RESUMEN
Aspirin-exacerbated respiratory disease is a chronic and treatment-resistant disease, characterized by the presence of eosinophilic rhinosinusitis, nasal polyposis, bronchial asthma, and nonsteroidal anti-inflammatory drugs hypersensitivity. Alterations in arachidonic acid metabolism may induce an imbalance between pro-inflammatory and anti-inflammatory substances, expressed as an overproduction of cysteinyl leukotrienes and an underproduction of prostaglandin E2. Although eosinophils play a key role, recent studies have shown the importance of other cells and molecules in the development of the disease like mast cells, basophils, lymphocytes, platelets, neutrophils, macrophages, epithelial respiratory cells, IL-33 and thymic stromal lymphopoietin, making each of them promissory diagnostic and treatment targets. In this review, we summarize the most important clinical aspects of the disease, including the current topics about diagnosis and treatment, like provocation challenges and aspirin desensitization. We also discuss recent findings in the pathogenesis of the disease, as well as future trends in diagnosis and treatment, including monoclonal antibodies and a low salicylate diet as a treatment option.
Asunto(s)
Antiinflamatorios no Esteroideos/efectos adversos , Aspirina/efectos adversos , Asma Inducida por Aspirina/inmunología , Asma/inducido químicamente , Pólipos Nasales/inducido químicamente , Enfermedades Respiratorias/inducido químicamente , Rinitis/inducido químicamente , Sinusitis/inducido químicamente , Adulto , Anticuerpos Monoclonales/uso terapéutico , Ácido Araquidónico/metabolismo , Asma/terapia , Asma Inducida por Aspirina/diagnóstico , Asma Inducida por Aspirina/epidemiología , Asma Inducida por Aspirina/terapia , Cisteína/metabolismo , Citocinas/metabolismo , Desensibilización Inmunológica/métodos , Dinoprostona/metabolismo , Progresión de la Enfermedad , Síndrome de Hipersensibilidad a Medicamentos , Eosinófilos/metabolismo , Femenino , Humanos , Leucotrienos/metabolismo , Masculino , Mastocitos/metabolismo , Pólipos Nasales/terapia , Enfermedades Respiratorias/diagnóstico , Enfermedades Respiratorias/epidemiología , Enfermedades Respiratorias/terapia , Rinitis/terapia , Sinusitis/terapia , Linfopoyetina del Estroma TímicoRESUMEN
ABSTRACT INTRODUCTION: Aspirin-exacerbated respiratory disease (AERD) consists of a classic tetrad: moderate/severe asthma, chronic rhinosinusitis, nasal polyps, and intolerance to aspirin or other nonsteroidal anti-inflammatory drugs. Clinical control with drugs, surgery, and desensitization are treatment options. OBJECTIVE: To evaluate the efficacy and tolerability of aspirin desensitization in patients with AERD. METHODS: Periodic symptom assessment and endoscopy in patients with AERD undergoing surgery who were desensitized. RESULTS: Seventeen patients were desensitized. Eight patients completed the desensitization and were followed for a minimum of a one-year period (mean 3.1 years). These patients showed improvement in all symptoms. Moreover, surgical reassessment was not indicated in any of these patients and there was a decrease in costs with medication and procedures. Eight patients did not complete desensitization, mainly due to procedure intolerance and uncontrolled asthma, whereas another patient was lost to follow-up. CONCLUSION: Aspirin desensitization, when tolerated, was effective in patients with AERD and with poor clinical/surgical response.
Resumo Introdução: A doença respiratória exacerbada por aspirina é composta pela tétrade clássica: asma moderada/grave, rinossinusite crônica, pólipos nasais e intolerância à aspirina ou outro anti-inflamatório não esteroide. Controle clínico com medicamentos, cirurgias e dessensibilização são opções de tratamento. Objetivo: Avaliar a eficácia e tolerabilidade da dessensibilização à aspirina em pacientes com doença exacerbada por aspirina. Método: Avaliação periódica dos sintomas e exame endoscópico em pacientes com doença respiratória exacerbada por aspirina submetidos à cirurgia e dessensibilizados. Resultados: Dezessete pacientes foram dessensibilizados, dos quais oito pacientes completaram a dessensibilização e foram acompanhados pelo tempo mínimo de 1 ano (média de 3,1 anos). Todos referiram melhora de todos os sintomas; não houve nenhuma indicação de reabordagem cirúrgica, e houve redução de gastos com medicações e procedimentos. Outros oito pacientes não completaram a dessensibilização, principalmente por intolerância ao procedimento e descontrole da asma, enquanto outro paciente perdeu o seguimento. Conclusão: A dessensibilização à aspirina, quando tolerada, mostrou-se eficaz nos pacientes com doença respiratória exacerbada por aspirina com resposta clínica/cirúrgica insatisfatória.
