cardinal Carter, Toronto, ON, M5B 1WB, Canada
| | - Doron D Sommer
- Department of Surgery - Division of Otolaryngology Head and Neck Surgery, McMaster University, Hamilton, ON, Canada
| | - Andrew Thamboo
- Department of Surgery - Division of Otolaryngology Head and Neck Surgery, University of British Columbia, Vancouver, BC, Canada
| | - John M Lee
- Division of Rhinology, Department of Otolaryngology - Head and Neck Surgery, St. Michael's Hospital, Unity Health Toronto, University of Toronto, 30 Bond Street, 8 Cardinal Carter, Toronto, ON, M5B 1WB, Canada.
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2
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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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3
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Mehta MP, Wise SK. Unified Airway Disease. Otolaryngol Clin North Am 2023; 56:65-81. [DOI: 10.1016/j.otc.2022.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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4
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Siña MJ, Valdés F, Zelada Ú, Tagle MT, Campillay R, Sandoval D, Herrera P, Bastías C. Aspirin desensitization in nonsteroidal anti-inflammatory exacerbated respiratory disease: The first prospective cohort in Chile. FRONTIERS IN ALLERGY 2023; 3:951323. [PMID: 36816475 PMCID: PMC9929946 DOI: 10.3389/falgy.2022.951323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 12/30/2022] [Indexed: 02/04/2023] Open
Abstract
Background Nonsteroidal anti-inflammatory exacerbated respiratory disease (N-ERD) is characterized by the Samter triad: chronic rhinosinusitis with nasal polyps, asthma, and nonallergic hypersensitivity to NSAIDs. Its diagnosis is based on a complete clinical history and an aspirin (ASA) challenge test. Medical treatments include biological drugs and ASA desensitization. Objective This study aims to evaluate the clinical response of patients with N-ERD undergoing functional endoscopic surgery (FES), followed by ASA desensitization and maintenance treatment, being the first prospective cohort study carried out in Chile. Methods We conducted 1-year follow-up of 12 patients with N-ERD treated with FES, desensitization, and maintenance with ASA. For each control, the medication score, sinonasal symptomatology (SNOT-22), PEF (peak expiratory flow), nasal polyposis (Lildholdt score), and the appearance of adverse effects were recorded. Computed tomography (CT) of the paranasal cavities was performed at baseline and at the 12-month follow-up to calculate the Lund-Mackay score. Results Patients presented a reduction of SNOT-22 after the FES, which was maintained at 12 months (p = 0.002); the symptoms that showed the greatest reduction were feeling embarrassed and nasal obstruction. The Lildholdt score was also significantly reduced (p = 0.001); in only three patients, the nasal polyps recurred, and all were small. The PEF showed a slight nonsignificant increase of 3.3%. In total, 75% of patients had an adverse effect, the most frequent being abdominal pain (66.7%), but none of the 12 patients required discontinuation of aspirin treatment in 1-year follow-up. The Lund-Mackay score had a significant reduction of 6.6 points (p < 0.001). Conclusion ASA desensitization is safe and effective in reducing upper and lower respiratory symptoms in patients with N-ERD and delays the reappearance of nasal polyps, although it is not exempt from adverse effects, with the vast majority being mild.
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Affiliation(s)
- María Josefina Siña
- Department of Pediatrics, Immunology Section, Clínica Universidad de los Andes, Santiago, Chile
| | - Felipe Valdés
- Department of Internal Medicine, Immunology Section, Barros Luco Trudeau Healthcare Complex, Santiago, Chile,Faculty of Medicine, University of Chile, Santiago, Chile,Correspondence: Felipe Valdés
| | - Úrsula Zelada
- Faculty of Medicine, University of Chile, Santiago, Chile,Department of Otorhinolaryngology, Barros Luco Trudeau Healthcare Complex, Santiago, Chile
| | - María Teresa Tagle
- Department of Internal Medicine, Immunology Section, Barros Luco Trudeau Healthcare Complex, Santiago, Chile
| | - Rolando Campillay
- Department of Internal Medicine, Immunology Section, Barros Luco Trudeau Healthcare Complex, Santiago, Chile
| | | | - Pablo Herrera
- Department of Internal Medicine, Immunology Section, Barros Luco Trudeau Healthcare Complex, Santiago, Chile
| | - Carla Bastías
- Department of Internal Medicine, Immunology Section, Barros Luco Trudeau Healthcare Complex, Santiago, Chile,Faculty of Medicine, University of Chile, Santiago, Chile
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5
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Landa E, Javaid S, Vigandt E, Campos F, Mercado L. Aspirin-Exacerbated Respiratory Disease Requiring Desensitization Prior to Planned Percutaneous Catheterization Intervention. Cureus 2022; 14:e26686. [PMID: 35949785 PMCID: PMC9359106 DOI: 10.7759/cureus.26686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2022] [Indexed: 11/18/2022] Open
Abstract
Aspirin-exacerbated respiratory disease (AERD) consists of a triad of asthma, chronic rhinosinusitis with nasal polyposis, and a hypersensitivity reaction to aspirin consisting of nasal congestion and broncho-constriction. This disease presents a conundrum in cardiac patients undergoing percutaneous catheterization intervention (PCI) who might require stent deployment due to the need for aspirin as part of the dual antiplatelet therapy required if a stent is placed. Here, we present the case of a patient who underwent a coronary angiogram showing two-vessel disease but had to undergo aspirin desensitization first before planned PCI as he had a history of severe aspirin allergy in the past.
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6
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Eraso I, Sangiovanni S, Morales EI, Fernández-Trujillo L. 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. PLoS One 2021; 16:e0247871. [PMID: 33770090 PMCID: PMC7996991 DOI: 10.1371/journal.pone.0247871] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 02/16/2021] [Indexed: 11/18/2022] Open
Abstract
Background Nonsteroidal anti-inflammatory drug-exacerbated respiratory disease (NERD) might benefit from aspirin desensitization (AD) as an alternative treatment to standard care. However, there is conflicting evidence regarding its role in bronchial symptoms and asthma exacerbations. Objective To analyze the clinical effects of AD in terms of lung function, systemic and inhaled steroid use, the frequency of acute asthma exacerbations, and adverse effects in patients with NERD and asthma. Methodology We identified randomized clinical trials (RCTs) from PubMed, EMBASE, SCOPUS, and EBSCO. We also searched the RCT references for additional studies. Studies comparing AD to placebo in patients with a previous history of pulmonary symptoms triggered by ASA or other NSAIDs or with a positive provocation test to ASA were included. Primary results Five studies with 210 participants with NERD were included in this review. The study duration ranged from 3 to 6 months. Overall, the risk of bias across the included RCTs was low. We identified 3 studies evaluating lung function, 2 of which reported a significant improvement in FEV1 in the AD group after 6 months, while the other reported no difference among the treatments. Due to high heterogeneity, we did not pool the results. The remaining primary outcomes were reported only in a single study each, hindering their interpretation. Secondary outcomes revealed reduced symptom and medication scores in patients with AD. Conclusions Due to the small number of studies included in this systematic review, conclusions should be made with caution. AD shows a trend towards improving lung function (FEV1) following 6 months of treatment, although no conclusions can be made regarding the use of corticosteroids or the frequency of acute exacerbations. AD appears to reduce both symptom and medication scores. Additional RCTs are needed to fully assess the efficacy of AD in reducing bronchial symptoms in patients with NERD.
