What Is Aspirin-Induced Asthma?

Aspirin-induced asthma (AIA) is a potentially fatal reaction to common painkillers that for most people are safe. Despite the name, aspirin (acetylsalicylic acid) isn't the only drug that can bring on AIA; others, such as nonsteroidal anti-inflammatory drugs (NSAIDs), may also be responsible. AIA is especially common in people who have severe adult-onset asthma accompanied by chronic rhinosinusitis that involves nasal polyps. It's rare in children but it can occur.Treating AIA typically is a three-pronged endeavor combining asthma management, treating rhinosinusitis, and shrinking or removing nasal polyps.

AIA Symptoms

People with AIA tend to develop symptoms within 30 minutes to two hours of taking aspirin or NSAIDs. The symptoms, typical of garden-variety asthma attacks, often are severe. They include:

• Shortness of breath
• Wheezing
• Coughing
• Congestion

Difficulty breathing due to AIA can last for hours. In addition, additional symptoms may develop, which can help to differentiate AIA from "regular" asthma:

• Hives
• Swelling around the eyes
• Red eyes
• Facial flushing
• Abdominal pain
• Nausea
• Diarrhea
• Chest pain

Preceding Symptoms and Onset

Drug-related asthma attacks usually begin to occur between two and five years after the onset of chronic rhinosinusitis—inflammation of nasal and sinus passages that persists for more than 12 weeks—causing:

• Facial pressure and pain
• Loss of smell
• Runny nose

Some people with chronic rhinosinusitis also develop nasal polyps—noncancerous growths in the nose and sinus cavities, usually on both sides. They're most common among people in their 30s and 40s.

Causes

Aspirin-induced asthma is a hypersensitivity reaction, which is biologically different than an allergic response to aspirin. It's unclear what may cause a person to have this hypersensitivity; genetics may may play a small role, although it's rare for it to run in families.

The drugs most often linked to aspirin-induced asthma are COX-1 inhibitors, although other medications and substances have also been associated with AIA.

COX-1 Inhibitors

COX-1 (cyclooxygenase-1) is an enzyme involved in the function of platelets, which help with blood clotting and healing. It also plays a role in the production of prostaglandins, hormones that are part of the inflammatory response. A COX-1 inhibitor is a drug that interferes with this enzyme, lowering prostaglandin levels and decreasing inflammation.

COX-1 inhibitors are potentially problematic for people with asthma of any type because their platelets tend to be more activated than those of otherwise heathy people. It's thought that increased platelet activity leads to overproduction of inflammatory compounds called leukotrienes, which in turn can bring on chronic inflammation in the airways.

Under normal circumstances, COX-1 enzymes and prostaglandins block the release of leukotrienes. COX-1 inhibitors remove that block, potentially allowing even more leukotrienes to flood the system and ramp up inflammation of the airways.

What's more, COX-1 inhibitors have been found to stimulate platelet activity in people with AIA, which in turn can lead to bronchoconstriction (airway tightening) and cytotoxicity (cellular damage and death.)

Besides aspirin, COX-1 inhibitors include:

• Advil/Motrin (ibuprofen)
• Aleve (naproxen)
• Zorvolex/Voltaren/Cataflam/Cambia (diclofenac)
• Tivorbex (indomethacin)

Other Triggers

Some people, especially those who are sensitive to even small amounts of aspirin, develop AIA symptoms in response to other drugs as well, specifically:

• Tylenol (acetaminophen)
• Beta-blockers (blood pressure medications) such as Corgard (nadolol), Lopressor (metoprolol), and Trandate (labetalol)

What's more, some people with aspirin-induced asthma are hypersensitive to certain kinds of mint and tend to cough after consuming it or using toothpaste that contains it. Researchers suspect this is because the chemical structure of mint is similar to that of aspirin and other salicylates.

For reasons unknown, alcohol, even in small amounts, can trigger AIA symptoms. Research shows that between 50% and 70% of people with aspirin-induced asthma have mild-to-moderate lower-respiratory symptoms after just a few sips of alcohol.

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Diagnosis

Not everyone with AIA has all three Samter's Triad conditions. But since they so often go together, a diagnosis of AIA is made easier when they are all detected.

For this reason, healthcare providers will look for:

• Asthma
• Chronic rhinosinusitis with nasal polyps
• COX-1 inhibitor sensitivity

If it's not clear a COX-1 inhibitor triggered an attack, a test called an aspirin challenge may be used to diagnose AIA. This involves being given small doses of aspirin over the course of several days while under medical observation in a hospital to see if symptoms develop.

In addition, you may have blood tests to measure levels of leukotrienes and white blood cells called eosinophils, both of which are related to the formation of nasal polyps.

