Personalized management of aspirin-exacerbated respiratory disease: From clinical presentation to therapeutic strategies

Aspirin-exacerbated respiratory disease (AERD), defined as the triad of asthma, chronic rhinosinusitis with nasal polyps (CRSwNP), and development of upper- and/or lower-respiratory symptoms after exposure to aspirin or other cyclooxygenase-1 inhibitors, has a prevalence of up to 30% for adults with asthma and with CRSwNP. The pathogenesis is likely due to a combination of abnormal genetic variants and environmental exposures, which results in types 1, 2, and/or 3 inflammation and dysregulation of arachidonic acid metabolism. Patients with AERD often fail to respond to conservative medical treatment, including all topical corticosteroids, antileukotrienes, and saline solution irrigation; furthermore, short courses of SCS generally provide only temporary improvement. Advanced therapeutic options include endoscopic sinus surgery; aspirin treatment after aspirin desensitization; and biologics, e.g., dupilumab, omalizumab, and mepolizumab. A successful and long-lasting clinical response often requires combination or sequential treatments with more than one of these therapeutic approaches. After a review of the efficacy, safety, and logistical considerations of each of these therapeutic options, an algorithmic approach for patient management is presented.