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Affiliation(s)
- Isabel Eraso
- Department of Internal Medicine, Allergology Service, Fundación Valle del Lili, Cali, Colombia
- Faculty of Health Sciences, Universidad Icesi, Cali, Colombia
| | | | - Eliana I. Morales
- Faculty of Health Sciences, Universidad Icesi, Cali, Colombia
- Department of Internal Medicine, Pulmonology Service, Fundación Valle del Lili, Cali, Colombia
| | - Liliana Fernández-Trujillo
- Faculty of Health Sciences, Universidad Icesi, Cali, Colombia
- Department of Internal Medicine, Pulmonology Service, Interventional Pulmonology, Fundación Valle del Lili, Cali, Colombia
- * E-mail: ,
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7
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Ishitsuka Y, Kondo Y, Kadowaki D. Toxicological Property of Acetaminophen: The Dark Side of a Safe Antipyretic/Analgesic Drug? Biol Pharm Bull 2020; 43:195-206. [PMID: 32009106 DOI: 10.1248/bpb.b19-00722] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Acetaminophen (paracetamol, N-acetyl-p-aminophenol; APAP) is the most popular analgesic/antipyretic agent in the world. APAP has been regarded as a safer drug compared with non-steroidal anti-inflammatory drugs (NSAIDs) particularly in terms of lower risks of renal dysfunction, gastrointestinal injury, and asthma/bronchospasm induction, even in high-risk patients such as the elderly, children, and pregnant women. On the other hand, the recent increasing use of APAP has raised concerns about its toxicity. In this article, we review recent pharmacological and toxicological findings about APAP from basic, clinical, and epidemiological studies, including spontaneous drug adverse events reporting system, especially focusing on drug-induced asthma and pre-and post-natal closure of ductus arteriosus. Hepatotoxicity is the greatest fault of APAP and the most frequent cause of drug-induced acute liver failure in Western countries. However, its precise mechanism remains unclear and no effective cure beyond N-acetylcysteine has been developed. Recent animal and cellular studies have demonstrated that some cellular events, such as c-jun N-terminal kinase (JNK) pathway activation, endoplasmic reticulum (ER) stress, and mitochondrial oxidative stress may play important roles in the development of hepatitis. Herein, the molecular mechanisms of APAP hepatotoxicity are summarized. We also discuss the not-so-familiar "dark side" of APAP as an otherwise safe analgesic/antipyretic drug.
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Affiliation(s)
- Yoichi Ishitsuka
- Department of Clinical Chemistry and Informatics, Graduate School of Pharmaceutical Sciences, Kumamoto University
| | - Yuki Kondo
- Department of Clinical Chemistry and Informatics, Graduate School of Pharmaceutical Sciences, Kumamoto University
| | - Daisuke Kadowaki
- Department of Clinical Pharmaceutics, Faculty of Pharmaceutical Sciences, Sojo University
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8
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Schoettler N, Strek ME. Recent Advances in Severe Asthma: From Phenotypes to Personalized Medicine. Chest 2019; 157:516-528. [PMID: 31678077 DOI: 10.1016/j.chest.2019.10.009] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 09/15/2019] [Accepted: 10/18/2019] [Indexed: 12/31/2022] Open
Abstract
This review focuses on recent clinical and translational discoveries in severe and uncontrolled asthma that now enable phenotyping and personalized therapies in these patients. Although asthma is common in both children and adults and typically responds to standard therapies, a subset of individuals with asthma experience severe and/or persistent symptoms despite appropriate therapies. Airflow obstruction leading to frequent symptoms requiring higher levels of controller therapy is the cardinal feature of severe asthma, but the underlying molecular mechanisms, or endotypes, are diverse and variable between individuals. Two major risk factors that contribute to severe asthma are genetics and environmental exposures that modulate immune responses, and although these often interact in complex manners that are not fully understood, certain endotypes converge in severe asthma. A number of studies have evaluated various features of patients with severe asthma and classified patients into phenotypes with clinical relevance. This phenotyping is now incorporated into clinical practice and can be used to guide advanced biological therapies that target specific molecules and inflammatory pathways that contribute to asthma pathogenesis.
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Affiliation(s)
- Nathan Schoettler
- Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, Chicago, IL.
| | - Mary E Strek
- Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, Chicago, IL
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9
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Youroukova VM, Dimitrova DG, Valerieva AD, Lesichkova SS, Velikova TV, Ivanova-Todorova EI, Tumangelova-Yuzeir KD. Phenotypes Determined by Cluster Analysis in Moderate to Severe Bronchial Asthma. Folia Med (Plovdiv) 2019; 59:165-173. [PMID: 28704185 DOI: 10.1515/folmed-2017-0031] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 12/07/2016] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Bronchial asthma is a heterogeneous disease that includes various subtypes. They may share similar clinical characteristics, but probably have different pathological mechanisms. AIM To identify phenotypes using cluster analysis in moderate to severe bronchial asthma and to compare differences in clinical, physiological, immunological and inflammatory data between the clusters. PATIENTS AND METHODS Forty adult patients with moderate to severe bronchial asthma out of exacerbation were included. All underwent clinical assessment, anthropometric measurements, skin prick testing, standard spirometry and measurement fraction of exhaled nitric oxide. Blood eosinophilic count, serum total IgE and periostin levels were determined. Two-step cluster approach, hierarchical clustering method and k-mean analysis were used for identification of the clusters. RESULTS We have identified four clusters. Cluster 1 (n=14) - late-onset, non-atopic asthma with impaired lung function, Cluster 2 (n=13) - late-onset, atopic asthma, Cluster 3 (n=6) - late-onset, aspirin sensitivity, eosinophilic asthma, and Cluster 4 (n=7) - early-onset, atopic asthma. CONCLUSIONS Our study is the first in Bulgaria in which cluster analysis is applied to asthmatic patients. We identified four clusters. The variables with greatest force for differentiation in our study were: age of asthma onset, duration of diseases, atopy, smoking, blood eosinophils, nonsteroidal anti-inflammatory drugs hypersensitivity, baseline FEV1/FVC and symptoms severity. Our results support the concept of heterogeneity of bronchial asthma and demonstrate that cluster analysis can be an useful tool for phenotyping of disease and personalized approach to the treatment of patients.
