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Aspirin-induced asthma

aspirin induced asthma, aspirin induced asthma mechanism
Aspirin-induced asthma, also termed Samter's triad, Samter's syndrome, aspirin-exacerbated respiratory disease AERD,1 and recently by an appointed task force of the European Academy of Allergy and Clinical Immunology/World Allergy Organization EAACI/WAO Nonsteroidal anti-inflammatory drugs-exacerbated respiratory disease N-ERD1 is a medical condition initially defined as consisting of three key features: asthma, respiratory symptoms exacerbated by aspirin, and nasal/ethmoidal polyposis; however, the syndrome's symptoms are exacerbated by a large variety of other nonsteroidal anti-inflammatory drugss NSAIDs besides aspirin234 The symptoms of respiratory reactions in this syndrome are hypersensitivity reactions to NSAIDs rather than the typically described true allergic reactions that trigger other common allergen-induced asthma, rhinitis, or hives The NSAID-induced reactions do not appear to involve the common mediators of true allergic reactions, immunoglobulin E or T cells4 Rather, AERD is a type of NSAID-induced hypersensitivity syndrome EAACI/WHO classifies the syndrome as one of 5 types of NSAID hypersensitivity or NSAID hypersensitivity reactions


  • 1 Signs and symptoms
  • 2 Cause
  • 3 Treatment
    • 31 Testing
    • 32 Medication
    • 33 Surgery
    • 34 Diet
  • 4 Alternate and related names
  • 5 History
  • 6 See also
  • 7 References

Signs and symptomsedit

The various non-allergic NSAID hypersensitivity syndromes affect 05-19% of the general population, with AERD affecting about 7% of all asthmatics and about 14% of patients with severe asthma 5 AERD, which is more prevalent in women, usually begins in young adulthood twenties and thirties are the most common onset times although children are afflicted with it and present a diagnostic problem in pediatrics67 and may not include any other allergies Most commonly the first symptom is rhinitis inflammation or irritation of the nasal mucosa, which can manifest as sneezing, runny nose, or congestion The disorder typically progresses to asthma, then nasal polyposis, with aspirin sensitivity coming last Anosmia lack of smell is also common, as inflammation within the nose and sinuses likely reaches the olfactory receptors8

The respiratory reactions to aspirin vary in severity, ranging from mild nasal congestion and eye watering to lower respiratory symptoms including wheezing, coughing, an asthma attack, and in rare cases, anaphylaxis In addition to the typical respiratory reactions, about 10% of patients with AERD manifest skin symptoms like urticaria and/or gastrointestinal symptoms such as abdominal pain or vomiting during their reactions to aspirin2 In addition to aspirin, patients usually also react to other NSAIDs such as ibuprofen, and to any medication that inhibits the cyclooxygenase-1 COX-1 enzyme, although paracetamol acetaminophen in low doses9 is generally considered safe NSAID that are highly selective in blocking COX-2 and do not block its closely related paralog, COX-1, such as the COX-2 inhibitors celecoxib and rofecoxib, are also regarded as safe10 Nonetheless, recent studies do find that these types of drugs, eg acetaminophen and celecoxib, may trigger adverse reactions in these patients; caution is recommended in using any COX inhibitors11 In addition to aspirin and NSAIDs, consumption of even small amounts of alcohol also produces uncomfortable respiratory reactions in many patients12


The disorder is thought to be caused by an anomaly in the arachidonic acid metabolizing cascade which leads to increased production of pro-inflammatory cysteinyl leukotrienes, a series of chemicals involved in the body's inflammatory response When medications like NSAIDs or aspirin block the COX-1 enzyme, production of thromboxane and some anti-inflammatory prostaglandins is decreased, and in patients with aspirin-induced asthma this results in the overproduction of pro-inflammatory leukotrienes to causes severe exacerbations of asthma and allergy-like symptoms131415161718 The underlying cause of the disorder is not fully understood, but there have been several important findings:

