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Why Does Aspirin Cause Asthma

Who Should Take Aspirin

What is an aspirin allergy?

For people who have had a heart attack: Aspirin can help prevent a second heart attack. Your doctor has probably already prescribed aspirin for you.

For people who have had a stroke: Aspirin can help prevent a second stroke or a transient ischemic attack , which is often a warning sign of a stroke.

For people who have never had a heart attack or stroke: Talk to your doctor before you start taking aspirin every day. Aspirin lowers the risk of heart attack. But aspirin can also cause serious bleeding. And it is not clear that aspirin can help prevent a stroke if you have not already had a heart attack or stroke in the past. You and your doctor can decide if aspirin is a good choice for you based on your risk of a heart attack and your risk of serious bleeding. For help on this decision, see: Aspirin: Should I Take Daily Aspirin to Prevent a Heart Attack or Stroke?.

Aspirin may also be used by people who:

Pathophysiology Of Nsaids Hypersensitivity

Other arachidonic acid metabolites generated by the 5-lipoxygenase pathway have been associated with aspirin-hypersensitivity. For example, aspirin triggers 15-HETE generation in nasal polyp epithelial cells and peripheral blood leukocytes from aspirin-intolerant but not aspirin-tolerant patients suggesting the presence of a specific abnormality of the 15-LOX pathway in these patients. Upregulation of 15-lipoxygenase and decreased production of lipoxin A4, an anti-inflammatory 15-LO metabolite found in leukocytes and nasal polyp tissue from ASA-intolerant patients, further points to a distinctive but not yet understood role for the 15-lipoxygenase pathway17.

Several single nucleotide polymorphisms in candidate genes coding molecules related mainly to the arachidonic acid metabolic pathway, for example, LTC4 synthase, 5-LOX, prostaglandin EP or leukotriene LT1 receptors, were found to be associated with ASA-intolerance20. More recently a differential gene expression profile with potent discriminative power has been reported in leukocytes of N-ERD patients21. Therefore, a genetic component may be important in the pathogenesis of the disease.

How Do You Take Aspirin

Your doctor will recommend a dose of aspirin and how often to take it. A typical schedule is to take aspirin every day. But your doctor might recommend that you take aspirin every other day. Be sure you know what dose of aspirin to take and how often to take it.

Low-dose aspirin is the most common dose used to prevent a heart attack or a stroke. But the dose for daily aspirin can range from 81 mg to 325 mg. One low-dose aspirin contains 81 mg. One adult-strength aspirin contains about 325 mg.

For aspirin therapy, do not take medicines that combine aspirin with other ingredients such as caffeine and sodium.

Low-dose aspirin seems to be as effective in preventing heart attacks and strokes as higher doses.

If aspirin upsets your stomach, you can try taking it with food. But if that doesn’t help, talk with your doctor. Aspirin can irritate the stomach lining and sometimes cause serious problems.

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What Happens During An Aspirin

An aspirin-induced asthma attack can be deadly.4 The attack can begin within minutes or up to two hours after taking aspirin or another NSAID.6 The reaction is usually dose dependent: small doses cause a mild attack and large doses cause a severe attack.2

Signs of an attack are:2,6

  • Runny or stuffy nose
  • Swollen, watery or itchy eyes
  • Redness in the face and neck
  • Difficulty breathing
  • Stomach pain

In very serious cases, the airways can narrow severely. The person goes into shock, becomes unconscious, or stops breathing.6

Identifying The Medicines That Can Cause Problems

Why it is not advisable to administer aspirin to asthmatic ...

First, not only is it necessary to avoid aspirin, it is equally important to avoid all medicines of the family called “non-steroidal antiinflammatory drugs.” These medicines, such as ibuprofen and naproxen, are used to treat the inflammation of arthritis and are routinely taken as pain killers. Just like aspirin, they can cause severe attacks of asthma in persons with aspirin-sensitive asthma. Incidentally, they do not help the inflammation of the bronchial tubes in asthma. Second, both aspirin and non-steroidal antiinflammatory drugs are sold over-the-counter in a variety of preparations and under many different names. One must be careful to read labels on over-the-counter cold remedies, allergy medicines, pain killers, and relievers of stomach discomfort, many of which contain aspirin.

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Will Aspirin And Other Pain Relievers Make My Asthma Worse

Aspirin and other drugs called nonsteroidal anti-inflammatory drugs may be harmful for people who have asthma. Ibuprofen and naproxen are a few examples of NSAIDs. If you are allergic to aspirin, ask your doctor or pharmacist to make sure any new medicine you might take is not related to aspirin.

