Aspirin sensitive rhinosinusitis: the clinical syndrome and effects of aspirin administration

doi:10.1016/0091-6749(83)90440-2

Journal of Allergy and Clinical Immunology

Volume 71, Issue 6, June 1983, Pages 580-587

https://doi.org/10.1016/0091-6749(83)90440-2 Get rights and content

Abstract

Nineteen aspirin sensitive adult patients were identified who experienced naso-ocular responses without associated bronchospasm during standardized oral aspirin challenge. These 19 patients exhibited the characteristics of the aspirin triad except asthma. These included hypertrophic rhinitis with or without associated nasal polyps, abnormal sinus roentgenograms, nasal eosinophilia, aspirin-provoked responses of the upper airway identical to those observed in aspirin-sensitive asthmatics, capacity of the upper airway to be desensitized to aspirin, and cross-reactivity andlor cross-desensitization of the upper airway to indomethacin. Of the 17 patients who were treated with daily aspirin after desensitization, 77% experienced improvement in their nasal symptoms.

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Cited by (72)

The role of aspirin desensitization followed by oral aspirin therapy in managing patients with aspirin-exacerbated respiratory disease: A Work Group Report from the Rhinitis, Rhinosinusitis and Ocular Allergy Committee of the American Academy of Allergy, Asthma & Immunology
2021, Journal of Allergy and Clinical Immunology
Citation Excerpt :
One limitation of these early seminal studies was the small sample size including as few as 1 to 2 patients each. Subsequent observational studies have examined larger cohorts of patients with AERD who were desensitized and maintained on daily aspirin for weeks, months, or years12-14,23-33 (Table II). Patients reported subjective improvement in upper and lower respiratory tract symptoms and objective reductions in daily oral steroid requirements as early as 4 weeks following desensitization while on maintenance therapy.25
Aspirin-exacerbated respiratory disease (AERD) is characterized by the clinical triad of chronic rhinosinusitis with nasal polyps, asthma, and an intolerance to medications that inhibit the cycloxgenase-1 enzyme. Patients with AERD on average have more severe respiratory disease compared with patients with chronic rhinosinusitis with nasal polyps and/or asthma alone. Although patients with AERD traditionally develop significant upper and lower respiratory tract symptoms on ingestion of cycloxgenase-1 inhibitors, most of these same patients report clinical benefit when desensitized to aspirin and maintained on daily aspirin therapy. This Work Group Report provides a comprehensive review of aspirin challenges, aspirin desensitizations, and maintenance aspirin therapy in patients with AERD. Identification of appropriate candidates, indications and contraindications, medical and surgical optimization strategies, protocols, medical management during the desensitization, and recommendations for maintenance aspirin therapy following desensitization are reviewed. Also included is a summary of studies evaluating the clinical efficacy of aspirin therapy after desensitization as well as a discussion on the possible cellular and molecular mechanisms explaining how this therapy provides unique benefit to patients with AERD.
Objective and subjective sinonasal and pulmonary outcomes in aspirin desensitization therapy: A prospective cohort study
2019, Auris Nasus Larynx
Citation Excerpt :
Despite this, patients have ongoing symptoms and reduced quality of life [1]. ASA desensitization was first described by Widal et al. [4] and was later pioneered as a treatment for AERD in the 1980’s, predominantly from the perspective of asthma management [5–7]. The pathophysiologic process behind AERD is believed to involve an imbalance of eicosanoid inflammatory mediators, including cysteinyl leukotrienes, which promote airway hyper-responsiveness, bronchoconstriction, and eosinophil activation [8].
Aspirin exacerbated respiratory disease (AERD) patients are challenging to manage with sinonasal and pulmonary symptoms refractory to maximal medical and surgical therapies. Our objective was to comprehensively examine objective and validated, disease-specific subjective sinonasal and pulmonary outcomes of aspirin (ASA) desensitization therapy in this patient population.
Prospective cohort study at an academic tertiary center. AERD patients with a history of chronic rhinosinusitis with nasal polyposis (CRSwNP), prior diagnosis of asthma, and a history of ASA sensitivity were eligible for inclusion. Patients underwent ASA desensitization using an established institutional protocol and continued on a 650 mg twice daily maintenance dose. Baseline Sinonasal Outcome Test (SNOT-22) and Asthma Control Questionnaire (ACQ) responses, acoustic rhinometry, peak flow readings, and endoscopic scoring of nasal polyps were recorded prior to desensitization and after 6 months of maintenance therapy.
Twelve patients were recruited for participation and underwent desensitization. Eight patients continued maintenance therapy and follow up at 6 months. Prior to desensitization, patients reported bothersome sinonasal symptoms with a median SNOT-22 score of 30.0 ± 34.5 (interquartile range (IQR)). There was significant improvement after 6 months of maintenance therapy to a median SNOT-22 score of 18.5 ± 17.3 (p = 0.025, Wilcoxon signed rank test). Acoustic rhinometry, endoscopic scores, ACQ and forced expiratory volume values remained stable at 6 months.
