Asthma and Sinusitis: The connection is nasal polyps.
I frequently see patients with severe sinus disease (almost always with nasal polyps) who also have pretty severe asthma, requiring daily medication, usually inhaled steroids, and often oral steroids.
Many of these patients have not been told about the connection between asthma and nasal polyps or sinus disease, so let me blog about this for a few minutes.
A subset of these patients with asthma and polyps will be sensitive to aspirin and other nonsteroidal anti-inflammatory medications such as Motrin, ibuprofen, Anaprox, and Alleve. There are dozens more anti-inflammatory drugs, most of which will be listed in a separate handouts.
In our clinic, we try to whether a patient has asthma with aspirin sensitivity or asthma without aspirin sensitivity early in the evaluation process, because this factor often substantially affects our treatment recommendations (as well as the outcomes for various possible treatments of nasal polyps). So, if you’re evaluated in our clinic, you may be asked if you had a reaction to aspirin, Motrin, ibuprofen, or other anti-inflammatory drugs. You may want to consider this before your evaluation are clinic, or before evaluation by any ENT surgeon. The reaction that is of most interest to us is whether you’ve ever had an asthma attack or exacerbation of your wheezing within 20 minutes to three hours after taking any of these drugs. Also, if you had worse nasal congestion, clear runny nose, or watery eyes after taking these drugs, you should alert your caregiver about the possibility of a reaction to aspirin. This has a good chance of altering your treatment recommendations.
Identifying patients who are sensitive to aspirin and other anti-inflammatory drugs is very important to treat their polyps, but also can be life saving from the perspective of the patient’s asthma. We have seen many patients who have not identified their sensitivity to aspirin and anti-inflammatory drugs and several patients who have had heart attacks or strokes due to severe allergic reactions to aspirin which the patient took because he or she was unaware of their sensitivity to the drug.
Medical treatment of patients with aspirin sensitivity and nasal polyps is often different (at least in some ways) than patients with polyps who do not have sensitivity to these anti-inflammatory drugs. What are those differences?
- First, patients with aspirin sensitivity frequently have severe asthma and require multiple medications to control their asthma symptoms. We find that most of these patients need to be on a long acting steroid inhaler or asteroid inhaler that is combined with a drug to dilate the airwaves (a bronchodilator).
- Second, patients with aspirin sensitivity may benefit from the addition of a pill named Singulair to improve their asthma. Singulair is a drug designed to block the inflammatory pathway that is particularly overactive in patients with aspirin sensitive asthma. Your ENT doctor may discuss these drugs with you if you’re not currently taking them and may work with you or your asthma doctor to consider whether these drugs are warranted in your case or whether a trial of these drugs may be warranted.
- Patients with aspirin and nonsteroidal drug sensitivities may respond to oral prednisone to shrink the polyps in their nose and sinuses. Unfortunately, the effect is usually short lasting and the polyps will often (but not always) grow back rather quickly after a short burst of oral steroids has been given. We occasionally see a patient who can take a short course of oral steroids and obtain an improvement for several months.
- Patients with aspirin sensitivity and nasal polyps frequently have polyps are so large that the nasal steroid spray that they inhale each day only covers a very small amount of the surface and of the polyps. When polyps are very large and steroid sprays only cover a small were sent into the polyps, the steroid sprays don’t work particularly well. These steroid sprays may be slowing growth the polyps, but the sprays may not be truly shrinking the polyps. In this situation, we sometimes recommend surgery, but there are several factors that go into this consideration, most of which are brought beyond the scope of this webpage.
- If there is a clinical concern that a patient might possibly be aspirin sensitive, we will often have them assessed by our allergy colleagues who can perform testing for sensitivity to aspirin or other anti-inflammatory drugs. Identification of such allergies is critical since patients may benefit from avoiding aspirin and other anti-inflammatory drugs. In addition, identifying the sensitivity to anti-inflammatory drugs opens another treatment possibility: aspirin desensitization.
6. Aspirin desensitization can be performed as part of the treatment for triad asthma. There are several reports out of the Stanford University that have evaluated aspirin desensitization as a treatment option for patients with asthma, aspirin sensitivity, and nasal polyps. ( J Allergy Clin Immunol 98:751-8, 1996). These studies have shown that a substantial number of patients who undergo aspirin desensitization have less frequent asthma exacerbations and require nasal polyps surgery less frequently. Our experience is similar to this. In addition, we have found that many of our patients with nasal polyps have diminished amounts of thick, yellow, mucinous discharge and lesser amounts of clear, watery rhinorrhea if they are able to undergo the aspirin desensitization. For more information on aspirin desensitization, follow this link on aspirin desensitization.
More on this in another post, later. For those who are interested in learning more about Triad Asthma now, see one of my videos on YouTube
Jeff Terrell, MD