AERD

Question 1

Definition of AERD

Answer 1

Asthma, nasal polyps, chronic rhinitis and sensitizations to ASA or CoX1 inhibitors which manifests in 30 minutes to 3 hours

Question 2

Samter’s triad

Answer 2

Aspirin sensitivity, nasal polyp and asthma

Question 3

Prevalence of AERD in severe asthma

Answer 3

7% in mild asthma

14% in severe asthma

Question 4

Pathophysiology of AERD (not well understood!)

Answer 4

Arachidonic acid pathway

• COX-1 and COX2 –> PGD2 and PGE2
• Lipoxygenase

People with AERD have imbalance in pathway and more infiltration of eos and mast cells and more release of leukotrines and imbalance of prostoglandin production

Question 5

Clinic symptoms of AERD

Answer 5

• age 20-50s most common
• long standing rhinitis
• Anosmia is a main feature
• mucosal thickening on CT scans
• sensitivity to asa

Question 6

Type 1 NSAID rxn

Answer 6

induced asthma and rhino sinusitis
most common
non ige mediated
rhinitis with asa

Question 7

Type 2 NSAID reaction

Answer 7

patients with CSU
presents with urticaria and/or angioedema
non ige mediated
occurs with multiple NSAIDs

NB- Type 1-4 all occur with multiple NSAIDs
Type 5 is usually Ibu (single NSAID)
Type 6 is usually ASA

Question 8

Type 3 AERD is what type of reaction

Answer 8

non ige mediated

Question 9

Has Asa anaphylaxis ever been reported?

Answer 9

No

Question 10

Diagnosis of AERD

Answer 10

1. Clinically with history - asthma, nasal polyps, and asa sensitivities

Question 11

Indications for ASA desensitizations

Answer 11

1. Nasal polyps refractory to other therapies bc chronic asa can slow the rate of nasal polyps
2. asa- anti plts therapy in CVS patients
3. NSAIDs are needed for an inflammatory condition (arthritis)

Question 12

Contraindications for ASA desensitization

Answer 12

1. FEV1 < 70% and <1.5 L
2. Acute coronary syndromes?
3. Pregnancy
4. Previous GI bleed?
5. Patient is on a BB?

Question 13

Premed for ASA desensitizations

Answer 13

1. Monteleukast 10 mg for 3 days prior - this will control the LRT symptoms, but they will still have UR sx (runny nose, itchy eyes etc)
2. INCS, and ICS/Laba should be continued
3. AH should be held for a week

Question 14

How long does the ASA challenge take?

Answer 14

Always book 3 hours bc symptoms appear within 30 minutes to 3 hours

Question 15

ASA Challenge steps

Answer 15

1. Starting dose ~40.5 mg of Asa (40, 80, 120, 160)
2. Most protocols go with doubling doses of Asa
3. The dose that provokes symptoms should be repeated after the symptoms are treated
4. Baseline spiro should be conducted at the start and throughout the challenge
5. Tx the symptoms - Nasal decongestant, AH, Epi, Antacids
6. Goal is 325 mg BID or 650 BID

Question 16

ASA Challenge steps

Answer 16

1. Starting dose ~40.5 mg of Asa (40, 80, 120, 160)
2. Most protocols go with doubling doses of Asa
3. The dose that provokes symptoms should be repeated after the symptoms are treated
4. Baseline spiro should be conducted at the start and throughout the challenge
5. Tx the symptoms - Nasal decongestant, AH, Epi, Antacids
6. Goal is 325 mg BID or 650 BID

Question 17

what is the refractory period after asa desensitization?

Answer 17

3-5 days

If so stop your asa for more than 5 days you need to undergo desensitization again

Question 18

Dupilumab MOA

Answer 18

blocks IL4 and IL13 which blocks migrations of Eos to the blood stream/ site of inflammation

Question 19

Dupilumab MOA

Answer 19

blocks IL4 and IL13 which blocks migrations of Eos to the blood stream/ site of inflammation.

Has shown improvement in polyps and asthma

Question 20

What is the most common SE of Dupi?

Answer 20

Conjunctivitis

Question 21

Dupilumab can trigger what condition?

Answer 21

EGPA

Question 22

Pathophysiology of AERD

Answer 22

• mechanism is unclear
• may be related to inhibition of an enzyme COX with subsequent shunting of arachidonic acid metabolism to the lipoxygenase pathway, culminating in a massive leukotriene release