AERD patients may benefit from ASA desensitization with subjective sinonasal symptom improvement at 6 months and stable asthma and objective sinonasal measures. Further discussion is needed in the otolaryngology community regarding ASA desensitization in AERD management.
Adverse reactions to drugs and biologics in patients with clonal mast cell disorders: A Work Group Report of the Mast Cells Disorder Committee, American Academy of Allergy, Asthma & Immunology
2019, Journal of Allergy and Clinical Immunology
Citation Excerpt :
Moreover, mediators derived from MCs are released during these reactions.63,64 Third, a second aspirin-related respiratory condition, aspirin-sensitive rhinosinusitis, can occur independently of aspirin-sensitive asthma in some patients.59,65 Fourth, although the prevalence of atopy in patients with mastocytosis does not differ from that of the general population,66,67 there is concern that patients with mastocytosis, particularly adults with ISM without skin involvement, have an increased risk of anaphylaxis triggered by a variety of agents.7,9,13,68
Providers caring for patients with mastocytosis are tasked with the decision to consider therapeutic options. This can come with some trepidation because information available in the public domain lists numerous mast cell (MC) activators based on data that do not discriminate between primates, rodents, and MC lines; do not consider dosage; and do not take into account previous exposure and resultant clinical findings. This being said, there is support in the literature for an enhanced MC response in some patients with mastocytosis and in cases in which there is a greater incidence of adverse reactions associated with certain antigens, such as venoms and drugs. Thus this report provides a comprehensive guide for those providers who must decide on therapeutic options in the management of patients with clonal MC disease.
Aspirin-Exacerbated Respiratory Disease
2017, Otolaryngologic Clinics of North America
Citation Excerpt :
The rhinosinusitis of AERD is typically severe and, among currently defined subtypes, one of the more difficult to control. Fortunately, there are specific treatment options available to patients with aspirin sensitivity, including aspirin desensitization, which may ameliorate the severity of upper and lower airway inflammatory disease.2–7 In this sense AERD is a prototype for the application of precision medicine principles; it is a well-defined subtype of chronic rhinosinusitis (CRS) with individualized treatment strategies tailored to the underlying pathophysiologic mechanism.
Clinical Characteristics of Aspirin-Exacerbated Respiratory Disease
2016, Immunology and Allergy Clinics of North America
Aspirin or Nonsteroidal Anti-inflammatory Drug–Exacerbated Chronic Rhinosinusitis
2016, Journal of Allergy and Clinical Immunology: In Practice
Aspirin (ASA)-exacerbated respiratory disease (AERD) is characterized by upper airway congestion due to eosinophilic inflammation of the nasal and sinus membranes and nasal polyposis, associated with increased leukotriene production that is further accentuated by ASA or other nonsteroidal anti-inflammatory drug (NSAID) ingestion. It occurs in 5% to 10% of subjects with chronic rhinosinusitis (CRS) and in 15% to 40% of those with nasal polyposis. Although AERD with CRS is usually associated with asthma, this is not always the case. The eosinophilic airway inflammation and symptoms precede clinical reactions to ASA or other NSAIDs, but ultimately affected subjects experience worsening of symptoms with ingestion of ASA/NSAIDs. The endotypic mechanism for this worsening is related to a chronic increase in leukotriene and a decrease in prostaglandin production, particularly prostaglandin E2, that is further aggravated by the inhibition of cycloxgenase I. IgE does not likely play a role in the pathogenesis of the disease although nasal and sinus staphylococcal infection increases local IgE level and may increase total IgE and specific IgE levels. Genetic studies suggest that multiple genes may be involved, but the genetic abnormalities may differ in affected subjects from different ethnicities and candidate genes have not been confirmed in multiple studies. Genome-wide association studies have not been revealing. The phenotype is recognized by the mucosal inflammation and worsening of symptoms acutely with ASA/NSAID. There is clinical improvement with ASA desensitization followed by regular ingestion of ASA or other NSAIDs. Further understanding of this unique phenotype and endotype of CRS will likely improve the understanding of other eosinophilic airway diseases.

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^☆: Supported by NIAID grants AI 10386 and RR 00833.

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Original articleAspirin sensitive rhinosinusitis: the clinical syndrome and effects of aspirin administration☆

Abstract

J Allergy Clin Immunol

J Allergy Clin Immunol

Med Clin North Am

J Allergy

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

Original article
Aspirin sensitive rhinosinusitis: the clinical syndrome and effects of aspirin administration☆