Show notes
Aspirin or biologics? How do you choose the right treatment for AERD? On this episode of the BackTable ENT & Allergy Podcast, Dr. Basil Kahwash interviews Dr. Andrew White, Director of the AERD Clinic at Scripps Clinic, to discuss the diagnosis and management of this often underrecognized condition. They cover practical strategies for identifying AERD, the importance of a detailed NSAID history, and how treatment decisions are shaped by patient goals and disease severity.
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Timestamps
00:00 - Introduction
02:08 - What Is AERD and Prevalence
06:32 - History Taking and Mechanism
11:10 - Typical Symptom Progression and Alcohol Intolerance
16:41 - When to Do Aspirin Challenge
19:00 - Challenge Protocol And Upper Airway Reactions
24:53 - Aspirin Desensitization vs Challenge
27:58 - Aspirin therapy after desensitization and Risk of GI Bleeds
31:17 - Biologics Change AERD
33:42 - Choosing Aspirin Desensitization vs Biologics
35:52 - Patient Counseling and Motivational Interviewing
41:26 - Convenience and Cost of Therapy
44:10 - ENT Allergy Collaboration
47:22 - Rapid Fire Pearls
51:13 - Future Research & Management Direction
54:05 - Final Takeaways
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More about this episode
Dr. White explains that AERD affects about 8 to 10 percent of asthmatics, with even higher rates in those with severe asthma or nasal polyps. He reviews typical adult-onset progression, alcohol-related respiratory symptoms, and the underlying pathophysiology, including imbalances in arachidonic acid mediators and leukotriene surges after NSAID exposure.
The conversation includes practical questions to ask when taking an NSAID history, such as reactions to common pain relievers or alcohol, and when to consider aspirin challenge. Dr. White also details long-term treatment strategies, including the role of biologics like dupilumab and aspirin therapy after desensitization, with considerations for dosing and gastrointestinal risk. He explains how factors like asthma severity, recurrent polyp disease, sense of smell, cost, and convenience all influence therapy choice. The episode concludes with a discussion of multidisciplinary collaboration, patient counseling, and Dr. White’s insights on future research directions in AERD management.
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Resources
Aspirin sensitivity and severity of asthma: evidence for irreversible airway obstruction in patients with severe or difficult-to-treat asthma
https://pubmed.ncbi.nlm.nih.gov/16275362/
Polyphenolic Activation of Basophils Explains Alcohol Hypersensitivity in AERD
https://pubmed.ncbi.nlm.nih.gov/41065188/
New insights into the mechanisms of aspirin-exacerbated respiratory disease
https://pubmed.ncbi.nlm.nih.gov/39641750/
The role of aspirin desensitization followed by oral aspirin therapy in managing patients with aspirin-exacerbated respiratory disease: A Work Group Report from the Rhinitis, Rhinosinusitis and Ocular Allergy Committee of the American Academy of Allergy, Asthma & Immunology
https://pmc.ncbi.nlm.nih.gov/articles/PMC7980229/
Safety and outcomes of aspirin desensitization for aspirin-exacerbated respiratory disease: A single-center study
https://pubmed.ncbi.nlm.nih.gov/28550988/
Selection of aspirin dosages for aspirin desensitization treatment in patients with aspirin-exacerbated respiratory disease
https://pubmed.ncbi.nlm.nih.gov/17208597/
Factors influencing aspirin therapy after desensitization (ATAD) tolerance in aspirin-exacerbated respiratory disease (AERD) patients
https://pubmed.ncbi.nlm.nih.gov/41022281/
Feed the Good Wolf: Motivational Interviewing, Cognitive Behavioral Therapy, and Mindset
https://pubmed.ncbi.nlm.nih.gov/42103433/
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