Asunto(s)
Humanos , Masculino , Femenino , Adulto , Persona de Mediana Edad , Sinusitis/terapia , Rinitis/terapia , Antiinflamatorios no Esteroideos/administración & dosificación , Aspirina/administración & dosificación , Pólipos Nasales/terapia , Desensibilización Inmunológica , Asma Inducida por Aspirina/terapia , Sinusitis/inducido químicamente , Sinusitis/inmunología , Rinitis/inducido químicamente , Rinitis/inmunología , Antiinflamatorios no Esteroideos/efectos adversos , Antiinflamatorios no Esteroideos/inmunología , Aspirina/efectos adversos , Aspirina/inmunología , Pólipos Nasales/inducido químicamente , Pólipos Nasales/inmunología , Enfermedad Crónica , Resultado del Tratamiento , Asma Inducida por Aspirina/inmunologíaRESUMEN
INTRODUCTION: Aspirin-exacerbated respiratory disease (AERD) consists of a classic tetrad: moderate/severe asthma, chronic rhinosinusitis, nasal polyps, and intolerance to aspirin or other nonsteroidal anti-inflammatory drugs. Clinical control with drugs, surgery, and desensitization are treatment options. OBJECTIVE: To evaluate the efficacy and tolerability of aspirin desensitization in patients with AERD. METHODS: Periodic symptom assessment and endoscopy in patients with AERD undergoing surgery who were desensitized. RESULTS: Seventeen patients were desensitized. Eight patients completed the desensitization and were followed for a minimum of a one-year period (mean 3.1 years). These patients showed improvement in all symptoms. Moreover, surgical reassessment was not indicated in any of these patients and there was a decrease in costs with medication and procedures. Eight patients did not complete desensitization, mainly due to procedure intolerance and uncontrolled asthma, whereas another patient was lost to follow-up. CONCLUSION: Aspirin desensitization, when tolerated, was effective in patients with AERD and with poor clinical/surgical response.
Asunto(s)
Antiinflamatorios no Esteroideos/administración & dosificación , Aspirina/administración & dosificación , Asma Inducida por Aspirina/terapia , Desensibilización Inmunológica , Pólipos Nasales/terapia , Rinitis/terapia , Sinusitis/terapia , Adulto , Antiinflamatorios no Esteroideos/efectos adversos , Antiinflamatorios no Esteroideos/inmunología , Aspirina/efectos adversos , Aspirina/inmunología , Asma Inducida por Aspirina/inmunología , Enfermedad Crónica , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pólipos Nasales/inducido químicamente , Pólipos Nasales/inmunología , Rinitis/inducido químicamente , Rinitis/inmunología , Sinusitis/inducido químicamente , Sinusitis/inmunología , Resultado del TratamientoRESUMEN
La tríada de la aspirina, caracterizada por intolerancia a la aspirina, asma bronquial y poliposis nasal, fue descrita inicialmente por Widal en 1922. La prevalencia de intolerancia a la aspirina en la población general es de aproximadamente 6 por ciento, pero estudios han revelado que hasta 78 por ciento de los pacientes con poliposis nasal padecen la triada. La presentación clínica consiste en un patrón característico evolutivo de la aparición de los síntomas, presentándose en primer lugar rinitis, luego poliposis nasal, asma bronquial y finalmente IA. Si bien es sabido que esta patología corresponde a una pseudoalergia, donde ocurre una degranulación inespecífica de los mastocitos, los mecanismos fisiopatológicos que gatillan esta degranulación no están totalmente dilucidados, siendo la hipótesis más aceptada actualmente aquella que guarda relación con las modificaciones en el metabolismo del ácido araquidónico causadas por la aspirina. Actualmente no existen exámenes de laboratorio para la confirmación diagnóstica de intolerancia a la aspirina, por lo que frente a la sospecha clínica de esta patología debe someterse al paciente a pruebas de provocación para hacer el diagnóstico certero de esta enfermedad, siendo la más utilizada la prueba de provocación con aspirina oral.
The aspirin triad, characterized by aspirin intolerance, bronchial asthma and nasal polyposis was first described by Widal in 1922. Prevalence of aspirin intolerance in the general population is near 6 percent, but studies have shown that 78 percent of the patients with nasal polyps suffer from the triad. Clinical presentation consists of a characteristic evolutive pattern, with rhinitis appearing first, then nasal polyps, bronchial asthma and finally aspirin intolerance. Even though it is well known that this pathology corresponds to pseudoallergy where unspecific mast cell degranulation occurs, the physiopathologic mechanisms that trigger this degranulation are not completely understood. The most accepted hypothesis involves aspirin-induced modifications in the metabolism of arachidonic acid. Currently there are no in vitro tests available for aspirin intolerance diagnosis, so if this pathology is suspected, a provocation test with aspirin is necessary to confirm the diagnosis, oral provocation test being the most frequently used in clinical practice.