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Affiliation(s)
- Vania M Youroukova
- Clinical Center for Lung Diseases, St. Sofi a Hospital for Pulmonary Diseases, Medical University of Sofi a, Sofi a, Bulgaria
| | - Denitsa G Dimitrova
- Clinical Center for Lung Diseases, St. Sofi a Hospital for Pulmonary Diseases, Medical University of Sofi a, Sofi a, Bulgaria
| | - Anna D Valerieva
- Clinic of Allergy, Alexandrovska University Hospital, Medical University of Sofi a, Sofi a, Bulgaria
| | - Spaska S Lesichkova
- Department of Clinical Immunology, Alexandrovska University Hospital, Medical University of Sofi a, Sofi a, Bulgaria
| | - Tsvetelina V Velikova
- Department of Clinical Laboratory and Clinical Immunology, St. Ivan Rilski University Hospital, Medical University of Sofi a, Sofi a,
Bulgaria
| | - Ekaterina I Ivanova-Todorova
- Department of Clinical Laboratory and Clinical Immunology, St. Ivan Rilski University Hospital, Medical University of Sofi a, Sofi a,
Bulgaria
| | - Kalina D Tumangelova-Yuzeir
- Department of Clinical Laboratory and Clinical Immunology, St. Ivan Rilski University Hospital, Medical University of Sofi a, Sofi a,
Bulgaria
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10
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Nassif M, van Steenwijk RP, Hogenhout JM, Lu H, de Bruin-Bon RHACM, Hirsch A, Sterk PJ, Bouma BJ, Straver B, Tijssen JGP, Mulder BJM, de Winter RJ. Atrial septal defect in adults is associated with airway hyperresponsiveness. CONGENIT HEART DIS 2018; 13:959-966. [PMID: 30242971 DOI: 10.1111/chd.12665] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 06/17/2018] [Accepted: 07/15/2018] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The association between secundum atrial septal defects (ASD) and asthma-like dyspnea with consequent long-term pulmonary inhalant use, is poorly understood in adult ASD patients. Airway hyperresponsiveness is suggested to be the underlying mechanism of cardiac asthma from mitral valve disease and ischemic cardiomyopathy. We hypothesized that airway hyperresponsiveness may also be found in adult ASD patients. Our aim was to study airway responsiveness in adult ASD patients before percutaneous closure and at short-and long-term postprocedural follow-up. METHODS This prospective study included 31 ASD patients (65% female, mean age 49 ± 15y) who underwent spirometry and bronchoprovocation testing pre-and six-month postprocedurally, with additional bronchoprovocation at 2-year follow-up. Airway hyperresponsiveness was defined as ≥20% fall of forced expiratory volume in 1-second (FEV1 ) following <8.0 mg/mL of inhaled methacholine. RESULTS Airway hyperresponsiveness was found in 19/30 patients (63%[95%CI 45%-81%]; post hoc statistical power = 89%). Asthma-like symptoms wheezing, chest tightness, and cough were more frequently reported in airway hyperresponsive patients. Airway responsiveness was not influenced by successful percutaneous ASD closure, corresponding to persistence of asthma-like symptoms postclosure. Regardless of airway responsiveness, postprocedural right-sided reverse remodeling significantly improved dyspnea and pulmonary function. CONCLUSIONS This study is the first to report a high prevalence of airway hyperresponsiveness in a cohort of unrepaired adult ASD patients, and confirms the association between asthma-like symptoms and ASD in adults. Attention to symptoms and pulmonary function should be given during clinical follow-up of adult ASD patients, both before and long after repair.
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Affiliation(s)
- Martina Nassif
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
| | | | | | - Huangling Lu
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Alexander Hirsch
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands.,Department of Cardiology and Radiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Peter J Sterk
- Department of Respiratory Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Berto J Bouma
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Bart Straver
- Department of Pediatric Cardiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Jan G P Tijssen
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Barbara J M Mulder
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands.,Netherlands Heart Institute, Utrecht, The Netherlands
| | - Robbert J de Winter
- Department of Cardiology, Academic Medical Center, Amsterdam, The Netherlands
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11
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Assessing asthma in the otolaryngologist's office. Curr Opin Otolaryngol Head Neck Surg 2018; 25:223-230. [PMID: 28234779 DOI: 10.1097/moo.0000000000000351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To familiarize otolaryngologists and other practitioners with basic diagnosis and treatment of asthma in adults and children based on current literature. RECENT FINDINGS Increased fractional excretion of nitrous oxide and sputum eosinophils have been identified in asthmatic patients being evaluated for chronic cough and appear to be more sensitive in diagnosis than traditional spirometry. Both sublingual and subcutaneous immunotherapy modalities are effective in decreasing symptoms and medication use in patients with allergic rhinitis and allergic asthma. SUMMARY Undiagnosed comorbid asthma is prevalent among patients with chronic rhinosinusitis and allergic rhinitis and control of all diseases processes greatly improves quality of life. Office spirometry is a helpful tool in the evaluation and management of asthma. Otolaryngologists should be able to recognize undiagnosed or poorly controlled asthma, initiate and improve medical therapy, and treat rhinosinusitis to improve asthma control.
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12
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Rodríguez-Jiménez JC, Moreno-Paz FJ, Terán LM, Guaní-Guerra E. Aspirin exacerbated respiratory disease: Current topics and trends. Respir Med 2018; 135:62-75. [PMID: 29414455 DOI: 10.1016/j.rmed.2018.01.002] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 12/22/2017] [Accepted: 01/08/2018] [Indexed: 12/21/2022]
Abstract
Aspirin-exacerbated respiratory disease is a chronic and treatment-resistant disease, characterized by the presence of eosinophilic rhinosinusitis, nasal polyposis, bronchial asthma, and nonsteroidal anti-inflammatory drugs hypersensitivity. Alterations in arachidonic acid metabolism may induce an imbalance between pro-inflammatory and anti-inflammatory substances, expressed as an overproduction of cysteinyl leukotrienes and an underproduction of prostaglandin E2. Although eosinophils play a key role, recent studies have shown the importance of other cells and molecules in the development of the disease like mast cells, basophils, lymphocytes, platelets, neutrophils, macrophages, epithelial respiratory cells, IL-33 and thymic stromal lymphopoietin, making each of them promissory diagnostic and treatment targets. In this review, we summarize the most important clinical aspects of the disease, including the current topics about diagnosis and treatment, like provocation challenges and aspirin desensitization. We also discuss recent findings in the pathogenesis of the disease, as well as future trends in diagnosis and treatment, including monoclonal antibodies and a low salicylate diet as a treatment option.
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Affiliation(s)
| | | | - Luis Manuel Terán
- Department of Immunogenetics, National Institute of Respiratory Diseases (INER), Mexico City, Mexico
| | - Eduardo Guaní-Guerra
- Department of Medicine, University of Guanajuato, León, Guanajuato, Mexico; Department of Immunology, Hospital Regional de Alta Especialidad del Bajío, León, Guanajuato, Mexico.
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13
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Dunn NM, Katial RK. Chronic Rhinosinusitis and Aspirin-Exacerbated Respiratory Disease. Immunol Allergy Clin North Am 2017; 36:503-14. [PMID: 27401622 DOI: 10.1016/j.iac.2016.03.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Patients with severe asthma and concomitant chronic rhinosinusitis often have severe, refractory upper and lower airway inflammation. This inflammation has been proposed to be similar throughout the upper and lower airways leading to the unified airways concept. This article reviews chronic rhinosinusitis with and without nasal polyps, and the subgroup with aspirin-exacerbated respiratory disease, while focusing on the relationship with asthma. Additionally, diagnosis and treatment with current and newer therapies are discussed.
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Affiliation(s)
- Neha M Dunn
- Department of Allergy and Immunology, National Jewish Health, 1400 Jackson Street, Denver, CO 80206, USA
| | - Rohit K Katial
- Department of Allergy and Immunology, National Jewish Health, 1400 Jackson Street, Denver, CO 80206, USA.
