Aspirin-exacerbated respiratory disease
Aspirin-exacerbated respiratory disease is an acquired, non-IgE-mediated triad of adult-onset asthma, chronic rhinosinusitis with nasal polyps, and reproducible bronchospasm or rhinitis after ingesting aspirin or any COX-1-inhibiting NSAID. Diagnosis is clinical and management pairs lifelong NSAID avoidance with stepwise asthma and sinus therapy, leukotriene modification, aspirin desensitization, or biologics for refractory disease.
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What this article covers
- Overview
A triad, not just a drug allergy: aspirin-exacerbated respiratory disease (AERD, also called Samter triad or aspirin-sensitive asthma) describes asthma and rhinosinusitis precipitated by aspirin or…
- Epidemiology
Adult-onset disease: onset is in adulthood, not a pediatric presentation of asthma.
- Risk factors
Pre-existing chronic rhinosinusitis with nasal polyps and moderate-to-severe persistent asthma: this combination is the substrate on which the reaction develops.
- Pathophysiology
COX-1 inhibition is the trigger: aspirin and other NSAIDs precipitate the reaction by inhibiting cyclooxygenase-1, the enzyme that normally metabolizes arachidonic acid down the prostaglandin pathway.
- Clinical features
The defining triad (establishes the diagnosis): asthma, chronic rhinosinusitis with nasal polyps, and a reproducible respiratory reaction after ingesting aspirin or a COX-1-inhibiting NSAID together…
- Differential diagnosis
IgE-mediated single-NSAID hypersensitivity or anaphylaxis: limited to one NSAID (or a related subset) rather than every COX-1 inhibitor; produces urticaria, angioedema, or anaphylaxis without underlying asthma or polyps.
- Diagnosis
This is a clinical diagnosis made by the Samter triad: all three of (1) asthma, (2) chronic rhinosinusitis with nasal polyps, and (3) a reproducible reaction to aspirin or another COX-1-inhibiting…
- Management
First, stop and avoid the trigger indefinitely: discontinue aspirin and all COX-1-inhibiting NSAIDs, lifelong; for analgesia use choline salicylate 870 mg PO every 3-4 hours as needed (maximum 6…
- Complications
Life-threatening or fatal bronchospasm: aspirin ingestion can cause acute, severe, and fatal asthma in a small subset of patients, the most dangerous complication of unrecognized disease.
- Prognosis
Chronic and non-remitting without ongoing management: the underlying eosinophilic disease persists regardless of further NSAID reactions, so control depends on continued avoidance and maintenance therapy, not a single intervention.
- Prevention
Lifelong avoidance is the core preventive measure: every confirmed AERD patient avoids aspirin and all COX-1-inhibiting NSAIDs indefinitely, using choline salicylate for analgesia instead.
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Related articles
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Asthma is a chronic inflammatory airway disorder causing episodic, reversible airflow obstruction confirmed by spirometry or bronchial challenge testing. Management is a stepwise ladder led by inhaled glucocorticoids plus as-needed SABA or ICS-formoterol, escalating to biologics for severe type 2-high disease, with an oral glucocorticoid burst and frequent SABA for exacerbations.
- Nasal polyps
Nasal polyps are benign, typically bilateral outgrowths of edematous nasal mucosa driven by chronic mucosal inflammation, most often arising with chronic rhinosinusitis, aspirin-exacerbated respiratory disease, or cystic fibrosis. Unilateral polyps or a mass that does not respond to treatment must be biopsied to exclude tumor.
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