  • Abnormally low levels of prostaglandin E2 PGE2, which is protective for the lungs, has been found in patients with aspirin-induced asthma and may worsen their lung inflammation19
  • In addition to the overproduction of cystinyl leukotrienes, overproduction of 15-lipoxygenase-derived arachidonic acid metabolites viz, 15-hydroxyicosatetraenoic acid and eoxins by the eosinophils isolated from the blood of individuals with AERD; certain of these products may help promote the inflammatory response2021
  • Overexpression of both the cysteinyl leukotriene receptor 122 and the leukotriene C4 synthase23 enzyme has been shown in respiratory tissue from patients with aspirin-induced asthma, which likely relates to the increased response to leukotrienes and increased production of leukotrienes seen in the disorder
  • The attachment of platelets to certain leukocytes in the blood of patients with aspirin-sensitive asthma has also been shown to contribute to the overproduction of leukotrienes24
  • There may be a relationship between aspirin-induced asthma and TBX21, PTGER2, and LTC4S25
  • Eosinophils isolated from the blood of aspirin-induced asthma subjects as well as severe asthmatic patients greatly overproduce 15-hydroxyicosatetraenoic acid and eoxin C4 when challenged with arachidonic acid or calcium ionophore A23187, compared to the eosinophils taken from normal or mildly asthmatic subjects; aspirin treatment of eosinophils from aspirin intolerant subjects causes the cells to mount a further increase in eoxin production20 These results suggest that 15-lipoxygenase and certain of its metabolites, perhaps eoxin C4, as contributing to aspirin-induced asthma in a fashion similar to 5-lipoxygenase and its leukotriene metabolites



Urinary cystyl-leukotriene or urinary LTE4 can be used after a supervised challenge with aspirin In aspirin sensitivity, no change in N-methylhistamine is observed; while LTE4 levels are increased This test however lacks sensitivity and has a 25 percent false negative rate among affected persons26


The preferred treatment for many patients is desensitization to aspirin, undertaken at a clinic or hospital specializing in such treatment In the United States, the Scripps Clinic in San Diego, CA,27 the Massachusetts General Hospital in Boston, MA,28 the Brigham and Women's Hospital in Boston, MA,29 National Jewish Hospital in Denver 30 and Stanford University Adult ENT Clinic have allergists who routinely perform aspirin desensitization procedures for patients with aspirin-induced asthma Patients who are desensitized then take a maintenance dose of aspirin daily and while on daily aspirin they often have reduced need for supporting medications, fewer asthma and sinusitis symptoms than previously, and many have an improved sense of smell Desensitization to aspirin reduces the chance of nasal polyp recurrence, and can slow the regrowth of nasal polyps Even patients desensitized to aspirin may continue to need other medications including nasal steroids, inhaled steroids, and leukotriene antagonists

Leukotriene antagonists and inhibitors montelukast, zafirlukast, and zileuton are often helpful in treating the symptoms of aspirin-induced asthma Some patients require oral steroids to alleviate asthma and congestion, and most patients will have recurring or chronic sinusitis due to the nasal inflammation


Often surgery is required to remove nasal polyps,31 although they typically recur, particularly if aspirin desensitization is not undertaken 90% of patients have been shown to have recurrence of nasal polyps within 5 years after surgery, with 47% requiring revision surgery in the same time period32


Some people have reported relief of symptoms by following a low-salicylate diet such as the Feingold diet Aspirin is quickly converted in the body to salicylic acid, also known as 2-Hydroxybenzoic acid Sommer et al reported a multi-center prospective randomized cross-over trial with 30 patients following a low-salicylate diet for 6 weeks This study demonstrated a clinically significant decrease in both subjective and objective scoring of severity of disease, but made note of the challenge for patients in following what is a fairly stringent diet33

A diet low in omega-6 oils precursors of arachidonic acid, and high in omega-3 oils, may also help In a small study, aspirin-sensitive asthma patients taking 10 grams of fish oil daily reported relief of most symptoms after six weeks, however symptoms returned if the supplement was stopped34

Alternate and related namesedit

  • Aspirin-induced asthma is also referred to as leukotriene associated hypersensitivity 35

Samter's triad goes by several other names:

  • Acetylsalicylic acid triad 36
  • Widal's triad
  • Francis' triad
  • Aspirin triad
  • Aspirin-exacerbated respiratory disease AERD37
  • Aspirin-induced asthma and rhinitis AIAR38

