The first report of what is now called the asthmatic triad appeared in 1922 in La Presse Médicale, a French medical journal. The authors of the report, Widal, Abrami, and Lermoyez, described an association between sensitivity to aspirin—introduced commercially by the Bayer Company by 1899—and the occurrence of nasal polyps and asthma. In the late 1960s, Dr. Max Samter published a series of articles characterizing the triad and further elucidated the nature of the aspirin intolerance.
Dr. Samter greatly advanced knowledge in the area, and in recognition of the fact, the asthmatic triad is also known as Samter’s syndrome. Aspirin, or acetylsalicylic acid, is a widely prescribed and consumed drug with beneficial anti-inflammatory, anti-fever, and pain-relieving properties. It is also useful for its blood thinning effects in the treatment of heart diseases and in certain types of stroke prevention.
The consumption of aspirin in the United States has been estimated at approximately 80 billion tablets per year. In many ways, aspirin is an ideal medication: inexpensive, safe, and highly effective. In some people with asthma, however, aspirin carries a real risk. The term aspirin-induced asthma,or AIA, refers to the development of wheezing and bronchoconstriction after the ingestion of aspirin, or aspirin-like products called NSAIDs—non-steroidal anti-inflamma-tory drugs. AIA usually occurs in the setting of severe, chronic asthma and is more common among females. Approximately 10–20% of people with asthma also have AIA. The NAEPP reports that 21% of all adults with asthma and 5% of children with asthma have AIA.
It is estimated that, of those asthmatics with AIA, 50% have steroid-dependent asthma classified as severe persistent, 30% have moderate persistent disease, and 20% have mild persistent or intermittent asthma. Symptoms of AIA include, first and foremost, an acute exacerbation of asthma within 3 hours of taking aspirin or one of the NSAIDs. Respiratory symptoms include wheezing, cough, and breathlessness, secondary to bronchoconstriction and inflammation.
The acute chest symptoms are accompanied by nasal, eye, and skin symptoms including severe runny nose; red, puffy, itchy eyes; and flushing and reddening of the skin of the face or neck. The asthmatic exacerbation can be quite severe and may require emergency room treatment or even admission to hospital. AIA is a cause of near-fatal asthma. Studies have suggested that up to 25% of all persons with asthma admitted to hospital in respiratory failure requiring intensive care and ventilator support may have had the event precipitated by aspirin or NSAID ingestion. Treatment of AIA consists of lifelong aspirin and NSAID avoidance .
The oral leukotriene modifier medications (zafirlukast, zileuton, and montelukast) are useful in blocking and preventing the response to aspirin and NSAIDs to a variable extent in AIA. If aspirin therapy is deemed essential for medical reasons, then the person with asthma and AIA should be referred to an allergist with expertise in aspirin desensitization. Aspirin desensitization is a special, individualized treatment that eventually permits an individual with AIA to tolerate regular, daily doses of aspirin. Desensitization could, for example, be considered in the case of a man with aspirin-induced asthma who is recuperating from a heart attack and whose cardiologist believes that a small daily dose of aspirin is essential in preventing a second heart attack.
Medicines to Avoid in Aspirin-Induced Asthma
Aspirin or acetylsalicylic acid
“Pure” aspirin is available over the counter without a prescription, in generic and non-generic (or brand) formulations. Examples include: acetylsalicylic acid (generic), Ascriptin, Bayer, Bufferin, Ecotrin, Empirin, Halfprin, and St. Joseph. Look at the list of ingredients carefully for the words aspirin or acetylsalicylic acid, alone or in combination. Aspirin-containing formulations Many remedies contain aspirin as an ingredient, combined with other medicines. These remedies include both over-the-counter and prescription formulations. In the first category are products such as:
Alka Seltzer Plus, Anacin, Aspergum, Doan’s Pills, Excedrin, Goody’s Headache Powders, Pamprin, Pepto Bismol products, and others. Many products you see on the shelves in addition to those listed here may contain aspirin. They may be labeled for treatment of arthritis pain, cold symptoms, headache, indigestion, menstrual pain, pain from minor sprains or injury, and sinus symptoms. Make sure to check the list of ingredients carefully and look for the words aspirin or acetylsalicylic acid, alone or in combination.
Prescription medicines that contain aspirin are also very common, and are often used for pain control and relief. Some such medicines are Darvon, Fiorinal, Percodan, Tal-win, and Zorprin. Make certain that all your treating doctors know that you have AIA, and that you must avoid taking aspirin, as well as NSAIDs. Check to make sure that the pharmacist who fills your prescription is aware of your aspirin sensitivity. Read any inserts provided with the prescribed medicine.
NSAIDs
NSAIDs include a large number of products, including both over-the-counter and prescription drugs. NSAIDs are useful in pain and arthritis treatment. Some of the most commonly used NSAIDs are ibuprofen (Advil, Motrin) and naprosyn (Aleve), which are available without a prescription. Newer Cox-2 medications such as celecoxib (Celebrex) and valdecoxib (Bextra) should likewise be avoided.
“Safe” Medicines in Aspirin-Induced Asthma
Your physician and your pharmacist are professionals who can pro-vide you with information about the safety of both prescription and over-the-counter medications in AIA. You have a responsibility to inform them that you have a diagnosis of AIA and should ask them any questions you have about any medicine.
Many of the products you must avoid are used in the treatment of pain (headache, menstrual cramps, sprains, and injuries) and inflammatory conditions (arthritis, osteoarthritis). A list of the generic name of medicines that are usually considered safe by medical experts follows:
- Acetaminophen
- Sodium salicylate
- Salicylamide
- Choline magnesium trisalicylate
- Benzydamine
- Chloroquine
- Azapropazone
- Dextropropoxyphene