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14
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Pavón-Romero GF, Reséndiz-Hernández JM, Ramírez-Jiménez F, Pérez-Rubio G, Camarena Á, Terán LM, Falfán-Valencia R. Single nucleotide polymorphisms in TNF are associated with susceptibility to aspirin-exacerbated respiratory disease but not to cytokine levels: a study in Mexican mestizo population. Biomark Med 2017; 11:1047-1055. [PMID: 29172674 DOI: 10.2217/bmm-2017-0164] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
AIM To evaluate the association of three single nucleotide polymorphisms in TNF and one in LTA in Mexican patients with aspirin-exacerbated respiratory disease (AERD) and the correlation of those single nucleotide polymorphisms with serum levels of TNF-α. PATIENTS & METHODS Case-control study including 133 patients with AERD, 135 patients with asthma (aspirin-tolerant asthmatics) and 182 healthy subjects. RESULTS GA genotype of rs1800629 in TNF was found to be associated with the risk of developing AERD (p < 0.05; odds ratio = 2.36) and by dominant model (p < 0.05; odds ratio = 2.51). Furthermore, there was a difference in the serum levels between the aspirin-tolerant asthmatics group and the other groups (p < 0.001). CONCLUSION The GA genotype of rs1800629 is associated with genetic susceptibility to AERD, but it does not correlate to protein serum levels.
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Affiliation(s)
- Gandhi F Pavón-Romero
- Department of Allergy & Clinical Immunology, Instituto Nacional Enfermedades Respiratorias Ismael Cosío Villegas, Tlalpan 4502, Sección XVI, Tlalpan, 14080, Mexico City, Mexico.,HLA Laboratory, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Tlalpan 4502, Sección XVI, Tlalpan, 14080, Mexico City, Mexico.,Biomedicine In the Post-Genomic Era, Tlalpan 4502, Sección XVI, Tlalpan, 14080, Mexico City, Mexico
| | - Juan M Reséndiz-Hernández
- Department of Allergy & Clinical Immunology, Instituto Nacional Enfermedades Respiratorias Ismael Cosío Villegas, Tlalpan 4502, Sección XVI, Tlalpan, 14080, Mexico City, Mexico.,HLA Laboratory, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Tlalpan 4502, Sección XVI, Tlalpan, 14080, Mexico City, Mexico.,Biomedicine In the Post-Genomic Era, Tlalpan 4502, Sección XVI, Tlalpan, 14080, Mexico City, Mexico
| | - Fernando Ramírez-Jiménez
- Department of Allergy & Clinical Immunology, Instituto Nacional Enfermedades Respiratorias Ismael Cosío Villegas, Tlalpan 4502, Sección XVI, Tlalpan, 14080, Mexico City, Mexico.,HLA Laboratory, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Tlalpan 4502, Sección XVI, Tlalpan, 14080, Mexico City, Mexico.,Biomedicine In the Post-Genomic Era, Tlalpan 4502, Sección XVI, Tlalpan, 14080, Mexico City, Mexico
| | - Gloria Pérez-Rubio
- Department of Allergy & Clinical Immunology, Instituto Nacional Enfermedades Respiratorias Ismael Cosío Villegas, Tlalpan 4502, Sección XVI, Tlalpan, 14080, Mexico City, Mexico.,HLA Laboratory, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Tlalpan 4502, Sección XVI, Tlalpan, 14080, Mexico City, Mexico.,Biomedicine In the Post-Genomic Era, Tlalpan 4502, Sección XVI, Tlalpan, 14080, Mexico City, Mexico
| | - Ángel Camarena
- Department of Allergy & Clinical Immunology, Instituto Nacional Enfermedades Respiratorias Ismael Cosío Villegas, Tlalpan 4502, Sección XVI, Tlalpan, 14080, Mexico City, Mexico.,HLA Laboratory, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Tlalpan 4502, Sección XVI, Tlalpan, 14080, Mexico City, Mexico.,Biomedicine In the Post-Genomic Era, Tlalpan 4502, Sección XVI, Tlalpan, 14080, Mexico City, Mexico
| | - Luis M Terán
- Department of Allergy & Clinical Immunology, Instituto Nacional Enfermedades Respiratorias Ismael Cosío Villegas, Tlalpan 4502, Sección XVI, Tlalpan, 14080, Mexico City, Mexico
| | - Ramcés Falfán-Valencia
- HLA Laboratory, Instituto Nacional de Enfermedades Respiratorias Ismael Cosío Villegas, Tlalpan 4502, Sección XVI, Tlalpan, 14080, Mexico City, Mexico
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15
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De Schryver E, Derycke L, Campo P, Gabriels E, Joos GF, Van Zele T, Bachert C, Hellings PW, Gevaert P. Alcohol hyper-responsiveness in chronic rhinosinusitis with nasal polyps. Clin Exp Allergy 2016; 47:245-253. [DOI: 10.1111/cea.12836] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Revised: 09/02/2016] [Accepted: 10/02/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Els De Schryver
- Upper Airways Research Laboratory; Department Otorhinolaryngology; Ghent University Hospital; Ghent Belgium
| | - Lara Derycke
- Upper Airways Research Laboratory; Department Otorhinolaryngology; Ghent University Hospital; Ghent Belgium
| | - Paloma Campo
- Unidad de Gestión Clínica Allergy-IBIMA; University Hospital; Málaga Spain
| | - Eline Gabriels
- Upper Airways Research Laboratory; Department Otorhinolaryngology; Ghent University Hospital; Ghent Belgium
| | - Guy F. Joos
- Laboratory for Translational Research in Obstructive Pulmonary diseases; Department of Respiratory Medicine; Ghent University Hospital; Ghent Belgium
| | - Thibaut Van Zele
- Upper Airways Research Laboratory; Department Otorhinolaryngology; Ghent University Hospital; Ghent Belgium
| | - Claus Bachert
- Upper Airways Research Laboratory; Department Otorhinolaryngology; Ghent University Hospital; Ghent Belgium
- Division of ENT Diseases; Clintec, Karolinska Institutet; Stockholm Sweden
| | - Peter W. Hellings
- Clinical Division of ENT, Head & Neck Surgery; Laboratory of Clinical Immunology; University Hospitals Leuven; Leuven Belgium
- Department of Otorhinolaryngology; Academic Medical Center; Amsterdam the Netherlands
| | - Philippe Gevaert
- Upper Airways Research Laboratory; Department Otorhinolaryngology; Ghent University Hospital; Ghent Belgium
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16
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Cook KA, Stevenson DD. Current complications and treatment of aspirin-exacerbated respiratory disease. Expert Rev Respir Med 2016; 10:1305-1316. [PMID: 27817219 DOI: 10.1080/17476348.2016.1258306] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Aspirin-exacerbated respiratory disease is defined by the clinical tetrad of aspirin sensitivity, nasal polyps, asthma, and chronic rhinosinusitis. Patients experience acute upper and lower airway reactions with exposure to aspirin and other cyclooxygenase-1 inhibiting medications. However, airway inflammation and disease progression occur even in the absence of exposure to these medications, often leading to aggressive polyp formation and need for systemic corticosteroids to treat exacerbations in asthma and rhinosinusitis. Areas covered: This review focuses on the direct and indirect complications of aspirin-exacerbated respiratory disease. Current and potential management strategies are discussed with emphasis on aspirin desensitization. Expert commentary: Aspirin desensitization remains the gold standard of treatment. Demonstrated benefits of desensitization include improved symptom scores, reduction in use of systemic corticosteroids, slowing of polyp regrowth, and tolerance of aspirin and other NSAIDs for various therapeutic purposes. Continued investigation into the pathogenic mechanisms of AERD is likely to yield new diagnostic and therapeutic approaches.
