SAN FRANCISCO — Most patients with aspirin-exacerbated respiratory disease (AERD) can be safely desensitized to aspirin in a single day with a four-step dose escalation protocol, researchers reported here.
In a study involving 44 patients with confirmed AERD, stable asthma and a baseline FEV1 of ≥70%, single-day challenge and desensitization in an outpatient setting resulted in desensitization in more than 90% of patients, said Tanya Laidlaw, MD, of Brigham and Women’s Hospital in Boston.
Laidlaw and colleague Geneva DeGregorio, MD, presented the findings at the 2019 American Academy of Allergy, Asthma & Immunology annual meeting.
And in a separate study, researchers found that aspirin sensitivity decreased or disappeared entirely following nasal polyp removal.
Aspirin-exacerbated respiratory disease involves a triad of symptoms that include asthma, which is usually severe; sinus disease with recurrent nasal polyps; and sensitivity to aspirin and other non-steroidal anti-inflammatory COX-1 drugs.
“That works out to about 1.5 million or 2 million patients in the United States, so this is not a rare disorder,” Laidlaw told MedPage Today in an interview.
“It is certainly underdiagnosed. We have good data that suggests between 11% and 17% of patients who clearly have all three of these criteria have no idea that they have this.”
Because daily aspirin therapy is a recommended treatment to reduce the growth of nasal polyps, aspirin challenge remains the gold standard for the diagnosis of AERD and aspirin desensitization is routinely used in those with confirmed AERD.
But the currently used protocols can be both time and resource intensive, often occurring over several days.
Laidlaw said her group’s study was intended to show that oral challenge and desensitization can be safely performed in an outpatient setting in one day.
She explained that the protocol involved a starting dose of 40.5 mg of aspirin, with escalating doses (81 mg, 162.5 mg, and 325 mg) at 90-minute intervals until symptoms occurred.
When reactions occurred, the researchers would wait 3 hours before re-challenging with the dose that provoked the reaction.
“The most common thing we did after a reaction was just wait, because within 3 hours the reaction tended to fade away,” she said.
Among the 44 patients with documented AERD included in the study, most experienced no symptoms at the initial dosage of 40.5 mg and 50% had only nasoocular symptoms during the desensitization process. When bronchial symptoms did occur, the median change in FEV1 was less than 25%.
None of the patients required epinephrine and none required an emergency department visit or hospitalization.
In all, 93% of patients completed the challenge and desensitization in one day, with an average protocol completion time of 9 hours and 29 minutes.
Two patients (4.6%) chose to complete the protocol over two days. One patient (2.3%) was discontinued from the protocol due to ongoing abdominal discomfort and diarrhea.
While studies suggest that most patients with AERD can be desensitized to aspirin, Laidlaw said it is still not clear if aspirin therapy is as effective for treating respiratory disease in these patients as it is in the general population of patients with chronic sinus disease and recurrent nasal polyps.
It is also important for patients to remain compliant with a daily aspirin regimen to avoid re-sensitization, she added.
Are polyps the problem?
A separate study, presented at the AAAAI meeting by Elina Jerschow, MD, of Montefiore Medical Center, Bronx, New York, found that aspirin desensitization often followed surgery to remove nasal polyps.
Jerschow and colleagues followed 28 patients with AERD challenged with aspirin before endoscopic sinus surgery (ESS) and three or four weeks after surgery. Aspirin reactions were less severe at follow-up in many cases, with 43% of the patients showing no allergic reaction to aspirin when challenged following polyp removal. Those who did react generally had milder reactions than were seen before surgery.
The findings suggest that nasal polyp removal results in decreased aspirin sensitivity and that nasal polyps may interfere with aspirin desensitization, Jerschow told MedPage Today, explaining that several of the patients in the study had failed aspirin desensitization prior to surgery.
“We feel that there is something about the polyps themselves that causes this strange reaction that interferes with desensitization,” she said. “Once the bulk of the tissue was removed they did a lot better.”
She added that more research is needed to better understand the role of nasal polyps in chronic sinus disease.
“When the polyps are removed patients are almost healthy again,” she said.
The researchers reported no relevant relationships with industry related to the studies.