Aspirin Desensitization for AERD (Samter's Triad)

About Aspirin Desensitization

Aspirin desensitization, followed by long term aspirin therapy, is considered the gold standard treatment for Aspirin Exacerbated Respiratory Disease (AERD, Samter's Triad). Clinical studies have found that about 87% of AERD patients who undergo desensitization and continue daily aspirin therapy show improvement in their symptoms and are able to reduce their use of oral steroids and other medications. Once you are desensitized to aspirin, you are also desensitized to all other NSAIDs like ibuprofen and naproxen. The degree of improvement varies by individual, but the majority of patients do experience significant benefits. In the Scripps Patient Survey, 91% of patients who had been desensitized reported that aspirin desensitization was "effective," but fewer than 50% of patients had ever been desensitized. This is an underutilized treatment that can significantly improve quality of life for most patients. 

There are different protocols for desensitization, but all involve taking gradually increasing doses of aspirin until you are able to tolerate a regular strength aspirin (325 mg) without a reaction. This may be done in an outpatient setting or in a hospital, depending on your doctor and your individual history. Scripps recommends a rapid desensitization approach, usually accomplished in 1-3 days. Research has shown that almost all AERD patients are able to be successfully desensitized using this method. 

The process sounds scary to anyone who's ever had a severe reaction to aspirin, but doctors have been performing this procedure successfully for over 30 years. Many studies have shown that aspirin desensitization provides the following benefits:

  • Improvement in asthma symptoms

  • Reduced need for oral steroid medications

  • Improvement in sense of smell and taste

  • Delayed regrowth of nasal polyps and fewer polyp surgeries

  • Ability to take NSAIDs 

Aspirin desensitization must only be performed in a controlled medical setting, where you can immediately be treated for any reaction that occurs. 

Treatments

 

Reactions During Desensitization

Most patients do not have severe reactions during desensitization. A 2017 study found that out of 104 patients undergoing desensitization, 19% did not have any reactions during the procedure. Of those who did have reactions, 29% had a sinus reaction only. A larger study done at Scripps found that of 275 patients desensitized, 167 had reactions during desensitization. Of those, 23 were classified as "severe reactors." All patients were able to be safely desensitized.

Common reactions during aspirin desensitization include:

  • Increased nasal congestion 

  • Eye watering, itchiness or redness

  • Frontal headache or sinus pain

  • Cough, wheezing, or “tightness" in the chest

Less commonly, patients may experience:

  • Hives or a rash

  • Flushing 

  • Nausea or abdominal cramping

It is recommended that patients undergoing desensitization also take Singulair (montelukast), since this has been shown to reduce the severity of reactions.

Maintenance Aspirin Dose

The minimum dose of aspirin to maintain desensitization is 325 mg of aspirin per day. Following desensitization, you will need to take high dose aspirin daily to experience the full benefits of desensitization. Dosage varies by individual, but can range from 325 to 1300 mg per day. A study comparing 650mg a day to 1300mg a day found that both groups experienced benefits, but some patients required the higher dose to maintain control of symptoms. In a 2014 article, the doctors at Scripps recommended that patients be started at 650mg twice a day for one month. The dose can then be lowered by 325mg each month, until the minimum effective dose has been reached. 325mg daily is enough to maintain desensitization and allow patients to safely take NSAIDs, but it may not be enough to adequately treat the disease for most patients.

Aspirin therapy can be stopped for 24 to 48 hours if needed. If it is stopped for longer, it may be necessary to repeat the desensitization process.

 

Gastrointestinal Side Effects 

Unfortunately, some AERD (Samter's Triad) patients are unable to tolerate high dose aspirin therapy due to GI side effects. The number of patients who discontinue aspirin due to GI problems is fairly low - in one review, only one out of 30 patients had to stop taking aspirin for this reason. A long term study done by Scripps found that 14% of AERD patients had significant enough side effects to discontinue aspirin therapy. GI side effects are more common in older individuals and those with a history of GI problems.

 

If enteric coated aspirin cannot be tolerated, there are several options that can be tried to reduce these side effects. The dose of aspirin can be reduced. Proton-pump inhibitor medications, which reduce gastric acid production, can be prescribed. Some patients report fewer GI side effects from buffered aspirin, which contains small amounts of calcium and magnesium as antacids. Buffered aspirin can be hard to find, as it is less popular than enteric coated aspirin among the general population. 

If you have a history of GI problems, make sure you discuss it with your doctor. It is recommended that a lower starting dose be used following desensitization. In addition, there are pre-treatments available that may reduce the risk of GI side effects.

Risks

Aspirin desensitization can be performed safely, even if you have had a severe reaction to aspirin or NSAIDS in the past. Many patients experience only minor symptoms during the procedure. It is recommended that montelukast (Singulair) be given beforehand, to minimize the severity of reactions. 

Once you are desensitized, the risks of daily aspirin are low. The most common side effect of aspirin therapy is gastrointestinal pain, but there are strategies to prevent this as discussed above. Aspirin can also slow down blood clotting, so you may bleed longer if you cut yourself.

 

High dose aspirin should be stopped before any surgical procedure, but there are protocols for maintaining desensitization if you need to have surgery (see below). Consult your allergist (or other AERD/Samter's Triad specialist) before undergoing any elective surgery. Research suggests that desensitization may also be maintained short-term my transitioning to ibuprofen for elective surgery.

Scripps Protocol For Maintaining Desensitization During Elective Surgery

Brigham & Women's Protocol for Maintaining Desensitization During Elective Surgery

On the Bright Side

If you're going to be taking aspirin anyway, there's good news. Many studies have shown that aspirin has significant cardiovascular benefits, including reducing the risk of heart attack and stroke. More recent studies have indicated that daily aspirin use reduces the risk of several types of cancer and improves cancer survival rates.  

My Aspirin Desensitization: A Play-by-Play - read one patient's personal experience with aspirin desensitization.

Visit the research library to view studies that have been done on aspirin desensitization.

Join the Facebook Samter's Society Support Group to talk to other patients about their experience with aspirin desensitization.