Aspirin-exacerbated respiratory disease (AERD), also known as Samter’s Triad, is a complex chronic medical condition involving a combination of three key factors – asthma, aspirin allergy, and nasal polyps. If you think you could have AERD or are caring for someone who might, this article explores exactly what it is, how intolerance to aspirin and asthma could affect peoples, and what treatment options are available.
AERD is a respiratory condition consisting of three factors – asthma, recurring nasal polyps, and a sensitivity to aspirin and other non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, naproxen or diclofenac.
The condition gets its name from the immunologist Max Samter, who first identified it, while ‘Triad’ refers to the three key components involved.
When people with AERD take aspirin or other NSAIDs, they experience an adverse reaction that causes upper and lower respiratory problems. The reaction typically occurs between 30-120 minutes after taking aspirin and can be serious.
Upper respiratory symptoms include:
- Nasal congestion
- Sinus pain
- A stuffy or runny nose.
- Loss of smell or taste.
Lower respiratory symptoms include:
- Chest tightness
- Difficulty breathing.
There can be other symptoms too, such as abdominal pains and vomiting. Around 20% of people can also experience a rash. Some people with AERD also experience similar mild to moderate reactions when they consume alcohol, such as red wine or beer.
Those with AERD often have a history of chronic sinus infections and recurrent nasal polyps. Some people experience a loss of smell as a result and their symptoms may not respond well to conventional treatment.
What causes Samter’s Triad?
There is no single known cause of AERD. However, studies have shown that people are more likely to have it if they also have asthma, recurrent incidences of nasal polyps, and sinus infections.
Not everyone with asthma will develop AERD. Research shows that adult asthmatics have a 7% chance of having AERD, while people with severe asthma are 15% likely to have AERD. Those with both asthma and nasal polyps are up to 40% likely to have it.
The signs and symptoms are most likely to first show up when people are aged in their 30s and 40s.
How is Samter’s Triad diagnosed?
Getting a formal diagnosis of AERD can be tricky, as there is no single test that can be used to identify the condition. Instead, a clinical diagnosis is made based on the combination of symptoms and the reactions experienced in relation to aspirin or other NSAIDs. It can sometimes take time to eliminate other causes first.
If you are unsure if you’ve reacted to aspirin, a formal aspirin challenge procedure may be conducted under medical supervision to assess your reaction. This is a form of drug provocation in which medical professionals will give patients controlled doses of a drug they are hypersensitive to, to monitor their reactions and form a full diagnosis.
Is AERD life-threatening?
AERD is a chronic illness that can cause ongoing symptoms. These symptoms can be severe, impacting the quality of life of those with AERD, and finding the right combination of treatments can be challenging.
Asthma is one of the three main elements of AERD. Severe asthma that isn’t managed properly, or doesn’t respond well to treatment, could be life-threatening. This is one reason why anyone with AERD needs to follow a well-managed asthma treatment plan.
How can diet affect Samter’s Triad?
Drinking alcohol can affect those with AERD. Some people, for example, have been found to experience reactions when they consume alcohol such as red wine or beer, and so reducing alcohol consumption could be beneficial.
Immunologist Max Samter originally thought that AERD symptoms might be ongoing due to the consumption of salicylates in the diet. Some studies have explored the benefits of a low salicylate diet and found that it may improve nasal symptoms for those with AERD. However, the evidence is not conclusive and more research is needed to support this theory, especially as a low salicylate diet involves cutting out a lot of healthy and nutritious foods, such as fruits and vegetables, which is restrictive and not ideal for your general health.
Instead, some experts suggest that a diet low in omega-6 fatty acids and high in omega-3 fatty acids may be more appropriate for AERD. Research into the benefits of decreasing consumption of omega-6 fatty acids has seen positive results. As people with AERD often have high levels of cysteinyl leukotrienes and prostaglandin D2 (inflammatory lipids), which are derived from the metabolism of omega-6 fatty acids, decreasing these acids can be helpful. Study results showed that this reduction has improved sinus symptoms and asthma control. However, you should always consult a doctor before changing your diet – they can offer the best advice and approach on how to do so and recommend if it’s a good idea for you.
Is Samter’s Triad autoimmune?
While research into AERD is ongoing, it is currently not regarded as an autoimmune condition. With autoimmune diseases, antibodies attack the tissues in the body – this is not believed to occur with Samter’s Triad.
Instead, Samter’s Triad is regarded as being a disease based on chronic immune dysregulation.
