Controversies in Allergy: Aspirin Desensitization or Biologics for Aspirin-Exacerbated Respiratory Disease—How to Choose

Laidlaw, Tanya M.; Chu, Derek K.; Stevens, Whitney W.; White, Andrew A.

doi:10.1016/j.jaip.2021.12.030

Cited by 18 publications

(12 citation statements)

References 52 publications

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“…AERD is characterized by CRSwNP, asthma, and distinct respiratory reactions to aspirin and other non-specific nonsteroidal anti-inflammatory drugs (NSAIDs) [ 66 ]. The prevalence of AERD among CRSwNP patients is approximately 10%, and generally, these are amongst the most difficult to treat CRSwNP patients due to the severity of the underlying inflammation, leading to disease recalcitrance [ 66 – 68 ]. This is reflected at the cellular and molecular level; nasal polyps from patients with AERD have been shown to have over three times as many eosinophils and higher IL-5 concentrations when compared to polyps from subjects with non-AERD CRS [ 69 , 70 ].…”

Section: Discussionmentioning

confidence: 99%

Canadian multidisciplinary expert consensus on the use of biologics in upper airways: A Delphi study

Thamboo

Lee

Bhutani

et al. 2023

Journal of Otolaryngology - Head & Neck Surgery

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Background Chronic rhinosinusitis with nasal polyposis (CRSwNP) often coexists with lower airway disease. With the overlap between upper and lower airway disease, optimal management of the upper airways is undertaken in conjunction with that of the lower airways. Biologic therapy with targeted activity within the Type 2 inflammatory pathway can improve the clinical signs and symptoms of both upper and lower airway diseases. Knowledge gaps nevertheless exist in how best to approach patient care as a whole. There have been sixteen randomized, double-blind, placebo-controlled trails performed for CRSwNP targeted components of the Type 2 inflammatory pathway, notably interleukin (IL)-4, IL-5 and IL-13, IL- 5R, IL-33, and immunoglobulin (Ig)E. This white paper considers the perspectives of experts in various disciplines such as rhinology, allergy, and respirology across Canada, all of whom have unique and valuable insights to contribute on how to best approach patients with upper airway disease from a multidisciplinary perspective. Methods A Delphi Method process was utilized involving three rounds of questionnaires in which the first two were completed individually online and the third was discussed on a virtual platform with all the panelists. A national multidisciplinary expert panel of 34 certified specialists was created, composed of 16 rhinologists, 7 allergists, and 11 respirologists who evaluated the 20 original statements on a scale of 1–9 and provided comments. All ratings were quantitively reviewed by mean, median, mode, range, standard deviation and inter-rater reliability. Consensus was defined by relative interrater reliability measures—kappa coefficient ($$\kappa$$ κ ) value > 0.61. Results After three rounds, a total of 22 statements achieved consensus. This white paper only contains the final agreed upon statements and clear rationale and support for the statements regarding the use of biologics in patients with upper airway disease. Conclusion This white paper provides guidance to Canadian physicians on the use of biologic therapy for the management of upper airway disease from a multidisciplinary perspective, but the medical and surgical regimen should ultimately be individualized to the patient. As more biologics become available and additional trials are published we will provide updated versions of this white paper every few years. Graphical abstract

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Section: Discussionmentioning

confidence: 99%

Canadian multidisciplinary expert consensus on the use of biologics in upper airways: A Delphi study

Thamboo

Lee

Bhutani

et al. 2023

Journal of Otolaryngology - Head & Neck Surgery

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“…Another important factor to consider is the extent to which the patient can adhere to the treatment. Patients on aspirin treatment after aspirin desensitisation (ATAD) missing their dose for more than two days will gradually regain their intolerance and will need further desensitization ( 2 , 15 ).…”

Section: From the Perspective Of The Physicianmentioning

confidence: 99%

“…Finally, there are some prerequisites associated with the start of aspirin desensitization or biological therapy. For aspirin desensitization, it is recommended that the patient has stable/controlled asthma (FEV1 > 70% predicted) before initiating the therapy to prevent further exacerbation of patients’ asthma ( 13 , 15 ). For biologics, governments define criteria that need to be met for reimbursement of biologics.…”

Section: From the Perspective Of The Physicianmentioning

confidence: 99%

“…An important side note is that data for N-ERD patients are generated by post-hoc analysis as they constituted only a subgroup of the whole study population. The percentage of participants with N-ERD within the group of patients with CRSwNP was 27% for mepolizumab, 28% of the overall population for dupilumab, 30% in each treatment arm for benralizumab and between 17% and 39% for the two trials with omalizumab ( 15 ). A second site note is that diagnosis of N-ERD based on history alone is not always reliable ( 21 ), and that provocation tests are necessary to have a confirmed diagnosis of N-ERD.…”

Section: From the Perspective Of The Physicianmentioning

confidence: 99%

See 1 more Smart Citation

Monoclonal antibody or aspirin desensitization in NSAID-exacerbated respiratory disease (N-ERD)?

