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Although for therapeutic reasons it has become convenient to consider asthma as a single disease entity, this clearly is not the case, with many variants occurring. From a clinical standpoint, a minimal subdivision includes atopic asthma, cough variant asthma, brittle asthma, intrinsic asthma, occupational non-IgE dependent asthma, and aspirin intolerant asthma (AIA).1 This last variant constitutes a clearcut clinical syndrome. It is a remarkable model for investigating mechanisms that operate in asthma, rhinitis, and nasal polyposis. The recent introduction of anti-leukotriene drugs has amplified interest in this syndrome.
Definition, prevalence and clinical presentation
AIA is an aggressive mucosal inflammatory disease combined with precipitation of asthma and rhinitis attacks which occurs after ingestion of aspirin and most non-steroidal anti-inflammatory drugs (NSAID).2 Aspirin intolerance is underdiagnosed within the asthmatic population. Based on patients' history alone, the incidence of aspirin sensitivity in adult asthmatics is 3–5%, but this rises to 19% of consecutive adult asthmatic patients challenged with oral aspirin. Even in adult asthmatics with no history of aspirin intolerance, 9% show sensitivity to oral aspirin challenge and in those with rhinosinusitis the figure rises to 34%.3 The reasons for under-reporting of aspirin sensitivity may include the deliberate avoidance of NSAIDs by asthmatic patients who are aware of adverse reactions, or a lack of recognition by patients of mild NSAID induced reactions because of their delayed onset of action. Thus, in a population of 500 patients with AIA studied in the European Network of Aspirin-Induced Asthma (AIANE), 18% were unaware of aspirin intolerance before having aspirin provocation tests. This indicates that underdiagnosis of aspirin sensitivity may be due to the lack of routine aspirin challenge testing of asthmatic patients who do not report a positive history of aspirin sensitivity.
In most patients (women are affected 2.5 times more often than men), symptoms of rhinitis first …
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