How to manage Non-Steroidal Anti-Inflammatory Drug (NSAID) induced asthma exacerbations?

Management of NSAID-Induced Asthma Exacerbations

The management of NSAID-induced asthma exacerbations requires immediate discontinuation of the offending NSAID, standard asthma exacerbation treatment, and consideration of aspirin desensitization for long-term management in appropriate candidates.

Pathophysiology and Prevalence

NSAID-induced asthma exacerbations are part of a clinical syndrome known as Aspirin-Exacerbated Respiratory Disease (AERD), characterized by:

• Asthma
• Chronic rhinosinusitis with nasal polyps
• Acute respiratory reactions after intake of NSAIDs (particularly COX-1 inhibitors)
• Eosinophilic airway inflammation exacerbated by NSAIDs

The prevalence of AERD is approximately:

• 0.07% in the general population
• Up to 21% in adults with asthma 1
• Rare in children with asthma 2

Acute Management of NSAID-Induced Asthma Exacerbation

Step 1: Immediate Interventions

• Discontinue the offending NSAID immediately
• Assess exacerbation severity based on symptoms, peak expiratory flow (PEF), and respiratory rate 3
• Administer high-dose inhaled β-agonists:
  • For moderate-severe exacerbations: Salbutamol 5 mg or terbutaline 10 mg via nebulizer with oxygen 1
  • Alternative: Multiple actuations of metered-dose inhaler with spacer (2 puffs 10-20 times) 1

Step 2: Additional Medications

• Administer systemic corticosteroids immediately:
  • Prednisolone 30-60 mg orally or
  • Hydrocortisone 200 mg intravenously 1, 3
• For severe exacerbations, add ipratropium bromide 0.5 mg nebulized 1, 3
• Consider intravenous magnesium sulfate for severe exacerbations not responding to initial treatment 3

Step 3: Monitoring and Assessment

• Measure PEF 15-30 minutes after starting treatment and monitor oxygen saturation continuously 1, 3
• Reassess after initial 3 doses of bronchodilator (60-90 minutes after treatment initiation) 3
• Consider hospital admission if:
  • No response or worsening after initial treatment
  • PEF remains <40% of predicted after treatment
  • Oxygen saturation <90% despite supplemental oxygen
  • Signs of impending respiratory failure 3

Long-Term Management

NSAID Avoidance

• Patients with confirmed AERD should avoid all traditional NSAIDs 1, 4
• Educate patients about checking medication ingredients, including over-the-counter products

Alternative Pain Management Options

• Acetaminophen/paracetamol (with caution at higher doses)
• COX-2 selective inhibitors (e.g., celecoxib) are generally safe alternatives:
  • Studies have shown that celecoxib 200 mg is well-tolerated in patients with NSAID-induced asthma 5
  • COX-2 inhibitors have low cross-reactivity with traditional NSAIDs 1

Aspirin Desensitization

• Consider for patients with:

  • Recurrent nasal polyps requiring multiple surgeries
  • Poorly controlled asthma despite optimal therapy
  • Need for daily aspirin/NSAID therapy for other medical conditions 1

• Desensitization protocol:

  • Must be performed in a controlled setting with experienced physicians and emergency equipment available 2
  • Various protocols exist (see table in 1), typically starting with very low doses (20-40 mg) and gradually increasing
  • Once desensitized, daily aspirin therapy (usually 650 mg twice daily initially) must be maintained 1
  • Missing doses for >48 hours may lead to loss of tolerance; after 5 days, complete redesensitization is required 1

Optimization of Asthma Control

• Leukotriene modifiers (montelukast, zafirlukast) are particularly effective in AERD 2
• Optimize inhaled corticosteroid therapy
• Consider adding long-acting beta-agonists and other controller medications as needed

Special Considerations

Preoperative Management

• Avoid NSAIDs in the preoperative period for patients with asthma, especially those with nasal polyps or recurrent sinusitis 4
• For patients already desensitized to aspirin who require surgery:
  • If surgery can be performed within a 48-hour window of aspirin discontinuation, aspirin can be safely restarted immediately after surgery
  • For longer periods, consider reducing aspirin to 325 mg daily for 7 days prior to surgery, holding it the day before and day of surgery, then restarting immediately postoperatively 1

Common Pitfalls to Avoid

• Failing to recognize NSAID sensitivity in patients with asthma and nasal polyps
• Delaying corticosteroid administration in moderate-severe exacerbations
• Underestimating severity due to poor perception of symptoms by the patient
• Using sedatives, which should be strictly avoided in asthma exacerbations 3
• Discharging patients too early without adequate observation period
• Failing to provide a written asthma action plan that includes NSAID avoidance instructions

By following this structured approach to managing NSAID-induced asthma exacerbations, clinicians can effectively treat acute episodes and implement strategies to prevent future exacerbations.