Aspirin-exacerbated respiratory disease: NSAID challenge and desensitization
- Ronald A Simon, MD
Ronald A Simon, MD
- Adjunct Professor, Department of Molecular and Experimental Medicine
- Scripps Research Institute, La Jolla, CA
Patients with aspirin-exacerbated respiratory disease (AERD) present with one or more of the following disorders:
●Chronic rhinosinusitis with nasal polyposis
●Reactions to aspirin (acetylsalicylic acid [ASA]) and other cyclooxygenase-1 (COX-1)-inhibiting nonsteroidal anti-inflammatory drugs (NSAIDs), in which symptoms begin 30 minutes to 3 hours after ingestion and characteristically involve the upper and lower airways (eg, nasal congestion and bronchospasm)
AERD is also called NSAID-exacerbated respiratory disease (NERD). NSAID challenge protocols involve cautiously administering gradually increasing doses of an NSAID, usually aspirin, in an appropriately monitored medical setting. These procedures are used to diagnose NSAID pseudoallergy and also to desensitize AERD patients to NSAIDs, when indicated. The safety and technical aspects of these protocols, as well as the efficacy of aspirin therapy for AERD, are discussed here. The clinical manifestations and management of AERD and a general discussion of allergic and pseudoallergic reactions to NSAIDs are reviewed separately. (See "Aspirin-exacerbated respiratory disease" and "NSAIDs (including aspirin): Allergic and pseudoallergic reactions".)
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- The Scripps Clinic, San Diego, California. Dr. Simon may be reached at firstname.lastname@example.org.
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- OVERVIEW OF NSAID CHALLENGE
- Indications for challenge
- Contraindications to challenge
- TYPES OF CHALLENGES
- CHALLENGE PROTOCOLS AND PROCEDURES
- Oral aspirin challenge and desensitization
- - Use of placebo doses
- - Procedure
- - Provocation of symptoms
- - Treatment of symptoms during challenge
- Inhalational challenge and desensitization
- - Ketorolac nasal provocation
- Definition of a positive nasal challenge
- - Aspirin-lysine bronchial provocation
- Definition of a positive inhalational challenge
- Comparison of oral and inhalational challenge
- Outcomes of desensitization
- - Cross-desensitization to other NSAIDs
- - Missed doses
- - Breakthrough symptoms
- EFFICACY OF ASPIRIN THERAPY IN AERD
- Optimal aspirin dose for AERD
- Other issues of aspirin dosing after desensitization
- Prevention of gastrointestinal toxicity from NSAIDs
- Reasons for discontinuation
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS