Aspirin-Exacerbated Respiratory Disease: How to Diagnose and Treat AERD with Desensitization

What Is Aspirin-Exacerbated Respiratory Disease?

Aspirin-Exacerbated Respiratory Disease, or AERD, is not just a bad reaction to painkillers. It’s a chronic, progressive condition that affects the lungs and sinuses, often starting in adulthood. People with AERD have three things in common: asthma, nasal polyps, and severe breathing reactions when they take aspirin or other common NSAIDs like ibuprofen or naproxen. This trio is also called Samter’s Triad, named after the doctors who first mapped it out in the 1960s.

Unlike regular allergies, AERD isn’t triggered by pollen or pet dander. Instead, it’s a metabolic problem. When someone with AERD takes aspirin or an NSAID, their body overproduces inflammatory chemicals called cysteinyl leukotrienes. These cause swelling in the airways, mucus buildup, and intense congestion. The result? Worsening asthma, blocked sinuses, loss of smell, and sometimes life-threatening breathing attacks.

It’s more common than you might think. About 7% of all adults with asthma have AERD. That number jumps to 14% if they also have nasal polyps. Most people are diagnosed between ages 20 and 50, and women are slightly more likely to be affected. Once it starts, it doesn’t go away on its own. Without proper treatment, symptoms get worse over time-often leading to repeated sinus surgeries and hospital visits.

How Do You Know If You Have AERD?

There’s no single blood test or scan that confirms AERD. Diagnosis relies heavily on your medical history. If you’ve had asthma since adulthood, developed nasal polyps, and noticed your breathing gets worse after taking aspirin, ibuprofen, or even some cold medicines, AERD is likely.

Doctors look for three key signs:

1. You have persistent asthma that started in adulthood, not childhood.
2. You’ve had nasal polyps that keep coming back-even after surgery.
3. You’ve had a clear reaction to aspirin or NSAIDs: wheezing, nasal congestion, or trouble breathing within 30 to 120 minutes after taking the drug.

If your history isn’t clear, a supervised aspirin challenge is the gold standard for diagnosis. This isn’t something you do at home. It’s done in a hospital or specialized allergy clinic, where doctors slowly give you increasing doses of aspirin while watching your breathing closely. Starting at 20-30 mg, doses double every 90 to 120 minutes until either you reach 325 mg or you have a reaction. The whole process takes about 5 to 6 hours. If your airways tighten up, they treat it immediately and confirm the diagnosis.

Lab tests can support the diagnosis. Many people with AERD have high eosinophils (a type of white blood cell) in their blood-often over 500 cells/μL. Urine tests may show elevated leukotriene E4, a marker of inflammation linked directly to AERD. But these aren’t diagnostic on their own. They’re clues, not proof.

What Happens If You Keep Taking NSAIDs?

Some people with AERD try to avoid aspirin and NSAIDs completely. But avoiding these drugs doesn’t stop the disease. The inflammation keeps going, even without triggers. Nasal polyps grow back. Asthma gets harder to control. Smell fades-or disappears entirely.

Studies show that 78% of AERD patients say nasal congestion severely limits their daily life. Nearly half have had at least one sinus surgery within two years of diagnosis. And even after surgery, polyps return in 70-80% of cases within 18 months if no other treatment is used.

Hidden NSAIDs are a major problem. Many over-the-counter cold medicines, headache pills, and even some topical creams contain aspirin or ibuprofen. People with AERD often don’t realize they’re being exposed until they have a reaction. Reading labels isn’t enough-you need to know which ingredients to avoid. Common culprits include: aspirin, ibuprofen, naproxen, diclofenac, and ketoprofen. Even some topical gels and patches can trigger reactions.

First-Line Treatments: What Works Right Away

Before jumping to surgery or desensitization, most patients start with medical therapy. These treatments don’t cure AERD, but they can bring symptoms under control.

Steroid nasal rinses are one of the most effective tools. Using a rinse with 50-100 mg of budesonide twice a day reduces polyp size by 30-40% in just eight weeks. It’s messy, but it works better than sprays. Many patients report clearer breathing and better smell after just a few weeks.

Intranasal sprays like fluticasone (two sprays per nostril, twice daily) help too. They improve nasal congestion scores by 35% after 12 weeks. But they’re not enough on their own for moderate to severe cases.

For asthma, the standard is a combination inhaler: fluticasone and salmeterol (250/50 mcg), two puffs twice daily. This improves lung function by 15-20% in most patients. It’s not a cure, but it prevents flare-ups.

Leukotriene modifiers like montelukast (10 mg daily) are often prescribed. But they only help 15% of patients significantly. Zileuton works better-reducing inflammatory markers by 75% in two weeks-but it’s harder to tolerate due to liver side effects and the need to take it four times a day.

Biologics: The New Hope for Severe Cases

If steroids and nasal rinses aren’t enough, biologics are the next step. These are injectable drugs that target specific parts of the immune system driving inflammation.

Dupilumab (injected every two weeks) has changed the game. In clinical trials, it reduced nasal polyp size by 55% and improved quality-of-life scores by 40% in just 16 weeks. It also helps restore smell-something many patients thought was lost forever.

Mepolizumab (injected monthly) cuts eosinophil levels by 85% and reduces the need for repeat sinus surgeries by 57% over a year. It’s especially helpful for people who’ve had multiple operations.

These drugs are expensive. Many patients struggle to afford them, especially without good insurance. But for those who qualify, they’re life-changing. One patient on Reddit said, “After three years of no smell, I smelled my wife’s perfume for the first time since my diagnosis. I cried.”

Aspirin Desensitization: The Game-Changer

If you’ve had sinus surgery-or are planning to-aspirin desensitization is the most effective long-term treatment for AERD.

The process starts with a supervised aspirin challenge, just like the diagnostic one. But instead of stopping when you react, doctors keep going. They give you increasing doses over two days until you can tolerate 650 mg twice daily. About 98% of patients complete it successfully.

After desensitization, you take high-dose aspirin every day-650 mg, twice a day. This isn’t just for pain relief. It’s therapy. Daily aspirin reprograms your body’s inflammatory response. Over time, it reduces polyp regrowth, improves asthma control, and brings back your sense of smell.

Studies show that after desensitization:

• Oral steroid bursts drop from 4.2 per year to just 1.1
• Nasal polyp recurrence falls from 85% to 35% within two years
• Smell scores improve by nearly double compared to those who don’t desensitize

One 2022 study found that combining desensitization with sinus surgery cuts polyp recurrence from 70% to just 25-30%. That’s the difference between needing another surgery every year and staying symptom-free for years.

Who Shouldn’t Try Desensitization?

Desensitization isn’t for everyone. It’s risky if you have:

• Severe heart disease or uncontrolled high blood pressure
• Active peptic ulcers or a history of GI bleeding
• Difficulty remembering to take daily medication

Missing just two or three days of aspirin can undo your progress. In 68% of cases, you’ll need to go through the entire desensitization process again if you stop.

Also, about 22% of people on long-term aspirin develop stomach issues. Taking it with food helps. Some doctors recommend a low-dose proton pump inhibitor (like omeprazole) to protect the stomach lining.

Doctors estimate that about 15% of AERD patients aren’t good candidates due to these risks. But for the rest, it’s the best chance to take back control.

What About Surgery?

Functional endoscopic sinus surgery (FESS) is often part of the plan. It clears out polyps and opens blocked sinuses. But surgery alone isn’t enough. Without desensitization, polyps come back fast.

When you combine FESS with daily aspirin therapy, the results are dramatically better. One major study showed that patients who had surgery and desensitization were 65% less likely to need a second operation than those who had surgery alone.

Many patients report feeling like they can breathe again the day after surgery. But without aspirin therapy, that relief lasts only months.

Living With AERD: Practical Tips

Managing AERD is a daily job. Here’s what works for people who’ve been through it:

• Use saline rinses daily-even on days you feel fine. Some add a drop of tea tree oil to reduce fungal buildup.
• Always check OTC meds. Look for “NSAID,” “ibuprofen,” or “aspirin” on labels. Even topical creams can trigger reactions.
• Keep a symptom journal. Note when you feel congested, wheezy, or lose smell. This helps your doctor adjust treatment.
• Carry a medical alert card. In an emergency, paramedics need to know you can’t have NSAIDs.
• Join a support group. The AERD Warriors forum and r/SamtersTriad on Reddit have thousands of people sharing tips and encouragement.

One woman in Bristol told me she started using a humidifier at night after losing her sense of smell. Within a month, she could smell her morning coffee again. Small changes matter.

Where Can You Get Help?

AERD requires specialized care. In the U.S., there are only about 35 dedicated AERD centers. Most are at academic hospitals. If you’re not near one, telemedicine consultations can help connect you with experts.

Only 18% of U.S. allergists feel confident managing AERD. That’s why finding the right team matters. Look for clinics with experience in aspirin desensitization and biologics. Ask if they use the standardized protocols from Penn Medicine or Brigham and Women’s Hospital.

Insurance coverage for biologics and desensitization varies. But many centers have patient assistance programs. Don’t give up if you’re denied-appeal, ask for help, or reach out to patient advocacy groups.

What’s Next for AERD Treatment?

The future looks promising. New drugs like MN-001 (tipelukast), which blocks two inflammatory pathways at once, are in early trials. Early results show a 60% drop in leukotriene levels with no major side effects.

Researchers are also studying how to predict who will respond best to which treatment. Some patients respond better to dupilumab; others do better with aspirin therapy. Personalized treatment plans are on the horizon.

For now, the best approach is clear: diagnose early, use medical therapy to control symptoms, consider surgery if needed, and pursue aspirin desensitization if you’re a candidate. It’s not a cure-but for many, it’s the difference between living with disease and living well.