A sufferer who has not yet experienced asthma or aspirin sensitivity might be diagnosed as having:

  • Non-allergic rhinitis
  • Non-allergic rhinitis with eosinophilia syndrome NARES


It is named for Max Samter39

Initial reports on the link between asthma, aspirin and nasal polyposis were made by Widal in 192240 Further studies were done by Samter & Beers in reports published in 196841

See alsoedit

  • Salicylate sensitivity
  • Drug intolerance
  • Alcohol-induced respiratory reactions


  1. ^ a b Allergy 2013 Oct;6810:1219-32 doi: 101111/all12260
  2. ^ a b Clin Chest Med 1988 Dec;94:567-76
  3. ^ Kim JE, Kountakis SE July 2007 "The prevalence of Samter's triad in patients undergoing functional endoscopic sinus surgery" Ear Nose Throat J 86 7: 396–9 PMID 17702319 
  4. ^ a b Allergy 2011 Jul;667:818-29 doi: 101111/j1398-9995201102557
  5. ^ J Allergy Clin Immunol 2015 Mar;1353:676-81
  6. ^ Welch, Kevin C "Aspirin Desensitization" American Rhinologic Society 
  7. ^ Int J Pediatr Otorhinolaryngol 2013 Feb;772:281-3 doi: 101016/jijporl201210017
  8. ^ Clin Rev Allergy Immunol 2003 Apr;242:113-24
  9. ^ Settipane RA, Schrank PJ, Simon RA, Mathison DA, Christiansen SC, Stevenson DD October 1995 "Prevalence of cross-sensitivity with acetaminophen in aspirin-sensitive asthmatic subjects" J Allergy Clin Immunol 96 4: 480–5 PMID 7560658 doi:101016/S0091-67499570290-3 
  10. ^ Lancet Neurol 2008 Sep;79:812-26 doi: 101016/S1474-44220870169-8
  11. ^ Allergy Asthma Immunol Res 2014 Mar;62:156-62 doi: 104168/aair201462156
  12. ^ Cardet JC, White AA, Barrett NA, et al 2014 "Alcohol-induced respiratory symptoms are common in patients with aspirin exacerbated respiratory disease" J Allergy Clin Immunol Pract 2 2: 208–13 PMID 24607050 doi:101016/jjaip201312003 
  13. ^ Narayanankutty A, Reséndiz-Hernández JM, Falfán-Valencia R, Teran LM May 2013 "Biochemical pathogenesis of aspirin exacerbated respiratory disease AERD" Clin Biochem 46 7-8: 566–78 PMID 23246457 doi:101016/jclinbiochem201212005 
  14. ^ Prostaglandins Other Lipid Mediat 2009 Sep;893-4:120-5 doi: 101016/jprostaglandins200812003
  15. ^ Respir Med 2010 Oct;10410:1404-9 doi: 101016/jrmed201004017
  16. ^ Allergy 2011 Jul;667:818-29 doi: 101111/j1398-9995201102557x
  17. ^ J Allergy Clin Immunol Pract 2014 Nov-Dec;26:653-7 doi: 101016/jjaip201409009
  18. ^ Curr Opin Allergy Clin Immunol 2014 Feb;141:1-6 doi: 101097/ACI0000000000000021
  19. ^ Picado C 2002 "Aspirin-intolerant asthma: role of cyclo-oxygenase enzymes" Allergy 57 Suppl 72: 58–60 PMID 12144557 doi:101034/j1398-999557s7214x 
  20. ^ a b Int Arch Allergy Immunol 2013;1622:135-42 doi: 101159/000351422
  21. ^ Int Arch Allergy Immunol 2014;1631:1-2 doi: 101159/000355949
  22. ^ Sousa AR, Parikh A, Scadding G, Corrigan CJ, Lee TH November 2002 "Leukotriene-receptor expression on nasal mucosal inflammatory cells in aspirin-sensitive rhinosinusitis" N Engl J Med 347 19: 1493–9 PMID 12421891 doi:101056/NEJMoa013508 
  23. ^ Cowburn AS, Sladek K, Soja J, et al February 1998 "Overexpression of leukotriene C4 synthase in bronchial biopsies from patients with aspirin-intolerant asthma" J Clin Invest 101 4: 834–46 PMC 508632  PMID 9466979 doi:101172/JCI620 
