Effectiveness of endoscopic sinus surgery and aspirin therapy in the management of aspirin-exacerbated respiratory disease

Abstract

Background: Aspirin therapy and/or type 2 (T2) biologics are used in the management of aspirin-exacerbated respiratory disease (AERD). Objective: To identify the number of patients with AERD who tolerated aspirin therapy, yet due to persistent symptoms, incorporated T2 biologic management. Methods: A retrospective review was performed between July 2016 and June 2019. Patients with AERD and who underwent endoscopic sinus surgery (ESS), aspirin desensitization (AD), and at least 6 months of aspirin therapy (ATAD) after AD, and who remained biologic-naive up through this timepoint were included in the study. Introduction of a T2 biologic while on ATAD was the primary outcome. The secondary outcome was a change in a validated patient-reported outcome measure for chronic rhinosinusitis score between the postoperative predesensitization timepoint, and the 6-month postdesensitization timepoint, presented as means and compared by using the Student's t-test. Results: A total of 103 patients met inclusion criteria. Two patients (1.9%) ultimately supplemented ATAD with a T2 biologic. The mean outcomes measure test score after 6 months of ATAD for patients who received biologics was 40.5 versus 15 in those who did not receive biologics (p = 0.02). The mean differences between the postoperative predesensitization test score and the 6-month postdesensitization test score for patients who went on to receive biologics was an increase of 13 versus a decrease of 10 for those patients who did not receive biologics (p = 0.12). Conclusion: ESS, coupled with AD and ATAD, was successful in the long-term management of the majority of the patients with AERD, which rarely required the incorporation of T2 biologics. Patient questionnaires, such as outcomes measure test score, may identify aspirin therapy failures and help guide the practitioner in deciding when to introduce T2 biologics into the patient's treatment regimen.

What's New in the Diagnosis and Treatment of Aspirin-Exacerbated Respiratory Disease: A Brief Review

“…Acutely, treatments are focused on the specific organ system affected; however, to achieve long-term symptom control, a combined approach with comprehensive ESS followed by systemic treatment with aspirin desensitization (AD) and aspirin therapy after desensitization (ATAD) is usually indicated. [34][35][36] Below we review the various categories of treatment options.…”

“…Our prior publications have shown that ESS coupled with AD and aspirin therapy after desensitization (ATAD) result in strongly favorable patient outcomes. 34,36,50 Aspirin Therapy After Desensitization Aspirin desensitization aims to build an individual's tolerance to ASA and other NSAIDs and has shown favorable outcomes in the management of patients with AERD. 51,52 .…”

“…Our prior publications have shown that ESS coupled with AD and aspirin therapy after desensitization (ATAD) result in strongly favorable patient outcomes. 34,36,50…”

“…64,65 Our experience has shown that very few patients who tolerate ATAD for six months or longer will require salvage with a T2 biologic. 34…”

Controversies in Allergy: Aspirin Desensitization or Biologics for Aspirin-Exacerbated Respiratory Disease—How to Choose

“…The specialties that share the care of patients must work together to determine not only the treatment path that is most likely to ensure long-term health, but also to safeguard societal health care resources. For many patients with AERD, an initial "clean-out" surgery followed by sinus-directed topical corticosteroids and aspirin therapy 49,50 might lead to inexpensive long-term control, as well as remediate the dilemma of needing to avoid other NSAIDs for pain control. When this treatment approach fails patients, biologics should be considered.…”