People who have asthma can usually take acetaminophen safely. This medicine is typically used to relieve fever and pain. Very rarely, even acetaminophen may make asthma worse, which has prompted further studies to explore the link between acetaminophen and asthma. If acetaminophen makes your asthma worse, tell your doctor. He or she can help you find another type of pain reliever.

Management Of A Patient With Aspirin Triad

Management of asthma and rhinosinusitis in an NSAIDs-hypersensitive patient is similar to treatment of other forms of asthma and rhinosinusitis. However, there are several important additional treatment modalities to be considered when N-ERD is diagnosed3.

Avoidance of NSAIDs and use of alternative analgesics

Patient education and careful avoidance of ASA and other NSAIDs which are strong COX-1 inhibitors is important because COX-1 inhibitors can cause severe asthma leading to hospitalization in an intensive care unit and even intubation. Therefore, ideally, the aspirin-hypersensitivity should be confirmed by a challenge test.

In general three groups of NSAIDs can be distinguished based on their capacity to induce hypersensitivity reactions in N-ERD patients24, Table 1.

Alternative antipyretic or analgesic drugs, such as acetaminophen are preferred. Preferential COX-2 inhibitors, such as nimesulide and meloxicam, are tolerated by most, but not all, NSAIDs-intolerant subjects. Selective preferential COX-2 inhibitors, such as celecoxib or valdecoxib, are tolerated by almost all aspirin-intolerant subjects. However, oral challenge in the office is recommended to ensure that patients are able to tolerate COX-2 inhibitors.

Mangement of chronic rhinosinusitis and nasal polyposis

Management of asthma

Desensitization toaspirin and Aspirin Treatment after Desensitization

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How Is It Treated

If you have been diagnosed with AIA, do not take products that contain aspirin.

In general, AIA is managed in the same way as other types of asthma. Three types of medicines are used to control asthma:

  • Quick-relief medicines, also called reliever, or rescue medicines. These medicines are used as needed to treat asthma attacks. They are not used on a regular, daily basis to prevent asthma symptoms. You should learn to recognize the symptoms of an asthma attack and take these medicines as soon as symptoms start. To prevent asthma attacks, you may need a different type of medicine called a controller.
  • Long-term control medicines, also called controller medicines. By taking this medicine regularly every day, it helps to control your symptoms. You will take these medicines every day, even if you are not having symptoms. They do not provide quick relief of wheezing in acute asthma attacks.
  • Steroid medicines, also called asthma controller medicines, because by taking them regularly every day, they help to control your symptoms. You will take these medicines every day, even if you are not having symptoms. They do not provide quick relief of wheezing in acute asthma attacks. Steroid medicines are similar to hormones made by your body. They block some of the chemicals that cause irritation and swelling in your airways. By lessening the swelling, you will have fewer symptoms and be able to breathe better.

Can It Be Prevented

Aspirin and Prostaglandins

AIA can be prevented. Avoid products that contain aspirin. Be sure to read labels. There are several medicines that contain aspirin or other NSAIDs.

Do not give aspirin to children 18 years or younger unless told to do so by your healthcare provider. This is due to the risk of ReyeĆ¢s syndrome .

If you have asthma, use NSAIDs such as ibuprofen with caution. If you have asthma and nasal polyps, do not use NSAIDs without the approval of your healthcare provider.

In rare cases, acetaminophen may also trigger an asthma attack. Reactions are usually less intense than reactions to aspirin or other NSAIDS. Acetaminophen is the medicine most often used for fever and pain relief for people who cannot take aspirin and NSAIDs.

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Table : Indications For Treatment With Aspirin After Desensitization In N

Adapted from Kowalski ML, Agache I, Bavbek S, et al. Diagnosis and management of NSAID-Exacerbated Respiratory Disease -a EAACI position paper. Allergy. 2019 74:28-393.

  • rhinosinusitis symptoms not responding to pharmacological treatment
  • highly recurrent nasal polyposis/hypertrophy
  • prevention of nasal polyps after sinus surgery
  • asthma symptoms difficult to control with standard therapy
  • need to reduce the dose or withdraw chronic oral corticosteroids
  • need for anti-platelet treatment with aspirin of ischemic heart disease or stroke
  • need for chronic anti-inflammatory treatment

Why Does Aspirin Cause Bronchospasm

Aspirin is a non-selective and irreversible inhibitor of a classof enzymes known as COX. These enzymes are responsible for theproduction of prostaglandins and thromboxane. There are severalsubtypes of prostaglandins, some of which induce bronchospasm and others that cause bronchodilation . But this isunimportant since aspirin will block the production of allprostaglandins.