Your healthcare provider may also order a computed tomography (CT) scan or nasal endoscopy to get a look at the sinus passages and any polyps.

A pulmonary function test (PFT) may also be performed to measure:

• How well inhaled oxygen moves into your bloodstream
• How much air you exhale
• How much air is in your lungs after exhaling

PFT results are used to guide treatment decisions.

Treatment

Treatment for AIA is usually multi-faceted to address co-occurring concerns.

Asthma Management

The treatment is the same as that for an acute asthma attack: a quick-relief rescue inhaler, as well as oxygen and steroids for severe symptoms.

Depending on the severity of your asthma, you may need:

• A rescue inhaler: Nearly everyone with asthma has a rescue inhaler to halt attacks.
• Inhaled corticosteroids: These are maintenance drugs that can prevent symptoms.
• Other inhalers: If inhaled corticosteroids aren't adequate, you may also be given other types of inhaled medications, including combinations of drugs from different classes.
• Oral medications: Leukotriene modifiers and oral steroids can help prevent asthma attacks.

Because leukotrienes are involved in AIA, leukotriene modifiers may be especially effective. Options include:

• Accolate (zafirlukast)
• Dupixent (dupilumab)
• Singulair (montelukast)
• Zyflo (zileuton)

Chronic Rhinosinusitis Treatment

Rhinosinusitis can be treated with antihistamines (allergy medications) in tablet form and/or in nasal spray. If you have seasonal allergies, you may need to take this every day. Allergy shots may also be an option for you.

Nasal sprays can be used for between 14 and 20 days for severe outbreaks of sinus symptoms.

If your healthcare provider suspects a current sinus infection, they may prescribe antibiotics, such as amoxicillin.

Nasal Polyps Treatment

Typically, nasal polyps are first treated with medication to shrink them. The drugs most often used are oral, nasal, or injectable corticosteroids, powerful anti-inflammatory medications that work differently than NSAIDs and don't cause an AIA reaction. Sometimes Dupixent is prescribed to shrink nasal polyps.

If medication doesn't work, nasal polyps can be removed in a surgical procedure called polypectomy. However, the nasal polyps involved in AIA often grow back after surgery, possibly due to the low-level inflammation that's present even when symptoms are under control.

Aspirin Desensitization

If you have a known COX-1 inhibitor sensitivity but need to take aspirin or anti-inflammatory medications for other conditions such as heart disease or rheumatic conditions, you may want to undergo aspirin desensitization.

This is considered the gold-standard treatment for AIA because it addresses the disease trigger. Studies show that it provides sustained control of respiratory symptoms and makes polyps less likely to reoccur.

Desensitization involves medical monitoring by an allergist/immunologist for several days to a week, during which time you'll be given increasing doses of aspirin. If you have AIA symptoms, you'll stay at the dose that triggered it until you no longer have a reaction.

Once you're desensitized, you will continue to take a daily dose to keep yourself from becoming sensitized again. This dosage may be gradually decreased over time. Be sure to follow your healthcare provider's dosage recommendations and don't try lowering the dosage on your own.

While desensitization can take away concerns about AIA, side effects of taking aspirin daily have to be considered. They include:

• Gastric bleeding
• Stomach ulcer
• Increased risk of hemorrhagic stroke

You shouldn't undergo aspirin desensitization if you're pregnant, have a stomach ulcer or bleeding disorder, or if your asthma is unstable.

Aspirin Substitutes

You do have some drug options other than COX-1 inhibitors for managing pain and inflammation.

Some people with AIA have reactions to Tylenol, especially at high doses, but others are able to take it safely. Talk to your healthcare provider about how to determine whether you're sensitive to acetaminophen.

A class of anti-inflammatories called cyclooxygenase-2 (COX-2) inhibitors is considered safe for people with AIA who have acute pain or chronic pain from diseases like arthritis and migraine. These drugs act on a more specific target than COX-1 inhibitors, and COX-2 has different functions in the body than COX-1.

Some COX-2 inhibitors were withdrawn from the market due to increased risk of heart attack and stroke, so the only one currently available in the United States is Celebrex (celecoxib).

Opioid (narcotic) pain relievers such as codeine also are considered safe for people sensitive to aspirin. Be sure to discuss the risks versus potential benefits of these medications with your healthcare provider.

A Word From Verywell

Aspirin-induced asthma is a complex and potentially serious disease. If you're at risk due to chronic rhinosinusitis and nasal polyps, be sure to get proper treatment for those issues and talk to your healthcare provider about the possibility of developing AIA.

If you suspect you're having a reaction to aspirin or another drug, don't hesitate to get medical help and follow up with testing by a specialist. With a diagnosis, treatment, and prevention measures, you can safeguard your health from the potentially serious effects of AIA.