Benefits and harms of aspirin desensitization for aspirin‐exacerbated respiratory disease: a systematic review and meta‐analysis

Abstract

Background: Aspirin desensitization is increasingly recommended for the treatment of aspirin-exacerbated respiratory disease (AERD). The objective of this study is to systematically review the efficacy and safety of aspirin desensitization in patients with AERD. Methods:We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and World Health Organization (WHO) International Clinical Trials Registry Platform from inception to January 5, 2019. We included randomized trials and comparative observational studies in any language. Data extraction and risk of bias assessment were performed in duplicate independently. Results: Five randomized controlled trials (RCTs) enrolled 233 patients with AERD. Compared to placebo, aspirin desensitization (mean daily dose 800 mg) improved quality of life (risk ratio [RR] 2.00; 95% confidence interval [CI], 1.31 to 3.06; heterogeneity measure [I 2 ] = 0%; risk difference [RD] +24%; 22-item Sino-Nasal Outcome Test [SNOT-22] scale [0 to 110, higher worse]; mean difference [MD] −10.27 [95% CI, −6.39 to −14.15]; moderate-certainty); and respiratory symptoms (RR 2.20 [95% CI, 1.55 to 2.73], I 2 = 34%, RD +36%; American Academy of Otolaryngology (AAO) scale [0 to 20, higher worse]; MD −2.56 [95% CI,−1.12 to −3.92]; high-certainty). Aspirin desensitization increasedadverse events severe enough to cause treatment discontinuation (major bleeding, gastritis, asthma exacerbation, or rash causing drug discontinuation, RR 4.39 [95% CI, 1.43 to 13.50], I 2 = 0%, RD +11%, moderate-certainty), and gastritis (RR 3.84 [95% CI, 1.12 to 13.19], I 2 = 0%, RD +9%, lowcertainty). Findings were robust to sensitivity analyses. Two available observational studies were not informative because they lacked adjustment for confounders and/or contemporaneous controls. Conclusion:In patients with AERD, moderate-certainty and high-certainty evidence shows that aspirin desensitization meaningfully reduces symptoms of rhinosinusitis and improves quality of life, but results in a significant increase in adverse events. C 2019 ARS-AAOA, LLC.

Guidance for contemporary use of biologics in management of chronic rhinosinusitis with nasal polyps: discussion from a National Institutes of Health–sponsored workshop

“…Other work has identified that within 5 years of their initial surgery, over 35% of AERD patients will require a second surgical intervention 23 . Aspirin desensitization and daily aspirin maintenance therapy has been shown to improve symptoms, endoscopy, and quality of life, and revision FESS rates as low as 9% have been reported 23‐26 . Current expert panel guidelines state that aspirin desensitization with daily aspirin maintenance therapy is indicated for recurrent polyps after surgery, severe asthma, and sinus symptoms despite standard therapy, or a need for aspirin therapy due to cardiac disease or stroke 27 .…”

“…Likely there is a lack of accessibility and/or adoption of this treatment in some practices, 28 or patients and physicians decide against maintenance therapy due to risks of gastrointestinal complications or challenges with convenience of this daily treatment. Additionally, most studies regarding aspirin maintenance have had relatively short follow‐up and some patients do not respond to aspirin desensitization 24,29 …”

Surgical outcomes in aspirin‐exacerbated respiratory disease without aspirin desensitization

“…To manage this challenging disease, aspirin desensitization (AD) has emerged as an adjunctive therapy. AD was shown to improve sinonasal symptoms, quality of life, and reduce the recurrence of nasal polyps after surgery 4‐7 . Although AD provides meaningful clinical improvement, the benefits are counterbalanced by relatively high rates of adverse effects and subsequent discontinuation of therapy 7 .…”

“…AD was shown to improve sinonasal symptoms, quality of life, and reduce the recurrence of nasal polyps after surgery 4‐7 . Although AD provides meaningful clinical improvement, the benefits are counterbalanced by relatively high rates of adverse effects and subsequent discontinuation of therapy 7 . In addition, AD may not be an easily accessible treatment, with one recent study demonstrating that only 7% of AERD patients in the United States underwent AD 8 .…”

Aspirin exacerbated respiratory disease (AERD) treatment revisited

“…The diagnosis of nasal polyps was also usually made after the diagnosis of asthma. Chu et al., in a review article, evaluate the benefits and risks of aspirin desensitization. Their meta‐analysis provides high‐certainty and moderate‐certainty evidence that, compared to placebo, aspirin desensitization in the AERD meaningfully improves upper respiratory symptoms and disease‐related quality of life (QOL).…”