  24. ^ Laidlaw TM, Kidder MS, Bhattacharyya N, et al April 2012 "Cysteinyl leukotriene overproduction in aspirin-exacerbated respiratory disease is driven by platelet-adherent leukocytes" Blood 119 16: 3790–8 PMC 3335383  PMID 22262771 doi:101182/blood-2011-10-384826 
  25. ^ Online Mendelian Inheritance in Man OMIM Asthma, Nasal Polyps, and Aspirin Intolerance -208550
  26. ^ Urinary metabolites of histamine and leukotrienes before and after placebo-controlled challenge with ASA and food additives in chronic urticaria patients Di Lorenzo G, Pacor ML, Vignola AM, Profita M, Esposito-Pellitteri M, Biasi D, Corrocher R, Caruso C Allergy 2002 Dec;5712:1180-6 PMID 12464047
  27. ^ "Frequently Asked Questions About Aspirin-Exacerbated Respiratory Disease AERD Treatment" Specialized Services: Aspirin Desensitization Scripps Health 
  28. ^ http://wwwmassgeneralorg/allergy/
  29. ^ "Aspirin Exacerbated Respiratory Disease/Samter’s Triad" Brigham and Women’s Hospital 2012 
  30. ^ "Aspirin Desensitization" 2013 National Jewish Health Accessed 2013-10-15
  31. ^ McMains KC, Kountakis SE 2006 "Medical and surgical considerations in patients with Samter's triad" American journal of rhinology 20 6: 573–6 PMID 17181095 doi:102500/ajr2006202913 
  32. ^ Mendelsohn, Daniel; Jeremic, Goran; Wright, Erin D; Rotenberg, Brian W March 2011 "Revision rates after endoscopic sinus surgery: a recurrence analysis" The Annals of Otology, Rhinology, and Laryngology 120 3: 162–166 ISSN 0003-4894 PMID 21510141 doi:101177/000348941112000304 
  33. ^ Sommer, Doron D; Rotenberg, Brian W; Sowerby, Leigh J; Lee, John M; Janjua, Arif; Witterick, Ian J; Monteiro, Eric; Gupta, Michael K; Au, Michael April 2016 "A novel treatment adjunct for aspirin exacerbated respiratory disease: the low-salicylate diet: a multicenter randomized control crossover trial" International Forum of Allergy & Rhinology 6 4: 385–391 ISSN 2042-6984 PMID 26751262 doi:101002/alr21678 
  34. ^ Healy E, Newell L, Howarth P, Friedmann PS Control of salicylate intolerance with fish oils Br J Dermatol 2008 Dec;1596:1368-9 PMID 18795922
  35. ^ Charles A Lewis, Enteroimmunology, ibid
  36. ^ Amar YG, Frenkiel S, Sobol SE February 2000 "Outcome analysis of endoscopic sinus surgery for chronic sinusitis in patients having Samter's triad" J Otolaryngol 29 1: 7–12 PMID 10709165 
  37. ^ Williams AN, Woessner KM May 2008 "The clinical effectiveness of aspirin desensitization in chronic rhinosinusitis" Current allergy and asthma reports 8 3: 245–52 PMID 18589844 doi:101007/s11882-008-0041-7 
  38. ^ Bochenek G, Bánska K, Szabó Z, Nizankowska E, Szczeklik A March 2002 "Diagnosis, prevention and treatment of aspirin-induced asthma and rhinitis" Current drug targets Inflammation and allergy 1 1: 1–11 PMID 14561202 doi:102174/1568010023345011 
  39. ^ Samter's syndrome at Who Named It
  40. ^ Widal MF 1922 "Anaphylaxie et idiosyncraise" Press Med in French 119: 48–51 
  41. ^ Samter M, Beers RF 1968 "Intolerance to aspirin Clinical studies and consideration of its pathogenesis" Ann Intern Med 68 5: 975–83 PMID 5646829 doi:107326/0003-4819-68-5-975 

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