Aspirin-exacerbated respiratory disease: NSAID challenge and desensitization
- Ronald A Simon, MD
Ronald A Simon, MD
- Head, Division of Allergy, Asthma, and Immunology
- Scripps Clinic, San Diego, CA
INTRODUCTION AND TERMINOLOGY
Patients with aspirin-exacerbated respiratory disease (AERD) present with one or more of the following disorders:
●Chronic rhinosinusitis with nasal polyposis (CRSwNP)
●Reactions to aspirin (acetylsalicylic acid [ASA]) and other cyclooxygenase-1 (COX-1) inhibiting nonsteroidal antiinflammatory 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)
Pseudoallergic NSAID reactions — Patients with AERD can develop intolerance to aspirin and other structurally distinct NSAIDS, which are categorized as type 1 pseudoallergy. These reactions are classified as pseudoallergic because they are not immunologically mediated, although they can be as severe as immunoglobulin E (IgE)-mediated anaphylaxis. Mechanistically, symptoms result from an abnormal biochemical response to the pharmacologic actions of NSAIDs.
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- The Scripps Clinic, San Diego, California. Dr. Simon may be reached at email@example.com.
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- INTRODUCTION AND TERMINOLOGY
- Pseudoallergic NSAID reactions
- 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
- SUMMARY AND RECOMMENDATIONS