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Aspirin-exacerbated respiratory disease: NSAID challenge and desensitization

Ronald A Simon, MD
Section Editor
N Franklin Adkinson, Jr, MD
Deputy Editor
Anna M Feldweg, MD


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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Literature review current through: Sep 2016. | This topic last updated: Oct 20, 2014.
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  1. White A, Bigby T, Stevenson D. Intranasal ketorolac challenge for the diagnosis of aspirin-exacerbated respiratory disease. Ann Allergy Asthma Immunol 2006; 97:190.
  2. Lee RU, White AA, Ding D, et al. Use of intranasal ketorolac and modified oral aspirin challenge for desensitization of aspirin-exacerbated respiratory disease. Ann Allergy Asthma Immunol 2010; 105:130.
  3. Casadevall J, Ventura PJ, Mullol J, Picado C. Intranasal challenge with aspirin in the diagnosis of aspirin intolerant asthma: evaluation of nasal response by acoustic rhinometry. Thorax 2000; 55:921.
  4. White AA, Stevenson DD, Simon RA. The blocking effect of essential controller medications during aspirin challenges in patients with aspirin-exacerbated respiratory disease. Ann Allergy Asthma Immunol 2005; 95:330.
  5. Berges-Gimeno MP, Simon RA, Stevenson DD. The effect of leukotriene-modifier drugs on aspirin-induced asthma and rhinitis reactions. Clin Exp Allergy 2002; 32:1491.
  6. Lee DK, Haggart K, Robb FM, Lipworth BJ. Montelukast protects against nasal lysine-aspirin challenge in patients with aspirin-induced asthma. Eur Respir J 2004; 24:226.
  7. Stevenson DD, Simon RA, Mathison DA, Christiansen SC. Montelukast is only partially effective in inhibiting aspirin responses in aspirin-sensitive asthmatics. Ann Allergy Asthma Immunol 2000; 85:477.
  8. Szczeklik A, Serwonska M. Inhibition of idiosyncratic reactions to aspirin in asthmatic patients by clemastine. Thorax 1979; 34:654.
  9. Dahl R. Oral and inhaled sodium cromoglycate in challenge test with food allergens or acetylsalicylic acid. Allergy 1981; 36:161.
  10. Macy E, Bernstein JA, Castells MC, et al. Aspirin challenge and desensitization for aspirin-exacerbated respiratory disease: a practice paper. Ann Allergy Asthma Immunol 2007; 98:172.
  11. Hope AP, Woessner KA, Simon RA, Stevenson DD. Rational approach to aspirin dosing during oral challenges and desensitization of patients with aspirin-exacerbated respiratory disease. J Allergy Clin Immunol 2009; 123:406.
  12. Morwood K, Gillis D, Smith W, Kette F. Aspirin-sensitive asthma. Intern Med J 2005; 35:240.
  13. Milewski M, Mastalerz L, Nizankowska E, Szczeklik A. Nasal provocation test with lysine-aspirin for diagnosis of aspirin-sensitive asthma. J Allergy Clin Immunol 1998; 101:581.
  14. Alonso-Llamazares A, Martinez-Cócera C, Domínguez-Ortega J, et al. Nasal provocation test (NPT) with aspirin: a sensitive and safe method to diagnose aspirin-induced asthma (AIA). Allergy 2002; 57:632.
  15. Bianco S, Robuschi M, Petrigni G. Aspirin-induced tolerance in aspirin induced asthma detected by a new challenge technique. IRCS J Med Sci 1977; 5:129.
  16. Dahlén B, Zetterström O. Comparison of bronchial and per oral provocation with aspirin in aspirin-sensitive asthmatics. Eur Respir J 1990; 3:527.
  17. Nizankowska E, Bestyńska-Krypel A, Cmiel A, Szczeklik A. Oral and bronchial provocation tests with aspirin for diagnosis of aspirin-induced asthma. Eur Respir J 2000; 15:863.
  18. The Scripps Clinic, San Diego, California. Dr. Simon may be reached at simon.ronald@scrippshealth.org.
  19. Mathison DA, Lumry WR, Stevenson DD, et al. Aspirin in chronic urticaria and/or angioedema: Studies of sensitivity and desensitization. J Allergy Clin Immunol 1982; 69:135.
  20. Stevenson DD, Pleskow WW, Simon RA, et al. Aspirin-sensitive rhinosinusitis asthma: a double-blind crossover study of treatment with aspirin. J Allergy Clin Immunol 1984; 73:500.
  21. Sweet JM, Stevenson DD, Simon RA, Mathison DA. Long-term effects of aspirin desensitization--treatment for aspirin-sensitive rhinosinusitis-asthma. J Allergy Clin Immunol 1990; 85:59.
  22. Williams AN, Woessner KM. The clinical effectiveness of aspirin desensitization in chronic rhinosinusitis. Curr Allergy Asthma Rep 2008; 8:245.
  23. Rozsasi A, Polzehl D, Deutschle T, et al. Long-term treatment with aspirin desensitization: a prospective clinical trial comparing 100 and 300 mg aspirin daily. Allergy 2008; 63:1228.
  24. Stevenson DD, Hankammer MA, Mathison DA, et al. Aspirin desensitization treatment of aspirin-sensitive patients with rhinosinusitis-asthma: long-term outcomes. J Allergy Clin Immunol 1996; 98:751.
  25. McMains KC, Kountakis SE. Medical and surgical considerations in patients with Samter's triad. Am J Rhinol 2006; 20:573.
  26. Berges-Gimeno MP, Simon RA, Stevenson DD. Long-term treatment with aspirin desensitization in asthmatic patients with aspirin-exacerbated respiratory disease. J Allergy Clin Immunol 2003; 111:180.
  27. Berges-Gimeno MP, Simon RA, Stevenson DD. Early effects of aspirin desensitization treatment in asthmatic patients with aspirin-exacerbated respiratory disease. Ann Allergy Asthma Immunol 2003; 90:338.
  28. Lee JY, Simon RA, Stevenson DD. Selection of aspirin dosages for aspirin desensitization treatment in patients with aspirin-exacerbated respiratory disease. J Allergy Clin Immunol 2007; 119:157.
  29. Świerczyńska-Krępa M, Sanak M, Bochenek G, et al. Aspirin desensitization in patients with aspirin-induced and aspirin-tolerant asthma: a double-blind study. J Allergy Clin Immunol 2014; 134:883.
  30. Cho KS, Soudry E, Psaltis AJ, et al. Long-term sinonasal outcomes of aspirin desensitization in aspirin exacerbated respiratory disease. Otolaryngol Head Neck Surg 2014; 151:575.
  31. Fruth K, Pogorzelski B, Schmidtmann I, et al. Low-dose aspirin desensitization in individuals with aspirin-exacerbated respiratory disease. Allergy 2013; 68:659.
  32. Hoyte FC, Weber RW, Katial RK. Pancreatitis as a novel complication of aspirin therapy in patients with aspirin-exacerbated respiratory disease. J Allergy Clin Immunol 2012; 129:1684.
  33. Stevenson DD, White AA, Simon RA. Aspirin as a cause of pancreatitis in patients with aspirin-exacerbated respiratory disease. J Allergy Clin Immunol 2012; 129:1687.