From the Guidelines
Samter's triad, also known as aspirin-exacerbated respiratory disease (AERD), is a medical condition characterized by three key features: chronic rhinosinusitis with nasal polyps, asthma, and hypersensitivity to aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs). This condition typically develops in adulthood, often in the third or fourth decade of life, and affects approximately 7% of adults with asthma, as reported in a 2022 practice parameter update 1. The underlying mechanism involves an abnormality in the arachidonic acid metabolism pathway, specifically with the cyclooxygenase-1 (COX-1) enzyme. When patients with AERD take aspirin or NSAIDs, these medications inhibit COX-1, leading to increased production of inflammatory leukotrienes and decreased production of protective prostaglandins, triggering respiratory symptoms.
Some key features of AERD include:
- Chronic rhinosinusitis with nasal polyps
- Asthma
- Hypersensitivity to aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) Patients typically experience worsening nasal congestion, rhinorrhea, wheezing, chest tightness, and sometimes severe asthma attacks within minutes to hours after taking these medications. Management includes strict avoidance of aspirin and NSAIDs, use of alternative pain relievers like acetaminophen, treatment of underlying asthma and rhinosinusitis, and in some cases, aspirin desensitization therapy under medical supervision, as suggested in a 2022 practice parameter update 1. Leukotriene modifiers such as montelukast may be particularly helpful in these patients due to the role of leukotrienes in the disease process.
Aspirin desensitization is a form of pharmacologic induction of drug tolerance, which can be used to diagnose AERD when there is diagnostic uncertainty, and to place a patient on a daily therapeutic aspirin dose for cardioprotection, pain relief, or to control nasal polyp regrowth, as stated in a consensus-based statement 1. The procedure typically starts with milligram amounts and is performed over hours to days. The most common indication for aspirin desensitization in the United States is poorly controlled airway disease despite use of appropriate medications for patients who require long-term treatment with systemic corticosteroids to control their upper and lower respiratory disease.
From the Research
Definition of Samter's Triad
Samter's Triad, also known as aspirin-exacerbated respiratory disease (AERD), is a condition characterized by the presence of three main features:
Epidemiology
The condition affects approximately 0.3-0.9% of the general population in the USA and approximately 7% of asthmatic patients 4. It is more common in adults, but cases have been reported in children as well 5.
Pathophysiology
The condition is related to the abnormal metabolism of arachidonic acid, implicating both the lipoxygenase and the cyclooxygenase pathways 2. The exact mechanisms are not fully understood, but research has focused on new strategies of aspirin desensitization therapy, especially oral administration using high-dosage protocols 2, 3.
Diagnosis and Management
Diagnosis is typically made through a combination of medical history, physical examination, and aspirin provocation testing 4. Management is challenging and often requires a multimodality approach, including medical and surgical treatments 4. Aspirin desensitization therapy has demonstrated therapeutic effects and is a common treatment option 6, 2, 3, 4. Surgical approaches, including advanced endoscopic techniques, may also be necessary in some cases 4.