Transcript Pulmonary Function_HandsOn_ASA_test2

Aspirin provocation tests for aspirin
exacerbated respiratory diseases.
Choon-Sik Park, M.D.
Division of Allergy and Respiratory Diseases
Soonchunhyang University Bucheon Hospital
Korea
WAC2011
LT.
Aspirin-Exacerbated Respiratory Disease
RT.
Aspirin-exacerbated respiratory disease (AERD) is a clinical tetrad of nasal polyps,
chronic hypertrophic eosinophilic sinusitis, asthma and sensitivity to any medication
that inhibits cyclooxygenase-1 (COX-1) enzymes, namely aspirin and other
nonsteroidal anti-inflammatory drugs (NSAIDs)
AERD affects 0.3-0.9% of the general population, but the prevalence rises
to 10-20% of asthmatics and up to 30-40% in those asthmatics with nasal polyposis.
Lee RU. Stevenson DD.
Allergy Asthma Immunol Res.
2011;3:3-10.
AERD remains under-diagnosed
•Twenty-five percent of asthma patients who required
emergency mechanical ventilation were aspirin
intolerant.(1,2)
•15% of patients were unaware that they may be
susceptible to aspirin intolerance and learned about it
only after undergoing provocation tests.(3)
•AERD is associated with increased asthma severity,
including life threatening asthma attacks and possible
remodeling of both the upper and lower airways.(4)
1.Am Rev Respir Dis 1992;146:76-81
2. Eur Respir J 1989;2:127-9.
3. Eur Respir J 2000;16:432-6.
4.J Allergy Clin Immunol 2005;116:970-5
Limitation in prediction of AERD using clinical parameters
HS Jang, CS Park et al:
Allergy Asthma Immunol Res. 2011 October;3(4):256-264.
Diagnosis of AERD
•Aspirin challenge is the gold standard for diagnosing AERD
•Four routes of provocation challenges: oral, bronchial inhalation, nasal
inhalation and intravenous.
• Contraindications for oral aspirin challenges:
1. history of very severe anaphylactic reactions by aspirin or other NSAIDs*
2. Severe disease of the heart, digestive tract, liver, kidney.
3. Infection of respiratory tract within 4 weeks prior to the challenge.
4. Pregnancy.
5. Current treatment with b-receptor blocker.
6. Oral corticosteroids exceeding 10 mg of prednisolone or equivalent.
* nasal aspirin challenge should be considered in any such case.
EAACI/GA2LEN guideline: aspirin provocation tests for
diagnosis of aspirin hypersensitivity
Allergy 2007: 62: 1111–1118
Drug withdrawal before oral aspirin challenge procedures
EAACI/GA2LEN guideline: aspirin provocation tests for
diagnosis of aspirin hypersensitivity
Allergy 2007: 62: 1111–1118
Table 1. The consecutive and cumulative doses of
aspirin used in oral aspirin challenge
* a history of a severe reaction (very severe dyspnea and/or anaphylactic shock)
Symptoms and signs checked
1. Bronchial (bronchospasm, tightness of chest,
wheezing).
2. Upper airway (rhinorrhea, nasal congestion).
3. Other reactions (ocular injection, periorbital
swelling,
4. Erythema of the skin of the upper thorax and face,
5. Nausea, stomach cramps,
6. Blood pressure
An example
• A 25 yr old male
• Asthma and rhinitis for 3 yrs
• One episode of urticaria after
URI medication
LT.
RT.
Ref
FVC
Liters
FEV1
Liters
FEV1/FVC %
FEF25-75% L/sec
FEF25% L/sec
FEF50% L/sec
FEF75% L/sec
PEF
L/sec
FEV1
Liters
PIF
L/sec
2.61
1.94
75
2.44
3.06
1.03
5.23
Pre
Meas
FVC
Liters 2.47
FEV1
Liters 1.95
FEV1/FVC %
79
FEF25L/sec
1.74
75%
FEF25% L/sec
5.05
FEF50% L/sec
2.09
FEF75% L/sec
0.65
PEF
L/sec
5.58
FEV1
Liters
PIF
L/sec
3.6
ASA (mg) Pre ASA (mg) Level 1 ASA (mg) Level 2 ASA (mg) Level 3
% Ref
0
10
% Ref
27
% Ref
44
% Ref
2.47
94
2.49
95
2.5
96
2.45
94
1.95
100
1.96
101
1.95
101
1.89
97
79
79
78
77
1.74
71
1.77
73
1.71
70
1.59
65
5.05
5.44
5.42
4.59
2.09
68
2.21
72
2.23
73
2.23
73
0.65
63
0.62
60
0.61
60
0.54
52
5.58
107
5.68
109
5.75
110
5.51
105
3.6
3.96
2.88
ASA (mg) Level 4 ASA (mg) Level 5
Pre
% Ref
117
% Ref
312
% Ref
94
2.42
93
1.58
60
100
1.76
90
1.0
51
73
63
71
1.26
52
0.6
25
68
63
107
3.7
1.66
0.52
5.1
54
51
97
1.38
0.67
0.28
2.88
22
27
55
2.7
2.81
2.72
Level 6
Meas
Level 6
% Ref
Post
% Chg
0
-5
-17
-1
-12
-19
-2
-35
Level 7
Meas
Level 7
% Ref
FEV1 (%)
100
80
60
40
0
Accumulative ASA concentration (mg)
Single-blind, placebo-controlled bronchial
(inhalation) aspirin challenge
• Lysine-aspirin (AspisolTM;Bayer, Leverkusen, Germany)
• a dosimeter-controlled jet-nebulizer
• Solutions and doses of lysine-aspirin used in the inhalation aspirin
challenge
Intranasal ketorolac (Toradol®)
• In Asia and Europe,
intranasal lysine-aspirin is
used as a diagnostic and
therapeutic agent for
AERD. Lysine-aspirin is
not commercially available
in the United States.
• intranasal ketorolac
(Toradol®) is a safe and
effective alternative for
diagnosing AERD.
Lee RU. Stevenson DD.
Allergy Asthma Immunol Res.
2011;3:3-10.