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Affiliation(s)
- Kevin A Cook
- a Division of Allergy, Asthma and Immunology , Scripps Clinic , San Diego , CA , USA
| | - Donald D Stevenson
- a Division of Allergy, Asthma and Immunology , Scripps Clinic , San Diego , CA , USA
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17
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Sakalar EG, Muluk NB, Kar M, Cingi C. Aspirin-exacerbated respiratory disease and current treatment modalities. Eur Arch Otorhinolaryngol 2016; 274:1291-1300. [PMID: 27538737 DOI: 10.1007/s00405-016-4273-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 08/16/2016] [Indexed: 01/14/2023]
Abstract
Aspirin-exacerbated respiratory disease (AERD) refers to the combination of asthma, chronic rhinosinusitis with nasal polyposis, and acute upper and lower respiratory tract reactions to the ingestion of aspirin (acetylsalicylic acid, ASA) and other cyclooxygenase-1 inhibiting non-steroidal anti-inflammatory drugs. AERD affects 0.3-0.9 % of the general population. AERD generally occurs due to abnormalities in mediators and expression of arachidonic acid biosynthesis. Local IgE responses to staphylococcal enterotoxins may also be responsible for eosinophilic activation in the nasal polyp tissues of AERD patients. Clinical features of AERD include the onset of nasal congestion with anosmia, progressing to chronic pansinusitis and nasal polyps that regrow rapidly after surgery. Aspirin desensitization, Leukotriene-modifying agents, biologic agents, management of asthma, chronic rhinosinusitis, and nasal polyposis are recommended as treatment modalities. Immunotherapy is prescribed only to those AERD patients who experience clear seasonal or perennial allergy symptoms in addition to the symptoms attributable to chronic nasal polyposis. There are also investigational and dietary therapies. In this review, the important aspects of AERD will be presented, along with a literature survey.
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Affiliation(s)
| | - Nuray Bayar Muluk
- Department of Otorhinolaryngology, Medical Faculty, Kirikkale University, Kirikkale, Turkey. .,, Birlik Mahallesi, Zirvekent 2. Etap Sitesi, C-3 blok, No: 6-3/43, 06610, Çankaya, Ankara, Turkey.
| | - Murat Kar
- ENT Clinics, Kumluca State Hospital, Antalya, Turkey
| | - Cemal Cingi
- Department of Otorhinolaryngology, Medical Faculty, Eskisehir Osmangazi University, Eskisehir, Turkey
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18
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Simon RA, Dazy KM, Waldram JD. Aspirin-exacerbated respiratory disease: characteristics and management strategies. Expert Rev Clin Immunol 2015; 11:805-17. [PMID: 25936612 DOI: 10.1586/1744666x.2015.1039940] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Aspirin-exacerbated respiratory disease is a clinical entity comprising chronic rhinosinusitis with nasal polyposis, asthma and intolerance to COX-1 inhibiting drugs. The pathogenesis is not completely understood at this point, but abnormal arachidonic acid metabolism is a key feature in this syndrome. The diagnosis is confirmed only by direct drug challenge. Aspirin desensitization followed by daily aspirin therapy is a useful treatment option in these patients. In this review article are discussed the important characteristics and treatment of aspirin-exacerbated respiratory disease.
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Affiliation(s)
- Ronald A Simon
- Scripps Clinic, Division of Allergy, Asthma and Immunology, 3811 Valley Centre Drive, San Diego, CA 92130, USA
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19
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Nabavi M, Esmaeilzadeh H, Arshi S, Bemanian MH, Fallahpour M, Bahrami A, Mortazavi N, Kamrava K, Farhadi M, Taghipour R, Rezaei N. Aspirin hypersensitivity in patients with chronic rhinosinusitis and nasal polyposis: frequency and contributing factors. Am J Rhinol Allergy 2015; 28:239-43. [PMID: 24980235 DOI: 10.2500/ajra.2014.28.4034] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Aspirin-exacerbated respiratory disease (AERD) is a syndrome frequently seen in patients with chronic rhinosinusitis and nasal polyposis (CRSwNP). However, there are few studies on evaluating the prevalence of aspirin (acetylsalicylic acid [ASA]) hypersensitivity in patients with CRSwNP using the oral aspirin challenge (OAC) test. This cross-sectional study was designed to determine the frequency of ASA hypersensitivity and factors associated with it in patients with CRSwNP in Tehran, Iran. METHODS Adult patients with CRSwNP who were presented to the asthma and allergy clinic were recruited for the study. After confirming CRS and NP, OAC was performed to evaluate/confirm the diagnosis of ASA hypersensitivity. Atopic evaluation was performed using skin-prick test, nasal smear, blood eosinophil count, and serum total IgE. RESULTS Eighty Iranian patients (43 women and 37 men) with CRSwNP were enrolled (mean age, 38.9 ± 10.7 years). OAC was performed in all of the patients and 39 patients (48.8%) had a positive reaction; among them, 14 (35.8%) had a self-reported history of ASA hypersensitivity. Concomitant asthma, previous polyp surgery, high polyp score, and ASA hypersensitivity history were all associated with positive OAC (p < 0.05). Presence of AERD was not associated with age, stage of asthma, blood eosinophilia, nasal smear eosinophilia, and atopy. CONCLUSION ASA hypersensitivity is common in patients with CRSwNP in Tehran, Iran. Patients at risk for AERD should be evaluated for the presence of ASA hypersensitivity with ASA provocation challenge test to confirm the diagnosis.
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Affiliation(s)
- Mohammad Nabavi
- Department of Allergy and Immunology, Rasool-e-Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
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20
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Mourad AA, Bahna SL. Hypersensitivities to non-steroidal anti-inflammatory drugs. Expert Rev Clin Immunol 2014; 10:1263-8. [DOI: 10.1586/1744666x.2014.946905] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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21
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Woessner KM, White AA. Evidence-based approach to aspirin desensitization in aspirin-exacerbated respiratory disease. J Allergy Clin Immunol 2014; 133:286-7.e1-9. [PMID: 24369807 DOI: 10.1016/j.jaci.2013.11.016] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Revised: 11/15/2013] [Accepted: 11/18/2013] [Indexed: 10/25/2022]
Affiliation(s)
- Katharine M Woessner
- Division of Allergy, Asthma and Immunology, Scripps Clinic Medical Group, San Diego, Calif.
| | - Andrew A White
- Division of Allergy, Asthma and Immunology, Scripps Clinic Medical Group, San Diego, Calif
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22
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Park JS, Heo JS, Chang HS, Choi IS, Kim MK, Lee JU, Park BL, Shin HD, Park CS. Association analysis of member RAS oncogene family gene polymorphisms with aspirin intolerance in asthmatic patients. DNA Cell Biol 2014; 33:155-61. [PMID: 24555545 DOI: 10.1089/dna.2013.2213] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Member RAS oncogene family (RAB1A), a member of the RAS oncogene family, cycles between inactive GDP-bound and active GTP-bound forms regulating vesicle transport in exocytosis. Thus, functional alterations of the RAB1A gene may contribute to aspirin intolerance in asthmatic sufferers. To investigate the relationship between single-nucleotide polymorphisms (SNPs) in the RAB1A gene and aspirin-exacerbated respiratory disease (AERD), asthmatics (n=1197) were categorized into AERD and aspirin-tolerant asthma (ATA). All subjects were diagnosed as asthma on the basis of the Global Initiative for Asthma (GINA) guidelines. AERD was defined as asthmatics showing 15% or greater decreases in forced expiratory volume in one second (FEV(1)) or naso-ocular reactions by the oral acetyl salicylic acid (ASA) challenge (OAC) test. In total, eight SNPs were genotyped. Logistic regression analysis identified that the minor allele frequency of +14444 T>G and +41170 C>G was significantly higher in the AERD group (n=181) than in the ATA group (n=1016) (p=0.0003-0.03). Linear regression analysis revealed a strong association between the SNPs and the aspirin-induced decrease in FEV(1) (p=0.0004-0.004). The RAB1A gene may play a role in the development of AERD in asthmatics and the genetic polymorphisms of the gene have the potential to be used as an indicator of this disease.
