Is aspirin desensitization therapy of proven value?

From the Guidelines

Aspirin desensitization therapy is of proven value for specific patients, particularly those with aspirin-exacerbated respiratory disease (AERD) or aspirin-sensitive asthma, as it can improve respiratory symptoms, reduce nasal polyp recurrence, and decrease dependence on corticosteroids 1. The therapy involves gradually introducing increasing doses of aspirin under medical supervision until a patient can tolerate therapeutic doses without adverse reactions. A typical protocol starts with very low doses (often 20-40 mg) and incrementally increases to 325-650 mg twice daily over 1-3 days in a controlled setting, followed by daily maintenance therapy. Some key points to consider when evaluating the effectiveness of aspirin desensitization therapy include:

• The benefits of aspirin desensitization are moderate and are balanced by the risk of adverse effects that can lead to discontinuation 1.
• Conditions that may be important during shared decision making include risks that impact the safety of performing an aspirin desensitization, such as severe poorly controlled asthma, and risks that impact the safety of long-term aspirin use, such as conditions or treatments that increase bleeding risk 1.
• Aspirin desensitization has been shown to be cost-effective, with a cost of $6768 per quality-adjusted life-year for AERD patients 1.
• The mechanism of aspirin desensitization involves downregulation of cysteinyl leukotriene receptors and decreased production of leukotrienes, which are inflammatory mediators responsible for hypersensitivity reactions 1.
• Patients should be aware that the procedure carries risks of severe reactions, including bronchospasm and anaphylaxis, so it must be performed in facilities equipped to handle emergencies, typically by allergists or immunologists with experience in drug desensitization 1. Some of the key benefits of aspirin desensitization therapy include:
• Improvement in respiratory symptoms, such as reduction in sinusitis and frequency of short courses of prednisone 1.
• Reduction in nasal polyp recurrence and improvement in sense of smell 1.
• Decrease in dependence on corticosteroids 1.
• Cost-effectiveness, with a cost of $6768 per quality-adjusted life-year for AERD patients 1. However, it is essential to weigh these benefits against the potential risks and consider individual patient factors, such as the severity of asthma and the risk of bleeding, when deciding whether to pursue aspirin desensitization therapy 1.

From the Research

Aspirin Desensitization Therapy Value

• Aspirin desensitization is a treatment option for aspirin-exacerbated respiratory disease (AERD) that has shown to improve quality of life and reduce respiratory symptoms 2, 3.
• The therapy involves desensitizing patients to aspirin, allowing them to take the medication without experiencing adverse reactions, and has been found to be effective in reducing symptoms of rhinosinusitis and improving quality of life 2, 4.
• Studies have reported that aspirin desensitization can be done safely and efficiently in an outpatient setting, with most patients experiencing symptoms during the procedure, but these can be managed with appropriate medical care 4.

Benefits and Harms

• Aspirin desensitization has been found to improve quality of life and reduce respiratory symptoms in patients with AERD, with moderate-certainty and high-certainty evidence supporting its effectiveness 2.
• However, the therapy also increases the risk of adverse events, such as major bleeding, gastritis, asthma exacerbation, and rash, which can be severe enough to cause treatment discontinuation 2, 5.
• The benefits and harms of aspirin desensitization should be carefully considered, and patients should be selected and monitored appropriately to minimize the risks associated with the therapy 5, 3.

Clinical Applications

• Aspirin desensitization is recommended for patients with AERD who have suboptimally controlled asthma or rhinosinusitis, or require multiple revision polypectomies 5, 3.
• The therapy may also be beneficial for patients with coronary artery disease (CAD) who have a history of hypersensitivity reactions to aspirin, as it can reduce morbidity and mortality associated with CAD 5.
• Aspirin desensitization protocols and procedures should be standardized and optimized to ensure safe and effective treatment, and further research is needed to fully understand the mechanisms and benefits of this therapy 3, 6.