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Asthma

Samter`s triad

12/08/2008

Question:

I am a 28 year old female that developed asthma at age 14. Shortly after I began having sinus problems. I have had two sinus surgeries, shortly after both the polyps returned. At about age 16 I had an asthmatic reaction to Aleve. I have since been able to tolerate advil and ibuprofen. I am constantly congested and cannot smell. My doctor thinks I have samters triad. My question is if I have it why can I tolerate ibuprofen and what are some treatments for it? My doctor suggested using liquid Pulmicort as a nasal spray.

Answer:

The association of asthma, nasal polyp disease and exacerbation of respiratory disease by aspirin, was reported by Samter and Beers in the 1960's and has been known since as Samter's triad. The association of aspirin and the other non-steroidal anti-inflammatory drugs, including Aleve (naproxen) and Advil (ibuprofen), with respiratory disease is now also known as aspirin-associated respiratory disease, or AERD. Typical features are nasal polyp disease, nasal and ocular congestion, asthma, tendency to flushing and hives, and a history of asthma exacerbation by one of the non-steroidal anti-inflammatory drugs (NSAIDs). The NSAIDs prevent inflammation because they inhibit an enzyme called COX-1. This enzyme produces chemicals that perpetuate inflammation, such as arthritis. It is thought that the respiratory effects of these drugs occur because, in blocking the COX-1 enzyme, chemicals that would be made in the COX-1 pathway are no longer produced. Those chemicals in turn would ordinarily inhibit another pathway that produces leukotrienes, factors that cause spasm of bronchial muscle in asthma and swelling of the nasal mucosa. Thus blocking one inflammation pathway leads to increased activity in another pathway, an effect that has been called ?shunting? of inflammation. Your physician feels that your history suggests aspirin-exacerbated respiratory disease. There is some variability in how much NSAID is required to produce exacerbation and there are differences in which NSAIDs are the most like to produce these effects. You might be able to tolerate lower doses of certain NSAIDs without significant reaction. The sensitivity to NSAIDs usually develops later than the initial presentation of nasal disease and asthma. Treatment of the condition includes the use of nasal corticosteroids as have been suggested for you. Other treatments include the use of leukotriene modulating drugs, such as the leukotriene receptor blockers and drugs that block leukotriene synthesis. Avoidance of all NSAIDs is suggested initially. A COX-2 enzyme inhibitor such as celecoxib can be used for pain without triggering asthma. Therapies such as aspirin desensitization have been tried on more intractable cases. It may be helpful to have your case reviewed by an allergist/immunologist to evaluate whether you have AERD and whether your case warrants consideration of these other treatments.

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Response by:

Charity C Fox, MD Charity C Fox, MD
Clinical Associate Professor of Pulmonary, Allergy, Critical Care & Sleep
College of Medicine
The Ohio State University