Management of Respiratory Symptoms Induced by Non-Steroidal Anti-Inflammatory Drugs

Opinion Statement

Non-steroidal anti-inflammatory drugs (NSAIDs)-exacerbated respiratory disease (NERD) is defined by the combination of chronic rhinosinusitis, nasal polyps, bronchial asthma, and hypersensitivity reactions involving upper and/or lower airways after the exposure to acetylsalicylic acid (ASA) and other NSAIDs. However, airway inflammation occurs even in the absence of exposure to these drugs, leading to disease progression with aggressive polyp formation and non-optimal controlled asthma and rhinosinusitis. In this review, we discuss current and potential management strategies of NERD. This management should be multidisciplinary and comprise medical and surgical treatment of the underlying diseases. In order to prevent reactions due to NSAIDs, avoidance of COX-1 inhibitors with provision of safe therapeutic alternatives should be indicated. However, avoidance of NSAIDs does not ensure disappearance of the airway inflammation and this progresses and persists for life. ASA desensitization followed by daily ASA therapy remains the gold standard of NERD treatment. It is indicated in patients with uncontrolled bronchial and nasal symptoms as well as in patients who require NSAID treatment for specific diseases, such as rheumatic or cardiovascular conditions. ASA desensitization improves upper and lower respiratory symptoms, reduces the need for new nasal surgeries and increases quality of life. Different ASA desensitization protocols have been reported, although the addition of intranasal ketorolac and lysine aspirin prior to an oral ASA schedule has made ASA desensitization safer and more efficient. New therapeutic strategies are being investigated and may provide an alternative treatment for those patients in which ASA desensitization are contraindicated or continuous ASA therapy is discontinued because of adverse effects. Among them, biologic agents are an important treatment option, useful for controlling symptoms of the upper and lower airways. More investigation studies into the mechanisms involved in NERD are needed in order to identify additional therapeutic targets.

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