A survey of aspirin desensitization practices among allergists and fellows in training in the United States

Aspirin-exacerbated respiratory disease (AERD) is characterized by chronic rhinosinusitis (CRS) with nasal polyposis, asthma, and reactions to cyclooxygenase-1 inhibiting medications. The prevalence of AERD is 7% in adult asthmatics and 9% in patients with CRS. It has a significant impact on quality of life due to difficult-to-treat CRS and asthma, which results in an increased dependence on systemic corticosteroids, a higher rate of exacerbations, and reduced lung function when compared with aspirin-tolerant asthmatics and/or patients with CRS. Aspirin desensitization followed by continuous aspirin therapy has been used as a treatment modality in AERD for many years now. Although initially offered only at specialized tertiary care centers, it has gradually become a treatment modality used by the community allergist. Multiple studies comparing patients with AERD on aspirin therapy with those not on it support the benefits of treatment, including improvement in quality of life, decreased rate of polyp formation, improved nasal and asthma symptom scores, and decreased need for systemic corticosteroids. Safety and efficiency of aspirin desensitization have improved over time, and it is now safely accomplished in a properly equipped allergy clinic in most cases. One of the reasons for this is the use of premedication with leukotriene modifying drugs, which has decreased the severity of bronchospasm. In addition to being safer, desensitization is now less cumbersome to perform for both patients and providers alike. Historically, the process often took 3-5 days, but can now be safely completed in 2 or fewer days in most cases. Proven benefit, enhanced safety, and improved efficiency should equate to high utilization of aspirin desensitization in patients with AERD among allergists in practice. We sought to assess its use via a 16-question survey that was generated and distributed through American Academy of Allergy, Asthma, and Immunology membership to physician members in the United States in 2013. A total of 684 physicians completed the survey, which is a response rate of 14.5%. Of those who completed it, 53.1% received their primary training in internal medicine with the remainder trained in pediatrics. More than 90% of the respondents were practicing allergists, whereas less than 10% were currently in an allergy training program. The majority of respondents (78.0%) indicated that they perform drug desensitization in their practices. Nearly all (98.4%) of the fellows-in-training reported performing drug desensitization. Among all responders, 66.8% desensitize to aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs), whereas 63.1% desensitize to antibiotics. Among fellows-in-training, 95.2% desensitize to antibiotics and 82.5% to aspirin and other NSAIDs. The majority (62.5%) of respondents perform aspirin desensitization for AERD (79.7% of fellows-in-training), and desensitization is most commonly performed to control nasal polyposis and/or asthma. More than 70% of those who use aspirin desensitization for AERD perform 5 or fewer per year. Most of the patients on whom respondents perform aspirin desensitization come from within their own practice (42.1%), but 28.5% are referred from otolaryngologists and another 16.8% from primary care physicians. Respondents most commonly perform aspirin desensitization for AERD in an outpatient setting, but more than 25% performed them in an intensive care unit, inpatient setting, or a combination inpatient/outpatient setting (Figure 1). Approximately 90% of respondents have not had an aspirin desensitization patient who reacts severely and require an unanticipated transfer to a higher level of care. Most of the respondents (54.2%) recommend aspirin desensitization to patients with AERD after a failure of typical medical treatment, but more than 25% use it only as a final option after all other measures have been exhausted. Most respondents who perform aspirin desensitization for AERD indicate that it is beneficial, whereas only 1.5% responded that it is rarely helpful. Of those who do not perform aspirin desensitization for AERD in their practice, 28.2% (41.7% of fellows-in-training) do not refer patients with AERD to other allergists who do perform the procedure. Safety risks were the most commonly selected deterrent to performing aspirin desensitization in one’s practice, followed by logistics of nursing care and lack of training to perform the procedure during fellowship (Figure 2). Fellowship training programs are where most respondents learned how to perform aspirin desensitization, but a large number (36.0%) learned by reviewing the relevant literature. More than 70% of respondents performed fewer than 5 aspirin desensitization procedures during fellowship training. In summary, the survey results indicate that only 62.5% of respondents perform aspirin desensitization for AERD in their practices. The actual percentage of allergists performing the procedure in practice is likely even lower than this due to voluntary response bias inherent in survey-based research. This study indicates that the primary deterrents to performing aspirin desensitization are safety concerns, logistics of nursing care, and lack of exposure to the procedure during fellowship training. The finding that more than 20% of fellows-in-training do not perform aspirin desensitization for AERD is troubling. In addition, another deterrent appears to be a lack of awareness of the clinical benefit of aspirin desensitization for AERD. Among those who do not perform it in their practices, 28.2% do not refer these patients to providers who do use this treatment option, possibly indicating that it is not seen by these providers as an effective treatment modality in AERD. Multiple studies, including 4 double-blind placebo-controlled trials, demonstrate efficacy of aspirin desensitization in AERD.