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Aspirin Desensitization in NERD in the Era of Biologics: First or Last Resource?

  • Precision Medicine and Allergy Treatments (J Maspero, Section Editor)
  • Published:
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Abstract

Purpose of the Review

The classic treatment of non-steroidal anti-inflammatory drug (NSAID) exacerbated respiratory disease (NERD) includes aspirin desensitization (AD). Introduction of biologics in the treatment of asthma and chronic rhinosinusitis with nasal polyps (CRSwNP) has raised the question: which of the two options may be the most suitable for NERD?

Recent Findings

NERD is a highly eosinophilic disease. Monoclonal antibodies targeting IL-5 or the IL-5 receptor, involved in eosinophil recruitment, have been shown to be effective in asthma and CRSwNP. However, no difference in clinical efficacy was observed between NERD and aspirin-tolerant patients. Dupilumab, an IL-4 alpha receptor antagonist, demonstrated greater efficacy in NERD than in aspirin-tolerant patients for some clinical symptoms in a sub-analysis. Patients with NERD respond very rapidly to omalizumab with improvement in asthma and CRSwNP symptoms associated with reductions in prostaglandin D2 and cysteinyl leukotrienes release. Furthermore, omalizumab and dupilumab partially or totally restored tolerance to aspirin in NERD patients.

Summary

The decision to treat a NERD patient with AD or a biologic depends on many variables, such as differences between countries in the use of AD treatment in specialized units, limitations in accessing very expensive treatment in low-income countries and in countries where insurance systems do not cover or partially cover the cost of treatment. Patients who live in countries with public health systems that fully fund biologic treatments are more likely to benefit from biologic treatment. The limited data available so far suggest that, among current biologics, dupilumab ranks best for the treatment of CRSwNP associated with NERD.

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Abbreviations

AC:

Arachidonic acid

ACT:

Asthma control test

AD:

Aspirin desensitization

CS:

Corticosteroid

CRSwNP:

Chronic rhinosinusitis, with nasal polyps

CT:

Computed tomography

CySLT:

Cysteinyl leukotrienes

FcεRI:

High-affinity receptor Fc-epsilon-RI

FeNO:

Fractional exhaled nitric oxide

FEV1:

Forced expiratory volume in the first second

GETE:

Global evaluation of treatment effectiveness

IgE:

Immunoglobulin E

IL:

Interleukin

LTE4:

Leukotriene E4

NERD:

NSAID-exacerbated respiratory disease

NP:

Nasal polyp

NPS:

Nasal polyp score

NSAIDs:

Non-steroid anti-inflammatory drugs

PGE2:

Prostaglandin E2

PGD:

Prostaglandin D2

SNOT-22:

Sinonasal outcome test 22 score

TSLP:

Thymic stromal lymphopoietin

T2:

Type 2 immune response

TSLP:

Thymic stromal lymphopoietin

UPSIT:

University of Pennsylvania Smell Identification Test score

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Authors and Affiliations

  1. Department of Pulmonology and Allergy, Hospital Clinic, Universitat de Barcelona, Villarroel 170, 08036, Barcelona, Spain

    Irina Bobolea MD, PhD & César Picado MD, PhD, FERS

  2. Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain

    Irina Bobolea MD, PhD & César Picado MD, PhD, FERS

  3. Spanish Network of Centers for Biomedical Research on Respiratory Diseases (CIBERES), Barcelona, Spain

    Irina Bobolea MD, PhD & César Picado MD, PhD, FERS

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Correspondence to César Picado MD, PhD, FERS.

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Related to this article, César Picado declares to have received honoraria from Novartis as a member of advisory boards. He also received financial support from Teva, GSK, and AstraZeneca for attending scientific symposia and other educational programs.

Related to this article, I Bobolea declares to have received honoraria from Novartis, GSK, Teva, and Astra Zeneca, for speaking at symposia and as a member of advisory boards. She also received financial support from the aforementioned companies for attending scientific symposia and other educational programs.

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Bobolea, I., Picado, C. Aspirin Desensitization in NERD in the Era of Biologics: First or Last Resource?. Curr Treat Options Allergy 9, 91–106 (2022). https://doi.org/10.1007/s40521-022-00300-x

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