Broeck

Steelant²,

Scadding³

et al. 2023

Front. Allergy

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Nonsteroidal anti-inflammatory drug (NSAID)-exacerbated respiratory disease (N-ERD) is a clinical syndrome characterized by nasal polyposis, asthma, and intolerance to aspirin/NSAID. It affects approximately 15% cases of severe asthma, 10% of nasal polyps and 9% of rhinosinusitis. N-ERD results in associated asthma exacerbations, oral corticosteroids bursts, corticosteroid-dependent disease, and multiple endoscopic sinus surgeries. Unknown influences cause polyp epithelium to release alarmins, such as IL-33 and TSLP. These cytokines activate lymphoid cells, both Th2 and ILC2, to release cytokines such as IL5, IL4 and IL13, resulting in complex type 2 inflammation involving mast cells, eosinophils and platelets. Arachidonic acid released from such cells is metabolized into mediators. N-ERD is characterized by an imbalance in eicosanoid levels, especially CysLTs, PDG and PGE2. Patients with N-ERD present nasal symptoms (congestion, hyposmia/anosmia, nasal discharge) and lower airways symptoms (cough, sneezing, shortness of breath, chest tightness), anosmia, severe hyposmia as well as severe asthma which impacts the quality of life in this disease and leads to safety concerns in patients daily lives. Despite the variety of treatment strategies, the likelihood of recurrence of symptoms is high in patients with N-ERD. The most important strategies for treating N-ERD are listed as following: drug therapies, aspirin desensitization, monoclonal antibodies and other therapies associated. N-ERD treatment remains a major challenge in the current situation. Selecting the appropriate patient for aspirin desensitization, monoclonal antibodies or both is essential. This review provides an overview on aspirin desensitization and biologics in N-ERD and might help in decision making from both the perspective of the physician and patient. Patient characteristics, safety, efficacy, health care costs, but also patient preferences are all factors to take into account when it comes to a choice between biologics or aspirin desensitization.

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“…57 With the addition of biologic therapies to the list of treatment options for CRSwNP, which will be covered in a later chapter, there is controversy regarding treating AERD patients with aspirin desensitization or initiating a biologic, as outlined by Laidlaw et al, aspirin desensitization is a more cost-effective and perhaps more accessible option to more patients, although there are associated risks and side effects that may be unacceptable to certain patients. 59 When approaching this decision, providers should take individual patient factors into consideration.…”

Section: Leukotriene Inhibitors and Other Aerd Treatmentsmentioning

confidence: 99%

State of the Art Medical Management of Nasal Polyps

Staricha

Ali

Stokken

2023

Am J Rhinol�Allergy

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Background Chronic rhinosinusitis with nasal polyposis (CRSwNP) is an inflammatory disease with a treatment goal of controlling symptoms and limiting disease burden. While endoscopic sinus surgery is effective for removing polyps and aerating sinuses, proper medical management remains necessary for reducing inflammation and limiting polyp recurrence. Objective This article aims to summarize the literature regarding medical treatment of chronic rhinosinusitis with nasal polyposis, with a specific focus on developments in the past 5 years. Methodology We conducted a literature review using PubMed to identify studies assessing medical treatment strategies for patients with CRSwNP. Articles focusing on chronic rhinosinusitis without nasal polyposis were excluded unless specifically stated. Surgical treatment and biologic therapies for CRSwNP will be covered in subsequent chapters and are therefore not included. Results Intranasal saline irrigations and topical steroids are mainstays of CRSwNP treatment in the pre-surgical, post-surgical, and maintenance phases of the disease. Alternative steroid delivery methods and adjunctive treatments with antibiotics, anti-leukotrienes, and other topical therapies have been investigated and may benefit certain patient populations, but convincing evidence does not exist to warrant addition of these treatments to the standard of care for CRSwNP. Conclusions Topical steroid therapy is clearly effective for CRSwNP, and recent studies demonstrate the safety and efficacy of high-dose nasal steroid rinses. Alternate delivery methods for local steroids may be useful for patients who are not responding to or who are noncompliant with conventional intranasal corticosteroid sprays and rinses. Future studies are needed to clarify if oral or topical antibiotics, oral anti-leukotrienes, or other novel therapies are significantly effective in decreasing symptoms and improving the quality of life in patients with CRSwNP.

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Controversies in Allergy: Aspirin Desensitization or Biologics for Aspirin-Exacerbated Respiratory Disease—How to Choose

Cited by 18 publications

References 52 publications

Canadian multidisciplinary expert consensus on the use of biologics in upper airways: A Delphi study

Canadian multidisciplinary expert consensus on the use of biologics in upper airways: A Delphi study

Monoclonal antibody or aspirin desensitization in NSAID-exacerbated respiratory disease (N-ERD)?

State of the Art Medical Management of Nasal Polyps

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