Aspirin Exacerbated Respiratory Disease

What is AERD?

AERD stands for Aspirin Exacerbated Respiratory Disease. It is estimated that 10% of adults with asthma and 40% of patients with both asthma and nasal polyps have AERD. This is an adult condition with three cardinal features:

  1. Nasal Polyps
  2. Asthma
  3. Respiratory reactions to aspirin and other non-steroidal anti-inflammatory drugs

Many patients with AERD are difficult to treat with respect to their sinus disease and asthma, often requiring nasal surgery every 1-3 years to treat rapid re-growth of nasal polyps, along with suffering multiple asthma exacerbations per year. The polyps can cause severe nasal obstruction, loss of sense of smell, and uncontrolled asthma.

What causes AERD?

No one knows for sure, however patients with AERD have seemingly acquired overproduction of and sensitivity to chemicals known as leukotrienes. Even though patients may once have been able to take aspirin, they are now unable to take it without causing a sudden asthma attack or other allergic symptoms. Even while avoiding aspirin, these patients continue to have asthmatic symptoms, nasal congestion, formation of nasal polyps and repeated sinus infections.

What treatments exist for AERD?

Without aspirin desensitization, the typical treatment is repeated sinus surgeries, avoidance of aspirin and other NSAIDs, and treatment of asthma. Even with optimal therapy, the disease is often suboptimally controlled with rapidly recurring polyps and frequent asthma exacerbations.  Alternatively, aspirin desensitization and therapy combined with surgery is a well-recognized therapeutic option for patients with AERD, particularly those with severe asthma and polyp disease.

Who discovered this procedure?

In 1979, researchers at the Scripps clinic in La Jolla, CA began studying aspirin sensitivity in asthmatic patients. They noticed that with each successive dose of aspirin, the severity of the aspirin reactions lessoned. After several small doses of aspirin, the allergic reaction disappeared altogether. Under carefully controlled conditions, the patients were gradually able to take full adult strength doses of aspirin.

At this point, they were said to be desensitized to aspirin. With continued daily aspirin therapy, the patients reported less nasal congestion, fewer nasal polyps, better asthma control and less sinusitis. Many patients also experience an improvement in their sense of smell. Through several follow-up studies, it has been shown that the procedure reduces upper and lower respiratory tract inflammation, in part by altering the patients’ leukotriene levels and sensitivity.

What is entailed in aspirin desensitization?

During the aspirin desensitization, you will receive small incremental doses of aspirin, so as to minimize the risk of a serious reaction. Doses are gradually escalated depending on your tolerance. Once a reaction occurs, it will be treated, and after at least three hours the desensitization procedure will be continued. Repeat and escalating doses depending on tolerance are continued until you are able to ingest 325 mg of aspirin without reaction. The procedure generally takes two days, but in rare cases may take longer.

How successful is aspirin desensitization?

Clinical studies have shown that aspirin desensitization followed by daily aspirin use reduces symptoms of asthma, nasal polyps and sinusitis. Approximately 87% of patients experienced improvements in their symptoms and were able to reduce their use of steroids and/or other medications.

What is aspirin therapy?

After desensitization, you will be instructed to continue taking 325 to 650 mg of aspirin once or twice daily, depending on your case.

Am I a candidate for aspirin desensitization?

Candidates for aspirin desensitization and treatment must fall into one of three categories:

  • Aspirin sensitive patients with asthma who are experiencing uncontrolled respiratory inflammation 
  • despite optimal medical management.
  • Aspirin sensitive patients requiring repeated sinus surgeries.
  • Aspirin sensitive patients who need aspirin or NSAIDs for the treatment of other diseases.

Who is not a candidate for aspirin desensitization?

Aspirin desensitization is not indicated for patients:

  • Who have had aspirin induced hives or anaphylaxis that do not require daily aspirin therapy for treatment of other conditions.
  • Who are pregnant.

What are the potential benefits associated with aspirin desensitization and treatment?

Aspirin desensitization candidate patients may experience the following benefits:

  • Decreased corticosteroid doses
  • Improved asthma control
  • Fewer sinus surgeries
  • Tolerance to aspirin and NSAIDs
  • Improved sense of smell

What are the risks associated with the aspirin desensitization procedure?

Since the doses given are usually much smaller that what you have taken in almost all cases, the reactions are no greater and usually less severe than the reaction you may have experienced previously when taking a full therapeutic dose. The most serious risk during the desensitization procedure is the development of a life-threatening asthma exacerbation. Other symptoms may include nasal congestion, profuse runny nose, tightness of the throat, flushing of the skin, hives, and rarely, a drop in blood pressure.

We will closely monitor your physical status, vital signs, oxygen saturation and lung function for three hours after each dose looking for any reaction. When a reaction occurs, the procedure will be stopped and the symptoms will be treated with one or more inhalation treatments, nasal sprays, oral medications, and/or injections of medications to relieve the symptoms. The desensitization will then resume after a period of at least three hours.

What are the risks associated with long-term aspirin treatment?

Long-term risks from aspirin include pain or bleeding of the stomach or stomach ulcers. Aspirin slows down blood clotting, so you may bleed longer if you cut yourself or have surgery. Once you are desensitized to aspirin, the risks of daily aspirin are small. If you take it with food, stomach problems are less likely. Taking an antacid can lessen stomach pain. Coated aspirin tablets that bypass the stomach before they dissolve are also recommended. There are additional medications that could be prescribed if needed. If you start bleeding anywhere in your body, call your primary care physician.

What do I need to do prior to aspirin desensitization?

Understand that aspirin desensitization must be conducted in a medical setting equipped to handle life-
threatening asthma attacks. Although the desensitization may be completed in two days, it may take longer. To ensure the utmost safety, you must not be ill and your asthma must be controlled.

For the one week prior to desensitization, your asthma must be stable on all of your usual asthma controller medications. Your doctor may also recommend medications that will help block the clinical effects of thoseleukotrienes, such as Singulair and Zyflo CR. These medications should be continued during the procedure.You should also continue all other medications recommended by your physician.

How long will it take?

The aspirin desensitization takes the full day over two or three days. Expect to arrive early as directed by the medical staff. Since you are here for the whole day please bring books, laptop, snacks and / or other activities.

What do I need to do after desensitization?

You need to continue your daily dose of aspirin. We recommend enteric coated aspirin to help lessen the effects of stomach irritation. In time, you will slowly notice improvement of your asthma and nasal symptoms. Tapering of medications will be done on a regular basis. Typically the doctor will see you back one month after completing the aspirin desensitization.

Once desensitized to aspirin, you are most likely desensitized to several other NSAIDs. Thus, if you are desensitized to aspirin and are taking it regularly you can take other NSAID medications, but do not exceed the recommended dose and check with your doctors to make sure they are safe to take in addition to your daily aspirin dose.

What treatment will I be on following aspirin desensitization?

Once desensitized and on long-term aspirin treatment, desensitization is maintained only as long as you continue to take uninterrupted aspirin doses. Aspirin should not be discontinued without speaking to The Center for Allergy & Immunology.

What if I miss a dose, am I still desensitized?

Once desensitized, your body can tolerate one or two days without aspirin. If you forget to take your aspirin and remember within 48 hours since your most recent dose, simply take your usual dose. After 48 hours of a missed dose, your body begins to lose the desensitized state. You should not consider yourself desensitized after missing a dose for 48 hours or more. If you take aspirin then, you could have a reaction. Call your doctor for instructions if a dose is missed for 48 hours or more. After three to five days of missed doses, you will need to come into the office, where you will receive the 325 mg dose and be observed. Beyond five days of missed doses, you will need to undergo another full desensitization procedure.