Studies have shown that people who have AERD often have high levels of eosinophils in their nasal polyps and high levels of eosinophils in their blood. Eosinophils are immune cells that are connected to inflammation and could lead to chronic inflammation in the airways.
It’s also been found that people with AERD have impaired cyclooxygenase enzyme (COX) pathways and produce high levels of leukotrienes – or inflammatory molecules. Levels of leukotrienes increase further when aspirin is taken, suggesting AERD has an element of inflammatory disease.
What treatments are there for AERD?
The majority of people who have AERD will need to use medications daily to cope with and manage their symptoms. There are various treatments available often recommended in conjunction with each other – you can discuss the best options for you with your family doctor or specialist.
Managing asthma symptoms
Anyone with AERD must manage their asthma symptoms daily, by taking prescribed corticosteroid medication, such as preventer and reliever inhalers.
Sinus inflammation can be managed by the use of intra-nasal steroid sprays and steroid rinses. Oral steroids may be needed periodically to treat nasal polyps.
Nasal surgery can be used to remove troublesome nasal polyps. However, they do often grow back, so this is not a long-term solution.
De-sensitization treatment can be used to improve an individual’s tolerance to aspirin. This approach is especially relevant for anyone who needs to take aspirin due to cardiovascular disease or chronic pain. For some people, desensitization can improve asthma symptoms, decrease nasal polyps and reduce sinus inflammation.
Avoidance of aspirin
For some, avoiding aspirin and other NSAID drugs is the best option to reduce the risk of a reaction occurring. However, it can be hard to avoid all these drugs completely as they’re often prescribed for other conditions.
Biologic injections can be helpful for people with moderate to severe asthma and nasal polyps. Biologics are a type of drug made from or containing biological sources that help to prevent inflammation.
If you think you may have AERD, you should speak to a medical professional who can offer advice.
Badrani JH, Doherty TA. 2021. Cellular interactions in aspirin-exacerbated respiratory disease. Curr Opin Allergy Clin Immunol. Feb 1;21(1):65-70. doi: 10.1097/ACI.0000000000000712. PMID: 33306487; PMCID: PMC7769923.
Cardet JC, White AA, Barrett NA et al. 2014. Alcohol-induced respiratory symptons are common in patients with aspirin exacerbated respiratory disease. J Allergy Clin Immunol Pract. March/April. 2(2). 208-213.
Kennedy JL, Stoner AN, Borish L. 2016. Aspirin-Exacerbated Respiratory Disease: Prevalence, Diagnosis, Treatment, and Considerations for the Future. American Journal of Rhinology & Allergy. 30(6):407-413. doi:10.2500/ajra.2016.30.4370
Laidlaw TM, Gakpo DH, Bensko JC et al. 2020. Leukotriene-associated rash in aspirin-exacerbated respiratory disease. J Allergy Clin Immunol. July; 8(9): 3170-3171. https://doi.org/10.1016/j.jaip.2020.06.061
Laidlaw TM. 2019. Clinical updates in aspirin-exacerbated respiratory disease. Allergy Asthma Proc. 40(1):4-6. doi:10.2500/aap.2019.40.4188
Li KL, Lee AY, Abuzeid WM. 2019. Aspirin Exacerbated Respiratory Disease: Epidemiology, Pathophysiology, and Management. Med Sci (Basel). Mar 17;7(3):45. doi: 10.3390/medsci7030045. PMID: 30884882; PMCID: PMC6473909.
Modena BD, White AA. 2018. Can diet modification be an effective treatment in aspirin-exacerbated respiratory disease?. J Allergy Clin Immunol Pract, 6(3), 832–833. https://doi.org/10.1016/j.jaip.2017.11.043
Rajan JP, Wineinger NE, Stevenson DD et al. 2015. Prevalence of aspirin-exacerbated respiratory disease among asthmatic patients: A meta-analysis of the literature. J Allergy Clin Immunol. Mar;135(3):676-81.e1. doi: 10.1016/j.jaci.2014.08.020.
Sommer DD, Hoffbauer S, Au M et al. 2014. Treatment of aspirin exacerbated respiratory disease with a low salicylate diet: a pilot crossover study. Otolaryngol Head Neck Surg. 2015 Jan;152(1):42-7. doi: 10.1177/0194599814555836. Epub 2014 Oct 24. Erratum in: Otolaryngol Head Neck Surg. 2015 Feb;152(2):378. PMID: 25344589.
Wangberg H, White AA. 2020. Aspirin-exacerbated respiratory disease. Current Opinion in Immunology. Vol 66: 9-13. https://doi.org/10.1016/j.coi.2020.02.006.