If you look at the figure below, you can see that COX enzymesare only half of the story in the metabolism of Arachidonic acid.The other half is known as the Lipoxygenase pathway

This LOX pathway is responsible for the production ofpro-inflammatory chemicals known as Leukotrienes . By blockadeof the COX pathways, all of the arachidonic acid is funneled intothe LOX pathway, thereby increasing these pro-inflammatorychemicals. And since pro-inflammatory chemicals are the samechemicals that produce Allergies and anaphylaxis –> Bronchoconstriction occurs.

In other words, by blocking the synthesis of PGs , the balance between bronchodilators andbronchoconstrictors is deregulated, leading to a predominance ofbronchoconstrictors, hence the Asthma.

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What About Medicines For Blood Pressure

Beta-blockers, used to control blood pressure and heart disease, can make asthma worse. This group of drugs includes propranolol, atenolol and metoprolol. If you have started taking a beta-blocker and your asthma gets worse, tell your doctor.

ACE inhibitors are another type of medicine given to treat blood pressure, heart disease and, sometimes, diabetes. Drugs such as captopril, enalapril and lisinopril are included in this group. These medicines appear to be safe for people who have asthma. However, some people develop a cough when taking ACE inhibitors. If you start coughing while youre taking an ACE inhibitor, remember that the cough might not be caused by your asthma. If the cough is caused by the ACE inhibitor, it will usually go away a week or so after you stop taking the medicine. If you develop other problems that make your asthma worse, call your doctor to see if you should stop taking your ACE inhibitor.

Clinical Characteristics Of Aspirin Triad

NSAIDs

N-ERD patients usually suffer from moderate or severe forms of asthma requiring chronic treatment with moderate to high doses of inhaled glucocorticosteroids oral glucocorticoids are necessary to control asthma in many of these patients2. In addition, the majority of NSAIDs-intolerant asthmatics have nasal and sinus symptoms. The incidence of rhinosinusitis, as demonstrated by CT scans, is up to 100%, and the frequency of nasal polyps may be as high as 90%6. Rhinosinusitis is protracted and the nasal polyps tend to recur following polypectomy: the recurrence rate for nasal polyps in N-ERD patients is several times higher than in aspirin-tolerant asthmatics after standard polypectomy, but also after Functional Endoscopic Sinus Surgery . Polypoid hypertrophy of the mucosa is not just limited to the nasal cavity it usually involves all sinuses and is more extensive in NSAIDs-intolerant compared to tolerant patients with nasal polyposis. There is also clinical evidence that uncontrolled chronic rhinosinusitis often aggravates the course of asthma in these patients. Although N-ERD is one of the best characterized phenotypes of asthma, recent studies indicate the heterogeneity of this syndrome7. NSAIDs intolerant asthmatics may differ in terms of asthma control, intensity of upper airways inflammation, presence of blended reactions, blood eosinophil level and urinary LTE4 generation8, 9.

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What Is Aspirin Desensitization

People with AERD can undergo a procedure, called aspirin desensitization, which can induce tolerance to aspirin. Even if youve had life-threatening respiratory reactions youll be able to take aspirin without reacting to it.

To do this, youre challenged with graded doses of aspirin over a period of several days. Your provider starts by giving a very small dose of aspirin and watches to see if you react. When you get to the dose that causes symptoms, youll keep getting that dose until you can tolerate this dose without adverse reaction. Youll then get higher and higher doses of the drug. As you keep getting the higher doses, your body will start to accept the drug without reacting.

Aspirin desensitization is generally done over a period of several days.

What Are The Symptoms

The first symptoms of AIA may include sneezing, a runny or stuffy nose, and redness and warmth of the face. Symptoms start 1 to 3 hours after taking aspirin or NSAIDs. The asthma attack triggered by aspirin and NSAIDs can be life threatening. In many cases, people with AIA also have nasal polyps , long-term sinus disease, and loss of the sense of smell.

Adults with asthma may not be as sensitive to aspirin as children. They may have taken aspirin or NSAIDS in the past without any side effects. Symptoms may not start until adulthood.

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How Does Aspirin Work To Prevent A Heart Attack Or Stroke

Aspirin slows the blood’s clotting action by reducing the clumping of platelets. Platelets are cells that clump together and help to form blood clots. Aspirin keeps platelets from clumping together, thus helping to prevent or reduce blood clots.

During a heart attack, blood clots form in an already-narrowed artery and block the flow of oxygen-rich blood to the heart muscle . When taken during a heart attack, aspirin slows clotting and decreases the size of the forming blood clot. Taken daily, aspirin’s anti-clotting action helps prevent a first or second heart attack.