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Affiliation(s)
- Jong-Sook Park
- 1 Division of Allergy and Respiratory Medicine, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital , Bucheon, Republic of Korea
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23
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Abstract
Asthma has many triggers including rhinosinusitis; allergy; irritants; medications (aspirin in aspirin-exacerbated respiratory disease); and obesity. Paradoxic vocal fold dysfunction mimics asthma and may be present along with asthma. This article reviews each of these triggers, outlining methods of recognizing the trigger and then its management. In many patients more than one trigger may be present. Full appreciation of the complexity of these relationships and targeted therapy to the trigger is needed to best care for the patient with asthma.
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Affiliation(s)
- Justin C. McCarty
- Lake Erie of Osteopathic Medicine, 5000 Lakewood Ranch Boulevard, Bradenton, FL 34211–4909, USA
| | - Berrylin J. Ferguson
- UPMC Mercy, University of Pittsburgh School of Medicine, 1400 Locust Street, Suite B11500, Pittsburgh, PA 15219, USA
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24
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Choi GS, Kim JH, Shin YS, Ye YM, Kim SH, Park HS. Eosinophil activation and novel mediators in the aspirin-induced nasal response in AERD. Clin Exp Allergy 2014; 43:730-40. [PMID: 23786280 DOI: 10.1111/cea.12096] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Revised: 01/16/2013] [Accepted: 01/21/2013] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- G-S Choi
- Department of Internal Medicine, Kosin University College of Medicine, Busan, South Korea
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25
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Abstract
Hypersensitivity diseases caused by nonsteroidal anti-inflammatory agents are
relatively common in the population. This article summarizes the present
understanding on the various allergic and nonallergic clinical pictures produced
through hypersensitivity to these drugs using the pathogenic classification of
hypersensitivity reactions recently proposed by the Nomenclature Committee of the
World Allergy Organization to guide clinicians in the diagnosis and management of
patients with these conditions.
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26
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Abstract
Staphylococcus aureus (S. aureus) is correlated with the development of persistent severe inflammatory disease of the upper airway including chronic rhinosinusitis with nasal polyps. This inflammation of the upper airways is characterized by a T-helper 2-driven disease: interleukin-5 is significantly increased and local production of immunoglobulin E is observed. S. aureus and its enterotoxins are deregulating the tissue inflammation at different levels: structural cells and the innate and adaptive immune system. Knowing the triggers of the pathomechanisms involved will greatly help us to find new therapeutic approaches to resolve this chronic inflammatory process.
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27
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Aspirin-intolerant asthma in the Korean population: prevalence and characteristics based on a questionnaire survey. Respir Med 2012. [PMID: 23195335 DOI: 10.1016/j.rmed.2012.10.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Aspirin-intolerant asthma is a unique clinical syndrome characterized by acute bronchoconstriction following the administration of aspirin and/or non-steroidal anti-inflammatory drugs. OBJECTIVE We assessed the prevalence and investigated the demographic and clinical characteristics of adult patients with aspirin-intolerant asthma in Korea. METHODS Using an adult asthma cohort (COREA) from 11 university hospitals in Korea, we analyzed the prevalence of aspirin-intolerant asthma, defined as a positive response to the question: "Have you ever experienced dyspnea and cough after taking an aspirin or any NSAID (cold medicine)?" Demographic and clinical characteristics were compared between patients with aspirin-intolerant asthma and aspirin-tolerant asthma. RESULTS Aspirin-intolerant asthma was reported in 68 (5.8%) of 1173 adult asthmatics (age 15-84). Patients with aspirin-intolerant asthma had a lower mean age (43.9 ± 13.4 vs. 49.0 ± 15.6, P = 0.003) and a higher prevalence of rhinosinusitis (77.9% vs. 61.7%, P = 0.012) and atopic dermatitis (16.2% vs. 5.7%, P = 0.001) than aspirin-tolerant asthma patients. There were no significant differences in lung function, asthma severity or the use of asthma controllers. However, aspirin-intolerant asthma was associated with greater use of healthcare services over a lifetime and over the past 12 months. Aspirin-intolerant asthma was significantly associated with emergency room visits over the past 12 months (P = 0.029, OR 2.19, 95% CI 1.08-4.42). CONCLUSION Based on histories, the prevalence of aspirin-intolerant asthma is 5.8% among adult asthma patients in Korea. Aspirin-intolerant asthma is associated with lower age, higher prevalence of rhinosinusitis and atopic dermatitis, and more frequent exacerbations.
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28
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[Aspirin desensitization: therapy options in patients with aspirin-exacerbated respiratory disease]. HNO 2012; 60:369-83. [PMID: 22491884 DOI: 10.1007/s00106-011-2444-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Aspirin desensitization has established itself as an additional therapy option in the treatment of aspirin- exacerbated respiratory disease, recurrent chronic rhinosinusitis and nasal polyps. Inpatient treatment is strongly recommended due to the risk of life-threatening side effects. In addition, the necessary requirements, indications and contraindications should be carefully considered from a medicolegal perspective. A maintenance dose of 300 (-500) mg ASS is currently recommended. Indications include persisting symptoms despite intensive medical care and/or recurrent nasal polyps, leading to recurrent sinus operations and/or the need to take systemic corticosteroids in order to control nasal symptoms or asthma. If ASS intake is interrupted for more than 48 h, aspirin desensitization should be resumed to prevent renewed intolerance reactions.
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29
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Farnam K, Chang C, Teuber S, Gershwin ME. Nonallergic drug hypersensitivity reactions. Int Arch Allergy Immunol 2012; 159:327-45. [PMID: 22832422 DOI: 10.1159/000339690] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2012] [Accepted: 05/23/2012] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Nonallergic drug hypersensitivities, also referred to as pseudoallergic or anaphylactoid reactions, have clinical manifestations that are often indistinguishable from allergic reactions. METHODS We performed a PubMed search using the terms 'drug allergy, drug hypersensitivity, pseudoallergies, anaphylaxis and nonallergic drug reactions' and reviewed 511 publications dated between 1970 and 2012. A total of 160 papers that were relevant to the most common nonallergic drug hypersensitivity reactions were selected for discussion. RESULTS Nonallergic drug hypersensitivities do not involve either IgE-mediated (type 1) or delayed (type 4) hypersensitivity. Nonallergic hypersensitivities are commonly referred to as pseudoallergic or idiosyncratic reactions. The common nonallergic drug hypersensitivities are secondary to chemotherapeutic drugs, radiocontrast agents, vancomycin, nonsteroidal anti-inflammatory agents, local anesthetic reactions and opiates. Protocols for skin testing of radiocontrast, nonsteroidal anti-inflammatory agents, local anesthetics and chemotherapeutic agents have been developed, though most have not been validated or standardized. Other diagnostic tests include in vitro-specific IgE tests, and the current 'gold' standard is usually an oral challenge or bronchoprovocation test. In the case of aspirin, even though it is not believed to be IgE-mediated, a 'desensitization' protocol has been developed and utilized successfully, although the mechanism of this desensitization is unclear. CONCLUSIONS Diagnostic methods exist to distinguish allergic from nonallergic drug hypersensitivity reactions. The best option in nonallergic drug hypersensitivity is avoidance. If that is not possible, premedication protocols have been developed, although the success of premedication varies amongst drugs and patients.
