Aspirin-Exacerbated Asthma: Take This Breath Test

There is evidence of atopy in at least one-third of patients with AERD.

Although not well understood, the asthma phenotype known as aspirin-exacerbated respiratory disease, or AERD, is most likely related to leukotriene metabolism. AERD is chronic and often severe asthma identified by attacks of bronchoconstriction after ingestion of COX-1 inhibitors, including aspirin and other NSAIDs. Severe episodes can be life-threatening. 

Find out what you know about this dangerous respiratory disease with these 6 questions.

1. Approximately what percentage of adults and adolescents with asthma in the general population probably have aspirin- and NSAID-exacerbated asthma (AERD)?

A. Less than 5%

B. 5%

C. 10%

D. 15%

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Answer: C. 10%

The exact prevalence of AERD is unknown and varies based on the population surveyed, but most research supports a prevalence of about 10%. Reports range from 2% to 25%. The differences may be an indication of the range of severity of the disorder, with 2% representing mild disease and 25% representing severe, persistent asthma. Adults with more severe asthma have a higher prevalence of AERD, compared with children or adults with mild asthma.¹

2. Which of the following is not a diagnostic criterion for AERD?

A. History of respiratory symptoms within 4 hours of ingestion of aspirin or other NSAID

B. Chronic rhinosinusitis

C. Nasal polyps

D. Peripheral blood eosinophilia

E. Onset of respiratory symptoms after 20 years of age

F. All of the above are criteria

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Answer: F. All of the above are criteria

The pathophysiology of AERD is not completely understood. Leukotriene synthesis is increased in AERD, and ingestion of aspirin and other NSAIDs further increases leukotriene levels, perhaps contributing to symptoms. The inflammatory response in AERD includes increased leukotriene production; decrease in select prostaglandins; and increase in Th2 cytokines, eosinophils, and general inflammatory markers. Rhinosinusitis is usually one of the first symptoms to develop. Over time, the nasal symptoms become persistent and are associated with nasal polyps. Age of onset is usually early in the third decade.¹

3. AERD usually takes a less severe form of asthma than aspirin-tolerant asthma.

A. True

B. False

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Answer: B. False

AERD is more likely to manifest as a more severe form of asthma than aspirin-tolerant asthma (ATA). Compared with ATA, patients with AERD are more likely to have reduced lung function, increased need for glucocorticoids, inadequate control on standard asthma medications, and more life-threatening exacerbations.¹

4. Aspirin desensitization, followed by daily administration of aspirin, can improve respiratory symptoms in approximately what percentage of individuals with AERD?

A. 30%

B. 40%

C. 50%

D. 60%

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Answer: D. 60%

Confirmation of AERD requires aspirin or other NSAID challenge, but can be life-threatening and/or expensive to perform. Aspirin challenge can also be falsely negative if the patient is receiving leukotriene modifiers. Leukotriene synthesis inhibitors and leukotriene receptor antagonists may benefit some individuals, but may not always provide the amount of control needed. Aspirin desensitization followed by daily aspirin therapy may improve respiratory symptoms in about 60% of patients.¹

5. Respiratory symptoms in AERD are usually associated with allergen exposure.

A. True

B. False

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Answer: B. False

While allergen exposure may play a role in the respiratory symptoms found in ATA, in AERD the pathophysiology is linked instead to increased leukotriene metabolism. After ingesting aspirin or other NSAIDs, affected individuals produce even more leukotrienes, exacerbating symptoms. The inflammatory response in AERD includes increased leukotriene production; decrease in select prostaglandins; and increase in Th2 cytokines, eosinophils, and general inflammatory markers.¹

6. Which of the following is a potential trigger for respiratory reactions in patients with AERD?

A. Pollen

B. Mold

C. Alcoholic beverages

D. Peanuts

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Answer: C. Alcoholic beverages

Past research has suggested an association between aspirin sensitivity and alcohol-induced respiratory reactions in asthma patients. A recent study among 200 patients found that the prevalence of alcohol-induced upper respiratory tract reactions was 75% in those with AERD, compared with 33% with ATA, 30% with chronic rhinosinusitis, and 14% for healthy controls (P<.001 for all). The prevalence of alcohol-induced lower respiratory tract reactions was 51% in those with AERD, compared with 20% in those with ATA and 0% in both chronic rhinosinusitis and controls (P<.001 for all). Alcohol decreases leukotriene catabolism and its consumption likely increases systemic leukotriene levels, contributing to symptoms in patients with AERD.²

References:

1. Ledford DK, Wenzel SE, Lockey RF. Aspirin or other nonsteroidal inflammatory agent exacerbated asthma. J Allergy Clin Immunol Pract. 2014;2:653-657. http://dx.doi.org/10.1016/j.jaip.2014.09.009

2. Cardet JC, White AA, Barrett NA, et al. Alcohol-induced respiratory symptoms are common in atients with aspiring exacerbated respiratory disease. J Allergy Clin Immunol Pract. 2014;2:208-213.