How common is aspirin (acetylsalicylic acid) allergy in patients with nasal polyps and severe asthma?

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Prevalence of Aspirin Hypersensitivity in Patients with Nasal Polyps and Severe Asthma

Aspirin (ASA) hypersensitivity occurs in approximately 7% of all adults with asthma, but this rate doubles to 15% in patients with severe asthma, and reaches 10% in patients with nasal polyps and chronic rhinosinusitis. 1, 2

Prevalence by Clinical Phenotype

The likelihood of aspirin-exacerbated respiratory disease (AERD) varies substantially based on the underlying respiratory disease severity and phenotype:

  • General adult asthma population: 7.15% (95% CI, 5.26%–9.03%) have confirmed AERD 2
  • Severe asthma: 14.89% (95% CI, 6.48%–23.29%)—more than double the rate in typical asthma 2
  • Nasal polyps with chronic rhinosinusitis: 9.69% (95% CI, 2.16%–17.22%) 2
  • Cross-reactive respiratory reactions: Up to 21% of adults with asthma experience respiratory hypersensitivity to COX-1 inhibiting NSAIDs, particularly those with comorbid nasal polyps or recurrent sinusitis 3

Diagnostic Certainty and Clinical History

The diagnosis of AERD can be established with high confidence based on clinical history alone in most cases:

  • Patients with a typical history (asthma, nasal polyps, and a single documented respiratory reaction to aspirin or NSAIDs) have an 80% probability of a positive aspirin challenge 1
  • Patients with multiple reactions to structurally dissimilar NSAIDs (e.g., ibuprofen and aspirin) have an even higher positive challenge rate 4
  • Patients with severe reactions requiring hospitalization or ICU-level monitoring have a 100% positive challenge rate 4

When Formal Challenge Testing Is Unnecessary

Aspirin challenge to confirm the diagnosis is not required or recommended in the following scenarios: 4

  • History of ≥2 respiratory reactions to different NSAIDs
  • Any respiratory reaction requiring hospitalization
  • Clear history of aspirin causing a severe reaction with objective findings

Subclinical Sensitivity Is Rare

In patients with nasal polyps and asthma who lack a suggestive clinical history, subclinical aspirin sensitivity is uncommon. 5

  • Only 4 of 63 subjects (6.3%) without known aspirin sensitivity demonstrated a positive response to lysine aspirin challenge, including just 2 of 15 patients (13.3%) with both nasal polyps and asthma 5
  • There is no evidence of general subclinical sensitivity to aspirin in subjects with nasal polyps who lack a relevant clinical history 5

Pathophysiology: Not a True Allergy

AERD is not an IgE-mediated allergy but rather a pseudoallergic reaction related to COX-1 inhibition: 1

  • COX-1 inhibition diverts arachidonic acid metabolism toward the leukotriene pathway, resulting in overproduction of cysteinyl leukotrienes 1
  • This mechanism explains the universal cross-reactivity with all COX-1 inhibiting NSAIDs 4
  • Selective COX-2 inhibitors are generally safe, with only 8–11% cross-reactivity rates 3

Clinical Implications for Severe Asthma

Early identification of AERD is critical in patients with severe asthma because: 2

  • AERD is associated with increased morbidity and healthcare costs related to asthma exacerbations 2
  • Patients with AERD typically have severe, difficult-to-control asthma and refractory nasal polyposis 1
  • Aspirin desensitization followed by daily maintenance therapy is an important therapeutic option that improves both upper and lower respiratory tract disease 4, 1

Common Pitfalls to Avoid

  • Do not assume absence of AERD based solely on lack of known aspirin exposure—many patients with the classic triad (asthma, nasal polyps, chronic rhinosinusitis) avoid NSAIDs and remain undiagnosed 4
  • Do not perform unnecessary challenge testing in patients with clear histories of multiple NSAID reactions or severe reactions requiring hospitalization 4
  • Do not confuse the 7% prevalence in general asthma with the 15% prevalence in severe asthma—your index of suspicion should be much higher in patients with poorly controlled disease 2

References

1
Guideline

Aspirin-Exacerbated Respiratory Disease (AERD)

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

3
Guideline

NSAID Hypersensitivity Patterns and Management

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

4
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

5
Research

Subclinical aspirin sensitivity in subjects with nasal polyposis.

Clinical otolaryngology and allied sciences, 2003

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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