Adults who suffer from Aspirin-Exacerbated Respiratory Disease (AERD) often suffer from asthma, sinus congestion, and recurrent nasal polyps. The team of board certified allergists at North Texas Allergy & Asthma Associates can help patients manage this sensitivity at any of their three locations in North Texas: Texas Health Dallas, Baylor Regional Medical Center at Plano, and Baylor University Medical Center at Dallas.
Aspirin-exacerbated respiratory disease (AERD) is a sensitivity to aspirin and other non-steroidal anti-inflammatory drugs such as ibuprofen and naproxen. While it can develop in anyone, you’re at a higher risk if you already have asthma, nasal polyps, or chronic inflammation of the sinuses and nasal cavity, also called rhinosinusitis.
When people with AERD take aspirin, they develop asthma, rhinosinusitis, nasal polyps, and upper and lower respiratory symptoms, such as nasal congestion, sinus pain, sneezing, coughing, and chest tightness. In some cases, patients may experience skin flushing, a rash, and abdominal pain. Chronic sinus infections that often seem like a never-ending cold, and loss of the sense of smell are also common.
Many patients with AERD take medications to control their symptoms, including inhaled corticosteroids for asthma and corticosteroid sprays to relieve nasal symptoms. They also have to completely avoid aspirin and other nonsteroidal anti-inflammatory medications — unless they receive aspirin desensitization therapy.
Aspirin desensitization and ongoing aspirin therapy after desensitization are the most effective treatments for AERD. The treatment is beneficial because you’ll be able to take aspirin, but more importantly, long-term daily aspirin therapy improves asthma and nasal symptoms, cuts episodes of rhinosinusitis, reduces the need for corticosteroids, and delays regrowth of nasal polyps.
Aspirin desensitization begins by taking a very low dose of aspirin. Then you take an aspirin every 1.5-3 hours, with each dose slightly higher than the previous one. This continues until you react to a dose. After treating the reaction, desensitization continues with the reactive dose, which patients aren’t sensitive to the second time it’s given. The desensitization continues until you can take 325 milligrams of aspirin, the amount in 1 adult aspirin tablet. Once this maintenance dose is reached, you can prevent sensitivity by taking aspirin daily.
The desensitization procedure is safe and is usually done in the office, where nurses and doctors monitor your progress and treat any reactions. The most common reactions are just like typical symptoms, so you may experience increased nasal congestion, eye watering or itchiness, headache or sinus pain, and a cough or tightness in the chest. However, if you have severe asthma or a history of severe reactions to aspirin, the doctors may decide to do the procedure in the hospital to ensure your safety.
There are few institutions and clinicians around the country that will perform aspirin desensitization. A good desensitization program requires asthma and allergy specialists with substantial clinical experience, enthusiasm, and infrastructure support to perform the aspirin challenges and desensitization. This typically requires training or experience that is not widely available.
In 1979, researchers at the Scripps Clinic in La Jolla, CA began studying aspirin sensitivity in asthmatic patients. To their surprise, they noticed that with each successive dose of aspirin, the severity of the aspirin reactions lessened. In fact, after several small doses of aspirin, the allergic reaction disappeared altogether. Under carefully controlled challenges, the patients were gradually able to take full adult-strength doses of aspirin (650mg).
At this point, they were said to be "desensitized" to aspirin. With continued daily ASA therapy, the patients reported less nasal congestion, fewer nasal polyps, better asthma control and less sinusitis. Many patients also experienced an improvement in their sense of smell. Through several follow-up studies, it has been conclusively shown that this procedure reduces upper and lower respiratory inflammation in part by altering the patients leukotriene levels and sensitivity to leukotrienes.
During the aspirin desensitization, you will receive small incremental doses of aspirin, usually starting with approximately 1/20th of the therapeutic dose, so as to minimize the risk of a serious reaction. Doses are gradually escalated depending on your tolerance. Once a reaction occurs, it will be treated and the following day you will return for continuation of the desensitization procedure. Repeat and escalating doses depending on tolerance are continued until you are able to ingest 325 mg of ASA without reaction, depending on your individual case. The procedure generally takes 2 days but in rare cases may take longer.
Clinical studies have shown that aspirin desensitization followed by daily aspirin use reduces symptoms of asthma, nasal polyps and sinusitis. Approximately 87% of patients experienced improvement in their symptoms and were able to reduce their use of steroids and/or other medications.
After desensitization, you will be instructed to continue taking 325 mg to 650 mg of aspirin twice daily depending on your case.
Candidates for aspirin desensitization and treatment must fall into one of three categories:
•Aspirin sensitive patients with asthma who are experiencing uncontrolled respiratory inflammation despite optimal medical management, or who are requiring unacceptably large doses of corticosteroids.
•Aspirin sensitive patients requiring repeated polypectomies and/or sinus surgeries.
•Aspirin sensitive patients who need ASA or NSAIDS for the treatment of other diseases, such as arthritis or blood clots.
