Is a 160 mg aspirin loading dose safe for a 60‑year‑old man with asthma who has no known aspirin‑exacerbated respiratory disease or NSAID hypersensitivity?

Is 160 mg Aspirin Safe for an Asthmatic Patient?

Yes, a 160 mg aspirin loading dose is safe for most asthmatic patients who have no known history of aspirin-exacerbated respiratory disease (AERD), nasal polyposis, or prior respiratory reactions to NSAIDs. 1

Key Clinical Decision Points

Identify High-Risk Features for AERD

Before administering aspirin to any asthmatic patient, assess for the following clinical features that suggest AERD 1:

• Chronic rhinosinusitis with nasal polyposis (present in approximately one-third of asthmatics with AERD)
• History of respiratory reactions (bronchospasm, wheezing, rhinorrhea) after taking aspirin or any NSAID
• Anosmia (loss of smell)
• Adult-onset asthma (typically developing in the third or fourth decade)
• Refractory rhinosinusitis requiring multiple sinus surgeries
• Frequent systemic corticosteroid use for asthma or sinus disease control

If none of these features are present, aspirin can be administered safely. 1

Understanding the Risk Profile

The prevalence of NSAID hypersensitivity is only approximately 2% in the general population, and AERD affects only about 7% of adults with asthma 1, 2. Asthma alone is NOT a contraindication to aspirin use 1. The FDA label warning that "aspirin may occasionally trigger bronchospasm in asthmatic patients" refers specifically to the AERD phenotype, not all asthmatics 3.

For Cardiovascular Emergencies (ACS/STEMI)

In acute coronary syndrome settings, the 2025 ACC/AHA/SCAI guidelines and 2008 ESC guidelines recommend 1:

• Loading dose: 162-325 mg orally (chewable, non-enteric coated for faster onset)
• Alternative: 250-500 mg IV if oral administration is not possible
• Maintenance: 75-100 mg daily thereafter

The cardiovascular mortality benefit of aspirin in ACS substantially outweighs the small risk of bronchospasm in patients without AERD. 1

If AERD Features Are Present

If the patient has nasal polyposis, chronic rhinosinusitis, and asthma (the classic triad), aspirin administration requires a different approach 1:

• Do NOT give aspirin directly without desensitization if AERD is suspected
• For cardiovascular emergencies, perform rapid aspirin desensitization using a graded challenge protocol starting at 40.5 mg, followed by another 40.5 mg dose 90 minutes later 1
• Alternative: Use a selective COX-2 inhibitor (celecoxib), which is extremely safe in AERD patients and rarely causes reactions 1

Common Pitfalls to Avoid

Do not rely solely on prior aspirin tolerance to rule out AERD. 4 One case report documented a 58-year-old man with late-onset asthma who had previously taken aspirin safely but later developed confirmed AERD with a serious adverse outcome after inadvertent aspirin challenge. AERD can develop over time even in patients who previously tolerated aspirin 2, 4.

Do not confuse general asthma with AERD. The vast majority of asthmatics (93%) do NOT have aspirin hypersensitivity 1. The presence of asthma alone should not prevent aspirin administration for appropriate cardiovascular indications 1.

Monitoring After Administration

If aspirin is given to an asthmatic patient without known AERD 1:

• Observe for 90 minutes after the loading dose for signs of respiratory reaction (wheezing, increased work of breathing, rhinorrhea)
• Have bronchodilators readily available (albuterol nebulizer 2.5-5 mg)
• Epinephrine 0.3-0.5 mg IM should be immediately accessible for severe bronchospasm or anaphylaxis

Special Consideration: If Desensitization Is Needed

For patients with confirmed or highly suspected AERD who require aspirin for cardiovascular protection, formal aspirin desensitization can be performed 1:

• Starting dose: 40.5 mg, escalating every 90 minutes
• Target maintenance: 81-325 mg daily to maintain desensitized state
• Tolerance is lost if aspirin is discontinued for >48 hours 1
• Once desensitized, all COX-1 inhibiting NSAIDs can be tolerated 1

Bottom Line Algorithm

1. No nasal polyps + no prior NSAID respiratory reactions → Give aspirin 160 mg safely 1
2. Nasal polyps + chronic rhinosinusitis + asthma → Suspect AERD; use graded challenge or COX-2 inhibitor 1
3. Prior respiratory reaction to any NSAID → Confirm AERD diagnosis; perform desensitization if aspirin is essential 1
4. Cardiovascular emergency with suspected AERD → Rapid graded challenge protocol (40.5 mg × 2 doses) 1