Aspirin Desensitization in NERD in the Era of Biologics: First or Last Resource?

• Published in: Current treatment options in allergy 2022-06, Vol.9 (2), p.91-106
• Main Authors: Bobolea, Irina, Picado, César
• Format: Article
• Language: English
• Subjects: Allergology; Aspirin; Asthma; Cytokines; Disease; Family Medicine; General Practice; Immunoglobulin E; Immunological tolerance; Inflammation; Interleukin 5; Leukocytes; Leukocytes (eosinophilic); Leukotrienes; Medicine; Medicine & Public Health; Metabolism; Monoclonal antibodies; Nonsteroidal anti-inflammatory drugs; Olfaction disorders; Pathogenesis; Patients; Polyps; Precision Medicine and Allergy Treatments (J Maspero; Prostaglandin D2; Public health; Respiratory diseases; Rhinosinusitis; Section Editor; Steroids; Topical Collection on Precision Medicine and Allergy Treatments
• ISSN: 2196-3053; 2196-3053
• DOI: 10.1007/s40521-022-00300-x

Purpose of the Review The classic treatment of non-steroidal anti-inflammatory drug (NSAID) exacerbated respiratory disease (NERD) includes aspirin desensitization (AD). Introduction of biologics in the treatment of asthma and chronic rhinosinusitis with nasal polyps (CRSwNP) has raised the question: which of the two options may be the most suitable for NERD? Recent Findings NERD is a highly eosinophilic disease. Monoclonal antibodies targeting IL-5 or the IL-5 receptor, involved in eosinophil recruitment, have been shown to be effective in asthma and CRSwNP. However, no difference in clinical efficacy was observed between NERD and aspirin-tolerant patients. Dupilumab, an IL-4 alpha receptor antagonist, demonstrated greater efficacy in NERD than in aspirin-tolerant patients for some clinical symptoms in a sub-analysis. Patients with NERD respond very rapidly to omalizumab with improvement in asthma and CRSwNP symptoms associated with reductions in prostaglandin D2 and cysteinyl leukotrienes release. Furthermore, omalizumab and dupilumab partially or totally restored tolerance to aspirin in NERD patients. Summary The decision to treat a NERD patient with AD or a biologic depends on many variables, such as differences between countries in the use of AD treatment in specialized units, limitations in accessing very expensive treatment in low-income countries and in countries where insurance systems do not cover or partially cover the cost of treatment. Patients who live in countries with public health systems that fully fund biologic treatments are more likely to benefit from biologic treatment. The limited data available so far suggest that, among current biologics, dupilumab ranks best for the treatment of CRSwNP associated with NERD.