Beer, Aspirin Worsen Nasal Issues in a 35-Year-Old With Asthma

Thomas S. Higgins, Jr, MD, MSPH


September 15, 2022

AERD, formerly known as Samter's triad, is an inflammatory condition of the respiratory tract that includes eosinophilic asthma, nasal polyposis, and aspirin hypersensitivity. It represents approximately 10% of cases of CRSwNP. The disease is characterized by hypersensitivity to compounds that inhibit the cyclooxygenase pathway, including aspirin, NSAIDs, and acetaminophen.[1] Widal and colleagues[6] first described AERD in 1922. Max Samter, MD, coined the term "Samter's triad" in 1967.[7] The hypersensitivity reaction causes type 2 inflammation, which affects both the lower and upper airways.[8]

Diagnosis of AERD should be considered in patients with concomitant asthma and opacified paranasal sinuses on imaging. AERD is highly likely in the population of patients who report respiratory symptoms within 90 minutes of exposure to aspirin or NSAIDs, complete anosmia associated with nasal polyps, rapid regrowth of nasal polyps after sinus surgery, or asthma attacks after ingestion of alcoholic beverages.[9] It should be noted that alcohol consumption has been reported to aggravate symptoms associated with nasal polyps, such as certain beers did for the patient in this case.[10] AERD is considered highly unlikely in patients who report asthma and nasal polyps in childhood. Oral aspirin challenge is considered the standard diagnostic confirmatory test for AERD and was used to confirm the diagnosis in this patient.[9]

The goal of AERD management is control of airway inflammation. Medical therapies include systemic glucocorticosteroids, antileukotriene inhibitors (ie, montelukast or zileuton), topical anti-inflammatory inhalers and nasal sprays, and sinonasal rinses. Aspirin desensitization is a therapy unique to AERD that has been shown to improve outcomes in many patients.[9] The process of desensitization is performed by slowly increasing dosages of aspirin over 1-3 days until the hypersensitivity reaction fails to occur. The patients then continue to receive an aspirin regimen, usually between 325 mg or 650 mg twice a day, as maintenance therapy. Two potential complications of this therapy include peptic ulcer disease and excessive bleeding.[9]

A few monoclonal antibody therapies (biologic agents) are also available for control of severe asthma and/or nasal polyposis related to AERD. These medications include benralizumab, dupilumab, mepolizumab, and omalizumab. Their mechanism of action is to reduce type 2 inflammation by inhibiting immunoglobulin E or the proliferation of eosinophils.[8]


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