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Affiliation(s)
- Kevin Farnam
- Division of Rheumatology, Allergy and Clinical Immunology, University of California at Davis, Davis, CA 95616, USA
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30
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Chang HS, Park JS, Jang AS, Park SW, Uh ST, Kim YH, Park CS. Diagnostic value of clinical parameters in the prediction of aspirin-exacerbated respiratory disease in asthma. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2011; 3:256-64. [PMID: 21966606 PMCID: PMC3178824 DOI: 10.4168/aair.2011.3.4.256] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2010] [Accepted: 04/04/2011] [Indexed: 12/30/2022]
Abstract
Purpose Aspirin-exacerbated respiratory disease (AERD) has attracted a great deal of attention because of its association with increased asthma severity. However, oral aspirin challenge (OAC) to diagnose AERD is a time-consuming procedure, and some patients experience serious complications. Thus, we evaluated diagnostic values of non-invasive clinical parameters to predict AERD in asthmatic patients. Methods A total of 836 Korean subjects were recruited from an asthma cohort. They underwent OAC, and clinical parameters including the history of aspirin hypersensitivity, nasal polyposis, and chronic sinusitis of aspirin-tolerant asthma (ATA) and AERD asthmatic patients were compared. Results Significant differences
(P<0.01) were found in eight parameters: age at diagnosis, body mass index, FEV1%, PC20, history of urticaria, nasal polyps, chronic sinusitis, and history of aspirin hypersensitivity. After logistic regression analysis based on the eight clinical parameters, nasal polyps, history of aspirin intolerance, sinusitis, and log [PC20 methacholine] remained significantly associated with AERD (P<0.05). The sensitivity and specificity of the history of aspirin hypersensitivity to predict AERD were 64.7% and 92.0%, respectively, and the positive and negative predictive values were 56.9% and 94.1%, respectively. Overall, the accuracy of the test was 88.2%. The accuracy of the tests for nasal polyps and chronic sinusitis were 67.3% and 60.4%, respectively. Conclusions Among clinical parameters associated with AERD, the history of aspirin hypersensitivity has the best positive and negative predictive values for the oral aspirin challenge test. Because the false-positive and -negative rates were still high, additional non-invasive methods are needed to reduce the rate of false outcomes.
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Affiliation(s)
- Hun Soo Chang
- Pharmacogenetic Research Center for Psychotropic Drugs, Korea University, Seoul, Korea
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31
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The time delay between drug intake and bronchospasm for nonsteroidal antiinflammatory drugs sensitive patients. World Allergy Organ J 2010; 3:266-70. [PMID: 23282984 PMCID: PMC3651119 DOI: 10.1097/wox.0b013e3181fdfc5f] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
A study was performed to assess the time between drug intake and drug induced
hypersensitivity reaction for patients sensitive to nonsteroidal
antiinflammatory drugs (NSAID) in clinical patient history and after oral
provocation tests. Drug hypersensitivity ENDA questionnaires were filled for the
patients with suspected sensitivity to NSAID. Oral provocation tests were
performed with suspected NSAID according to the ENDA/EAACI recommendations.
There were 76 patients with history of hypersensitivity reactions after use of
NSAID enrolled in the study. Recorded were 154 hypersensitivity reactions to
NSAID in the clinical history. In the clinical history median time of immediate
reactions (76 cases, 81%) between drug intake and bronchospasm was 20 minutes
[15-30 minutes]. Median time of nonimmediate reactions (18 cases, 19%) was 120
minutes [120-390 minutes]. There were 50 oral provocation tests performed, 14 of
them (28%) were positive. Median time between drug intake and immediate
reactions (8; 57% of cases) was 22.5 minutes [20-30 minutes] and median time of
nonimmediate reactions (6; 43% of cases) was 167.5 minutes [125-206.25 minutes].
Time delay between drug intake and bronchospasm in the clinical history and
after oral provocation test was not statistically different.
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Abstract
BACKGROUND Injections into or adjacent to soft tissue structures, including muscle, tendon, bursa, and fascia, for pain relief and an earlier return to play have become common in the field of sports medicine. STUDY DESIGN Clinical review. RESULTS Corticosteroids, local anesthetics, and ketorolac tromethamine (Toradol) are the most commonly used injectable agents in athletes. The use of these injectable agents have proven efficacy in some disorders, whereas the clinical benefit for others remain questionable. All soft tissue injections performed for pain control and/or an anti-inflammatory effect have potentially serious side effects, which must be considered, especially in the pregame setting. CONCLUSIONS The primary concern regarding corticosteroid and local anesthetic injections is an increased risk of tendon rupture associated with the direct injection into the tendon. Intramuscular Toradol injections provide significant analgesia, as well as an anti-inflammatory effect via its inhibitory effect on the cyclooxygenase pathway. The risk of bleeding associated with Toradol use is recognized but not accurately quantified.
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Asthma: a syndrome composed of heterogeneous diseases. Ann Allergy Asthma Immunol 2008; 101:1-8; quiz 8-11, 50. [PMID: 18681077 DOI: 10.1016/s1081-1206(10)60826-5] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To review the concept that asthma comprises distinct heterogeneous inflammatory disorders characterized by patients showing different phenotypes with distinct genetic components, environmental causes, and immunopathologic signa- DATA SOURCES Ovid MEDLINE and PubMed databases from 1950 to the present time were searched for relevant articles and references regarding the heterogeneity of asthma. STUDY SELECTION Articles that described the various phenotypes of asthma were used for this review. RESULTS Asthma is unlikely to be a single disease but rather a series of complex, overlapping individual diseases or phenotypes, each defined by its unique interaction between genetic and environmental factors. These conditions include syndromes characterized by allergen-exacerbated, nonallergic, and aspirin-exacerbated factors along with syndromes best distinguished by their pathologic findings (eosinophilic, neutrophilic, pauci-granulocytic), response to therapy (corticosteroid resistant), and natural history (remodeling prone). Additional phenotypes will almost certainly be identified as advances in genetics and other profiling methods are made and will be accompanied by the availability of clear biomarkers for distinguishing among them. CONCLUSIONS Responses to asthma medications vary considerably among patients, likely reflecting, at least in part, the differing sensitivities of the various asthma phenotypes. Selecting the best possible treatment course in individual patients will be aided by clearly identifying the different phenotypes. Physicians need to recognize this when making decisions to adjust treatment to improve asthma control.
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Macy E, Bernstein JA, Castells MC, Gawchik SM, Lee TH, Settipane RA, Simon RA, Wald J, Woessner KM. Aspirin challenge and desensitization for aspirin-exacerbated respiratory disease: a practice paper. Ann Allergy Asthma Immunol 2007; 98:172-4. [PMID: 17304886 DOI: 10.1016/s1081-1206(10)60692-8] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Aspirin desensitization is indicated for patients who have aspirin-exacerbated respiratory disease and whose asthma and/or rhinosinusitis is suboptimally controlled with inhaled corticosteroids and leukotriene-modifying drugs. In this practice paper, the general requirements for aspirin desensitization are presented, the locations where desensitizations can be safely performed are outlined, prechallenge patient preparation is discussed, an oral aspirin challenge protocol is presented, treatment of adverse reactions is reviewed, and maintenance of aspirin desensitization is discussed.
