The first stop for professional medicines advice

Using NSAIDs in asthma

Published
Topics: Allergy and immunologyAspirinCautions and contraindications · CelecoxibDiclofenacEtodolacEtoricoxibIbuprofenIndometacinKetoprofenMefenamic acidNaproxen ·

Safety and prescribing scenarios for using nonsteroidal anti-inflammatory drugs (NSAIDs) in adults with asthma are outlined.

Contents
  1. NSAIDs in asthma
    1. Safety concerns
  2. Risk factors for NSAID sensitivity
  3. NSAID prescribing scenarios
    1. NSAID naive
    2. Previous tolerance to NSAIDs
    3. History of NERD
  4. Bibliography

NSAIDs in asthma

NSAIDs are cautioned or contra-indicated in people with asthma, depending on their previous history of NSAID use, as they may worsen asthma symptoms.

Safety concerns

NSAID-exacerbated respiratory disease (NERD) is a chronic, inflammatory, respiratory disorder occurring in people with asthma and/or chronic rhinosinusitis with nasal polyps, symptoms of which are exacerbated by NSAIDs, including aspirin.

There is a risk of immediate hypersensitivity reactions, bronchospasms and acute asthma exacerbations occurring within 30 minutes to 3 hours of taking an NSAID. This may be life threatening in some cases.

The main mechanism by which NSAIDs cause hypersensitivity in people with asthma includes inhibition of cyclooxygenase (COX) enzymes, particularly COX-1. It may also be related to the overproduction of leukotrienes.

Risk factors for NSAID sensitivity

People who are likely to be at risk of NERD should either avoid using NSAIDs or use them with caution. These include people who are or have:

  • severe or poorly controlled asthma
  • chronic rhinosinusitis and/or profuse rhinorrhoea
  • nasal polyps
  • female gender
  • history of NERD or atopic disease
  • aged 20-50 years
  • long-term smoking
  • family history of asthma or NERD or allergic rhinitis

Reactions to NSAIDs are likely to be dose dependent. However, in some cases, people are highly sensitive and develop worsening of their asthma even with low oral doses of NSAIDs such as an aspirin dose of 75mg.

NSAID prescribing scenarios

Based on prevalence data, approximately 80-90% of adult asthmatics will be able to tolerate NSAIDs.

Consider the risk factors for NERD mentioned above when deciding whether it is appropriate to prescribe an NSAID.

Where NSAIDs are not appropriate, consider prescribing an alternative treatment depending on the indication for use. Alternative analgesic options for NSAIDs include paracetamol and codeine.

NSAID naive

Use oral or topical NSAIDs with caution and monitor for symptoms such as exacerbation of asthma.

Previous tolerance to NSAIDs

Use oral or topical NSAIDs with caution and monitor for symptoms such as exacerbation of asthma. Counsel people on the risk of developing NERD, particularly in later life.

History of NERD

Do not use oral or topical NSAIDs.

If an NSAID is clinically necessary and there are no suitable alternatives, consider referring the person to an allergy or respiratory specialist for managing and preventing NERD. Treatment options include:

  • NSAID desensitisation therapy (aims to slowly increase a person’s tolerance to NSAIDs)
  • Leukotriene receptor agonists (such as montelukast)
  • Biological medicines (such as mepolizumab, benralizumab, reslizumab, dupilumab and omalizumab)

These treatment options are off-label and may not be suitable for everyone. There are limited and variable efficacy data for using leukotriene receptor agonists and biologics.

Bibliography

Full references are available on request.

Print this page