Aspirin-Exacerbated Respiratory Disease

Aspirin. Junophoto / Getty Images 

You may have heard aspirin-exacerbated respiratory disease (AERD) be called Samter's triad or aspirin-induced asthma. There are three conditions that individuals with AERD all have: asthma, sinus disease with nasal polyps, and a sensitivity to medications called NSAIDS (specifically aspirin and all other medications that block an enzyme called COX-1).

AERD affects 0.3 to 0.9 percent of the general population and 10 to 20 percent of individuals who have been diagnosed with asthma. However, its pathophysiology is not well understood. It seems to affect all ethnic groups equally, with an average onset age of 35, but does not seem to be inherited and is more likely to affect women than men.

If you suspect a diagnosis or have been diagnosed, there are several approached to help you manage symptoms and live well. Here's what you need to know.

Symptoms

If you have AERD you may suffer from a combination of some or all of the following symptoms:

  • Chronic sinusitis
  • Nasal polyps
  • Loss of smell
  • Asthma
  • Reaction to NSAID (aspirin or similar medications), which may include nasal congestion, flushing, headache, sneezing, coughing, wheezing, bronchospasm, laryngospasm or chest pain. These symptoms may also occur after drinking alcohol.

You may have difficulty treating symptoms by normal means. For example, nasal polyps may regrow rapidly after being surgically removed. Congestion and difficulty breathing may lead to difficulty sleeping at night and subsequent sleep deprivation as well as daytime fatigue.

It is also common for individuals to have overlapping illnesses that may make their AERD worse. These may include allergic rhinosinusitis, GERD, or exercise-induced asthma. These conditions should be managed separately from AERD and your doctor can recommend the best options.

Diagnosis

If you have asthma, sinus disease with nasal polyps, and have had or suspect you may have had a reaction to an NSAID, your doctor might suspect that you have AERD. Additional tests will be helpful in confirming this diagnosis.

One test is an aspirin challenge, which involves giving small doses of aspirin over a few days in a medical setting where you can be monitored for a reaction. After giving you a dose of aspirin your doctor may test your lung capacity to see if it has decreased.

Your doctor may choose to order other tests to aid in the diagnosis of AERD, including blood tests. Eosinophils are white blood cells, components of the immune system. People with AERD tend to have large numbers of eosinophils in their nasal polyps and may have elevated blood levels as well. Other immune cells such as mast cells may also be elevated. You may also have elevated levels of a substance called cysteinyl leukotrienes. CT scans, or other imaging tests to help visualize your sinuses.

It should be noted that none of these tests are definitive for a diagnosis of AERD but can help your doctor to get a clearer picture of your condition.

Treatment and Management

There is no cure for AERD, and as previously mentioned the pathophysiology of this disease is poorly understood by scientists and medical professionals. However, there are several treatment options available to help you better manage symptoms.

One option is to completely avoid aspirin and other NSAID medications (any medication that inhibits the enzyme COX-1). Acetaminophen may be used instead of these medications, but preferably only in low doses (up to 500mg).

Avoiding aspirin will not control other symptoms such as nasal polyps, sinus infections or asthma symptoms though. The growth of nasal polyps may be slowed down by using steroid injections, surgical removal, or a combination of both. Nasal sprays containing steroids and nasal irrigation may also be beneficial in managing other nasal symptoms and sinus problems.

The medications montelukast and zafirlukast are also often used and tend to be more helpful in managing symptoms than other asthma medications, including beta-agonists. Inhaled corticosteroids are also used to manage asthma and it may be necessary to use these medications on a daily basis. Occasionally oral prednisone has been used, but generally only if other medications have failed to control symptoms since oral steroids tend to have significant undesirable side effects.

Aspirin Desensitization

Another option, one that has shown to be most effective, is to undergo aspirin desensitization. Studies have shown that aspirin desensitization followed by a daily maintenance dose of aspirin can reduce the formation of nasal polyps and sinus infections as well as improve asthma scores.

doses of aspirin are given in a medical setting where you can be monitored for a reaction. The medical setting is usually a clinic with experienced medical staff (inpatient hospitalization is not usually necessary). The doses start out small and are very gradually increased in amount to desensitize your system to the medication. This is also similar to the treatment of immunotherapy for allergies.

Evidence suggests that aspirin desensitization is very cost effective and beneficial to most individuals with a diagnosis of AERD. Improvement may be noticeable after only four weeks of treatment. Studies have shown improvement in nasal scores, sense of smell, and a reduction in the amount of medication required to control asthma symptoms.

Not all people with AERD are eligible for aspirin desensitization. You should not have this treatment if you are pregnant, have stomach ulcers, bleeding disorders, or unstable asthma symptoms.

There are risks associated with aspirin desensitization and these include setting off the symptoms of your AERD including severe respiratory problems. Also, any side effects that can occur while taking aspirin, such as stomach problems or bleeding, can occur during aspirin desensitization. You should talk to your doctor or pharmacist about potential side effects and make sure that aspirin will not interfere with any other medications you might be taking.

After you have undergone aspirin desensitization it is necessary to continue taking a maintenance dose of aspirin on a daily basis to continue desensitization. At first this dose could be as high as 1300 mg per day but, ideally, your doctor will gradually decrease the amount of aspirin you are taking. Doses as low as 81mg per day (a very common dose for individuals with cardiovascular ailments) have been shown effective.

If you're overwhelmed with the side effects and protocols you just read about, know that the process is step-by-step, so try to focus on one thing at a time. Your doctor will guide you throughout, track side effects, and be aware of any contraindications.

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