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Affiliation(s)
- Eric Macy
- SCPMG-Kaiser Permanente San Diego, California, USA
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White A, Ludington E, Mehra P, Stevenson DD, Simon RA. Effect of leukotriene modifier drugs on the safety of oral aspirin challenges. Ann Allergy Asthma Immunol 2007; 97:688-93. [PMID: 17165280 DOI: 10.1016/s1081-1206(10)61101-5] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Aspirin-exacerbated respiratory disease can be diagnosed with oral aspirin challenges and treated with aspirin desensitization. OBJECTIVE To evaluate whether controller medications, particularly leukotriene modifier drugs, taken during oral aspirin challenges can reduce the risk of severe asthmatic responses. METHODS The medical records of 676 patients who had undergone oral aspirin challenges, followed by aspirin desensitization, were reviewed. Asthmatic responses were stratified based on severity of bronchospastic response or lack of response. The effect of pretreatment with controller medications on the outcome of oral aspirin challenges was measured. RESULTS Leukotriene modifier drugs had the most significant effect in protecting the lower airways from severe reactions (P = .004). The protective effect of leukotriene modifier drugs was observed in patients already taking systemic corticosteroids, where the addition of leukotriene modifier drugs significantly shifted the response toward a milder asthmatic response (P < .001). CONCLUSION Protection from significant aspirin-induced bronchospasm during oral aspirin challenge can be accomplished with leukotriene modifier drugs. The use of a combination of inhaled corticosteroids, long-acting beta-agonists, systemic corticosteroids, and leukotriene modifier drugs stabilized underlying airways in preparation for a reasonably safe and accurate oral aspirin challenge. However, only pretreatment with leukotriene modifier drugs enhanced the safety of oral aspirin challenge in patients with aspirin-exacerbated respiratory disease by significantly decreasing the degree of asthmatic responses. Therefore, outpatient oral aspirin challenges in most well-selected patients appear to be a reasonable decision.
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Affiliation(s)
- Andrew White
- Department of Allergy and Immunology, Naval Medical Center San Diego, San Diego, California 92106, USA.
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Abstract
PURPOSE OF REVIEW Hypersensitivity drug reactions are but one of the many different types of adverse drug reactions. They may be potentially life-threatening, prolong hospitalization, affect drug prescribing patterns of physicians and result in socioeconomic costs. This review summarizes current knowledge on the incidence, prevalence, mortality and risk factors for these reactions in different populations. RECENT FINDINGS Hypersensitivity reactions represent about one third of all adverse drug reactions. Adverse drug reactions affect 10-20% of hospitalized patients and more than 7% of the general population. Severe reactions including anaphylaxis, drug hypersensitivity syndromes, Stevens Johnson syndrome and toxic epidermal necrolysis are also associated with significant morbidity and mortality. Although several risk factors have been identified, their clinical importance has not been fully understood. Future progress in immunogenetics and pharmacogenetics may help identify populations at risk for specific types of reactions. SUMMARY Well designed epidemiological studies on hypersensitivity drug reactions are lacking as most studies have been on adverse drug reactions. Such studies will be helpful in identifying patients at risk of developing such reactions, in particular severe reactions, and implementing early preventive measures.
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Affiliation(s)
- Eva Rebelo Gomes
- Allergy Department, INSERM U454 - IFR3, Arnaud de Villeneuve Hospital, University Hospital of Montpellier, Montpellier, France
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Abstract
Aspirin-sensitive asthma, aspirin-intolerant asthma, aspirin- (or non-steroidal anti-inflammatory drug [NSAID]) exacerbated respiratory disease are terms for a disorder commonly described as affecting adults aged > 30y. With this perception, ibuprofen was administered for postoperative pain management to a 17-year-old boy with allergic rhinitis and previous severe asthma (at a time when well controlled), who then had a severe asthma exacerbation. Analysis of the literature in response to this case highlights four points: 1) NSAID-exacerbated asthma is not only a disorder of adults; it occurs in up to of 2% in asthmatic children, approaching probably 30% in older children with severe asthma and nasal disease. 2) The asthmatic reaction is dose-dependent and can occur with sub-therapeutic doses. Oral NSAID/aspirin challenge should be conducted in an environment where a severe asthma exacerbation can be appropriately managed. 3) The therapeutic use of non-selective [COX-1 preferential] NSAIDs should be avoided when sensitivity is known or suspected in adults and teenagers with severe asthma and chronic rhinosinusitis or nasal polyps. Use of these agents in younger children with mild episodic wheeze is probably safe. 4) Paracetamol use is probably safe, but aspirin-exacerbated respiratory disease may occur with clinical doses in a subgroup of aspirin-exacerbated respiratory disease patients. COX-2 selective inhibitors are probably safe, although this is controversial. Opioids and tramadol are suitable analgesic alternatives for patients with known or suspected susceptibility.
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Affiliation(s)
- G M Palmer
- Department of Anaesthesia and Pain Management, Royal Children's Hospital, Parkville, Victoria
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Abstract
Aspirin and the older nonsteroidal anti-inflammatory drugs (NSAIDs) that block cyclo-oxygenase-1 (COX-1) induce asthma attacks in patients with aspirin-exacerbated respiratory disease and urticaria in patients with chronic idiopathic urticaria. Weak inhibitors of COX-1, such as acetaminophen and salsalate, crossreact also but only with high doses of the drugs. Partial inhibitors of both COX-1 and COX-2, such as nimesulide and meloxicam, also cross-react but only at high drug doses. COX-2 inhibitors do not cross-react; however, all NSAIDs, including the selective COX-2 inhibitors, can sensitize patients and induce urticaria or anaphylaxis on next exposure to the drug.
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Affiliation(s)
- Donald D Stevenson
- Division of Allergy, Asthma, and Immunology, Department of Medicine, Scripps Clinic and The Scripps Research Institute, W 205, 10666 North Torrey Pines Road, La Jolla, CA 92037, USA.
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Sánchez-Borges M, Capriles-Behrens E, Caballero-Fonseca F. Hypersensitivity to non-steroidal anti-inflammatory drugs in childhood. Pediatr Allergy Immunol 2004; 15:376-80. [PMID: 15305949 DOI: 10.1111/j.1399-3038.2004.00159.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Although largely investigated in adults, the issue of hypersensitivity to non-steroidal anti-inflammatory drugs (NSAIDs) in childhood is unsettled due to lack of sufficient data. The purpose of this study is to examine the clinical syndromes of hypersensitivity to NSAIDs in children and adolescents. We performed a review of relevant papers on cutaneous and respiratory adverse reactions triggered by NSAIDs in pediatric patients, and a recount of our own experience in 43 well-characterized NSAID-sensitive children with cutaneous reactions who were submitted to controlled oral challenges with NSAIDs and the new inhibitors of the enzyme isoform cyclooxygenase-2 (COX-2). Although it has been suggested that allergic and pseudoallergic reactions to NSAIDs in children occur rarely, their prevalence remains largely unknown due to the scarcity of studies. About 23% of NSAID-sensitive patients seen in our institutions are young patients aged 8-18 yr who more frequently develop facial angioedema as their main clinical manifestation. Most patients are atopic and show reactions to more than one drug (cross-reactors). Drugs that inhibit COX-2 with higher specificity than classic NSAIDs are better tolerated in young NSAID-hypersensitive patients.
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