What is the management for a 40-year-old female with poorly controlled bronchial asthma and allergic rhinitis, taking aspirin and ibuprofen daily for migraines, with nasal polyps and chest wheezing despite using inhaled steroids and oral steroids?

Management of Aspirin-Exacerbated Respiratory Disease (AERD)

The first-line management for this patient is to discontinue aspirin and ibuprofen immediately, as this represents a classic case of Aspirin-Exacerbated Respiratory Disease (AERD) with the triad of asthma, nasal polyps, and NSAID sensitivity.

Diagnosis: Aspirin-Exacerbated Respiratory Disease

This 40-year-old female presents with:

• Poorly controlled bronchial asthma despite inhaled and oral steroids
• Allergic rhinitis
• Nasal polyps
• Daily aspirin and ibuprofen use for migraines
• Wheezing on examination

These features constitute the classic triad of AERD (also known as Samter's triad):

1. Bronchial asthma
2. Nasal polyps
3. Aspirin/NSAID sensitivity

Management Algorithm

1. Immediate Interventions

• Discontinue aspirin and ibuprofen immediately 1
  • NSAIDs inhibit COX-1 and shunt arachidonic acid down the leukotriene pathway, worsening respiratory symptoms in these patients
  • The prevalence of aspirin-exacerbated respiratory disease is as high as 21% in adults with asthma 1

2. Pharmacological Management

• Add montelukast (leukotriene receptor antagonist) 2

  • Montelukast has demonstrated significant improvement in parameters of asthma control in aspirin-sensitive patients 2
  • The magnitude of effect in aspirin-sensitive patients is similar to that observed in the general asthma population 2

• Optimize inhaled corticosteroid therapy 1, 3

  • Increase to medium-high dose if currently on low dose
  • Consider adding long-acting β-agonist if not already included

3. Diagnostic Evaluation

• Order IgE and serum eosinophils to assess inflammatory profile and rule out other conditions 1
  • Elevated eosinophils are common in AERD and can help confirm diagnosis
  • IgE levels help differentiate between allergic and non-allergic mechanisms

4. Additional Management Steps

• Refer to ENT for evaluation of nasal polyps 1

  • Upper airway involvement is predominant in the pathogenetic process of AERD
  • May require surgical intervention (polypectomy) for severe cases

• Consider aspirin desensitization for long-term management 4, 5

  • Only after stabilization of asthma symptoms
  • Must be performed under specialist supervision
  • Can improve long-term outcomes in selected patients

• Provide alternative migraine management options

  • Acetaminophen/paracetamol (generally better tolerated)
  • Triptans
  • Preventive medications (beta-blockers, anticonvulsants, etc.)

Monitoring and Follow-up

• Reassess asthma control in 2-6 weeks after medication changes 3
• Monitor for improvement in symptoms after NSAID discontinuation
• Follow criteria for well-controlled asthma: symptoms ≤2 days/week, nighttime awakenings ≤2 times/month, no activity limitations 3

Important Considerations and Pitfalls

1. Do not confuse with routine asthma exacerbation

   • The presence of nasal polyps and NSAID use is pathognomonic for AERD

2. Avoid CT chest as initial management

   • While imaging may be helpful later, addressing the NSAID trigger is the priority

3. Upper laryngoscopy alone is insufficient

   • While helpful for evaluating nasal polyps, it doesn't address the underlying mechanism

4. Beware of cross-reactivity

   • Patients with AERD typically react to all COX-1 inhibitors, not just aspirin
   • COX-2 inhibitors may be better tolerated but should be used with caution

5. Watch for systemic eosinophilia

   • Rarely, patients on montelukast may present with systemic eosinophilia, sometimes with features of Churg-Strauss syndrome 2

By following this management approach, most patients with AERD can achieve significant improvement in their asthma control and quality of life.