What is the workup and management for a patient with difficult to manage asthma, nasal polyposis, and a history of reactions to ibuprofen (Non-Steroidal Anti-Inflammatory Drug, NSAID)?

From the Guidelines

The management of a patient with difficult-to-manage asthma, nasal polyposis, and NSAID reactions should focus on treating the likely underlying condition of aspirin-exacerbated respiratory disease (AERD), with a comprehensive approach including complete pulmonary function testing, sinus CT scan, and allergy testing to identify triggers, as well as high-dose inhaled corticosteroids, intranasal corticosteroids, and consideration of biological therapies targeting type 2 inflammation, such as dupilumab or omalizumab, as recommended by the most recent practice parameter update 1.

Initial Workup and Diagnosis

The initial workup should include:

• Complete pulmonary function testing to assess asthma severity
• Sinus CT scan to evaluate the extent of nasal polyposis and sinusitis
• Allergy testing to identify potential triggers, although allergy is not a primary cause of nasal polyposis in AERD 1
• Consideration of an oral aspirin challenge to confirm the diagnosis of AERD in cases of diagnostic uncertainty, as suggested by the 2022 practice parameter update 1

Asthma Management

For asthma control, the following should be considered:

• High-dose inhaled corticosteroids, such as fluticasone 500 mcg twice daily
• Combination with a long-acting beta-agonist, like salmeterol
• Addition of a leukotriene modifier, such as montelukast 10 mg daily, for patients with severe disease or those not responding to initial therapy

Nasal Polyposis Management

For nasal polyposis, the following should be considered:

• Intranasal corticosteroids, such as fluticasone 2 sprays each nostril twice daily
• Saline irrigation to reduce nasal congestion and improve sinus drainage
• Short courses of oral prednisone, 40 mg daily for 5-7 days, for severe symptoms or exacerbations

NSAID Avoidance and Aspirin Desensitization

• Complete NSAID avoidance is essential, with acetaminophen as the preferred analgesic alternative
• Aspirin desensitization followed by daily aspirin therapy may be beneficial in select cases, but should only be performed by specialists in a controlled setting, as it can reduce nasal symptoms, frequency of sinus infections, and need for systemic corticosteroids 1

Biological Therapies and Surgery

• Biological therapies targeting type 2 inflammation, such as dupilumab (300 mg subcutaneously every 2 weeks) or omalizumab, should be considered for patients with severe disease
• Endoscopic sinus surgery may be necessary for patients with severe nasal polyposis not responding to medical therapy, although outcomes may be worse in patients with AERD 1

From the FDA Drug Label

Ibuprofen tablets should not be given to patients with the aspirin triad. This symptom complex typically occurs in asthmatic patients who experience rhinitis with or without nasal polyps, or who exhibit severe, potentially fatal bronchospasm after taking aspirin or other NSAIDs [see CONTRAINDICATIONS and PRECAUTIONS, Preexisting Asthma].

The workup and management for a patient with difficult to manage asthma, nasal polyposis, and a history of reactions to ibuprofen (Non-Steroidal Anti-Inflammatory Drug, NSAID) should avoid the use of NSAIDs, including ibuprofen, due to the risk of severe, potentially fatal bronchospasm.

• Key considerations:
  • Avoid NSAIDs in patients with aspirin triad (asthma, rhinitis, and nasal polyps)
  • Consider alternative therapies for pain management
  • Monitor for signs and symptoms of anaphylactoid reactions
  • Preexisting asthma is a contraindication for ibuprofen use 2 2 2

From the Research

Workup for Difficult to Manage Asthma, Nasal Polyposis, and Prior Ibuprofen Reactions

• The patient's history of reactions to ibuprofen, a non-steroidal anti-inflammatory drug (NSAID), suggests a possible diagnosis of Aspirin Exacerbated Respiratory Disease (AERD) 3, 4, 5.
• AERD is characterized by recalcitrant chronic rhinosinusitis (CRS) with recurrent nasal polyps, difficult to treat bronchial asthma, and adverse reactions to NSAID ingestion 3.
• The diagnostic approach to AERD includes a clinical history, physical examination, and diagnostic provocation challenge with NSAIDs, which remains the only way to confirm or exclude the diagnosis of AERD 5.
• The patient's symptoms of difficult to manage asthma and nasal polyposis, along with a history of reactions to ibuprofen, warrant further evaluation for AERD.

Management of AERD

• Treatment modalities for AERD include aspirin desensitization, leukotriene-modifying agents, biologic agents, management of asthma, chronic rhinosinusitis, and nasal polyposis 4.
• Montelukast, a leukotriene receptor antagonist, has been shown to be effective in improving symptoms of nasal polyposis and asthma in patients with AERD 6.
• Zileuton, a leukotriene synthesis inhibitor, is also considered effective in treating AERD, but is often underprescribed 7.
• Dietary modifications, such as a diet high in omega-3 fatty acids and low in omega-6 fatty acids, may also help reduce symptoms of AERD by decreasing the production of inflammatory leukotriene and prostaglandin D₂ lipids 7.

Treatment Options

• Aspirin desensitization is a treatment option for AERD, which involves gradually increasing the dose of aspirin to reduce symptoms and improve quality of life 3, 4.
• Biologic agents, such as those used to treat severe asthma, may also be effective in treating AERD, particularly in patients with severe asthma and nasal polyposis 7.
• Management of asthma, chronic rhinosinusitis, and nasal polyposis is crucial in treating AERD, and may involve the use of topical and systemic corticosteroids, as well as other medications to control symptoms 4.