Aspirin desensitization or biologics for AERD?

Abstract

https://doi.org/10.1016/j.anai.2019.07.015 1081-1206/ 2019 American College of Allergy, A Aspirin-exacerbated respiratory disease (AERD) is a syndrome characterized by asthma that is often severe, with progressive airway remodeling, the presence of eosinophilic chronic sinusitis with nasal polyp (CRSwNP) formation, and intolerance to aspirin and other nonselective cyclooxygenase 1 (COX-1) inhibitors.1 The prevalence of AERD in the general population is 1%, which increases to 7% amongst those with asthma. In the most severe cases, ingestion of aspirin can trigger systemic reactions and even death. The disease has high morbidity if not properly managed, often involving multiple surgeries to decrease nasal polyp (NP) burden, because untreated NPs can regrow rapidly. Current treatment of AERD that fails conventional therapy uses aspirin desensitization followed by daily high-dose aspirin therapy; however, with the approval of biological therapies, new approaches need to be considered. How both of these will be used in the future and the benefits and drawbacks of each are the focus of this perspective. Although aspirin can trigger acute respiratory symptoms through the release of inflammatory mediators, aspirin desensitization followed by daily high-dose aspirin therapy leads to improved long-term symptoms in AERD subjects, as shown in a double-blind placebo-controlled crossover study.2 Many variations of the desensitization protocol exist; however, the general theme is to start with small doses of aspirin and gradually increase the amount, ultimately achieving doses of 650 to 1300 mg daily, although the use of lower dosing regimens is being investigated. The approach is analogous to traditional allergy desensitization, which addresses immunoglobulin E (IgE)-mediated reactions; however, the pathophysiology is distinct. The most significant improvements observed with aspirin desensitization relate to upper airway symptoms, including restoration of smell and decreased polyp formation, along with decreased use of steroids and fewer hospitalizations related to the underlying asthma.3 In