A patient presents with asthma, nasal congestion, and nasal polyps, and she says she has weird reactions to aspirin or other nonsteroidal anti-inflammatory drugs. Do you know what condition this patient may have?
A patient presents with asthma, nasal congestion, and nasal polyps, and she says she has weird reactions to aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDs). Do you know what condition this patient may have?
Based on her symptoms, she may have a chronic condition called aspirin-exacerbated respiratory disease (AERD), also known as Samter’s triad or aspirin-sensitive asthma. Some reactions to aspirin or NSAIDs that patients with AERD may experience include increased nasal congestion, eye watering or redness, coughing or chest tightness, headache or sinus pain, flushing, rash, nausea, abdominal cramping, dizziness, and a feeling of malaise.
Around 10% of patients with asthma and 40% of patients with both asthma and nasal polyps are sensitive to aspirin and NSAIDs, according to the AERD Center at Brigham and Women's Hospital (BWH).
Tanya M. Laidlaw, MD, assistant professor of medicine at Harvard Medical School and director of translational research in allergy at BWH, told Pharmacy Times that greater awareness of AERD is crucial.
“We estimate that between 10% and 20% of all patients who have the full triad (asthma, nasal polyps, and respiratory reactions to cyclooxygenase-1 inhibitors [COX-1]) are unaware that they have this syndrome,” Dr. Laidlaw explained. “Increased awareness both on the part of the patients and their health care providers will be an incredible step toward identifying these patients and providing them with appropriate education and disease-tailored therapy.”
Here are 5 facts pharmacists should know about AERD.
1. Exactly how AERD develops is unknown.
What is known is that AERD isn’t a genetic disorder.
The AERD Center at BWH noted that affected patients often have high levels of eosinophils in their blood and sinuses, which could lead to chronic inflammation. Patients with AERD also tend to have elevated levels of leukotrienes, which are heightened further when they take aspirin or NSAIDS. Thus, antileukotriene treatments may help.
2. Patients with AERD will experience drug-induced reactions to all COX-1 inhibitors.
Dr. Laidlaw explained that any medication in this drug class, including aspirin, ibuprofen, Naprosyn, and ketorolac, will cause a reaction in AERD patients, even if it’s the first time they use it.
“If pharmacists note that a patient has more than 1 NSAID listed as an allergy or is described as having developed a respiratory reaction to any COX-1 inhibitor, pursuing that further with the patient could be very helpful,” she said.
3. Patients with AERD may know that they have reactions to aspirin, but they may not realize that they need to avoid other drugs, too.
More patient education would be helpful because not all patients and caregivers understand that reactions associated with AERD apply to all NSAIDS.
“We certainly have found patients who historically developed reactions to aspirin but didn’t realize that they also needed to avoid ibuprofen or ketorolac, and more education in that area could be lifesaving for them,” Dr. Laidlaw said.
4. Getting desensitized to aspirin is an effective AERD treatment option.
Desensitization involves increasing the dose of aspirin for patients while they’re at a hospital or clinic capable of doing so.
Once the patient is able to take a full dose of aspirin, he or she will be able to use aspirin and NSAIDs.
In an ironic turn of events, desensitized patients should then start taking daily aspirin, which can lead to less congestion, less polyp regrowth, and improvements in smell and asthma symptoms, according to the AERD Center at BWH.
5. Alternatively, patients can avoid NSAIDs, undergo surgery, or take medications that block leukotriene production.
Avoidance of all NSAIDs is crucial for patients with AERD who are not desensitized. For those patients, pharmacists can recommend acetaminophen (<1000 mg) as a pain reliever, though patients should know that some individuals still experience mild reactions to acetaminophen at higher doses.
Of note, celecoxib, which inhibits the COX-2 enzyme, is safe for patients with AERD to use, according to the AERD Center at BWH. Other options include zileuton, montelukast, and zafirlukast, which can block either leukotriene production or actions.
Patients may also need surgery to remove nasal polyps, though there is a good chance that the polyps may come back after surgery. However, montelukast use may help slow the recurrence, according to the AERD Center at BWH.