Asthma Nasal Polyps And Aspirin Intolerance

How do chest infections make asthma symptoms worse? | Asthma UK

Alternative titles symbols

Other entities represented in this entry:

Phenotype-Gene Relationships

Pulmonary Immunologic

TEXT

A number sign is used with this entry because of evidence of an association between aspirin-induced asthma and polymorphisms in the TBX21 , PTGER2 , and LTC4S genes.

Clinical Features

observed 2 families. In 1 family, consanguinity suggested recessive inheritance. The late onset and discordance in a pair of identical twins suggested that environmental factors may be important also. reported affected sisters. described a family in which autosomal dominant inheritance of aspirin asthma was suggested. In addition to mode of inheritance, differences from prior reports included an earlier age of onset, lack of nasal polyps and sinusitis, and milder asthma.

stated that between 3% and 10% of asthma patients have acute, severe asthma accompanied by rhinorrhea and sometimes associated with hives, flushing, or abdominal pain after the injection of aspirin or nonsteroidal antiinflammatory drugs . The common feature of drugs that provoke asthma attacks in aspirin-intolerant persons is that they inhibit cyclooxygenase-1 selective inhibition of cyclooxygenase-2 appears not to provoke such a response. Cautious, incremental administration of oral doses of aspirin can lead to a state in which persons with aspirin-sensitive asthma can ingest aspirin without untoward reactions, but daily administration must be continued to maintain this state.

Molecular Genetics

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What Medications Trigger Aspirin

Although it is called aspirin-induced asthma, medications related to aspirin can also cause an attack. These drugs are called NSAIDs. Traditional NSAIDs block an enzyme called COX-1.3 COX-1 has role in pain and inflammation. Therefore, blocking COX-1 relieves pain and reduces inflammation.

The Table contains list of prescription and non-prescription NSAIDs that may cause an asthma attack in people with aspirin-induced asthma.2,8,9

How Is It Diagnosed

There are no blood tests or skin tests that will diagnose allergy to aspirin or NSAIDs. Your healthcare provider will ask about:

  • Your use of aspirin
  • How often you are having symptoms
  • Any other allergies or triggers

The provider may refer you to an allergy specialist to see if you have other allergies.

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What Is The Cause

Asthma symptoms are caused by two different problems in the airways.

  • One problem is that the muscles in the airways tighten up, which causes the feeling of chest tightness and wheezing.
  • The other problem is swelling, irritation and too much mucus in the airways.

If you have asthma, symptoms often start after you are exposed to a trigger. Asthma triggers can include:

  • Exercise
  • Allergies, such as dust, pollen, mold, or animal fur
  • Something that irritates your lungs, such as cold air, smoke, or strong smells like paint or perfume
  • Medicines like aspirin or NSAIDs
  • An infection such as a cold, the flu, or a sinus infection
  • Strong emotions or stress
  • Indigestion, also called gastroesophageal reflux disease, or GERD. If you often have problems with acid indigestion you may have more asthma symptoms, especially at night.

Asthmatics With Nasal Polyps Should Avoid Nsaids Others Use With Caution

ABG 6 Series

NSAID-induced bronchospasm should be suspected in any patient whose asthma control worsens on initiation of a NSAID. Patients with a history of asthma should be warned of this reaction and to seek medical help if symptoms worsen on initiation of a NSAID.

NSAIDs should be used with caution in the presence of asthma and avoided in asthmatics with nasal polyps. As it is difficult to identify ‘at risk’asthmatics, it would seem prudent to prescribe paracetamol instead of aspirin unless there are any specific contra-indications.

Patients should be reminded to read labels of over-the-counter medicines as some, such as cough/cold preparations, may contain aspirin. Ibuprofen, diclofenac and other NSAIDs are also available over-the-counter.

References
  • Ayres JG, Fleming DM, Whittington RM. Asthma death due to ibuprofen. Lancet 1987 1:1082.
  • Bosso JV, Creighton D, Stevenson DD. Flurbiprofen cross-sensitivity in an aspirin-sensitive asthmatic patient. Chest 1992 101:856-858.
  • Chen AH, Bennett CR. Ketorolac-induced bronchospasm in an aspirin-intolerant patient. Anesth Prog 1994 41:102-107.
  • Zikowski D, Hord AH, Haddox JD, Glascock J. Ketorolac-induced bronchospasm. Anesth Analg 1993 76:417-419.
  • Slepian IK, Mathews KP, McLean JA. Aspirin-sensitive asthma.Chest 1985 87:386-391.
  • Power I. Aspirin-induced asthma Brit J Anaes1993 71:619-620.
  • Sitenga GL, Ing EB, Van Dellen RG, et al. Asthma caused by topical application of ketorolac. Ophthalmology 1996 103:890-892.
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