Aspirin / NSAID desensitization is not indicated for patients:
•Who has ASA / NSAID induced hives (urticaria) or swelling (angioedema) affecting the airway
•Who have ASA/NSAID induced anaphylactic shock
•Who are pregnant
Aspirin desensitization candidate patients may experience the following benefits:
• Decreased corticosteroid doses
•Improved asthma control
•Fewer nasal polypectomies and/or sinus surgeries
•Tolerance to ASA AND NSAIDS
•Improved sense of smell
Since the doses given are usually much smaller that you have taken, in almost all cases, the reactions are no greater and usually less severe than the reaction you may have experienced previously when taking a full therapeutic dose. The most serious risk during the desensitization procedure is the development of a life threatening asthma exacerbation. Other symptoms may include nasal congestion, profuse runny nose, tightness of the throat, flushing of the skin, hives, and rarely a drop in blood pressure.
Our physicians and staff will closely monitor your physical status, vital signs, oxygen saturation and lung function (FEV1) for 3 hours after each dose looking for any reaction. When a reaction occurs, the procedure will be stopped and the symptoms will be treated with one or more inhalation treatments, nasal sprays, oral medications, and/or injections of medications to relieve the symptoms. Aspirin desensitization should never be performed outside a medical facility.
Long-term risks from aspirin include pain or bleeding of the stomach or stomach ulcers. Aspirin slows down blood clotting, so you may bleed longer if you cut yourself or have surgery. Once you are desensitized to aspirin, the risks of daily aspirin are small. If you take it with food, stomach problems are less likely. Taking an antacid, such as Maalox or Mylanta can lessen stomach pain. Coated aspirin tablets that bypass the stomach before they dissolve are also recommended. There are additional medicines that could be prescribed if needed. If you start bleeding anywhere in your body, you should call us immediately and refrain from taking any further aspirin.
Understand that aspirin desensitization must be conducted in a medical setting equipped to handle life threatening asthma attacks. You should also be prepared to devote a week to the procedure. Although the desensitization may be completed in two days, it may take longer. We aim to schedule the desensitization immediately after sinus surgery/nasal polypectomy for optimal results and to limit your time off from work or school. To ensure the utmost safety, you must not be ill and your asthma must be controlled.
For the one week prior to desensitization, your asthma must be stable on all of your usual asthma controller medications but on NO MORE THAN 10 mg of PREDNISONE PER DAY. This will be reflected by peak expiratory flow rates (Peak Flows) within 80% - 100% of your personal best with no greater than 20 % variability. Peak flow measurements should be taken daily every 2 hours from 8 AM to 6PM and recorded for the few days prior to your desensitization. Your doctor will want to see this before beginning the desensitization. You will need to avoid ALBUTEROL or any short acting bronchodilator for at least 8 hours before and during desensitization. Use of long acting bronchodilators, (e.g. Serevent, Foradil), should be continued.
Your doctor may also recommend medications that will help block the clinical effects of those Leukotrienes (Singulair, Accolate, or Zyflo). These medications should be continued during the procedure. You should also continue all other medications recommended by your physician. The medications that we would like you to hold 2 days prior to the aspirin desensitization is anti-histamines (Claritin/loratadine, Zyrtec/cetirizine, Allegra/fexofenadine, Xyal, Clarinex, Benadryl, etc) and decongestants.
The aspirin desensitization takes the full day over two to three days. Expect to arrive at 07:45 AM or 9:00 AM as directed by the medical staff. Since you are here for the whole day please bring books, laptop, snacks (no dietary restrictions) and/or other activities.
•Have a light breakfast the morning of the procedure
•Continue all regular medications as scheduled unless otherwise directed (beta-blockers may be asked to be held)
•No anti-histamines or decongestants 48 hours prior to arrival
•Continue all asthma medications but we would like you to refrain from Albuterol or any other short acting bronchodilator 8 hours prior to procedure.
You need to continue your daily dose of aspirin. We recommend Ecotrin or other coated aspirin to help lessen the effects of stomach irritation. In time you will slowly notice improvement of your asthma and nasal symptoms. Tapering of medications will be done on a regular basis. Typically the doctor will see you back one month after completing the aspirin desensitization.
Once desensitized to aspirin, you are most likely desensitized to several other non-steroidal anti-inflammatory drugs (NSAID - Motrin, Naprosyn, etc). Thus, if you are desensitized to aspirin and are taking it regularly you can take the NSAID medication but do not exceed the recommended dose.
Once desensitized and on long term aspirin treatment, desensitization is maintained only as long as you continue to take uninterrupted aspirin doses. Aspirin should not be discontinued without speaking to your allergist.
Once desensitized, your body can tolerate one day without aspirin. If you forget to take your aspirin and remember within 48 hours since your most recent dose, simply take your usual dose. After 48 hours of a missed dose, your body begins to lose the desensitized state. You should NOT consider yourself desensitized after missing a dose for 48 hours or more. If you take aspirin then, you could have a reaction. Call your doctor for instructions if a dose is missed for 48 hours or more.
Have your allergist discuss a safe method to avoid discontinuing aspirin with you and your surgeon.
Below is a common recommendation (but clear it with your surgeon first):
•Decrease aspirin dose to 325 mg each day, beginning 8 days before surgery
•Two days before surgery, take your last aspirin tablet in the morning.
•On the day before surgery and the morning of surgery DO NOT take any aspirin
•After completing the operation and when you are completely recovered from anesthesia, take one 325 mg aspirin tablet
•On the day after surgery (post op day 1), take one 325 mg tablet of aspirin in the morning and one 325 mg at night.
•On the second day after surgery (post op day 2) take your usual dose of aspirin (resume pre-op aspirin regimen).
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