Five to ten percent of mild asthmatics will have a reaction to the most common and age-old remedy for inflammation—aspirin. In severe asthma patients, that amount more than doubles, reaching up to 25 percent.
“The body is always trying to maintain balance, and our immune system is always regulating,” says Christopher Davis, MD, an ENT surgeon with Excel ENT of Alabama. “But it’s a fine balance between regulation and hyper reaction to an immune response.”
Patients with aspirin-exacerbated respiratory disease (AERD) will exhibit three classic symptoms: chronic sinusitis with nasal polyps, severe to moderate bronchial asthma, and intolerance to aspirin and other NSAIDS.
Often called Samter's triad or ASA (acetylsalicylic acid) triad, this cluster of symptoms tends to get overlooked. “When you see a patient with a history of asthma—and they may have allergies—and they complain of sinus, and you see a lot of nasal polyps, you’ve got to start thinking of AERD,” Davis says.
Many patients don’t relate their symptoms to aspirin. “I can’t tell you how many times patients will say they don’t take any medications, but they’re taking aspirin,” says Davis. “Aspirin is almost like drinking water to some people."
The only conclusive way to determine aspirin sensitivity is through an oral challenge tolerance test. The patient is given rising doses of aspirin at specific intervals while being watched for symptoms. “There’s special expertise in doing that,” Davis says.
Though the procedure sounds simple, it must be done in an office under the expertise of an allergist who can manage any airway problems that arise. During the testing, the patient remains under constant supervision for heart rate, breathing, pulse oximetry—the concentration of oxygen in the blood.
“I’ve seen patients that have undergone several sinus surgeries before diagnosis with this,” Davis says. “They have polyp obstruction with chronic sinus infection, so they get the polyps removed.”
But the symptoms always return, because AERD stems from an inflammatory issue. “And surgery doesn’t control that. Surgery is just correcting the plumbing, so the resulting mucus can flow better,” Davis says.
Managing the inflammation and the resulting asthma falls to an allergist. “This is a multidisciplinary disease,” Davis says. Medications can involve the use of inhaled corticosteroids, oral steroids and leukotriene inhibitors.
Stopping the ingestion of aspirin or any NSAIDs (nonsteroidal anti-inflammatory drugs) can help control AERD. However, aspirin is a salicylate, and salicylates infiltrate everyone’s daily life through foods, cosmetics and other medications. From apples to zucchini and shaving cream to ice cream, salicylates can add up in a person’s system throughout the day, whether they take aspirin or not. “This affects the occasional patient rather than the majority, and low-salicylate diets are not considered a routine part of management,” Davis says.
Therefore, desensitization to aspirin can offer a more permanent solution. Under the strict supervision of an allergist trained in the process, the patient starts off taking low levels of aspirin, below the amount that causes the immune system to react so violently. Gradually the dosage increases until the patient can tolerate at least 650 mg.
“It takes three to five days to get tolerant,” Davis says. “But the key is that you then have to take aspirin daily for the rest of your life.” If a patient stops taking the daily dose, their desensitization disappears in only two to five days and, within seven days, their full hypersensitivity returns.
“Not all patients can be desensitized,” Davis says. The severity or non-stability of their asthma may preclude some people from undergoing the process, or other conditions may not allow for long-term ingestion of aspirin, such as peptic ulcers. The daily dosage to maintain aspirin desensitization can range from 1000 mg to over 1300 mg.
“The success rate of desensitization depends on the articles you read,” Davis says. Side effects from daily ingesting aspirin, such as blood thinning or problems arising in the digestive tract, can mean the end to the process.
The process also doesn’t stop the return of polyps. “But polyps are less likely to come back with desensitization,” Davis says. “Without desensitization, the chance of return is 100 percent.
“The goal of any AERD treatment is to control the symptoms the best we can and to keep the number of surgeries for polyps as far apart and as few as possible,” Davis says. With desensitization, the return of polyps can extend to several years. Without it, they can return within months.
“Chronic asthma and sinusitis from AERD make a major impact on quality of life. It’s similar to congestive heart failure. It’s that debilitating,” Davis says.
Primary physicians and specialists need to become more familiar with and vigilant in spotting aspirin sensitivity. “From a surgeon’s perspective, my job may not be to give the diagnosis,” Davis says. “I just need to be able to recognize it and raise the red flag when I see possible AERD.”