Treatment practices for aspirin‐exacerbated respiratory disease: analysis of a national insurance claims database

Abstract

Background Aspirin‐exacerbated respiratory disease (AERD) is the triad of asthma, nasal polyposis, and sensitivity to cyclooxygenase‐1 inhibitors. Treatment options include medical management, surgical intervention, and aspirin desensitization (AsaD). Methods AERD patients were identified using the MarketScan Database from 2009 to 2015. Patients were included using International Classification of Diseases, 9th edition (ICD‐9) codes for asthma, nasal polyposis, and drug allergy. Treatments were determined by Current Procedural Terminology (CPT) codes for drug desensitization and endonasal procedures. Geographic trends and timing of interventions between those exposed and not exposed to desensitization were explored. Results A total of 5628 patients met inclusion criteria for AERD, with mean age 46 years, 60% female; 395 (7%) underwent AsaD and 2171 (39%) underwent sinus surgery. Among patients who were desensitized, 229 (58%) underwent surgery, of whom 201 (88%) had surgery prior to AsaD (median [quartile 1, quartile 3]; 61 days [30, 208] prior to desensitization). For patients undergoing surgery following AsaD (n = 46), surgery was performed a median of 302 (163, 758) days after AsaD. Nineteen patients had multiple surgeries post‐AsaD with median time between surgeries being 734 days (312, 1484); 261 patients were not desensitized to aspirin but did undergo multiple surgeries, with the median of the median time between surgeries being 287 days (15, 617), which is shorter than for patients post‐AsaD (p < 0.001). Conclusion A very small percentage of AERD patients undergo AsaD. Patients who had AsaD underwent surgery approximately 2 months prior to AsaD. Patients who underwent AsaD experienced an increased time between surgeries compared to patients who did not undergo AsaD.

Surgical outcomes in aspirin‐exacerbated respiratory disease without aspirin desensitization

“…In fact, many cohort studies demonstrated high discontinuation rates of up to 50% 7,21‐24 . In addition, a large administrative database in the United States has shown that only 7% of AERD patients receive AD, suggesting either a lack of availability or patient willingness to undergo this treatment 8 . Considering these factors, it is imperative to fully understand the natural history of AERD after ESS without AD.…”

“…In our study, the median time to revision surgery was approximately 1215 days (3.33 years). In a recent study by Roland et al, 8 who examined a national insurance claim database of AERD patients who required multiple surgeries, the median time between surgeries was 734 days (2.01 years) for those who were desensitized compared with only 287 days (0.79 year) in patients without AD. Clearly, both of these time intervals are vastly shorter than what we reported and may suggest that complete ESS alone without AD can provide durable, long‐term results equivalent to those in AD cohorts.…”

“…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 . Given the paucity of literature on outcomes of patients with AERD undergoing endoscopic sinus surgery (ESS) without AD, it is necessary to better define and understand the natural history of AERD patients as we continue to investigate the merits of AD as a treatment option.…”

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

“…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 . However many patients are not offered this treatment option or opt out of aspirin desensitization 28 . 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.…”

“…However many patients are not offered this treatment option or opt out of aspirin desensitization 28 . 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 …”